In the pre- H. Gastric ulcers are associated with a two- to three-fold increased mortality risk 5 , Factors such as shock on admission or delayed surgery were associated with omental patch leakage with increased mortality The size of the opening may also determine the extent of the peritoneal contamination and adversely affects the prognosis.
The choice of operative technique will depend on the position and size of the ulcer and the age and fitness of the patient. Perforated pre-pyloric ulcers are treated similarly to perforated DU, but more proximal gastric ulcers are best excised where possible.
If it is likely to lead to significant stenosis then a patch repair can be performed Figure 4. On some occasions it may be best to proceed with partial gastrectomy.
Although the best palliation is resection of a perforated gastric tumor, at laparotomy the management is more difficult, especially with regard to decision-making in a critically-ill patient in whom speed and minimal tissue trauma is of over-riding importance Even in cases of benign ulceration with perforation where tissue is edematous and swollen and have appearances of a neoplasm, decision to resect is difficult in these usually unstable patients. If any doubt as to how to proceed, immediate patient safety must come first, with peritoneal lavage and drainage as priority Postoperative complications following repair of gastric ulcer perforation include intraperitoneal abscess in the subphrenic space or pelvis, persistence or recurrence of ulcer symptoms especially if post-operative H.
Laparoscopic treatment of peptic ulcer perforation was first reported in 52 and suggested that laparoscopically performed omental patching was feasible and safe and had comparable results to open surgery with less postoperative discomfort 53 — Avoiding omentoplasty might shorten operating time but might be the reason for the higher incidence of leakage 60 , However, practice depends on expertise and local availability of laparoscopic surgery 8.
The mortality after surgery despite technical and medical improvement was still 5. Other reasons associated with a significant conversion rate include failure to locate the perforation 21 , shock on admission 50 vs.
There is remarkable difference in morbidity However, there was an increase rate of re-operation for leakage. This may be due to difficulty in the laparoscopic suturing procedure and the learning curve required Thus, the need for a laparoscopically-trained surgeon to perform the procedure. Although the mortality and morbidity is comparable in other published series for open vs. Other methods include sutureless techniques involving the use of gelatin sponge plug with fibrin glue sealing or the use of endoscopic clipping techniques, but the complication and mortality rates are quite high limiting their use 68 — Another minimally-invasive alternative is the insertion of self-expandable metal stents and drainage.
This is one of the new treatment options for PPU which can be used primarily or secondarily to deal with post-operative leakage after surgical closure. A study involving 10 patients with PPU showed good clinical results Following gastroduodenal perforation repair, peritoneal washout with several liters of warm saline would prevent inter-loop and intra-abdominal abscesses 73 , Although the outcome of laparoscopic closure of perforated peptic ulcer outweigh the disadvantages such as prolonged surgery time and greater expense, there is no consensus on whether it should be preferred over the open approach.
Many trials are mostly non-randomized or retrospective. However, as laparoscopy can be both diagnostic and therapeutic for the acute abdomen 75 , it should be advocated as a diagnostic and therapeutic tool in the case of suspected perforated peptic ulcer.
Laparoscopic correction of PPU should be the first treatment of choice as it allows closure of the perforation and peritoneal lavage just like in open repair, but without a large upper abdominal incision In addition, definitive ulcer surgery including posterior truncal vagotomy and anterior highly selective vagotomy is performed laparoscopically without conversion or mortality in expert hands Nonetheless, it is not suitable for patients age over 70 years or for symptoms persisting longer than 24 h as there is associated morbidity and mortality After a thorough wash out of the peritoneal cavity with 2—3 L of saline drainage of the peritoneal cavity is unnecessary.
A routine drain insertion is unproven 79 — A drain will not reduce the incidence of intra-abdominal fluid collections or abscesses In case of suspected leakage, a CT scan will provide all the information needed, better than a non-productive drain 79 — The adhesions that occur in the healing process of the repair, anastomosis, or general peritoneal cavity will attract the peritoneal drain foreign body which may physically damage the repair or small bowel.
Secondly, the repair needs to gain some extra blood supply, which it does by forming adhesions to adjacent vascular structures. If a piece of corrugated plastic is placed beside a repair, it will be unable to do this and a leak will be encouraged. The only exceptions are where the repair is not watertight, such as bile or urine, and a collection will interfere with healing There is a potential danger of suction redivac drains placed in the vicinity of a repair or anastomosis and, should be removed after 48 h Drains can indeed mislead the surgeon as they easily get blocked.
Large bore drains are useful in sepsis following inadequate peritoneal lavage or residual sepsis and should be placed in the appropriate dependent areas of the abdominal cavity such as the paracolic gutters, pelvis, and subphrenic spaces away from the intestine Vigilance in the post-operative period is the key and to remember that leak can occur.
