Surg Endosc (2014) 28:2302–2308 DOI 10.1007/s00464-014-3481-2
and Other Interventional Techniques
ORIGINAL ARTICLES
Laparoscopic repair of perforated peptic ulcer: single-center results Simone Guadagni • Ismail Cengeli • Christian Galatioto • Niccolo` Furbetta Vincenzo Lippolis Piero • Giuseppe Zocco • Massimo Seccia
•
Received: 17 September 2013 / Accepted: 6 February 2014 / Published online: 8 March 2014 Ó Springer Science+Business Media New York 2014
Abstract Background Perforated peptic ulcer (PPU), the most common indication for emergency gastric surgery, is associated with high morbidity and mortality rates. Outcomes might be improved by performing this procedure laparoscopically, but no consensus exists on whether the benefits of laparoscopic repair (LR) of PPU outweigh the disadvantages. Methods From January 2002 to December 2012, 111 patients underwent surgery for perforated ulcer. A ‘‘laparoscopy-first’’ policy was attempted and then applied for 56 patients. The exclusion criteria for LR ruled out patients who had shock at admission, severe cardiorespiratory comorbidities, or a history of supramesocolic surgery. The aim of this study was a retrospective analysis of the 56 patients treated laparoscopically. Results The patient distribution was 30 men and 26 women, who had a mean age of 59 years (range 19–95 years). The mean ulcer size was 10 mm, and the Mannheim peritonitis index (MPI) was 21. LR was performed for 39 (69.6 %) of the 56 patients and included peritoneal lavage, suturing of the perforation, and omental patching. Conversion to laparotomy was necessary in 17 cases (30.4 %). The ‘‘conversion group’’ showed significant differences in ulcer size (larger ulcers: 1.9 vs 0.7 mm; Presented at the 21st EAES Congress, June 19-22, 2013, Vienna, Austria. S. Guadagni (&) I. Cengeli C. Galatioto N. Furbetta V. L. Piero G. Zocco M. Seccia Emergency Surgery Unit, Department of Emergency and Acceptance, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy e-mail:
[email protected] I. Cengeli e-mail:
[email protected]
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p \ 0.01), ulcer-site topography (higher incidence of posterior ulcers: 5 vs 0; p \ 0.01), and MPI score (higher score: 24 vs 20; p \ 0.05). The LR group had a mean operating time of 86 min (range 50–125 min), an in-hospital morbidity rate of 7.6 %, a mortality rate of 2.5 %, and a mean hospital stay of 6.7 days (range 5–12 days). None of these patients required reintervention. Conclusions The results showed that LR for PPU is feasible with acceptable mortality and morbidity rates. Skill in laparoscopic abdominal emergencies is required. Perforations 1.5 cm or larger, posterior duodenal ulcers, and an MPI higher than 25 should be considered the main risk factors for conversion. Keywords Laparoscopic surgery Omentoplasty Perforated peptic ulcer Suture Perforated peptic ulcer (PPU) is the second most frequent abdominal perforation requiring surgery, after perforated appendicitis [1]. The past two decades have seen a change in the pattern of PPU, with a greater prevalence of Helicobacter pylori (HP) infection and a wider use of nonsteroidal antiinflammatory drugs. Due to the effectiveness of proton pump inhibitors and HP eradication therapy, acidreduction procedures usually are not required, and simple closure of the perforation with an omental patch has become the favored management approach in many institutions [2]. Laparoscopy is an attractive option because it not only permits identification of the perforation but also allows its closure and peritoneal lavage, avoiding a large upper laparotomy. The current evidence for laparoscopic repair (LR) of PPU disease is inconclusive because of methodologic weaknesses in previous trials and the overall small number
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of participants. Some studies claim superiority of LR in terms of a smaller surgical wound, less postoperative pain, fewer postoperative complications, a shorter hospital stay, and an earlier return to daily activities [3, 4]. Other authors have found no such advantages, and some state that open repair is a safer alternative for patients with diffuse peritonitis due to perforated duodenal ulcers [5–8]. This ongoing debate prompted us conduct a retrospective review of our 10-year experience with minimally invasive surgical treatment of PPU.
