Duodenal Perforation

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Duodenal Perforation

• DR/FATMA AL-THOUBAITY
• SURGICAL CONSULTANT

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History of the Procedure

• Lau and Leow (PPU)was clinically recognized by
  1799 .
• In 1894, Henry Percy Dean from London was the
  first surgeon to report successful repair of a
  perforated duodenal ulcer.

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• The classic, pedicled omental patch that is
  performed for the 'plugging' of these
  perforations was first described by Cellan-Jones
  in 1929
• although it is commonly, and wrongly attributed
  to Graham, who described the use of a free graft
  of the omentum to repair the perforation in 1937

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• A strand of omentum is drawn over the perforation
  and held in place by full thickness sutures
  placed on either side of the perforation, and
  this procedure has become the "gold standard" for
  the treatment of such perforations

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• large perforations of the duodenum may be
  encountered in which there exists the threat of
  post-operative leakage following closure by this
  simple method .

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surgical options

• Partial gastrectomy.
• Jejunal serosal patch.
• Jejunal pedicled graft.
• Free omental plug.
• Suturing of the omentum to the nasogastric tube.
• Proximal gastrojejunostomy.
• Roux-en-Y duodeno-jejunostomy
• Gastric disconnection may be deemed necessary for
  adequate closure .

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• Emergency surgery for perforated duodenal ulcer
  preserves its steady rate despite disappearance
  of elective operations after tremendous progress
  in medical control of peptic ulcer disease. There
  is an obvious return from definitive anti-ulcer
  surgery to simple closure of the perforation
  followed by antisecretory and antibacterial
  medication in the recent years.

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Frequency

• Duodenal ulcer perforations are 2-3 times more
  common than gastric ulcer perforations. About a
  third of gastric perforations are due to gastric
  carcinoma.

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• Duodenal ulcer perforation is a common surgical
  emergency in our part of the world.
• The overall reported mortality rate varies
  between 1.3 to nearly 20 in different series,
  and recent studies have shown it to be around 10
  .

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• Endoscopy-associated bowel injuries are not a
  common cause of perforation.
• Perforations related to endoscopic retrograde
  cholangiopancreatography (ERCP) occur in about 1
  of patients.

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Outcome is improved with early diagnosis and
treatment. The following factors increase the
risk of death

• Advanced age
• Presence of preexisting underlying disease
• Malnutrition
• The nature of the primary cause of bowel
  perforation
• Appearance of complications

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The management of large perforations of duodenal
ulcers.

• There are three distinct types of perforations of
  duodenal ulcers that are encountered in clinical
  practice.
• 'small' perforations that are easy to manage and
  have low morbidity and mortality.
• 'large' perforations, that are also not
  uncommon, and omental patch closure gives the
  best results even in this subset of patients.
• 'giant' should be reserved for perforations that
  exceed 3 cms in diameter, and these are extremely
  uncommon.
• Gupta S, Kaushik R, Sharma R, Attri A. Department
  of Surgery, Government Medical College and
  Hospital, Sector 32, Chandigarh 160 030 India .
  Gupta S, Kaushik R, Sharma R, Attri A.

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• A total of 40 patients were identified to have
  duodenal ulcer perforations more than 1 cm in
  size, thus accounting for nearly 25 of all
  duodenal ulcer perforations operated during this
  period.
• These patients had a significantly higher
  incidence of leak, morbidity and mortality when
  compared to those with smaller perforations.

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The therapeutic strategies in performing
emergency surgery for gastroduodenal ulcer
perforation in 130 patients over 70 years of age.

• Duodenal ulcer cases, a simple closure and
  vagotomy is recommended because of its low
  mortality and minimal stress, except for cases
  with a giant perforation measuring over 20 mm in
  diameter at the perforation hole or with severe
  duodenal stenosis. In stomach ulcer cases, a
  gastrectomy may be recommended because of its low
  recurrence rate.
• Tsugawa K, Koyanagi N, Hashizume M, Tomikawa M,
  Akahoshi K, Ayukawa K, Wada H, Tanoue K,
  Sugimachi K. Department of Surgery and Sciences,
  Graduate School of Medical Sciences, Kyushu
  University, 3-1-1 Maidashi, Higashi-ku, Fukuoka
  812-8582, Japan. Hepatogastroenterology. 2001
  Jan-Feb48(37)156-62.

