Laparoscopic suture repair of perforated duodenal peptic ulcer for patients without risk factors

Introduction
The effectiveness of the medical therapy for ulcer disease has made suture repair with or without omental patch the standard surgical treatment for perforated duodenal ulcer (PDU). Current medical anti-ulcer therapy (H2-antagonists or proton pomp inhibitors and anti-Helicobacter pylori therapy) have replaced definitive surgical interventions (1). Laparoscopic suture repair represents another step in the therapeutic progress. Although it has been 16 years since it was introduced in surgical practice, the laparoscopic suture repair is still not generally accepted or recommended in all cases (2-4). Some authors have suggested that only pts without risk factors would benefit from the laparoscopic approach (4, 5). In some prospective studies comparing open suture repair vs. laparoscopic suture repair, patients with increased risk were usually treated using open surgery (6, 7). The aim of our prospective non-randomized study was to compare outcome of the suture repair with omental patch of PDU both through laparoscopy and open surgery in patients without risk factors.

Materials and Methods
For this study, patients with perforated duodenal ulcers were selected for the open surgery group (OSG) or laparoscopic suture group (LSG). Exclusion criteria, approved by the local ethics committee, were patients with either one or more of the following risk factors: age >50 years, interval between perforation and operation ³ 12 hours, presence of major comorbidities (American Society of Anesthesiologists [ASA] I-II), and previous abdominal surgery. The decision to perform open or laparoscopic suture repair was made by the surgeon according to their preference and laparoscopic experience.
Before surgery, all patients had a complete physical, plain abdominal and chest X-ray examination, nasogastric tube decompression, intravenous analgesic therapy (Metamizole 500 mg), acid secretion inhibitors, antibiotics (Ampicillin + Gentamicin or Cephalosporins II-III generation) and fluid resuscitation.
The operation was performed with the surgeon standing between the patients' legs with the assistant at his right hand. The pneumoperitoneum was obtained using a Veress needle introduced beneath the left costal margin. The working pressure was 12 mmHg. We used four ports. The 30º laparos-cope was introduced through a port placed above the umbilicus on the median line. A 5 mm trocar was placed just beneath the xiphoid process and two more trocars were placed along the right (5 mm) and left (10 mm) midclavicular line at the level of the umbilicus. After identifying the perforation, a peritoneal lavage was performed with at least 2 liter of warm isotonic saline solution. The perforation was sutured as follows: perforations with a diameter < 5 mm were closed with one or two longitudinal sutures or with one "Z" suture, with or without omental patch; perforations > 5 mm diameter were sutured with two or three longitudinal sutures, with omental patch.
The omental patch was fashioned as follows: after the suture or sutures were applied across the perforation, a conveniently vascularized fragment of the greater omentum was brought to the perforation, and the sutures were tied to maintain it in place (Graham's patc"); after closing the perforation by tying the suture, the long strands of the suture were tied about the piece of omentum (modified Graham patch).
The suture repair was performed using 2-0 non absorbable or slow absorbable sutures and the knots were tied intra-corporeally. The type of suture utilized was determined by the surgeon. After the closure of the perforation, another irrigation of the peritoneal cavity with 2-3 liters of warm normal saline was performed. In each case drains were placed (15Fr) subhepatically and in the pouch of Douglas.
Open suture repair was performed through an upper midline incision in the same manner as laparoscopic suture repair. In converted cases, a shorter incision was possible. We did not evaluate the presence of H pylori. All patients received the following care after surgery:
· IV analgesics by request (1 dose of 1 g Metamizole at minimum 6 hrs);
· IV fluids until bowel movements were present and oral hydration could be started;
· IV antibiotics for minimum of 3 days;
· IV antacid therapy until oral intake was possible;
· anti-H pylori chemotherapy for 15 days and oral PPI for 4 weeks postoperatively;
· oral intake of fluids and food after bowel movements were present;
· nasogastric tube was removed after 24-48 hours (gastric stasis up to 500 ml/24 hrs);
· drain tubes were removed after 48-96 hours.
Patients were discharged when they could tolerate a normal diet, presented intestinal movements, and had no evidence of sepsis. Patients were advised to undergo a gastroscopy examination 6 weeks after surgery.
Data were processed using SPSS 13.0 (Chicago, IL, USA). Statistical differences were determined by t-test, Mann-Whitney, and Chi square as necessary. Statistical significance was set at p < 0.05.

