Differentiated approach to surgical treatment of patients with perforative duodenal ulcer

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Differentiated approach to surgical treatment of patients with perforative duodenal ulcer

Ronald C. Merrell, Nizami A.Veliyev
Articole originale, no. 2, 2004
* Virginia Commonwealth University Department of Surgery
* Department of Surgical Diseases #3 of Azerbaijan State Medical University, Baku, Azerbaijan


Introduction
Even aggressive antiulcer therapy does not eliminate complications of duodenal ulcer that require surgical correction. Admissions for dangerous complication as perforation with high lethality remains almost unchanged (1, 2). In fact, a significant fraction of patients presenting with perforated ulcer have no priory history of ulcers (3, 4). Radical surgical treatment of complicated pylorduodenal ulcer is has a place in surgical treatment but less radical treatment for the routine is more prevalent (5, 6). In current practice lesser operations such as simple closure need not be considered palliative because medical treatment for H.pylori after simple closure provides excellent long-term results (6 - 8).
In traditional practice simple closure was reserved for situations of established fibrinopurulent peritonitis when generic resection or vagotomy & antrectory would have a high risk of complications including anastomotic failures. However, if simple closure is not to be considered palliative then such an approach should have merit earlier in the course of perforation. The feasibility of laparoscopic closure has been amply demonstrated (9-14).
This procedure is much more appropriate in early perforation where as late presentation would benefit from laparatomy and full lavage. In this study a test to quantify the stage and peritonitis was used to guide the surgeons' decision with regard to laparatomy. Patients with early peritonitis had radical operation in their disease was recurrent, there was a perforation of >5mm or the anatomy demanded resection as in the case of duodenal obstruction, mirror image ulcer or concomitant hemorrhage. Otherwise patients with early perforation were managed by laparoscopy only.

Methods and Materials
Between 1995-2001, 264 patients were admitted to the Emergency Surgical Service of Azerbaijan State Medical University in Baku for perforated duodenal ulcer. Diagnosis was made on clinical or radiographic grounds. At surgery purulent material was collected at laparoscopy or laparatomy. The age range was 14-82 years. Two hundred forty-four were men (92.5%). Without any additional instrumental study 77 (29.2%) patients with ulcerative anamnesis and typical picture of disease were operated urgently. Obscured perforations in 28 patients (10.6%) caused certain difficulties for diagnostics. Plain radiography of the abdominal cavity was conducted in 187 patients (70.8%) and gas was detected in only 106 patients (56.6%).
For the emergency diagnostics laparoscopy was conducted in 72 patients (27.3%). Suture of perforated ulcers in 48 of these patients (18.8%) was conducted by the laparoscopic method and in 24 patients (9.0%) laparoscopy was applied only with diagnostic purpose. Diagnostic value of laparoscopy was absolute. In difficult cases fibrogastroduoscopy was applied with introduction of air into stomach. Discharge of gas bubbles into abdominal cavity accelerated the search of perforated hole. It should be noted that emergency fibrogastroduoscopy was applied practically in all cases of laparoscopic variant of suture plication. It allowed detection of not only the ulcer localization but also to exclude second "mirror" ulcer on the contrary wall of duodenum, ulcer hemorrhage and stenosis. The number of neutrophils and macrophages as well as fibronectin concentration in abdominal exudation was studied to assess host defenses and duonicity.
Previous studies demonstrated that at the reactive stage (1-6 h) neutrophils were numerous and fibronectin was low. At the toxic stage (6-20 h) macrophages co-exist with a high concentration of fibronectin in neutrophils are numerous but most are not viable. Fibronectin is released by the macrophages. At the terminal stage (>20 h) all detected neutrophils are degenerate, macrophages are lacking and the fibronectin concentration in the exudate is very low. At this stage antitoxic and antibacterial properties of the exudates are very poor and infection is rampant (15).
These findings were used as a quick test for evaluation of the stage of peritonitis. Exudation was taken from abdominal cavity during the operation or laparoscopy neutrophil count and viability that was sent for study of leuko-formula macrophages were reported. Results were ready within 30 minutes (Table 1).
Table 1
Stage
Neutrophils
Macrophages
Fibronectin
Reactive (1 - 6 hours)
numerous
viable
few
low
Toxic (6-20 hours)
numerous
many non-viable
numeroous
high
Advanced (>20 hours)
less numerous
non viable
absent
low
Surgical approach was guided by these data. The findings demonstrated that functional neutrophils are found at the reactive stage of peritonitis (1-9 hours from the beginning of disease), non-viable neutrophils and macrophages are found at the toxic stage (6-20 hours from the beginning of disease), non-viable neutrophils and a lack of macrophages are found at the terminal stage (20 hours from the beginning of disease). The laparoscopic suture of perforated ulcer as well as radical operations were performed for the patients at reactive and toxic stages and open laparotomy suture was performed for the patients at the terminal stage of peritonitis.

