Page 8 - Laparoscopic Surgery Online Journal

10.5005/jp-journals-10033-1195
T Anil Kumar et al
ORIGINAL ARTICLE
Laparoscopic Management of Perforated Peptic Ulcer in

Early and Late Presentation: A Comparative Study

T Anil Kumar, Manoj Gowda, Manash Ranjan Sahoo

ABSTRACT condition in which laparoscopic repair is an attractive option.
Not only is it possible to identify the site and pathology of
Aim: To compare results of laparoscopic treatment of perforated
peptic ulcer (PPU) in early and late presentation. the perforation, but the procedure also allows closure of the
perforation and peritoneal lavage, just like in open repair
Materials and methods: Fifty-eight patients of age ranging
from 18 to 55 years underwent laparoscopic closure of PPU but without a large upper abdominal incision. 3,4
over a period of 4 years between 2008 and 2011 of which In the past 2 decades, there has been a change in the
43 were male, 15 were female. In our study we took early
presentation as 3 days and late presentation as 3 to 7 days pattern of perforated peptic ulcer disease in affecting old
(time taken for seeking treatment from the onset of symptoms). and infirm patients, with a high association with nonsteroidal
Thirty-seven presented early whereas other 21 presented late. anti-inflammatory agents. 5-12 They seldom require any
All patients were compared for variables like operating time, definitive procedure, which is associated with increased rates
intraoperative complications, risk of anesthesia, rate of 13
conversion to open surgery, postoperative pain and the opiate of perioperative death and complications. Helicobacter
analgesic requirements, postoperative morbidity and mortality, pylori is now the recognized culprit of the majority of
hospital stay.
patients with duodenal and gastric ulcers, and posteradication
Results: Mean operating time for patients with early presentation ulcer recurrence is uncommon. 14-16 Acid-reduction
was 60 vs 90 minutes for delayed presentation. Conversion procedures are not required for this group of patients. As a
rate was 0 in early presentation 47.6% (10 cases) in late
presentation. Thorough abdominal toileting was possible in all result, simple closure of the perforation with an omental
cases of early presentation. In late presentation it was possible patch has become the favored management approach in
only in 6 out of 11 cases after excluding conversion rate because many institutions. It is technically straightforward and
of intestinal matting. No patients had any anesthesia problem
in early presentation but 3 out of 11 cases had delayed recovery reliable and is also the preferred approach for high-risk
17-23
from anesthesia requiring treatment in intensive care unit. Post- patients. In this study we compare results of laparoscopic
operatively Opioid analgesia was required for mean of 3 days treatment of PPU in early and late presentation.
in early presentation vs mean of 4 days in late presentation.
Nasogastric tube was removed on 3rd day in early presentation
vs 4th day in late presentation which coincided with return of MATERIALS AND METHODS
bowel sounds. Port site infection was seen in 5 out of 37 cases
Not all patients are suitable for laparoscopic repair, and it is
in early presentation and 2 out of 11 in late presentation.
Intraperitoneal localized abscess was seen in 2 out of 11 cases important to preselect patients who are good candidates for
3
in delayed presentation and none in early presentation which laparoscopic surgery. Boey’s classification appears to be a
was then managed by aspiration. Mean hospital stay was helpful tool in decision-making. 24,25 The Boey score is a
5 days in early presentation and 7 days in late presentation.
count of risk factors, which are: shock on admission,
Conclusion: Laparoscopic treatment of PPU is safe, feasible American Society of Anesthesiologists (ASA) grade III and
done with ease in patients presenting less than 3 days and 26
V, and duration of symptoms. The maximum score is 3,
also in some cases of late presentation, with anesthetic
complication, postoperative complications and conversion rate which indicates high surgical risk. Laparoscopic repair is
increasing with delayed presentation. 27,28
reported only to be safe with Boey score 0 and 1. Elderly
Keywords: Laparoscopic, Perforated duodenal ulcer, Early patients more than 70 years, cardiac pathology, chronic
presentation, Delayed presentation, Opioid analgesia. respiratory insufficiency, obesity, severe cirrhosis, severe
How to cite this article: Kumar TA, Gowda M, Sahoo MR. coagulopathy, delayed presentation more than 7 days,
Laparoscopic Management of Perforated Peptic Ulcer in Early patients requiring continuous vasopressor infusion to
and Late Presentation: A Comparative Study. World J Lap Surg
2013;6(3):116-120. maintain blood pressure were excluded. Intraoperative
exclusion criteria for the laparoscopic repair are: a
Source of support: Nil
nonjuxtapyloric gastric ulcer, an ulcer greater than 2 cm in
Conflict of interest: None diameter, concomitant hemorrhage, inability to tolerate
pneumoperitoneum. After excluding patients from above
INTRODUCTION
criteria 58 patients of age ranging from 18 to 55 years
Laparoscopic treatment of perforated duodenal ulcer was underwent laparoscopic closure of PPU over a period of
1,2
first reported in 1990. Perforated peptic ulcer (PPU) is a 4 years between 2008 and 2011 of which 43 were male,
116