Results
Two hundred and fifty-nine patients were included from one center between February 1995 and September 2005. 175 patients underwent OSG, and 85 patients underwent LSG. The two groups were comparable for age, gender, associated diseases, ulcer history, time interval between onset of the symptoms and surgery, American Society of Anesthesiologists (ASA) grade, perforation >5 mm, and free air on abdominal plain X-ray (table 1). In the LSG group, we performed 37 suture repair of perforations and 41 suture repair with omental patch. A Graham patch was used in 23 cases and modified Graham patch in 18 cases. In the OSG group, we performed suture repair with omental patch in 153 patients (66 Graham patch).The duration of surgery, analgesic doses, time interval until postoperative bowel movement, IV fluid, and hospital length of stay are presented in table 2.
There were seven conversions (8.23%). Conversion was performed in two cases because additional diagnoses were established (perforated appendicites and perforated sigmoid diverticulitis), in three patients due to unsuccessful suture repair in one patient because a leak was recognized, and in one patient due to a small bowel injury caused by a trocar.
There were no deaths. Postoperative complications are presented in table 3. Laparoscopic suture repair of the PDU was performed by 12 surgeons: 7 surgeons performed one to three operations, 3 surgeons performed between three and 10, and 2 surgeons performed over 10 operations. Open repair was performed by 15 surgeons and 4 residents. All surgeons who performed laparoscopic suture repair also performed open suture repair. One hundred and twenty-nine patients (51.2%) underwent surgery during the night (between 10 pm and 6 am): 107 (61.5%) of 174 in OSG group and only 22 (25.8%) of 85 in LSG group.

Discussion
The treatment of perforated ulcer has changed in recent years. Sixteen years ago, surgical interventions were performed to treat PDU complications and in indicated cases to prevent the ulcer recurrence through definitive ulcer therapy (8). Definitive surgery has been replaced by current anti-ulcer therapy, antacid and chemotherapy anti-H pylori (29). Ulcer recurrence after suture repair followed by complete medical therapy at 12-43 months follow-up was 0 - 6.6%, without reperforation (10-12). In a study published in 2000, ulcer recurrence after suture repair was the same as after truncal vagotomy with piloroplasty (13). Suture repair is unanimously accepted in PDU with the exception of associated complications such as stenosis, bleeding, or reperforation (6, 15). Laparoscopic suture repair in PDU remains a subject of debate. In PDU, the postoperative outcome is dominated by peritonitis (20, 21). Patient selection is a problem in the laparoscopic approach of PDU as well as with other emergency laparoscopic interventions. The most common contraindications for laparoscopy are postoperative adhesions in previous upper abdominal surgery and severe peritonitis (22). In some experimental studies it was shown that capnoperitoneum can worsen peritonitis that is present for over 12 hours (23, 24). However, this finding has not been proved by other experimental studies and in vivo (25, 26). Contraindications for laparoscopy are hemodynamic instability and respiratory and/or severe cardiac comorbidities (22). Another sensitive point is the laparoscopic experience of the surgeon and the possibility of insufficient technical equipment. Our selection criteria were established early in the study due to the limited technical capabilities of intraoperative and postoperative monitoring of the patients and the laparos-copic experience of our team. Unfortunately, the development of an optimal learning curve in the laparoscopic approach of PDU is not easy to achieve, especially when there are many surgeons involved, as is the case of our team. Another problem lies in the major reduction in numbers of patients with this condition admitted to our hospital in the past years (27). The operation takes longer due to the peritoneal lavage, but also due to surgeons with difficulties in tissue approximation (20, 28). We have noticed a limit in laparoscopic interventions for PDU performed during the night (10 PM - 6 AM), which may be due to the estimated prolonged time of the intervention. The case selection is based on the existence of risk factors. The main risk factors in PDU are the Boey risk factors: preoperative shock, associated major medical comorbidities, and long-standing perforation (³ 24 hours). The Boey score based on the absence or presence of one, two, or three risk factors is emblematic for mortality (29). Other risk factors associated with an important role in the morbidity and mortality are: ASA III/IV, Acute Physiology and Health Evaluation (APACHE) > 5, age > 70 years, large perforations (> 6 mm), the surgeon's experience and that of its team (30). Anemia, malnutrition, abdominal distension, the volume of intraperitoneal liquid, corticoid therapy, and cocaine dependence are recognized in previous studies as secondary risk factors (6, 31, 32). In our study, we have evaluated the laparoscopic intervention when no significant risk factors were present. In prospective studies, the incidence of morbidity and mortality in laparoscopic approach of PDU were 3-25% and 0-10%, respectively (21). In our sample we did not have any deaths and the morbidity was 6.4% in LSG and 8.6% in OSG. A major advantage of laparoscopy found in our study is a clear diagnosis in equivocal clinical and imagistic findings. In unselected cases, the advantages of laparoscopic suture repair were the reduction of analgesics and parietal complications (16-19). Reduction of hospital stay and improvement of postoperative recovery are benefits of the laparoscopic approach as presented in this study (33, 34). In our first series published including 30 patients with PDU and laparoscopic approach, the medium hospital stay was 7.2 days (35). Once we gained experience and confidence in the laparoscopic approach, the patients were released after a shorter time. Disadvantages found in our study in LSG were the length of the operation time (not important in patients with no major risk factors), septic abdominal complications, and reoperations. Both patients who required another surgical intervention for suture repair leak and subphrenic abscess had suture repair without omental patch. In the beginning of our experience, we converted three cases with PDU because suture repair cut through the inflamed duodenal wall. There are no studies that recommend one suture repair technique over the other (10). Unfortunately, our study, like the majority of published studies on PPU, is not randomized.
Our findings suggest that suture repair with omental patch and complete anti-ulcer therapy could be considered the standard therapeutic solution in PDU for young patients without significant risk factors. Randomized controlled studies are mandatory for a better evaluation of this conclusion.

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