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Omental plugging for large-sized duodenal peptic
perforations A prospective randomized study of
100 patients.

• Omental plugging was a safe and reliable method
  of treatment for large-sized duodenal peptic
  perforations.
• Jani K, Saxena AK, Vaghasia R. Department of
  Surgery, Medical College SSG Hospital, Baroda,
  India. kvjani_at_gmail.com South Med J. 2006
  May99(5)455-6.

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Laparoscopic repair of perforated duodenal
ulcer early postoperative results and risk
factors

• Size of duodenal ulcer perforation and duration
  of ulcer perforation symptoms were found to be
  risk factors influencing the rates of conversion
  to open repair and genesis of postoperative
  morbidity.
• Lunevicius R, Morkevicius M, Stanaitis J. 2nd
  Abdominal Surgery Department, Vilnius University
  Emergency Hospital, Siltnamiu 29, 04130 Vilnius,
  Lithuania. Medicina (Kaunas). 200440(11)1054-68.
  

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Treatment of perforated duodenal ulcer by
laparoscopy. 35 cases

• This study shows that the laparoscopic procedure
  is reliable and adapted to treat ulcer
  perforation if the size is less than 1 cm.
• L'Helgouarc'h JL, Peschaud F, Benoit L, Goudet P,
  Cougard P. Service de Chirurgie viscerale et
  Urgences, CHRU de Dijon. Presse Med. 2000 Sep
  2329(27)1504-6.

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Factors contributing to releak after surgical
closure of perforated duodenal ulcer by Graham's
Patch.

• Age greater than 60 years
• pulse rate greater than 110/minute .
• systolic blood pressure less than 90 mm Hg.
• haemoglobin level less than 10 g/dl
• serum albumin less than 2.5 grams/dl .
• total lymphocyte count less than 1800 cells/mm-3
  .
• size of perforation greater than 5 mm .

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• Releak was a significant factor influencing
  mortality rate after omental patch closure of
  perforated duodenal ulcer.
• Kumar K, Pai D, Srinivasan K, Jagdish S,
  Ananthakrishnan N. Dept. of General Surgery,
  Jawaharlal Institute of Postgraduate Medical
  Education Research, Pondicherry-6. Trop
  Gastroenterol. 2002 Oct-Dec23(4)190-2.

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Prognostic risk factors in patients operated on
for perforated peptic ulcer. A retrospective
analysis of critical factors of mortality and
morbidity in a series of 40 patients who
underwent simple closure surgery

• Old age, great APACHE II scores, delay in
  treatment and large size of the perforation were
  associated significantly to mortality in
  perforated peptic ulcer patients.
• Efforts should be made perioperatively for
  patients having these risk factors.
• Chiarugi M, Buccianti P, Goletti O, Decanini L,
  Sidoti F, Cavina E. Dipartimento di Chirurgia,
  Universita degli Studi di Pisa. Ann Ital Chir.
  1996 Sep-Oct67(5)609-13.

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Giant perforations of duodenal ulcer.

• Over a period of eleven years, eight patients
  were treated for duodenal ulcer perforation. In
  five of these patients, the perforation was
  sealed using a jejunal loop as serosal onlay
  patch one patient underwent gastrectomy and in
  two patients catheter duodenostomy was done. Two
  patients died, both due to renal failure.
• Giant perforations of duodenal ulcer can safely
  be closed using a jejunal loop as serosal patch.
  Delay in doing the second stage definitive
  surgery for the ulcer may be dangerous.
• Chaudhary A, Bose SM, Gupta NM, Wig JD, Khanna
  SK. Department of Surgery, Postgraduate Institute
  of Medical Education and Research, Chandigarh.
  Indian J Gastroenterol. 1991 Jan10(1)14-5.