Results
Two-thirds of patients were operated during the first 6-20 hours after perforation and the remaining one-third had more advanced peritonitis (> 20 h). All 46 patients with general peritonitis operated later than 20 hours after perforation had laparotomy suture of the perforation hole. In the 6-20 hour group, laparoscopic suture was performed.
Thus, the perforated ulcer was sutured in 94 patients (35.6%) of 264, 48 laparoscopic sutures and 46 laparotomy sutures. The remaining 170 patients (64.4%) had radical operations. Partial gastrectomy was conducted in 136 (80%) of patients, antrectomy and vagatomy was performed in 34 (20%). The indications for resection were: combination of perforated ulcer with hemorrhage, perioperative signs of chronic obstruction in duodenum, subcompensated or decompensated stenosis and detection of "giant" penetrating ulcers (Figure 1).
Figura 1
Undesirable effects of vagotomy, including repeated operations for postvagatomic syndrome precluded vagotomy as an adjunct in treating perforated ulcers except for antrectomy, which was rarely done. More recent data, which do not support the necessity of vagotomy, further condemn this measure.
Partial gastrectomy (118/69.4%) had a Billroth I. Only duodenal obstruction was an absolute contra-indication for this operation. Extensive phlegmon along the lesser curvature occasionally precluded a tension free Billroth I. Partial gastrectomy was performed in 18 patients (10.6%). Other risk factors in Billroth II partial gastrectomy which distort Billroth I anatomy include extensive scar, giant penetrating ulcers into the pancreas, and any cause of tension between stomach and duodenum (16). In 34 patients (20%) antrectomy with trachea vagotomy was performed and all had a Billroth I. Thus in 170 resections, 152 (89.4%) had a Billroth I anastomosis.
Laparoscopic suture for perforated duodenal ulcers (17-18) was applied in 48 patients. This operation seems inappropriate with a long history of recurrence, repeated perforations, well established peritonitis, presence of multiple ulcers, size of perforation more than 5 mm, duodenal stenosis or localization of ulcer in an area difficult to access by laparoscopy suture such as the superior posterior aspect of the duodenum. The results of surgical treatment of patients with perforated duodenal ulcer were studied both in early and late follow-up. Complications in the postoperative period were encountered in 22 patients (8.0%). These inclu-ded gastric after the vagotomy and antrectomy, (19) anastomosic hemorrhage (2), anastomostic leak after the partial gastrectomy (4), infection (5), abdominal abscess (1), fasciitis (1) and pneumonia (6) (Table 2).
Eight patients (3.0%) died after the operation, six after laparatomy and simple closure in the setting of advanced peritonitis (2). The causes were general peritonitis with multiple organ failure (4). Two patients died after anastomotic of partial gastrectomy. There were no deaths after laparoscopic suture of perforated ulcer. Death after laparotomy and closure was, therefore, 6/46 (13%) and after resections 2/170 (1.2%) (Table 3).
Table 2
Table 3
Deaths
Resection
Anastomotic Leak
2/170
1.2%
2
Laparotomy & Closure
Generalized Peritonitis
Pneumonia
6/46
13%
4
2
Laparoscopy & Closure
0/49
0%
Late results two to five years after the operation were available in 108 patients. Good and excellent results were note in 105 patients (97.2%). A satisfactory result was recorded in one patient who has duodenogastric reflux, which didn't require surgical correction. Two unsatisfactory results (0.75%) were noted after resection due to afferent loop syndrome after Billroth II in one case and reflux-esophagitis after Billroth-I. Both patients required further surgical intervention.

Conclusions
Thus, early detection by means of endoscopic methods as well as express-method of perioperative detection of number of neutrophils and macrophages in abdominal exudation allow to detect in proper time localization and character of the ulcer, the type of complication, intensity and prevalence of inflammatory process and thereby to choose necessary kind of operation for each specific case.
Detection of macrophages in abdominal exudation is evidence of antibacterial and antitoxic function of peritonea that is an original express-test for extension of indications to operation. The application of radical surgery in the absence of general and local contra-indications to it gives more good functional results.

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