The incidence and prevalence of uncomplicated peptic ulcer have decreased in recent years, largely because of the availability of treatment to eradicate Helicobacter pylori and the decreasing prevalence of H. pylori infection (1-4). However, the use of acetylsalicylic acid (ASA) and other nonsteroidal anti-inflammatory drugs (NSAIDs) that are associated with adverse gastrointestinal events (5) is becoming more widespread (6). It is therefore possible that there may have been no corresponding decrease in peptic ulcer complications such as upper gastrointestinal hemorrhage or perforation.
The incidence of bleeding ulcers and its related mortality have decreased and its management—mainly guided by endoscopy and interventional radiology—have largely substituted surgery (7). In contrast the incidence of perforated peptic ulcers (PPUs) is largely unchanged, counting 2–4% of peptic ulcers which remain the second most frequent cause of abdominal perforation that requires surgery as well as the most frequent indication for gastric emergency surgery (7-9). In southern Italy the incidence of gastroduodenal perforations has always been lower than in the North, this in general due to reduced alcohol consumption; in recent years we have noticed an increase in cases of peptic perforations due to the greater presence of immigrants in our area with different eating habits than ours.
These complications of peptic ulcer disease have a substantial economic impact. The total cost of peptic ulcer disease in the USA, incorporating both direct costs and loss of work productivity, has been estimated to be USD 5.65 billion per year (10). It is likely that disease-related complications contribute substantially to these costs. A study in the Netherlands calculated the per person costs of hemorrhage, perforation, or a combination of both to be EUR 12,000, EUR 19,000 and EUR 26,000, respectively (11).
The aim of our work is to evaluate the laparoscopic treatment of gastroduodenal ulcers (GDU) perforated in a territory where the population is multiethnic and where, given that the main activity is agriculture, the presence of non-EU citizens (EX) and of Eastern European citizens (EE) is considerably higher. Based on our experience, the laparoscopic treatment of GDU perforated has become our gold standard, our first surgical approach with considerable advantages especially for the patient and also for health spending in view of the spending review.
From January 2007 to December 2017, 97 patients were operated for perforated GDU in our department all treated within 24 h from admission and/or from the beginning of the symptomatology, 70 males and 27 females, in most cases they were foreign citizens: 69 foreigner (71.1%) of which 45 from EE and 24 from EX and 28 Italians (28.9%), the average age was 34 [18–55] for foreigners and 58 [30–86] for Italians. In total, 68 (70.1%) were treated by laparoscopy (LS) and 25 (25.8%) by laparotomy (LT), the cases of conversion from LS to LT were 4 (4.1%) included in a third group. Usual direct suture accompanied by omentopexy (OP) if ulcer > of 5 mm and/or if it is in the stomach. We do not use any other ingredients during surgery (for example fibrin glue or omental caps) and we are not used to perform vagotomies. We usually perform abundant washes of the abdominal cavity (temporally they can be performed both at the beginning and, most of the time, at the end of the operation depending on the intra-abdominal situation that we are facing), place one or more drainages both perilesional and Douglas (depending on the size of the intra-abdominal sperm and the type of spilled contents), place a nasogastric tube that is held until the patient is channeled, perform broad-spectrum antibiotic therapy, antithrombotic therapy based on the patient's state, therapy with proton pump inhibitors according to guidelines and early mobilization. The average hospital stay was 6 days for LS (5–8 days) and 9 days for LT (8–10 days). At discharge, all patients were asked to perform two-month EGDS for evidence of successful healing or to perform targeted eradication therapy.
Our surgical procedure: All cases of LS were performed either by the attending consultants or by trainees under their supervision. LS was achieved by using 3- or 4-port technique. In the 4-port technique, the additional port was sometimes used to assist in liver retraction. Once pneumoperitoneum was established, the peritoneal cavity was explored and the degree of contamination was determined. The perforation was repaired with a tongue of omentum tied down in place using absorbable 3/0 sutures in interrupted fashion. Intracorporeal knot tying was frequently used. Peritoneal wash to all 4 quadrants was then performed under direct vision using several litres of warmed saline. We place always one or more drainage around the perforation and/or in Douglas cavity.
For the LT group, a midline LT incision was used. Following identification of the perforation area, extensive peritoneal toilet was performed using warm saline.
Patch repair was then done in standard fashion. Similarly, drain placement was a routine. Mass closure of fascia was performed using 1/0 suture and interrupted closure to skin incision subsequently done with either Prolene suture or skin stapler.
Of the 97 patients treated for GD ulcer the majority were foreign (69 patients, 71.1% of the total, of which 24 of EX and 45 of EE) between the ages of 18 and 55, while 28 (28.9% of the total) were Italians aged between 30 and 86 years. Among the strangers with a history the most frequent cause attributable to the onset of this pathology is the consumption of alcohol and smoking: present in 60 patients (87%) out of 69, instead in the remaining 9 the abuse of NSAIDs or corticosteroids in the days before the hospitalization seems to be the triggering cause. Among the Italians 21 had abused in NSAIDs and/or corticosteroids (75%) and 7 had at the anamnesis gastroduodenal diseases not adequately treated (25%).
All patients were treated in the same operative way, no difference of surgery treatment was applied between EU and non-EU patients.