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omentum was gently pulled away with forceps for assessment of the underlying pathology. Instrumental compression of the antrum of the stomach and the first part of the duodenum facilitated identification of the perforation by inducing the escape of fluid and bubbles from the perforation. The degree of peritoneal soiling was noted, and the peritoneal fluid was sampled for microbiologic
Materials and methods Study design From January 2002 to December 2012, 111 patients with a diagnosis of PPU were admitted to our tertiary care academic center. According to our ‘‘laparoscopy-first’’ policy, a minimally invasive approach was proposed to all the patients with PPU, excluding the patients who had shock at admission (systolic pressure \90 mmHg with evidence of peripheral organ hypoperfusion), the patients who had severe cardiorespiratory comorbidities with anesthetic contraindications for pneumoperitoneum, and the patients who had undergone previous open upper abdominal surgery. Our review focused on 56 patients (50.4 % of the total) for whom an ulcer repair had been attempted laparoscopically. The medical and operative records of all the patients scheduled for LR in the Unit of Emergency Surgery had been previously collected in a database. We aimed to analyze the data from the laparoscopic approach to determine the outcome measures of morbidity, mortality, and duration of hospital stay and to define the risk factors for conversion.
Fig. 1 Surgical field setup in a patient undergoing laparoscopic repair for a suspected gastroduodenal ulcer perforation
Surgical technique LR was performed with the patient and the team in the ‘‘French’’ position with a reverse Trendelenburg tilt. The operating surgeon stood between the patient’s thighs. In 80 % of the cases, pneumoperitoneum was established using a Veress needle. Trocars were placed at the umbilicus (size 12 mm for the videoscope) and on the left and right midclavicular line above the level of the umbilicus (size 5 mm for the instruments), as shown in Fig. 1. If necessary, a fourth trocar was placed in the subxiphoid space for lavage or retraction of the liver. The surgeons used a 30° videoscope for all the procedures. After full abdominal exploration, the supramesocolic region was meticulously assessed for perforation. If the omentum was attached to the suspected perforation site, the
Fig. 2 Laparoscopic photo showing direct repair of a perforated duodenal ulcer
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Surg Endosc (2014) 28:2302–2308 Table 1 Characteristics of patients undergoing laparoscopy All patients (n = 56) Male
Fig. 3 Laparoscopic photo of the omental patch fixed in position by a securing ligature
examination using a suction device. Closure of the PPU was achieved by interrupted stitches using an intracorporeal knotting technique (Fig. 2), and the omentum was secured across the perforation (Fig. 3). After repair of the defect, the peritoneal cavity was thoroughly irrigated with approximately 6 L of normal saline solution until the return was clear. The peritoneal cavity was drained in every case with three or four drains depending on the extent of the peritonitis. Perioperative management Perioperatively, all the patients received intravenous fluids and antibiotics, parenteral analgesics, proton pump inhibitors, and nasogastric tube decompression. On day 4 after surgery, the patients received a gastrografin meal for documentation of the suture tightness. If the results were negative, the nasogastric tube was removed and oral fluids were introduced. The patients were reassessed in the outpatient department 2 weeks after surgery and then monthly. Upper gastrointestinal endoscopies were performed 8 weeks after surgery for assessment of ulcer healing and evaluation of the HP status, with the patients then treated accordingly. Data collection Data analysis was performed in the Unit of Emergency Surgery. Two subgroups of patients were analyzed based on whether laparoscopy (group 1) or conversion to open repair (group 2) was performed. The following variables were noted and evaluated: age, sex, American Society of Anesthesiologists (ASA) classification, Mannheim peritonitis index (MPI), ulcer location, ulcer size, operative time
