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Perforated peptic ulcer
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Perforated peptic ulcerfamous fatalities
NapoleonJames Joyce
Rudolph Valentino
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Perforated peptic ulcerAcute abdomen (De Dombal n=30.000)
Appendicitis 28%
Cholecystolithiasis 9.7%
Occluded small intestine 4.1%
Gynecologic disorders 4.0%
Acute pancreatitis 2.9%
Urologic diagnosis 2.9%
Perforated peptic ulcer 2.5% (5-10 pro year)
Other diagnosis 1.5%
No diagnosis >40%
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Perforated peptic ulcerPathology
Most often chronic ulcer
50%: sealed off
Location: most oftenanterior juxtapyloric
Mean diameter: 5mm(>1cm=giant ulcer: rare)
10%: perforated gastriculcer)
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Perforated peptic ulcermorphology related to location
juxta-pyloric ulcer:
small, healthy border
gastric ulcer at lesser curvature:
large, fibrotic edematous border
(ulcus callosum)
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Perforated peptic ulcer
perforated gastric carcinoma
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Perforated peptic ulcersealing off by left liver half
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Perforated peptic ulcersealing off by segment IV
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Perforated peptic ulcersealing off by left liver lobe
X: free air below diaphragm in this patient
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Perforated peptic ulcerfibrinous peritonitis+parahepatic collection
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Perforated peptic ulcerulcer visible after lifting left liver lobe
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Perforated peptic ulcerBacteriology
48h: infected peritonitis, most often grampositive initially,
later gramnegative
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Perforated peptic ulcercause of death: peritonitis
Pre-antibiotics-mortality: 75%
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Perforated peptic ulcersubphrenisch abces
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Perforated peptic ulcerBoey prognostic parameters
Age Duration of symptoms
Shock
ASA III-IV
Diameter of ulcer
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Perforated peptic ulcer
Diagnosis
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Perforated peptic ulcer
Diagnosis
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Perforated peptic ulcer
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Perforated peptic ulcer
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Perforated peptic ulcerDiagnosis
1) X-thorax/abdomen in upright position If negative:
2) CT with oral contrast
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Perforated peptic ulcerduration of postoperative pneumoperitoneum
X:
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Perforated peptic ulcer
Operative therapy (history)
1892 resection: Heusner
1894 oversewe: Dean
1937 omental patch: Graham
1990 laparoscopy: Mouret
(1947 Taylor: conservative)
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Perforated peptic ulcerOperative therapy (closure+lavage)
Only after resuscitation
Closure+lavage
Postoperative gastric aspiration
Acid suppression (PPI s)
Antibiotics
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Perforated peptic ulcerlaparoscopic closure
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Perforated peptic ulcerlaparoscopic closure
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Perforated peptic ulcer
(stapler-fixation of omentum)
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Perforated peptic ulcerrendez vous omental patch
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Perforated peptic ulcerGraham 1937: omental patch plication (without primary closure of ulcer)
Kathkouda et al 1993: laparoscopic Graham omental patch
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Perforated peptic ulcer
3 stitch-Graham omental patch
Lam et al. Surg Endosc 2005; 19: 1627-30
Distance ulcer>1cm
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Perforated peptic ulcer
3 stitch-Graham omental patch
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Perforated peptic ulcer
Flat tire test
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Perforated peptic ulcer
drain?
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Perforated peptic ulceroperative therapy: abdominal complications
Re-leakage: 10%
Intra-abdominal abscess: 3%
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Perforated peptic ulceroperative therapy: results
Mortality: 0-8%
Morbidity: 13-23%
Parameters: ASA-, Boey scores
In general: results correlated with duration of symptoms,
ulcer diameter, age
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Management strategies, early results, benefits, and risk factors of laparoscopic repair of
perforated peptic ulcer.
Lunevicius R, Morkevicius M.
