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Duodenal Perforation

Duodenal Perforation. DR/FATMA AL-THOUBAITY SURGICAL CONSULTANT. History of the Procedure. Lau and Leow (PPU)was clinically recognized by 1799 . In 1894, Henry Percy Dean from London was the first surgeon to report successful repair of a perforated duodenal ulcer.

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Duodenal Perforation

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  1. Duodenal Perforation DR/FATMA AL-THOUBAITY SURGICAL CONSULTANT

  2. History of the Procedure • Lau and Leow (PPU)was clinically recognized by 1799 . • In 1894, Henry Percy Dean from London was the first surgeon to report successful repair of a perforated duodenal ulcer.

  3. The classic, pedicled omental patch that is performed for the 'plugging' of these perforations was first described by Cellan-Jones in 1929 • although it is commonly, and wrongly attributed to Graham, who described the use of a free graft of the omentum to repair the perforation in 1937

  4. A strand of omentum is drawn over the perforation and held in place by full thickness sutures placed on either side of the perforation, and this procedure has become the "gold standard" for the treatment of such perforations

  5. large perforations of the duodenum may be encountered in which there exists the threat of post-operative leakage following closure by this simple method .

  6. surgical options • Partial gastrectomy. • Jejunal serosal patch. • Jejunal pedicled graft. • Free omental plug. • Suturing of the omentum to the nasogastric tube. • Proximal gastrojejunostomy. • Roux-en-Y duodeno-jejunostomy • Gastric disconnection may be deemed necessary for adequate closure .

  7. Emergency surgery for perforated duodenal ulcer preserves its steady rate despite disappearance of elective operations after tremendous progress in medical control of peptic ulcer disease. There is an obvious return from definitive anti-ulcer surgery to simple closure of the perforation followed by antisecretory and antibacterial medication in the recent years.

  8. Frequency • Duodenal ulcer perforations are 2-3 times more common than gastric ulcer perforations. About a third of gastric perforations are due to gastric carcinoma.

  9. Duodenal ulcer perforation is a common surgical emergency in our part of the world. • The overall reported mortality rate varies between 1.3 to nearly 20 % in different series, and recent studies have shown it to be around 10 % .

  10. Endoscopy-associated bowel injuries are not a common cause of perforation. • Perforations related to endoscopic retrograde cholangiopancreatography (ERCP) occur in about 1% of patients.

  11. Outcome is improved with early diagnosis and treatment. The following factors increase the risk of death: • Advanced age • Presence of preexisting underlying disease • Malnutrition • The nature of the primary cause of bowel perforation • Appearance of complications

  12. The management of large perforations of duodenal ulcers. • There are three distinct types of perforations of duodenal ulcers that are encountered in clinical practice. • 'small' perforations that are easy to manage and have low morbidity and mortality. • 'large' perforations, that are also not uncommon, and omental patch closure gives the best results even in this subset of patients. • 'giant' should be reserved for perforations that exceed 3 cms in diameter, and these are extremely uncommon. • Gupta S, Kaushik R, Sharma R, Attri A. Department of Surgery, Government Medical College and Hospital, Sector 32, Chandigarh 160 030 India . Gupta S, Kaushik R, Sharma R, Attri A.

  13. 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.

  14. The therapeutic strategies in performing emergency surgery for gastroduodenal ulcer perforation in 130 patients over 70 years of age. • Duodenal ulcer cases, a simple closure and vagotomy is recommended because of its low mortality and minimal stress, except for cases with a giant perforation measuring over 20 mm in diameter at the perforation hole or with severe duodenal stenosis. In stomach ulcer cases, a gastrectomy may be recommended because of its low recurrence rate. • Tsugawa K, Koyanagi N, Hashizume M, Tomikawa M, Akahoshi K, Ayukawa K, Wada H, Tanoue K, Sugimachi K. Department of Surgery and Sciences, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan. Hepatogastroenterology. 2001 Jan-Feb;48(37):156-62.

  15. Omental plugging for large-sized duodenal peptic perforations: A prospective randomized study of 100 patients. • Omental plugging was a safe and reliable method of treatment for large-sized duodenal peptic perforations. • Jani K, Saxena AK, Vaghasia R. Department of Surgery, Medical College & SSG Hospital, Baroda, India. kvjani@gmail.com South Med J. 2006 May;99(5):455-6.

  16. [Laparoscopic repair of perforated duodenal ulcer: early postoperative results and risk factors] • Size of duodenal ulcer perforation and duration of ulcer perforation symptoms were found to be risk factors influencing the rates of conversion to open repair and genesis of postoperative morbidity. • Lunevicius R, Morkevicius M, Stanaitis J. 2nd Abdominal Surgery Department, Vilnius University Emergency Hospital, Siltnamiu 29, 04130 Vilnius, Lithuania. Medicina (Kaunas). 2004;40(11):1054-68.

  17. Treatment of perforated duodenal ulcer by laparoscopy. 35 cases • This study shows that the laparoscopic procedure is reliable and adapted to treat ulcer perforation if the size is less than 1 cm. • L'Helgouarc'h JL, Peschaud F, Benoit L, Goudet P, Cougard P. Service de Chirurgie viscerale et Urgences, CHRU de Dijon. Presse Med. 2000 Sep 23;29(27):1504-6.

  18. Factors contributing to releak after surgical closure of perforated duodenal ulcer by Graham's Patch. • Age greater than 60 years • pulse rate greater than 110/minute . • systolic blood pressure less than 90 mm Hg. • haemoglobin level less than 10 g/dl • serum albumin less than 2.5 grams/dl . • total lymphocyte count less than 1800 cells/mm-3 . • size of perforation greater than 5 mm .