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30 (53.6 %)
Mean age, mean (SD) (years)
59 ± 20
Smokers
29 (51 %)
History of NSAID
14 (25 %)
Mean WBC at admission (109/L)
13.1 ± 4.9
Free air at X-ray
44 (78.5 %)
ASA score of 3 or 4
25 (44.6 %)
Mean BMI (kg/m2)
24 ± 6
Mean ulcer size (mm)
10 ± 7
Duodenal ulcer
22 (39.3 %)
Juxtapyloric ulcer Gastric ulcer
16 (28.6 %) 18 (32.1 %)
Mean MPI
21 ± 5.6
Mean operative time (min)
115 ± 64
ICU admission
6 (10 %)
Mean postoperative stay (days)
8.5 ± 4.8
In-hospital complications
14 (25 %)
Surgical complications
2 (3.5 %)
Pulmonary complications
8 (14.2 %)
Mortality
2 (3.5 %)
Follow-up period (mouths)
9±2
NSAID nonsteroidal antiinflammatory drug; WBC white blood cell count; ASA American Society of Anesthesiologists; BMI body mass index; MPI Mannheim peritonitis index; ICU intensive care unit
(skin-to-skin time), conversion to open surgery, histologic diagnosis, need for reoperation, intensive care unit (ICU) admission, surgeon’s experience expressed in the number of previously performed LRs for PPU at the time of the repair, in-hospital mortality and morbidity, and hospital length of stay. Delayed complications and the readmission rate also were recorded. The data were entered into a database using the Microsoft Access XP program version 2007 for Windows XP (Redmond, WA, USA). The following protocol was used for the study calculations: study sample description; outcome results; influence of LR and converted operation on the outcome measures in terms of morbidity, mortality, and hospital stay; and definition of the risk factors for the conversion. Statistical analysis was performed using SPSS Statistics version 17.0.1 for Windows (IBM SPSS Inc., Chicago, IL, USA). The predictive values of the risk factors for conversion were classified according to sensitivity, specificity, and positive predictive value using a receiver operating characteristic (ROC) curve, with attempted identification of cutoff values that could be used for stratification of patients into high- and low-risk groups. Continuous data were compared using Student’s t test and are presented as means ± standard deviations. Proportional data were compared using Fisher’s exact test,
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with p values lower than 0.05 considered statistically significant.
Results During the 10-year period of this study, 56 consecutive patients with PPU were considered for minimally invasive ulcer repair in our department. The characteristics of the patients are given in Table 1. The distribution of the patients showed 30 men and 26 women, who had a mean age of 59 ± 20 years. The mean ulcer size was 10 ± 7 mm, and the MPI was 21 ± 6. Conversion to laparotomy was performed for 17 patients (30.4 %) and comprised 13 Graham repairs, 3 gastroresections, and 1 Graham repair associated with gastroenteroanastomosis. Inadequate ulcer identification was the most common reason for conversion, which occurred for 5 patients. Other reasons were marked inflammatory reaction involving the pancreas or the hepatoduodenal ligament (3 patients), perforation size (3 patients), friable and necrotic ulcer edges (2 patients), adhesions (2 patients), and suspected tumor (2 patients) (Table 2). Postoperative complications occurred for 3 patients in group 1 and for 11 patients in group 2 (p \ 0.05). In both groups, pulmonary complications were the most important factor affecting the postoperative course and the hospital stay (mean 14.6 days) and correlated with conversion and the severity of the peritonitis. Pneumonia or reactive
pleural effusion was observed in 7.9 % (n = 3) of the 39 patients in group 1 and in 29.4 % (n = 5) of the 17 patients in group 2. These complications were noted in 2.8 % (n = 1) of the 35 patients with an MPI lower than 25, in 31 % (n = 5) of the 16 patients with an MPI of 25–30, and in 40 % (n = 2) of the 5 patients with an MPI of 30 or higher (Table 3). Postoperative hematemesis controlled endoscopically in one case and intraabdominal fluid collection treated with percutaneous ultrasound-guided drainage in another case were the only surgical complications. Both complications were observed only in the converted group. No patients required reintervention. One patient in group 1 with diabetes, hypertension, nephropathy, and a recent myocardial infarction died of