Perforated peptic ulcers - Department of Surgery at …

1 Perforated peptic ulcersDr V. ulcer disease peptic ulcers are focal defects in the gastric or duodenal mucosa that extend into the submucosaor deeper Caused by an imbalance between mucosal defenses and acid/ peptic injury The costs of PUD, including lost work time and productivity, are estimated to be above $8 billion per year in the United States In the United States with a prevalence of about 2%, and a lifetime cumulative prevalence of about 10%, peaking around age 70 pylori 50% of the world's population is infected with H. pylori Only 10 to 15% of patients colonized with H. pyloriwill develop PUD over their lifetime HP possesses the enzyme urease: converts urea into ammonia and bicarbonate The Bicarbonate buffers the acid secreted by the stomach.

2 The ammonia is damaging to the SECs Inhibitory effect on antral D cells that secrete somatostatin No inhibition of antralG-cell gastrinproduction Local alkalinizationof the antrum(antralacidification is the most potent antagonist to antral gastrin secretion) The end result is hypergastrinemiaand acid causative agents :1. Drugs (all NSAIDs, aspirin, and cocaine) stress. In the United States, probably more than 90% of serious peptic ulcer complications can be attributed to H. pyloriinfection, NSAID use, and/or cigarette Johnson classification for gastric incidence of emergency Surgery and the death rate associated with peptic ulcers has not changed significantly for last few COMPLICATIONS OF PEPTICULCER DISEASE Perforation Bleeding Gastric Outlet Obstruction Intractable COMPLICATIONS OF PEPTICULCER DISEASE : PERFORATION Acute perforations of the duodenum are estimated to occur in 2% to 10% of patients with ulcers Surgery almost always indicated Conservative management should considered in patients who do not have.

3 Generalized peritonitis hemodynamic instability free peritoneal perforation on a Gastrografinupper gastrointestinal COMPLICATIONS OF PEPTICULCER DISEASE : PERFORATION Conservative management serial physical and laboratory examinations nasogastricsuction intravenous acid secretion suppression intravenous broad-spectrum antibiotics In any time during conservative management the patient deteriorates, an operation is indicated Retrospective and prospective, randomized studies suggest that conservative management is effective in properly selected TJ, Park KG, Steele RJ, et al. A randomized trial of nonoperativetreatment for Perforated peptic ulcer .

4 New Eng J Med1989;320:970 973 Berne TV, Donovan AJ. Nonoperativetreatment of Perforated duodenal ulcer . Arch Surg1989;124:830 832 Keane TE, Dillon B, AfdhalHH, et al. Conservative management of peforatedduodenal ulcer . Br J Surg1988;75:583 584 Donovan AJ, Berne TV, Donovan JA. Perforated duodenal ulcer : An alternative therapeutic plan. Arch Surg1998;133:1166 1171 Marshall C, RamaswamyP, Bergin FG, et al. Evaluation of a protocol for the nonoperativemanagement of Perforated peptic ulcer . Br J Surg1999;86:131 COMPLICATIONS OF PEPTICULCER DISEASE : PERFORATION Appropriate surgical management of Perforated ulcers remained controversial : Simple patch ( laparoscopic or open) vsantiulcer operation?

5 ?? (1929) /Graham Patch(1937) Between Open and Laparoscopic Repairof Perforated peptic ulcer DiseaseWorld J Surg(2008) 32:2371 2374 Prospective , non randomized study August 2006-2007, 33 patient included, single institution Laparoscopic patch 19, open Patch 14 The primary end points : total operative time nasogastrictube utilisation intravenous fluid requirement total time of urinary catheter and abdominal drainage usage return to normal diet intravenous/intramuscular opiate time to full mobilization total in-patient hospital Between Open and Laparoscopic Repairof Perforated peptic ulcer DiseaseWorld J Surg(2008) 32.

6 2371 The 2-cm length of ANTERIOR AND POSTERIOR nerve is resected Esophagus should be more widely mobilized for a distance of 4 5 cm above the gastroesophageal junction The "criminal nerve" of Grassi origin from posterior vagus Frozen section should be requested to confirm VagotomyPreserve: posteriorlyderived vagalbranch that innervates the small intestine and pancreas anteriorlyderived vagalbranch that supplies the gallbladder and liver involves interruption of both nerves of Latargetand therefore does not avoid the need for a drainage Selective VagotomyPreserve: posteriorlyderived vagalbranch that innervates the small intestine and pancreas anteriorlyderived vagalbranch that supplies the gallbladder and liver both nerves of Latargetand therefore avoid the need for a drainage procedures( with TV or SV )

7 Heinecke-Mikuliczpyloroplasty Full-thickness incision extends from 2 cm proximal to 1 2 cm distal to the pyloric ring The incision is closed vertically Illustration of proceduresFinney U-shaped pyloroplasty The inverted U-shaped incision into the lumens of the stomach and duodenum Suture of the posterior septum of the stomach and duodenum The first anterior tier of sutures (Connell) is tube duodenostomy in the management of giant duodenal ulcer perforation a new technique for a surgically challenging conditionDepartment of Surgery , MaulanaAzad Medical College (University of Delhi), and Associated LokNayakHospital, New Delhi, IndiaThe American Journal of Surgery (2009) 198, 319 for type 4 gastric ulcer Pauchetprocedure for ulcer > 2 cm from GE junction Csendesprocedure for ulcer < 2 cm from GE risk scores for the prediction of outcome in elderlypeople who require emergency surgeryWorld Journal of Emergency Surgery 2007, 2 EK, Lam YH, Sung JJ, et al.

8 Eradication of helicobacter pylori prevents recurrenceof ulcer after simple closure of duodenal ulcer perforation. Ann ;231:153-158. 129 patients with Perforated DU 104(81%) with positive HP Surgery simple patch Randomization: HP therapy + PPI PPI therapy alone 1 Year endoscopic evaluation for recurrent ulcer : HP therapy group 5% of recurrent ulcer PPI group 38% and Outcomes of Hospitalizations for peptic ulcer Diseasein the United States, 1993 to 2006 Ann Surg2010;251: 51 and Outcomes of Hospitalizations for peptic ulcer Diseasein the United States, 1993 to 2006 Ann Surg2010;251: 51 and Outcomes of Hospitalizations for peptic ulcer Diseasein the United States, 1993 to 2006 Ann Surg2010.

9 251: 51 Trends in peptic ulcer Disease andDamage Control Surgery in the H. pylori EraFrom the Department of Surgery , Harbor-UCLA Medical Center, Torrance, CaliforniaTHE AMERICAN SURGEON September management of large perforations of duodenal ulcersSanjay Gupta, Robin Kaushik*, Rajeev Sharma and Ashok AttriBMC Surgery 2005, 5 is the Patient with PUD perforation who needs antiulcer Surgery in 21 century? Failure of medical treatment ? Need for long term steroids or NSAIDs? Smokers /EtOH? Non compliant patients? Prepyloricand pyloric channel perforation? HP treatment +PPI have been replaced antiulcer Surgery ?

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