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Chapter18
Perforatedpepticulcer
MosheSchein
There’saholein mybucket… HowshouldI mendit? Just
patchit!
Afolksong
Everydoctor,faced witha perforatedulcer of thestomach
or intestine, must consider opening the abdomen, sewing
upthehole,andavertingapossibleoractualinflammation
bycarefulcleansingoftheabdominalcavity.
JohanMikulicz-Radecki
Thankstoeffective,modernanti-ulcerdrugmanagementtheincidence
ofperforatedpeptic ulcershasdecreased drastically(somesaythatthe
incidenceand‘virulence’ofpepticulcersstarted to decline even before
suchdrugsbecameavailableandHelicobacterpyloridiscovered)—but
noteverywhere.Perforatedulcersarestillcommoninsocioeconomically
disadvantaged or stressed populations worldwide. Usually, perforations
developagainstabackgroundofchronicsymptomaticulcerationbutfora
patient to present with a perforation ‘out of the blue’, without previous
history of peptic ulcer disease whatsoever, is not uncommon. In the
Western World perforated duodenal ulcers (DUs) are much more
common than perforated gastric ulcers (GUs), which are seen more in
lowersocioeconomicgroups.
Inthebackofyourmindyouhavetorememberthatnotallperforations
ariseinpepticulcers:rarely,agastricadenocarcinomaorlymphoma
canperforateaswell.
Naturalhistory
Inperforatedpepticulcers:“Itmustberememberedthattheexudatein
the early cases is sterile or nearly so, and the peritonealreaction is a
response to chemical irritation by the gastric and duodenal contents
ratherthantheresultofbacterialinvasion”(JohnBlairDeaver).
Classically, the abdominal pain caused by a peptic perforation
develops very suddenly in the upper abdomen. Most patients can
accurately time the dramatic onsetof symptoms. The natural historyof
suchanepisodecanbedividedintothreephases:
•
Chemicalperitonitis/contamination.Initially,theperforation leads
to chemical peritonitis, with or without contamination with microorganisms(notethatthepresenceofacidsterilizesgastroduodenal
contents; it is when gastric acid is reduced by acid-reducing
treatment or disease, e.g. achlorhydria of gastric cancer, that
bacteria and fungi are present in the stomach and duodenum).
Spillage of gastroduodenal contents is usually diffuse but may be
localized in the upper abdomen by adhesions or the omentum.
Spillage along the right gutter into the right lower quadrant,
mimickingacute appendicitis,is mentionedin everytextbook butis
almostneverseeninclinicalpractice(see Chapter23 aboutthe
‘Valentinoappendix’).
•
Intermediatestage.After6to12hours,manypatientsobtainsome
spontaneousrelieffromthepain.Thisisprobablyduetothedilution
of the irritating gastroduodenal contents by the ensuing peritoneal
exudate.
•
Intra-abdominal infection. If the patient initially escapes the
scalpel, then intra-abdominal infection supervenes 12 to 24 hours
later. The exact point in time in the individual patient when
contaminating micro-organisms become invasive/infective is
unknown. Therefore, you should consider any perforation
operateduponwithadelayofmorethan12hoursasinfection
rather than contamination. This bears on your postoperative
antibiotic therapy as discussed below. Neglected patients may
presentafewdaysaftertheperforationinsepticshock.Shockinthe
earlier stages is very rare, although quoted commonly by medical
students,butwhenconfrontedwithacombinationofshockand
abdominal pain, think about ruptured aortic aneurysm,
mesenteric ischemia or severe acute pancreatitis. Untreated
perforation can lead eventually to an early ‘septic’ death from
peritonitisorthedevelopmentofanintra-abdominalabscess.
Diagnosis
The vast majority of patients present with signs of diffuse or
localized peritoneal irritation; most lie still, groaning, and have a
board-like abdomen as described in textbooks (some call it
‘textbook peritonitis’). Spontaneous ‘sealing off’ of the perforation, or
localizationofthespillorleakageintothelessersac,causesanatypical
and delayed presentation. We had a patient who reperforated his
duodenalulcerafewyearsafterreceivinganomentalpatch.Thesecond
perforation was thus diverted backwards into the retroperitoneum —
behind the pancreas, the left colon and into the scrotum — while the
abdomenremainedsoft.
Inapatient withanabruptonsetof upperabdominalpainanddiffuse
peritonitis,thediagnosisissimple.Itcanbesummarizedinthefollowing
formulas:
Suddenonsetperitonitis+freegas=perforatedviscus
Suddenonsetperitonitis+nofreegas+normalamylase/lipase=
perforatedviscus
There is free gas under the diaphragm in about two-thirds of
perforated patients. Remember, free gas is visualized better on an
uprightchest X-raythan onplain abdominalradiographs ( Chapters4
and5).Ifyourpatientcan’tstand,orsitup,orderaleftlateraldecubitus
abdominalfilm.Rememberthatfreegaswithoutclinicalperitonitisis
NOTanindicationforanemergencylaparotomy.Asmentionedin
Chapter 4, there is a long list of ‘non-operative’ conditions that may
producefreeintraperitonealgas. Freegasina‘soft’abdomenmayalso
mean that the perforation has been spontaneously sealed and is thus
amenabletonon-operativetherapyasdiscussedbelow.