World J Surg 2005; 29: 1299-310
2nd Department of Abdominal Surgery, Clinic of General and Plastic Surgery, Orthopaedics, and
Traumatology, Vilnius University Emergency Hospital, Vilnius University, Siltnamiu Street 29, LT-
04130 Vilnius, Lithuania. [email protected]
The primary goal of this study was to describe epidemiology and management strategies of the
perforated duodenal ulcer, as well as the most common methods of laparoscopic perforated
duodenal ulcer repair. The secondary goal was to demonstrate the value of prospective and
retrospective studies regarding the early results of surgery and the risk factors. The tertiary goalwas to emphasize the benefits of this operation, and the fourth goal was to clarify the possible risk
factors associated with laparoscopic repair of the duodenal ulcer. The Medline/Pubmed database
was used. Review was done after evaluation of 96 retrieved full-text articles. Thirteen prospective
and twelve retrospective studies were selected, grouped, and summarized. The spectrum of the
retrospective studies' results are as follows: median overall morbidity rate 10.5 %, median
conversion rate 7%, median hospital stay 7 days, and median postoperative mortality rate 0%. The
following is the spectrum of results of the prospective studies: median overall morbidity rate was
slightly less (6%); the median conversion rate was higher (15%); the median hospital stay was
shorter (5 days) and the postoperative mortality was higher (3%). The risk factors identified werethe same. Shock, delayed presentation (> 24 hours), confounding medical condition, age > 70
years, poor laparoscopic expertise, ASA III-IV, and Boey score should be considered preoperative
laparoscopic repair risk factors. Each of these factors independently should qualify as a criterion for
open repair due to higher intraoperative risks as well as postoperative morbidity. Inadequate ulcer
localization, large perforation size (defined by some as > 6 mm diameter, and by others as > 10
mm), and ulcers with friable edges are also considered as conversion risk factors.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Lunevicius+R%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Morkevicius+M%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Morkevicius+M%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Lunevicius+R%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/utils/lofref.fcgi?PrId=3055&uid=16132404&db=pubmed&url=http://dx.doi.org/10.1007/s00268-005-7705-47/27/2019 perfor peptic ulcer treatment
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Systematic review comparing laparoscopic and open repair for perforated peptic ulcer.
Lunevicius R, Morkevicius M.
Br J Surg 2005; 92: 1195-207
Clinic of General and Plastic surgery, Orthopaedics and Trauma surgery, General Surgery Centre,
Vilnius University Emergency Hospital, 29 Siltnamiu Street, LT-04130, Vilnius, Lithuania.
BACKGROUND: The advantages of laparoscopic over open repair for perforated peptic ulcer are
not as obvious as they may seem. This paper summarizes the published trials comparing the two
approaches. METHODS: Two randomized prospective, five non-randomized prospective and eight
retrospective studies were included in the analysis. Relevant trials were identified from theMedline/Pubmed database and the reference lists of the retrieved papers were then analysed. The
outcome measures used were operating time, postoperative analgesic requirements, length of
hospital stay, return to normal diet and usual activities, and complication and mortality rates.
Published data were tested for heterogeneity by means of a chi2 test. Meta-analysis methods were
used to measure the pooled estimate of the effect size. In total, 1113 patients are represented from
15 selected studies, of whom 535 were treated by laparoscopic repair and 578 by open repair; 102
patients (19.1 per cent) underwent conversion to open repair. RESULTS: Statistically significant
findings in favour of laparoscopic repair were less analgesic use, shorter hospital stay, less
wound infection and lower mortality rate. Shorter operating time and less suture-site
leakage were advantages of open repair. Three variables (hospital stay, operating time and
analgesic use) were significantly heterogeneous in the papers analysed.
CONCLUSION: Laparoscopic repair seems better than open repair for low-risk patients.
However, limited knowledge about its benefits and risks compared with open repair
suggests that the latter, more familiar, approach may be more appropriate in high-risk
patients. Further studies are needed.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Lunevicius+R%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Morkevicius+M%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Morkevicius+M%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Lunevicius+R%22%5BAuthor%5D7/27/2019 perfor peptic ulcer treatment
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Perforated peptic ulceropen closure in the morbid obese
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Perforated peptic ulcerfree intraperitoneal air-differential diagnosis
Perforated peptic ulcer
Perforated diverticulitis
Perforated appendicitis
Perforated Crohn disease
Heimlich maneuver/Boerhaave syndrome
Through salpinx
Idiopathic
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Perforated peptic ulcerLAMA-trial: open vs laparoscopic closure (Marietta Bertleff)
Raw data
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Perforated peptic ulcer
exclusion of gastric carcinoma and helicobacter
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Perforated peptic ulcerremaining questions
Best technique of closure?
Postoperative gastric aspiration?
P f t d ti l
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Perforated peptic ulcer
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Perforated peptic ulcer
Tissue glue
Perforated peptic ulcer
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Perforated peptic ulcer
Stamp method
Bertleff M et al. Surg Endosc 2006 in press
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