Clinical signs backed by a water-soluble contrast study is the definitive investigation to determine if there is a leak Most patients with perforated peptic ulcer should be treated by operation, but there is a small place for conservative management.
Improvements in resuscitation techniques and the advent of powerful acid-suppressing agents PPIs have re-awakened interest in this treatment modality. The non-operative management is basically for 1 the asymptomatic and 2 the unfit patients. The asymptomatic patients are usually those who had typical symptoms of short duration with improvement by the time of hospital admission.
Unlike gastric ulcer perforation, a large portion of duodenal ulcer perforation can be treated non-surgically Pneumo-peritoneum has co-incidentally been discovered on erect chest or plain abdominal-x ray and, the computed tomography CT scan is used to investigate the pneumoperitoneum. The signs of peritoneal irritation are localized and when free gas is absent or minimal these patients have a small perforation which has already been sealed off with fibrin, omentum or an adjacent viscus.
A conservative policy is appropriate if in addition to the above criteria, there is no antecedent dyspeptic history which is in favor of an acute rather than a chronic duodenal ulcer. The efficiency of Taylor's method was established by Dascalescu et al.
Intra-abdominal abscess was the most common complication treated with antibiotics and drainage, but no mortalities. Early endoscopy is not advisable because of the risk of insufflation disrupting the plug which has sealed the gastroduodenal perforation, but it should be performed at a later stage to exclude malignancy. However, a definitive diagnosis is indispensable in performing non-surgical treatment because the perforation may lead to a fatal outcome. A water-soluble contrast meal may define those patients who do not have a free perforation into the peritoneal cavity or occasionally an endoscopic examination with carbon dioxide insufflation is useful 19 — 24 , 84 , Free leakage of contrast medium into the peritoneal cavity is usually an indication for operative intervention Treatment with intravenous IV infusion, nasogastric tube NGT decompression, broad spectrum antibiotics, analgesia, and intravenous PPIs is instituted, and a nil by mouth NBM policy is initially adopted.
Recovery is usually dramatically rapid for the properly selected patient and the right application of the protocol 88 , but close observation is important as the development of sepsis or peritonitis may alter treatment radically, and CT-guided drainage may be required 9 , 89 — The exception was patients older than 70 years of age which was a factor associated with higher risk of surgical intervention.
The study concluded that patients with perforated peptic ulcer may be observed in the initial 24 h and managed non-operatively Other factors such as shock hypotension and comorbidities have also been described as factors contributing to the poor response to conservative approach and associated higher mortality Thus, the decision of operative vs. Because of the significant incidence of intra-abdominal abscesses and sepsis with non-operative management, conservative management has been largely abandoned, even in high risk cases.
This is encouraged by the current advances in anesthetic approach. Thus, non-operative treatment is advocated in selected patients who do not have generalized peritonitis or continued duodenal leak, and for those in whom there is an absolute contraindication for surgery. Nonetheless, it still has several problems: 1 the high rate of mortality as well as prolonged hospital stay in the case of treatment failure or misdiagnosis 5 , 2 perforated gastric cancer is difficult to diagnose and will usually not respond, 3 gastric ulcer is less likely to respond to conservative therapy, but a large portion of duodenal ulcer perforation can, and 4 a colonic perforation is difficult to exclude and a free perforation will do badly with conservative treatment 90 , Non-operative management is less attractive in women than men because women who perforate are more likely to have a gastric than a duodenal ulcer 2 , 7.
They may be deemed unlikely to survive and it is important to discuss the implications with the patient and family. Perforation of an advanced gastric cancer may be another indication for pursuing a conservative course In elderly patients with advanced cardiac or respiratory disease the benefit of the operation must be weighed against its hazards. In some of these patients, and in those who refuse operation non-operative management should be pursued with vigor and enthusiasm rather than a spirit of hopelessness.
Perforated stomal ulcers are usually managed with omental patch The usual anatomy will be distorted by the presence of either an antecolic, retrocolic gastroenterostomy or a Roux-en Y anastomosis. An antecolic gastroenterostomy is relatively easy to find as there will be a loop of small bowel anterior to the transverse colon to the stoma but a retrocolic gastroenterostomy may not be immediately apparent as it lies deep to the transverse colon and omentum. Perforated hiatus hernia or gastric volvulus, when part or all of the stomach is in the chest, present extremely difficult scenarios.
Surgery in this situation may require thoracotomy, resection, and then a decision made regarding primary or delayed reconstruction 21 , The influencing factors are the time since presentation, degree of mediastinal and pleural soiling, and the general condition of the patient 21 , 22 , Traumatic perforation follows major trauma. Gastric injury is suspected following penetrating or blunt abdominal injury Gastric injury is likely to require surgery for hemorrhage and sepsis source control It is vital to inspect carefully the anterior and posterior gastric wall, gastrooesophageal junction GOJ , lesser sac entered with partial gastric mobilization, and to look for associated hepatic lacerations.