multiorgan failure on postoperative day 2, and one patient in group 2 died of pneumonia on postoperative day 20. These patients had ASA scores of 3 and 4, respectively, and both were older than 75 years. Two patients in group 1 and four patients in group 2 required ICU admission (p \ 0.05). The mean hospital stay was 6.6 ± 1.8 days for the patients in group 1 and 13.2 ± 7 days for the patients in group 2 (p \ 0.01). Histopathologic examination showed a malignant gastric ulcer in two patients, for whom conversion and gastroresection were necessary. During a mean follow-up period of 9 ± 2 months, an incisional hernia developed in Table 4 Comparative results in the laparoscopic repair and converted groups Laparoscopic repair group
Converted group n (%)
Total cases
39
17
Males
22 (56 %)
8 (47 %)
Mean age (years)
55 ± 21
66 ± 16
0.05
ASA score of 3 or 4
16 (41 %)
9 (52 %)
0.8
Mean BMI (kg/m2)
23.8 ± 4
24.1 ± 7
0.8
Posterior duodenal ulcers
0
5
0.0001
Mean ulcer size (mm)
7±4
19 ± 9
0.01
Table 2 Conversion reasons All conversions (n = 17) Inadequate ulcer identification
5 (8.9 %)
Perforation size
3 (5.3 %)
Involvement of surrounding tissues
3 (5.3 %)
Adhesions
2 (3.5 %)
Friable edges
2 (3.5 %)
Suspected tumor
2 (3.5 %)
Table 3 Relationships between pulmonary complications and the Mannheim peritonitis index (MPI) MPI
Patients in group 1
No. of PC group 1 n (%)
Patients in group 2
No. of PC group 1 n (%)
p value
p value
0.9
Mean MPI
20 ± 5
24 ± 6
0.03
Mean operative time (min)
86.2 ± 22
182.6 ± 79
0.0001
ICU admission
2 (5.1 %)
4 (23.5 %)
0.04
Mean postoperative stay (days)
6,7 ± 1,6
12.8 ± 7
0.003
In-hospital complications
3 (7.6 %)
11 (64 %)
0.005
Surgical complications
0 (0 %)
2 (12 %)
0.02
Pulmonary complications
3 (7.6 %)
5 (29 %)
0.03
\25
29
0 (0)
6
1 (16)
0.03
In-hospital mortality
1 (2.5 %)
1 (5.8 %)
0.6
25 to \30
9
3 (33)
7
2 (28)
0.1
Delayed complications
0 (0 %)
2 (11 %)
0.029
C30
1
0 (0)
4
2 (50)
0.1
PC pulmonary complications
ASA, American Society of Anesthesiologists; BMI body mass index; MPI Mannheim peritonitis index; ICU intensive care unit
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one patient from group 2 after 3 months, requiring surgical repair, and another patient who underwent a gastroresection was readmitted after 10 months for a perforated anastomotic ulcer. We identified several pre- and intraoperative risk factors that could influence the conversion rate because of inability to repair the perforation. The conversion group had older patients, larger ulcers, a higher incidence of posterior duodenal ulcers, and a higher MPI. The two groups were similar with respect to the rate of patients with an ASA classification of 3 or 4 (Table 4). We analyzed ulcer perforation size and peritonitis grade as intraoperative indicators of conversion. Patients with an ulcer size of 15 mm or larger were at significantly increased risk for conversion (conversion rate, 66 vs 33 %). Conversion to open repair was performed for 77 % of all the patients with an ulcer perforation size of 15 mm or larger (p \ 0.05), and 82 % of patients who underwent conversion had an ulcer size of 15 mm or larger. The same results were found for MPI, and the results were statistically significant when a cutoff value of 25 was used. These two criteria (MPI and ulcer size) were independent and not correlated, meaning that a higher MPI was not observed in patients with larger ulcers. When the patients were stratified according to ulcer location, juxtapyloric ulcers were found to be associated with a faster laparoscopic procedure (91.6 ± 43 min for juxtapyloric ulcers vs 119 ± 52 min for duodenal ulcers vs 132 ± 87 min for gastric ulcers; p \ 0.05). However, no statistically significant difference in conversion rate was observed (31 % for juxtapyloric ulcers vs 27 % for duodenal ulcers vs 33 % for gastric ulcers), hospital stay (8.1 ± 5.2 days for juxtapyloric ulcers vs 8.6 ± 5.3 days for duodenal ulcers vs 8.7 ± 4.2 days for gastric ulcers), or overall complication rate (25 % for juxtapyloric ulcers vs 35 % for duodenal ulcer vs 12 % for gastric ulcers). Surgeon expertise affected the conversion rate. We observed that for the 56 patients who underwent LR, the conversion rate decreased from 35.7 % for the first 28 cases to 25 % for the last 28 cases, although the difference was not statistically significant (p = 0.6). However, surgeons who had performed more than 10 LRs (learning curve of 10 cases) had a 25 % conversion risk compared with 48 % for those who had performed fewer than 10 procedures (p \ 0.05). As a secondary result, the size of the ulcer closed laparoscopically and the severity of the peritonitis successfully treated by LR were influenced by the surgeon’s experience. After a learning curve of 10 cases, the mean ulcer diameter and the mean MPI in group 1 increased significantly (ulcer diameter, 5 ± 2 to 8 ± 6 mm, p = 0.02; MPI, 18 ± 4 to 21 ± 4.8, p = 0.03).
