management of perforated gastric and duodenal...

Joyce Au SUNY Downstate Grand Rounds

September 27, 2012

Management of perforated gastric and duodenal ulcers

www.downstatesurgery.org

CASE

97 F with 2 days of sudden, diffuse, constant abdominal pain with some lightheadedness

No fevers/chills/N/V/diarrhea/bloody BM PMH/PSH: HTN, atrial fibrillation, s/p

hysterectomy, right knee surgery, left breast surgery

Meds: amlodipine, atenolol; no anticoagulation due to history of falls

Soc hx: lives alone


T=97.6, HR=125, BP=106/77, RR=20 Alert, oriented, responsive Abdomen soft, mildly distended, very tender

diffusely, + guarding and rebound tenderness, + bowel sounds; no mass on DRE, guaiac negative

RRR, clear breath sounds b/l, no CVA tenderness, no pedal edema


CBC: 16.2 (91% PMN) / 12 / 34.9 / 330 BMP: 137 / 3.6 / 94 / 30 / 49 / 1.2 / 82 UA negative Coags normal EKG – atrial fibrillation with HR of 99 CXR – large amount of free air CT - large amount of free air; no contrast

extravasation; no obstruction


OR findings Turbid fluid in the upper abdomen 5 mm circular perforation on anterior pyloric

channel with clean edges Extensive adhesions with the omentum

stuck to the abdominal wall


Procedure: Exploratory laparotomy Primary repair of ulcer with two interrupted

sutures Small patch of omentum sutured over the

repair


Cefotetan, vancomycin, diflucan as per ID Nexium Return of bowel function on POD#4 – diet

started and advanced Atrial fibrillation - echo negative; metoprolol,

digoxin Discharged to short-term rehab on POD#13


INTRODUCTION 2-10% peptic ulcers perforate M>F; trend towards more patients being

female, older, using NSAID, and having gastric ulcers

Etiology

H. pylori, NSAID, stress, gastrinoma, crack

Acid secretion

Mucosal defense


Modified Johnson’s classification of gastric ulcers

Giant gastric ulcers >3 cm – greater risk of malignancy (up to 30%) and complications

II

IV

III

I

V


Presenter

Presentation Notes

Giant duo ulcers assoc w crack

SIGNS & SYMPTOMS Pain - sudden, severe, constant, rebound,

guarding, rigid abdomen; radiates to R scapula with subphrenic abscess

Decreased bowel sounds, fever, tachycardia Free air


MANAGEMENT To operate or not? How sick is patient

Patch?

- Open or laparoscopic - Role of PPI and H. pylori antibiotics

Need definitive surgery? - Which definitive surgery


Perforated ulcer

Nonoperative

Patch

Definitive Ulcer

Operation


To operate or not Nonoperative in highly selected patients Perforation must be sealed

Acute ulcer, or chronic ulcer in high-risk patient Operate if deteriorate or no improvement in 12

hours

Berne et al. Arch Surg 1989 Donovan et al. Ann Surg 1979


Presenter

Presentation Notes

Fails in those age >70, today mostly in terminally septic pt

Perforated ulcer

Nonoperative

Patch

Definitive Ulcer

Operation


How sick is patient Emergency surgery for perforated ulcer with

mortality of 6-30% Definitive ulcer surgery often deferred with

shock, poor-risk patient, age >70, prolonged perforation, abscess, or generalized peritonitis

Lui et al. Scand J Surg 2010


Boey score 1 point each for preoperative shock severe comorbidities longstanding perforation >24 hr

Boey et al. Ann Surg 1987 Lohsiriwat et al. World J Surg 2009


Open vs. laparoscopic patch Graham patch popularized by Roscoe Graham,

1937


Laparoscopic omental patch

Variable techniques Convert to open with: large ulcer, friable ulcer

edge, posterior location of ulcer, unable to localize ulcer; also shock, delayed presentation >24 hrs


Presenter

Presentation Notes

Mouret 1990, depends on lap expertise of surgeon; primary repair then tie patch on top…knot of suture thru omentum and duo to fix patch, falciform