  19. Releak was a significant factor influencing mortality rate after omental patch closure of perforated duodenal ulcer. • Kumar K, Pai D, Srinivasan K, Jagdish S, Ananthakrishnan N.Dept. of General Surgery, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry-6. Trop Gastroenterol. 2002 Oct-Dec;23(4):190-2.

  20. Prognostic risk factors in patients operated on for perforated peptic ulcer. A retrospective analysis of critical factors of mortality and morbidity in a series of 40 patients who underwent simple closure surgery • Old age, great APACHE II scores, delay in treatment and large size of the perforation were associated significantly to mortality in perforated peptic ulcer patients. • Efforts should be made perioperatively for patients having these risk factors. • Chiarugi M, Buccianti P, Goletti O, Decanini L, Sidoti F, Cavina E. Dipartimento di Chirurgia, Universita degli Studi di Pisa. Ann Ital Chir. 1996 Sep-Oct;67(5):609-13.

  21. Giant perforations of duodenal ulcer. • Over a period of eleven years, eight patients were treated for duodenal ulcer perforation. In five of these patients, the perforation was sealed using a jejunal loop as serosal onlay patch; one patient underwent gastrectomy and in two patients catheter duodenostomy was done. Two patients died, both due to renal failure. • Giant perforations of duodenal ulcer can safely be closed using a jejunal loop as serosal patch. Delay in doing the second stage definitive surgery for the ulcer may be dangerous. • Chaudhary A, Bose SM, Gupta NM, Wig JD, Khanna SK. Department of Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh. Indian J Gastroenterol. 1991 Jan;10(1):14-5.

  22. 'Free omental plug': a nostalgic look at an old and dependable technique for giant peptic perforations. • The omental plug is a simple procedure which does not require expertise and can even be performed in a very short time by a trainee general surgeon in a seriously ill patient in emergency. We review 7 cases of giant peptic perforations closed by a free omental plug. • Sharma D, Saxena A, Rahman H, Raina VK, Kapoor JP. Department of Surgery, Government Medical College, Jabalpur, India. Dig Surg. 2000;17(3):216-8.

  23. Cholecystoduodenoplasty for high-output duodenal fistula. • .We have devised a new procedure where the duodenal ulcer perforation is closed by mobilizing the gall bladder. A hole is made in the fundus of the gall bladder and it is anastomosed to the freshened edges of the duodenal opening. • We have treated six patients by this technique. In five patients the leak was satisfactorily sealed. Three patients died - one due to persistent leak and two due to jejunostomy leak. • Rohondia OS, Bapat RD, Husain S, Shriyan PG, Pradhan R, Kumar KS. Department of Gastroenterology Surgical Services, Seth G S Medical College and K E M Hospital, Mumbai. Indian J Gastroenterol. 2001 May-Jun;20(3):107-8.

  24. Closure of an acute perforated peptic ulcer with the falciform ligament. • Fry DE, Richardson JD, Flint LM Jr. Arch Surg. 1978 Oct;113(10):1209-10.

  25. Surgical repair of giant gastroduodenal perforation with Teflon-Felt? • Teflon-Felt is a bioinert, polytetrafluoroethylene, flexible material used on patients with vascular defect. • Kung SP. Department of Surgery, Taipei Veterans General Hospital and School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC. spkung@vghtpe.gov.tw Med Hypotheses. 2002 Oct;59(4):473-4.

  26. Repair of duodenal fistula with rectus abdominis musculo-peritoneal (RAMP) flap • It can be used for repair of large duodenal defects with friable edges when omentum is not available or when other conventional methods are impractical. Agarwal Pawan, Sharma Dhananjaya :GI Surgery Units, Department of Surgery, Government N S C B Medical College, Jabalpur 482 003,India

  27. Postoperative peritonitis originating from the duodenum: operative management by intubation and continuous intraluminal irrigation • Intubation with intraluminal irrigation has proved effective in a homogeneous group of patients with peritonitis due to duodenal leakage • Parc 1, P. Frileux 2, J. C. Vaillant 1, J. M. Ollivier 1, Dr R. Parc 1 *1Department of Digestive Surgery, Hôpital Saint-Antoine, University Pierre et Marie Curie, Paris, UK2Department of Digestive Surgery, Hôpital Foch, Université René Descartes, Suresnes, France*Correspondence to R. Parc, Department of Digestive Surgery, Hôpital Saint-Antoine, University Pierre et Marie Curie, 184 rue du Faubourg Saint-Antoine, F-75571 Paris, France

  28. Pancreaticoduodenostomy for treatment of giant duodenal ulcer. • Ntlhe LM, Montwedi OD, Mokotedi SD, Moeketsi K. Department of General Surgery, Medical University of Southern Africa, PO Medunsa, 0204.S Afr J Surg. 2004 May;42(2):51-2.

  29. conclusion • The incidence of perforated duodenal ulcer has not been reduced despite the over all decline in the incidence of complicated peptic ulcer disease. • Urgent simple closure of the perforation with omental patching is widely applied for the vast number of these patients • Simple closure of ulcer perforation is followed by re-perforation in 7.6%-8% of cases • Minimum intervention is recommended when early surgery is performed in peritonitis • Nutritional support is an essential part of the treatment of external duodenal fistula ,establish enteral feeding line .

  30. THANK YOU

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