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Discussion Current trends in minimally invasive surgery seek to reduce access trauma [9, 10]. However, most procedures performed currently in emergency surgery use conventional open techniques, with only a small proportion of patients benefiting from the minimally invasive surgical approach. PPU is a condition for which the laparoscopic approach has significant attractions. Laparoscopy can confirm or refute the diagnosis and also allows identification of the position, site, and size of the ulcer. The procedure also allows closure of the perforation and adequate peritoneal lavage without the need for a large abdominal incision [11]. Accumulating evidence suggests that LR of PPU is feasible and efficacious, exhibiting benefits of reduced wound infection, less painful recovery, and a shorter hospital stay [12–14]. In reporting a series of 172 consecutive patients undergoing laparoscopic or open surgery, Siu et al. [15] concluded that with the use of stringent selection and conversion criteria, laparoscopy is a safe emergency procedure. Lunevicius and Morkevicius [16] also suggested that laparoscopic surgery is better than open repair for lowrisk patients because it involves less analgesic therapy, a shorter hospital stay, less wound infection, and a lower mortality rate. After the institution of our ‘‘laparoscopy-first’’ policy, a minimally invasive approach was proposed to all patients with PPU admitted to our center during the 10-year study period, excluding patients who had shock at admission (systolic pressure \90 mmHg with evidence of peripheral organ hypoperfusion), patients who had severe cardiorespiratory comorbidities with anesthetic contraindications for pneumoperitoneum, and patients with previous open upper abdominal surgery. We analyzed a continuous series of 56 consecutive patients with PPU for whom laparoscopy was attempted and divided our study sample into two groups: those with completed laparoscopy and those who had converted procedures. Although the two groups were not prospectively or retrospectively compared, their postoperative courses were dissimilar with respect to morbidity and hospital stay. Patients managed with LR of PPU have reported mortality rates ranging from 0 to 8.1 % and reported morbidity rates ranging from 3 to 14 % [17, 18]. Suture dehiscence, the most important complication, represents the first cause of reoperation [19, 20]. Some authors have reported a greater frequency of this life-threatening complication in LR than with a conventional approach [21, 22]. Lee et al. [14] found a 13 % incidence of postoperative suture leakage using sutureless fibrin glue repair. This risk is variable. We found no suture leakage in our series. We usually
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perform a direct suture, with two or three stitches placed on either side of the perforation, and reinforce the closure with an omental patch. Some authors have emphasized the necessity for omentoplasty to prevent tearing of the sutures and enlargement of the perforation by damage to the edges [23, 24]. Avoiding a Graham patch may shorten the operative time but might be the reason for a high incidence of leakage [21]. Another factor that possibly influenced our reduced rate of postoperative suture leakage may have been the prolonged retention of nasogastric decompression. We removed the nasogastric tube only after a radiologic gastrografin meal to document the suture tightness on postoperative day 4. Peritoneal lavage, considered one of the most important parts of surgery, consumes the bulk of the operative time. Our low rate of intraabdominal fluid collection may be explained by excellent laparoscopic vision