Of the 97 patients hospitalized for gastroduodenal ulcer perforated in 24 (24.7% of the total) we found a perforated gastric ulcer, in 69 (71.2% of the total) a perforated duodenal ulcer (mostly at the anterior wall level, 62 patients i.e., 90% of cases) and in 4 cases (4.1%) a perforated pyloric ulcer (which we treat with the same behavior that we use in perforated duodenal ulcer); in most cases of perforated duodenal ulcer the perforation diameter was between 0.5–1 cm (58 cases, 84% of the total) and this required an OP while in the others (11, 16%) the perforation was <5 mm and we are limited to the raffia (for all perforated gastric ulcers we usually perform OP regardless of the size of the perforation, allowing anatomy). Of all 97 patients undergoing emergency surgery, 68 (70.1% of the total) are laparoscopically treated, 25 (25.8% of the total) laparotomic and 4 (4.1% of the total) patients were converted from LS to LT for cardiorespiratory complications that occurred during surgery attributable to pneumoperitoneum or due to difficulties to identify LS perforation. The median duration of the intervention was of 93 minutes in LT [60–210] and of 66.3 minutes in LS [25–170] with reduction of the laparoscopic timing as more manuality was acquired. The average hospitalization of patients operated in LS was 6 days (5–8 days) with canalization to the gas and consequent removal of the nasogastric tube occurred between the II and III days postoperatively, the feeding to the liquids was resumed immediately after removal of the nasogastric tube and the semi-liquid diet the next day, usually in IV postoperative day; in patients operated in LT the average hospitalization was 9 days (8–10 days) with canalization to the gas and consequent removal of the nasogastric tube occurred between the III and the V postoperative day, the feeding to the liquids was resumed immediately after the removal of the SNG and the semi-liquid diet the next day, usually in V–VI postoperative day (Table 1). The only complications found in LS were: a postoperative hyperthermia in II and/or in III postoperative day in 5 patients resolved spontaneously, in one case a small perivesical collection (2 cm) found a month away from the intervention that determined a bridle of an intestinal loop resulting in intestinal obstruction and laparotomic reintervention and 2 bronchopneumonia outbreaks resolved after targeted antibiotic therapy. In LT we had: in one case of advanced sepsis the patient died in resuscitation at XV postoperative day operated by laparotomic route given the already very serious initial conditions to hospitalization and in three cases we had surgical wound infections resolved after appropriate dressings.
Laparoscopic repair of GDU is believed to reduce the post-operative morbidity and mortality. A recent systematic review of 3 randomized controlled trials with a total of 315 PPU patients compared LS with open surgery (12). This study failed to demonstrate differences in abdominal septic complications, pulmonary complications, mortality and re-operation. However, the operative time was shorter in laparoscopic group in contrast with previous study (9). A systematic review of 56 studies comparing laparoscopic vs open approach for PPU concluded that there was no consensus on the perfect operating techniques (10). The overall conversion rate for laparoscopic surgery was 12.4% mainly due to the size of perforation. Ulcer size more than 9 mm is a significant risk factor for conversion to open surgery (13). The operating time was longer and recurrent leakage was higher in laparoscopic group. However, the laparoscopic group also showed less postoperative pain and a shorter hospital stay. Furthermore, laparoscopic approach offers an alternative treatment with less pain, shorter hospital stays, and improved complications rate (11). For others, the laparoscopic treatment is also associated with equivalent costs compared with the open surgery as it reduces duration of hospital stays (8,12-19).
According to our experience given by the numerous cases of gastroduodenal perforation mostly in foreign subjects who find themselves in our territory for work purposes, since the main source of work is represented by the agriculture that in our town and in our territory in general involves the majority of the agri-food sector, the gold standard in the treatment of perforated gastroduodenal ulcer is represented by LS. LS that we can perform in almost all cases treated both because we have observed that in the foreigner the median age is lower respect to the Italians and, therefore, is more easy to perform LS in the foreigner respect to the Italians because of the minor cardiopulmonary complications that can determine its conversion, both because we have an operating team fully trained to deal with this disease. Another factor that has determined the success of the laparoscopic procedure is the treatment of the perforated patient within 24 hours from the symptomatological manifestation, even in the majority of the patients we managed to intervene within 18 hours from the beginning of the symptoms of pain, this precociousness of action has favored us both in terms of intra-abdominal collections (almost nil in our patients, only more or less noticeable) and in the inflammatory state of the periwound zone: the granulations around the site of perforation were minimal and this determined a greater resistance of the raffia and less difficulty in managing it. In our experience, laparoscopic treatment for perforated GDU is far superior to the laparotomic treatment both in terms of patient benefit and health expenditure and combines the advantages of LS with the reliability of laparotomic treatment.
Conflicts of Interest: The authors have no conflicts of interest to declare.
Ethical Statement: The study received approval from the Institutional Board Review (Comitato Etico Catania 1) Azienda Ospedaliera-Universitaria Policlinico Vittorio Emanuele Catania for interest of the company contact C.E. ASP Ragusa Dott. Aldo Gurrieri with a waiver of written informed consent.
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Cite this article as: Ragazzi S, Minardi R, Carnazza M. Laparoscopic treatment versus open treatment of gastroduodenal perforations: our decades of retrospective experience and literature review. Laparosc Surg 2019;3:2.