Primary closure is generally feasible, but this is not possible in severe trauma where damage limitation surgery aimed at hemorrhage control and limiting the soiling of the peritoneum is of essence Damage control surgery entails the acute resection stapling-off of damaged tissue, drainage and delayed reconstruction at re-look laparotomy at 48 h.
Thus, the correction of physiology takes precedence over anatomical correction in the exsanguinating critically ill patient. It is important to remember that acute gastric dilatation although commonly seen in trauma, is a rare but important postoperative complication of major upper abdominal surgery, post-splenectomy and with the gastric autonomic neuropathy of diabetes mellitus and, may cause gastric perforation — From the author's experience, the subtle presentation of left shoulder tip pain and hiccups from diaphragmatic irritation may lead to it being unrecognized and untreated with a fatal outcome due to vomiting and aspiration.
The correction of any biochemical abnormalities, such as potassium is essential, and the treatment is by large bore NG tube with regular aspiration The majority of gastroduodenal perforations are spontaneous from peptic ulcer disease. The management is not standardized as it essentially depends on the clinical scenario and the surgeon's experience. Perforated peptic ulcer is an indication for operation in nearly all cases except when patient is unfit for surgery.
Surgical techniques are varied, but laparotomy and omental patch repair remains the gold standard while laparoscopic surgery should only be considered when expertise is available. This must be followed by H. Gastrectomy is recommended in patients with large or malignant ulcer to enhance outcome. Primary closure is achievable in traumatic perforation but with the exsanguinating critically ill patient in severe major trauma, damage limitation surgery to correct physiology prior to a later anatomical reconstruction is the principle of management.
The author confirms being the sole contributor of this work and has approved it for publication. The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. National Center for Biotechnology Information , U. Journal List Front Surg v. Front Surg. Published online Nov 9.
Adv Wound Care New Rochelle ; 1 4 — Cell J. Experimental treatment of radiation pneumonitis with human umbilical cord mesenchymal stem cells. Asian Pac J Trop Med. Folia Med Plovdiv ; 62 1 — Biochem Cell Arch. Stem Cells Transl Med. Kidwai R, Ansari MA. J Nepalgunj Med Coll. Omental flaps reduces complications after pancreaticoduodenectomy.
Hepatobiliary Pancreat Dis Int. Effects of human umbilical cord blood—derived mesenchymal stromal cells and dermal fibroblasts on diabetic wound healing. Mesenchymal stem cells: Paracrine signaling and differentiation during cutaneous wound repair. Exp Cell Res. Adv Wound Care. Tissue specific human fibroblast differential expression based on RNAsequencing analysis. BMC Genomics. Stem Cells Dev. Manufacturing of primed mesenchymal stromal cells for therapy. Nat Biomed Eng. Use of mesenchymal stem cells for cutaneous repair and skin substitute elaboration.
Pathol Biol. Mol Ther. Bone marrow-derived mesenchymal stem cells laden novel thermo-sensitive hydrogel for the management of severe skin wound healing. Mater Sci Eng C. LR8 expression in fibroblasts of healthy and fibrotic human tissues. Biochem Biophys Rep. Effect of microgravity on the mesenchymal stem cell characteristics of limbal fibroblasts.
J Chin Med Assoc. Support Center Support Center. External link. Lancet ;— A standard laparotomy incision beginning just caudad to the xyphoid and ending several centimeters above the umbilicus is most often used. Many, though not all, studies suggest that transverse incisions may be associated with a lower postoperative hernia rate. Trocar placement varies based on surgeon preference and experience. One approach utilizes a Hassan trocar in the infraumbilical position, an mm trocar in the left midclavicular line approximately just above the level of the umbilicus, and a 5-mm trocar in the right midclavicular line just above the umbilicus.
Complications of trocar insertion are discussed separately in Section I, Chapter 7. Figure Incorrect placement of sutures across the perforation. Passage of the needle across the perforation in one pass can result in undue force and tension, resulting in tearing of the indurated tissue.
The suture should be placed across the perforation using two passes of the needle. Graham Patch Repair. The Jabalpur scoring system is useful because it incorporates perforation-operation interval, which is an important prognostic parameter in developing countries.
Moreover, its simplicity ensures objectivity and consistency in data collection. It can be applicable in centers where intensive care facilities are limited. The Jabalpur Scoring system can predict both morbidity and mortality [21].
Our patients of duodenal ulcer perforation are younger, with a high leak rate and mortality. Serum creatinine and size of perforation are factors linked to poor outcome.
Omental patch repair is suitable for large perforations in the emergency setting with limited expertise; more data is needed to validate other techniques. References Top.
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