and meticulous irrigation of the suprahepatic and subhepatic spaces, the lateral channel, the left subdiaphragmatic space, the pelvic cavities, and the dead spaces with *6 L of warm saline until the returned fluid was clear to reduce the bacterial load. Lavage adequately counteracts the negative effects of peritonitis, which is the major cause of morbidity and mortality among these patients. Some authors have obtained satisfactory results by performing only laparoscopic lavage and drainage [10]. Some authors state that laparoscopy is more dangerous with prolonged peritonitis. Experimental animal studies have shown that the increased intraabdominal pressure of carbon dioxide pneumoperitoneum is associated with an increased risk of bacteremia and sepsis when the duration of peritonitis exceeds 12 h [25]. Pneumonia may be caused by increased bacterial translocation from the peritoneal cavity into the bloodstream, but no evidence exists to support this concept from clinical studies [26, 27]. In our experience, pulmonary complications were more frequent in the converted group. Comparing pneumonia according to MPI between patients undergoing LR and patients initially explored laparoscopically and subsequently converted, we found a difference in favor of the latter group, although the difference was not statistically significant. Controlled trials to compare the effects of pneumoperitoneum on infectious complications between patients undergoing open surgery and patients undergoing a laparoscopic approach and subsequently converted are necessary to clarify the true risks and benefits of LR. Patient characteristics and ulcer location also are factors considered to influence LR feasibility [28, 29]. Our data suggest that laparoscopy tends to be more difficult to perform in older patients, with more patients in this subgroup converted to open surgery. The reason for this difficulty probably lies in the severity of the peritonitis because elderly patients tend to have a delayed presentation and a greater risk
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of an underlying gastric malignancy. Posterior duodenal ulcers are difficult to discover and make LR more demanding because they may require partial mobilization of the duodenum for clear visualization of the perforation’s extent. The feasibility of LR in PPU appears to depend on the ulcer size and the peritonitis grade. Surgical expertise determines the success of laparoscopic surgery in PPU, and we found that a learning curve of 10 procedures was necessary to reduce the conversion rate and to provide effective management of larger ulcers and the severity of peritonitis treated during the laparoscopic procedure. In other retrospective studies [3], the conversion rates have ranged from 6 to 30 %, with a mean of 18 %, showing that our failure rate in completing LR is one of the largest reported. The conversion rate decreased during the study period, which may be explained by increasing surgeon experience. Unfortunately, a PPU is not a particularly common condition, making laparoscopic expertise hard to attain. Increasing familiarity with this technique has led us to our current belief that it provides a high success rate for patients with an ulcer diameter smaller than 15 mm and an MPI of 25 or lower, offering a minimally invasive option for this pathology. In conclusion, patient selection for LR still is debated. Our ‘‘laparoscopy-first’’ policy has demonstrated findings comparable with those of other prospective or retrospective studies. The operative time and postoperative course in terms of morbidity, mortality, and hospital stay are aceptable. Patient’s age, ulcer size, ulcer location, and the severity of peritonitis are reliable factors predicting conversion. Conversion influences both the morbidity rate and the hospital stay, and because the risk factors can be determined only during laparoscopy, surgeons should attempt to perform the operation laparoscopically. Patients are more likely to benefit from LR after the surgeon has gained laparoscopic expertise.
Disclosures Simone Guadagni, Ismail Cengeli, Christian Galatioto, Niccolo` Furbetta, Vincenzo Lippolis Piero, Giuseppe Zocco, and Massimo Seccia have no conflicts of interest or financial ties to disclose.
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