Diagnostic and therapeutic role of laparoscopy in perforated peptic ulcer in the elderly patients.

AIM: The purpose of this study is to analyze the outcome of elderly patients with perforated peptic ulcer comparing laparoscopic treatment versus open approach. METHODS: In our General and Emergency Surgery Unit in the last 3 years, 20 elderly patients with perforated peptic ulcer were performed. We considered elderly all patients over the age of 65 years (10 females and 10 males; the mean age was 75 years). 16 patients (80%) were submitted to laparoscopic repair with omentoplasty and 4 (20%) to open repair. The patients were classified using the Boye's score which influenced the choice of surgical treatment and the outcoEmergency Romame. The two groups were compared in terms of operative surgery times, complication rate, mortality and postoperative outcomes. DISCUSSION: Perforated peptic ulcer is a common abdominal disease that is treated by surgery. The potential advantages of laparoscopy, both in terms of diagnosis and therapy, are clear and the major advantages may be observed in cases with peritonitis secondary as a perforated peptic ulcer where laparoscopy allows the confirmation of the diagnosis, the identification of the position of the ulcer and the repair. With the age the risks of comorbidities increases multidisease syndrome. Elderly patients suffer from frailty syndrome. All these factors make the elderly patient a major challenge for a laparoscopy treatment. CONCLUSION: The laparoscopic approach is an effective method for treatment of perforated peptic ulcer in the elderly with a great diagnostic and therapeutic role. Nowadays more prospective randomized studies are needed to evaluate the effectiveness of laparoscopic versus open repair.

Comparison and validation of scoring systems in a cohort of patients treated for perforated peptic ulcer.

BACKGROUND AND AIMS: The aim of this study is to evaluate the predictive accuracy of different scoring systems on surgery for perforated peptic ulcer referred to an academic department of general surgery in a tertiary reference center. PATIENTS AND METHODS: Seventy-five consecutive patients (Male/female ratio = 64:11; mean age, 44 years; range, 16-85) with perforated peptic ulcer disease were investigated. Disease severity scores and mortality predictions were calculated using the collected data during admission. Discrimination and calibration characteristics of each system, namely, the acute physiology and chronic health evaluation II and III, the simplified acute physiology score II, and the mortality probability models (MPM) II, were determined by using the area under receiver operating characteristics curve and the Hosmer-Lemeshow goodness-of-fit test, respectively. RESULTS: Among the 75 patients included, there were eight (10.6%) mortalities. All systems had a reliable power of discrimination and calibration. Among the systems tested, MPM II was the best performing as far as discrimination and calibration characteristics were considered. The parameters of MPM II system that were related to systemic perfusion of the patient were significantly positive in patients who died compared to those who survived. CONCLUSIONS: MPM II that predicted mortality at admission is better than the other systems in predicting mortality. Results also indicate the importance of maintenance of systemic perfusion of the patient at the early phases of peptic ulcer perforation.

The management of large perforations of duodenal ulcers.

BACKGROUND: Duodenal ulcer perforations are a common surgical emergency, but literature is silent on the exact definition, incidence, management and complications of large perforations of duodenal ulcers. METHODS: The case files of 162 patients who underwent emergency laparotomy for duodenal ulcer perforations over a period of three years (2001 - 2003) were retrospectively reviewed and sorted into groups based on the size of the perforations - one group was defined as 'small 'perforations (less than 1 cm in diameter), another 'large' (when the perforation was more than 1 cm but less than 3 cms), and the third, 'giant'(when the perforation exceeded 3 cm). These groups of patients were then compared with each other in regard to the patient particulars, duration of symptoms, surgery performed and the outcome. RESULTS: 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. CONCLUSION: There are three distinct types of perforations of duodenal ulcers that are encountered in clinical practice. The first, are the 'small' perforations that are easy to manage and have low morbidity and mortality. The second are the 'large' perforations, that are also not uncommon, and omental patch closure gives the best results even in this subset of patients. The word 'giant' should be reserved for perforations that exceed 3 cms in diameter, and these are extremely uncommon.

[Laparoscopic treatment of perforated duodenal ulcers. Results of a retrospective multicentric study. French Society of Laparoscopic Surgery]. / Le traitement laparoscopique de l'ulcère duodénal perforé. Résultats d'une étude rétrospective multicentrique. Société française de chirurgie laparoscopique (SFCL).

STUDY AIM: The aim of this multicentric retrospective study was to report procedures, mortality and morbidity rate in a series of patients operated on for perforated duodenal ulcer with a laparoscopic approach. PATIENTS AND METHODS: Four-hundred and nineteen patients from 18 centers were included. The duration of the study was ten years (1990 to 1999). There were 299 men and 120 women aged from 19 to 98 years (mean: 48 years). The ASA scores were as follows: I (48.7%), II (31.3%), III (17.5%), IV (2.5%). The mean duration between the onset of perforation and the time of operation was 13.4 hours (range: 1-70). The surgical procedures were suture (76.7%), epiploplasty (9.9%), only irrigation of the abdominal cavity (2.7%). RESULTS: Conversion into laparotomy was performed in 10.6% of the patients. Mean operative time was 85 minutes. The morbidity and mortality rates were 13.4 and 1.4% respectively. Seventeen patients were reoperated because of fistula (n = 5), intra-abdominal abscess (n = 5), small bowel obstruction (n = 4), bleeding ulcer (n = 1), iatrogenic perforation of the gallbladder (n = 1) and small bowel (n = 1). Mean hospital stay was 8.5 days. All patients were discharged with a medical treatment of the peptic ulcer disease and in most of the cases, with antibiotics for Helicobacter pylori eradication. Six patients out of 96 with a medical history of chronic peptic ulcer underwent a vagotomy. CONCLUSION: Laparoscopic repair of perforated duodenal ulcer is a safe option providing low rates of morbidity, reoperation and mortality, and can be considered the treatment of choice.