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'Free omental plug' a nostalgic look at an old
and dependable technique for giant peptic
perforations.

• The omental plug is a simple procedure which does
  not require expertise and can even be performed
  in a very short time by a trainee general surgeon
  in a seriously ill patient in emergency. We
  review 7 cases of giant peptic perforations
  closed by a free omental plug.
• Sharma D, Saxena A, Rahman H, Raina VK, Kapoor
  JP. Department of Surgery, Government Medical
  College, Jabalpur, India. Dig Surg.
  200017(3)216-8.

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Cholecystoduodenoplasty for high-output duodenal
fistula.

• .We have devised a new procedure where the
  duodenal ulcer perforation is closed by
  mobilizing the gall bladder. A hole is made in
  the fundus of the gall bladder and it is
  anastomosed to the freshened edges of the
  duodenal opening.
• We have treated six patients by this technique.
  In five patients the leak was satisfactorily
  sealed. Three patients died - one due to
  persistent leak and two due to jejunostomy leak.
• Rohondia OS, Bapat RD, Husain S, Shriyan PG,
  Pradhan R, Kumar KS. Department of
  Gastroenterology Surgical Services, Seth G S
  Medical College and K E M Hospital, Mumbai.
  Indian J Gastroenterol. 2001 May-Jun20(3)107-8.

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Closure of an acute perforated peptic ulcer with
the falciform ligament.

• Fry DE, Richardson JD, Flint LM Jr. Arch Surg.
  1978 Oct113(10)1209-10.

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Surgical repair of giant gastroduodenal
perforation with Teflon-Felt?

• Teflon-Felt is a bioinert, polytetrafluoroethylene
  , flexible material used on patients with
  vascular defect.
• Kung SP. Department of Surgery, Taipei Veterans
  General Hospital and School of Medicine, National
  Yang-Ming University, Taipei, Taiwan, ROC.
  spkung_at_vghtpe.gov.tw Med Hypotheses. 2002
  Oct59(4)473-4.

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Repair of duodenal fistula with rectus abdominis
musculo-peritoneal (RAMP) flap

• It can be used for repair of large duodenal
  defects with friable edges when omentum is not
  available or when other conventional methods are
  impractical.
• Agarwal Pawan, Sharma Dhananjaya GI Surgery
  Units, Department of Surgery, Government N S C B
  Medical College, Jabalpur 482 003, India

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Postoperative peritonitis originating from the
duodenum operative management by intubation and
continuous intraluminal irrigation

• Intubation with intraluminal irrigation has
  proved effective in a homogeneous group of
  patients with peritonitis due to duodenal leakage
  
• Parc 1, P. Frileux 2, J. C. Vaillant 1, J. M.
  Ollivier 1, Dr R. Parc 1 1Department of
  Digestive Surgery, Hôpital Saint-Antoine,
  University Pierre et Marie Curie, Paris,
  UK2Department of Digestive Surgery, Hôpital
  Foch, Université René Descartes, Suresnes,
  FranceCorrespondence to R. Parc, Department of
  Digestive Surgery, Hôpital Saint-Antoine,
  University Pierre et Marie Curie, 184 rue du
  Faubourg Saint-Antoine, F-75571 Paris, France

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Pancreaticoduodenostomy for treatment of giant
duodenal ulcer.

• Ntlhe LM, Montwedi OD, Mokotedi SD, Moeketsi K.
  Department of General Surgery, Medical University
  of Southern Africa, PO Medunsa, 0204.S Afr J
  Surg. 2004 May42(2)51-2.

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conclusion

• The incidence of perforated duodenal ulcer has
  not been reduced despite the over all decline in
  the incidence of complicated peptic ulcer
  disease.
• Urgent simple closure of the perforation with
  omental patching is widely applied for the vast
  number of these patients
• Simple closure of ulcer perforation is followed
  by re-perforation in 7.6-8 of cases
• Minimum intervention is recommended when early
  surgery is performed in peritonitis
• Nutritional support is an essential part of the
  treatment of external duodenal fistula ,establish
  enteral feeding line .

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THANK YOU