No significant difference in mortality or morbidity Conversion rate of 8%

Sanabria et al. Cochrane Database Syst Rev 2005


Sutureless patch with gelatin sponge and fibrin glue

Gastric ulcers - risk of malignancy biopsy or excision


PPI and H. pylori antibiotics About 1/3 patients with just patch closure

have ulcer recurrence H. pylori tests: serology, urease breath test,

rapid urease assay, biopsy Treatment of H. pylori Amoxicillin, clarithromycin, PPI;

metronidazole, bismuth Able to decrease ulcer recurrence at 1 year

to 5% Must test for eradication to determine need

for 2nd treatment or definitive ulcer surgery Feliciano. Surg Clinics North Amer 1992

Ng et al. Ann Surg 2000


Presenter

Presentation Notes

Sebastien 1995, marshall & warren w nobel for assoc of h pyl with perf ulc; gram neg, helical; 50% N am with h pyl but only 10% symptomatic

Perforated ulcer

Nonoperative

Patch

Definitive Ulcer

Operation


Indications Unable to afford the meds, noncompliance Intractable, multiple, or large ulcers Hemorrhage accompanying the perforation Gastric outlet obstruction Gastric ulcer


Which definitive ulcer operation

Duodenal perforation Truncal vagotomy and drainage Highly selective vagotomy Gastric perforation Truncal vagotomy and drainage and ulcer

excision Truncal vagotomy, antrectomy; gastrectomy


A.) Truncal vagotomy, drainage L anterior and R posterior vagal trunks; frozen

section Heineke-Mickulicz pyloroplasty


Presenter

Presentation Notes

2 cm vagus segment; pyl with 2 cm into antrum and duo; Gambee stitch

If scarring of pylorus or duodenum, then Finney pyloroplasty or Jaboulay gastroduodenostomy

Advantage: safe and quick Disadvantage: diarrhea, dumping syndrome


Presenter

Presentation Notes

F or J procedure may make later gastric resection difficult; ant connell stitch; avoid G-j with risk of marginal ulcer

B.) Highly selective vagotomy Aka parietal cell vagotomy, proximal gastric

vagotomy Spare nerves of Latarjet, hepatic and celiac

branches Include criminal nerve of Grassi


Advantage: safe, less side-effects Disadvantage: highest recurrence, longer

operation, requires more skill


Presenter

Presentation Notes

Not for prepyloric ulcers due to high recurrence, decrease gastric acid secretion by 75%

C.) Truncal vagotomy, antrectomy; gastrectomy Inclusion of vagotomy and extent of surgery

based on type of gastric ulcer


Presenter

Presentation Notes

Csendes if < 2 cm from gej; reflect on ulcer type

Reconstruction Billroth I - gastroduodenostomy Billroth II – gastrojejunostomy


Presenter

Presentation Notes

No roux-y for large gastric remnant with antrectomy; anast 5-6 cm to avoid stricture; retrocolic to minimize extra length needed and risk of kinking, duo stump leak, afferent loop synd

Advantage: reduces acid the most, lowest recurrence rate

Disadvantage: diarrhea, dumping, post-gastrectomy syndromes, not suitable if extensive inflammation or scarring which compromise the anastomosis


TV + pyloroplast

y

PCV TV + antrectomy

Gastrin release

Increased Increased Decreased

Gastric emptying of solids

Accelerated No change Slowed


Mulholland et al. Surg Clin North Am 1987


CONCLUSIONS

Perforated ulcer

Nonoperative

Patch

Definitive Ulcer

Operation

Patient’s clinical status and type of ulcer with important implications for surgery

Pathogenesis of ulcer disease may alter treatment options

Anatomy and physiology give

clues to effects and complications of surgery


QUESTIONS

1. A 45 yr old man requires surgery for intractable duodenal ulcer. Which best prevents ulcer recurrence?

a. Subtotal gastrectomy b. Truncal vagotomy and pyloroplasty c. Truncal vagotomy and antrectomy d. Parietal cell vagotomy


2. The pathogenesis of benign type I gastric ulcer is predominantly which?

a. Hypersecretion of acid b. Hypergastrinemia due to gastric stasis c. Antral stasis d. Hyperpepsinogenemia e. Defective mucosal barrier


3. A 52M has ulcer-like pain 15 years after a highly selective vagotomy, and EGD shows a recurrent duodenal ulcer, H. pylori negative. The most likely explanation for his recurrent ulcer is

a. Incomplete vagotomy b. Gastrinoma c. Antral G-cell hyperplasia d. Bile reflux e. Occasional NSAID use


That’s all, folks. Thank you!


management of perforated gastric and duodenal...

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