Positive predictive value of ICD-9th codes for upper gastrointestinal bleeding and perforation in the Sistema Informativo Sanitario Regionale database.

We identified patients whose records in the Sistema Informativo Sanitario Regionale database in the Italian region of Friuli-Venezia Giulia showed a code of upper gastrointestinal bleeding (UGIB) and perforation according to codes of the International Classification of Diseases (ICD)-9th revision. The validity of site- and lesion-specific codes (531 to 534) and nonspecific codes (5780, 5781, and 5789) was ascertained through manual review of hospital clinical records. The initial group was made of 1779 potential cases of UGIB identified with one of these codes recorded. First, the positive predictive values (PPV) were calculated in a random sample. As a result of the observed high PPV of 531 and 532 codes, additional hospital charts were solely requested for all remaining potential cases with 533, 534, and 578 ICD-9 codes. The overall PPV reached a high of 97% for 531 and 532 site-specific codes, 84% for 534 site-specific codes, and 80% for 533 lesion-specific codes, and a low of 59% for nonspecific codes. These data suggest a considerable research potential for this new computerized health care database in Southern Europe.

[The clinical and diagnostic characteristics of perforations in acutely bleeding gastroduodenal ulcers]. / Osoblyvost' kliniky ta diahnostyky perforatsiï hostrokrovotochyvykh hastroduodenal'nykh vyrazok.

Over the period 1982-1996 a total of 8822 patients with ulcerorrhagias were treated in a clinical setting. In 122 (1.4%) patients different variants of association of perforation of the bleeding ulcers (PBU) were recordable. Features of development, course, diagnosis and treatment of PBU patients were studied. Two variants of PBU development were identified: concurrently emerging perforation with ulcer bleeding--in 34 (27.9%) patients; when perforation of the ulcer emerged in 88 (72.1%) in--patients one to seven days following a bleeding event, presenting in 48 (54.5%) with bleeding recurrence, and in 40 (45.5%) patients without the above recurrence against the background of varying degrees gravity of loss of blood. As to PBU localization, 92 (75.4%) patients had the same site (in the stomach--18 subjects, pyloroduodenal region--74 ones), 30 (24.6%) patients developed simultaneously one perforating gastric or duodenal ulcer and some other ulcer bleeding. Analysis of symptoms in PBU and in 474 patients presenting with perforating ulcers without bleeding revealed varying degrees atypicalness of PBU course depending on variants of combination. A symptom complex of lesser PBU sign has been singled out, an algorithm proposed for procedures that might be helpful in making early diagnosis and planning surgical treatment to be done in a timely fashion. The suggested approach enabled the postoperative mortality to be reduced 3.5-fold (from 25% to as low as 7.1%).

Prospective evaluation of simple suture in the surgical treatment of perforated peptic ulcer.

In a prospective study aimed at evaluating a safe treatment for perforated peptic ulcer in tropical African conditions 205 patients who presented with perforation of a peptic ulcer in South-Eastern Nigeria during the ten year period January 1973 to December 1982 were treated by simple suture. The ulcers were classified at operation from appearance and feel as acute in 155 patients (75.6%), and chronic in the remaining 50 patients (24.4%). Of this number 21 patients (10.2%) died post-operatively. All 21 patients had chronic pyloroduodenal ulcers which were complicated by haemorrhagic in 10 patients (5.0%) and extensive scarring of the duodenum and pyloric stenosis in 9 patients (4.4%). By way of contrast, no patient with acute pyloroduodenal ulcer died and none was known to suffer from recurrent dyspepsia at 6 months to 1 year follow-up. These results clearly show that simple suture is adequate and safe treatment for perforated acute pyloroduodenal ulcer; however, this form of treatment carries an unacceptably high mortality in those patients with perforated chronic pyloroduodenal ulcers. These patients should, where feasible, be treated by definitive ulcer - curative surgery.

Perforated gastric ulcers. A plea for management by primary gastric resection.

One hundred one patients with perforated gastric ulcers have been treated at our institution during the past three decades. Ninety-one patients underwent operative repair, with a 24% mortality. A reduction in mortality and complications was realized when primary gastric resection, rather than patch closure, was performed. This could not be explained by selection bias, as risk factor prevalence was equally distributed between these two groups. We conclude that primary gastric resection, with or without vagotomy, is the procedure of choice for repair of perforated gastric ulcers. Only intraoperative hemodynamic instability should limit operative selection to a faster, less definitive procedure.

[Symptomatology and therapy of atypical perforations of gastrointestinal ulcers]. / Zur Symptomatik und Therapie der atypischen Perforation von Gastroduodenalulzera.

Starting from three patients, we observed the last three years, we discuss the pathogenesy and the symptomatology of different kinds of perforated gastroduodenal ulcers. We present a classification of these different kinds of adequate to the anatomical and pathological aspects and demonstrate the essential characteristics. We conclude with some aspects of nonsurgical treatment, which is possible in some few cases.