Laparoscopic Repair for Perforated Peptic Ulcer: A Retrospective Study

Discussions

Prior to laparoscopic treatment, the classical open surgery approach dominated the treatment of PPU. There was evidence that healing of perforated ulcers could be reached by conservative medical treatment such as the Taylor method [4] which showed recovery in more than half of the cases, different authors found that the need for emergency surgery is required in more than 70% of the cases [5]. Surgical treatment was, however, preferred because conservative therapy was marked by more complications, mainly in elderly patients [6].

    The development of the laparoscopic approach coincided with the introduction of anti-secretory medication. Using these medications in conjunction with surgery allowed the procedure to be limited to perforation closure only, with further interventions in order to reduce the gastric secretion of acid no longer being necessary. Perforation closure can be accomplished by primary suture (simple or with omentopexy), by omentopexy alone or by using a biological adhesive [7–9].

    For the laparoscopic approach to be accepted over traditional methods, there is a need for quality evidence of its safety and efficacy, in particular comparing the rates of duodenal leakage and deep abdominal space infections with the open approach. Also literature has raised concerns over bacteremia in the setting of pneumoperitoneum [10]. During our study period, 176 patients were operated in an open approach in the same hospitals as those operated laparoscopic. Due to retrospective nature of our study, we were not able to find all the reasons why surgeons preferred the open access, but the higher risk patients, the limited number of laparoscopic operating sets, the preference of some surgeons for the open approach were amongst.

    From the current study, 97.9% of patients were classified as ASA I or II, with only six (2.0%) patients ASA III. There were no patients in ASA risk class IV; this is because within the study centers an open approach is still the preferred method for high risk surgical candidates.

    Patient positioning was at the surgeon’s discretion, choosing either the French or the American positions. Our results show that currently Romanian surgeons prefer the American position over the French. This is not consistent with worldwide trends showed in 29 studies, only 33% of the worldwide surgeons preferred to operate from the left side of the patient (American position) [11]. The likely reasons for favoring this approach include the similarity in positioning to that of laparoscopic cholecystectomy (performed in Romania by the majority of surgeons in American position) and also a simpler surgical table positioning than the French position.

    A learning curve in the technique of the procedure was observed over the study period. The number of access sites was influenced by the need to perform adhesiolysis and the size of the patient, especially at the end of the procedure
when peritoneal lavage was done, and the pelvic region was out of reach of the regular laparoscopic instruments.
    The operative time depended on the surgeon’s training and lesion type. Since the onset of the laparoscopic approach, the authors have identified that more time is consumed with the peritoneal lavage rather than actually with the suturing of the perforated ulcer [12]. The shortest operative time in this study was achieved at patients with less than 6 h since the perforation and with less spillage in the peritoneal cavity.
    The surgeons participating in this study have estimated that surgeons with good experience in laparoscopic cholecystectomy and intracorporeal suturing skills needed 8–10 laparoscopic interventions for PPU in order to achieve an optimal operating time.
    There were only 6 (2%) conversions in the study period due to dense adhesions, a large ulcer callosity and infiltration of nearby organs leading to gastrectomy; others had same results with low conversions rate and complications [13].
    The most utilized technique for perforation closure was primary suture repair with omentopexy. There was no evolution or shift in technique observed over the study period. An omentopexy was thought to be necessary, in cases of large diameter perforation or when perforations margins were friable. However, recent literature has shown a shift in cases of smaller perforations with no callous edges that primary suture repair provides satisfactory results [14]. In fact, some authors have reported good results performing only perforation pluging with greater omentum flap or using biological adhesives [15].

With a large case volume, we have been able to refine our own technique. In cases with larger perforations with friable edges, suturing can often be technically difficult. In these cases, the suture thread can be passed far from the friable edges with intracorporeal knots carefully tied, without tightening, till the edges joined. A part of the great omentum is brought and fixed with 2 threads over this suture, for further sealing. Even despite this technical refinement, there was a case of conversion to open surgery because of the inability to perform primary suture repair due to thickened callous margins of the ulcer.
     The amount of the saline used for peritoneal lavage was of utmost importance. Our current study showed no increased risk of residual abscesses. Previously, there have been concerns that the laparoscopic approach might not allow complete lavage of the peritoneal cavity. Authors have shown that actually laparoscopic peritoneal lavage is more efficient than in open surgery. It allows a better view and exploration of the subfrenic, subhepatic and Douglas spaces when compared to a xipho-supraumbilical incision [16].

    With increased experience, the number of drainage tubes diminished during the study period, most recently the majority of cases had only one drainage tube in the peritoneal cavity after lavage. The tube was placed in the right subhepatic space. A meta-analysis on 29 studies regarding laparoscopic PPU has shown that in 21% of the operated patients no intraperitoneal drainage was used with no subsequent increased rate of complications [11].

    At the beginning of our study, oral feeding was resumed cautiously after the first 2–3 days, but toward the end of the study, liquid ingestion was recommended 24 h after the operation [17]. Less compliant patients, due to alcohol abuse usually, removed their nasogastric tube 6–12 h after the operation. Against medical recommendations they started nutrition with solid food in the first 24 h after the operation. Despite this, no complications were reported in
these patients.
    There were only 2 (0.6%) deaths in our study, which is much lower than in the reported literature. This is likely in part because only 6 (2%) patients with ASA III risk underwent laparoscopic treatment. Most studies reporting deaths include ASA III and ASA IV patients with associated pathology. Hence, in a meta-analysis including 29% ASA III and IV patients, an average mortality of 5.8% [11] was reported. Our current low mortality rate reflects our policy of laparoscopic approach of PPU being reserved for patients classified ASA I and ASA II.

    Our results show that severe peritonitis or its time from onset should not contraindicate a laparoscopic approach to PPU. This is because the laparoscopic approach permits a very efficient peritoneal lavage with reduced surgical injury. This is supported by recent published evidence [16, 17].

Conclusion

This study shows that laparoscopic approach of the PPU is feasible; the procedure is safe, with no increased risk of duodenal fistulae or residual intraperitoneal abscesses. We consider that laparoscopic approach of PPU should be the ‘‘gold standard’’ in the treatment of patients with a Boey score 0 or 1 or ASA I and II.

Authors’ contributions All authors have contributed to the design, acquisition of data, revised the manuscript for important data and approved the final form of the manuscript.

Disclosure Dr. Flore Varcus, Dr. Mircea Beuran, Dr. Ioan Lica, Dr.
Claudiu Turculet, Dr. Adrian Valentin Cotarlet, Dr. Stefan Georgescu,
Dr. Dan Vintila, Dr. Dan Sabau, Dr. Alexandru Sabau, Dr.
Constantin Ciuce, Dr. Vasile Bintintan, Dr. Eugen Georgescu, Dr.
Razvan Popescu, Dr. Cristi Tarta, Dr. Valeriu Surlin have nothing to
disclose.