In the absence of free air, acute pancreatitis — the ‘great
simulator’ — should be considered and excluded ( Chapter 19).
Normal pancreatic enzyme levels would support a diagnosis of a
perforation, while very elevated levels in a ‘susceptible’ patient (e.g.
alcohol, gallstones) would indicate acute pancreatitis. The ‘border-line’
patient with atypical presentation and marginal elevation of
amylase/lipaseremainsaproblembecauseaperforatedulcermaycause
hyperamylasemia. In the good old days, before imaging techniques
replaced clinical skills, our decision to operate or observe would have
dependedon thewhole clinicalpicture. Rarely,aGastrografin®contrast
study was performed to demonstrate or exclude leakage. Faced with
suchapatienttodaywewouldadviseyoutoobtainaCTscanofthe
abdomen,lookingforfreegas,extraluminalGastrografin®andfree
peritoneal fluid. CT is excellent at picking up minute amounts of free
intraperitonealgasand isthusavaluabletoolinclarifyingthe diagnosis
inpatientswithanambiguousclinicalpicture—isitacutediverticulitisto
bemanagednon-operativelyorperforatedulcertooperateupon?Those
ofyou whoarelucky topractice intheUnited Statesknow thatinmost
such patients a CT isobtained evenbefore you have achance tosee
them. From a self-interested pointof view this is not such a bad idea.
Imaginethe13th edition of this book (2049?) — this whole chapter will
consist of one sentence: “Obtain a CT; seal the perforation with CTguided injection of glue.” But perhaps, before then, perforated peptic
ulcerswilldisappearcompletely.
Philosophyoftreatment
“The primary goal of treatment is to save the patient’s life by
eliminating the source of infection and cleaning the abdominal
cavity.Thesecondarygoalistocure,ifpossible,theulcerdiathesis.The
formergoalisachievedbysimpleclosureoftheulcer;thelatterrequires
adefinitiveulceroperation.Sowhatshouldyoudoandwhen?”
Thatiswhatwewroteinthepreviouseditionsofthisbook,butis
itstillrelevanttoday?Notonlyaretheseperforationslessfrequentand
(perhaps)lessnasty,butsuchulcerscannowbehealedinthelongterm
(abolishing the ulcer diathesis) in most patients by modern anti-acid
drugs and the eradicationof thecausative Helicobacter pylori bacteria.
This being so, is there any place today for definitive anti-ulcer
operations?
To find out about the current (2015) practice concerning perforated
ulcersworldwide we polled theinternationalmembership of SURGINET
(anonlinegeneralsurgicaldiscussiongroup).Andhereiswhatwefound:
•
How common is the problem? It is very rare in developed
countries. Surgeons in the US, UK or Australia do not deal with
more than one or two cases per year. When westernlifestyle and
availability of medications reaches a previously developing region,
perforatedulcersbecomerare(e.g.Odessa,Ukraine).Ontheother
hand, perforated ulcers are still common in indigent
populations, as in South Africa, India or even Russia, where
somesurgeons reportas manyas 25casespermonth!Asurgeon
from St. Petersburg (Russia) reported operating on 10 perforated
DUslastyear.
•
What is the site of perforated ulcers? The vast majority are
situated in the duodenum. A few are pre-pyloric or gastric
(associatedwithNSAIDuse).Becausegastricresectionsforbenign
diseasearesorarelyperformed,perforatedanastomoticulcershave
almostdisappeared,althoughtheyareresurfacingfollowingbariatric
gastricoperations.
•
Which operation? All responders would use a simpleclosure as
thepreferredoperativetreatment.Somewouldadd,veryrarely,and
inspecialcircumstances—onlyif‘forcedtodo’—adefinitiveantiulcerprocedure,asdescribedbelow.
•
Open procedure vs. laparoscopy? The laparoscopic approach
seemstobeincreasinglypopularatleastinthehandsof‘advanced
laparoscopists’(orthosewhowishtheywere…).Buteventhelatter
(orthosewhoaresmart)wouldoptforopensurgeryinveryill,septic
patients.
Management
There is no need to repeat how important it is to optimize these
patientsalongthelinesdiscussedin Chapter6.
Antibiotics
As soon as the diagnosis of perforation is made, and the patient is
booked in for an operation, administer a dose of broad-spectrum
antibiotics.Thevastmajorityofpatientspresentfortreatmentwithin
12 hours of perforation and therefore suffer from peritoneal
contamination rather than infection. In many of them, in fact, the
peritonitis is chemical and does not contain any micro-organisms.
Antibiotics in this group will serve for prophylaxis. Prolonged
postoperativetherapeuticantibioticsarenotneeded.Thosewhopresent
later than 12 hours may suffer from an established intra-abdominal
infection;hereantibioticsshouldbecontinuedinthepostoperativephase
( Chapter44).Theantibioticsgiven,eitherintheformofmonotherapy
or combination therapy, should ‘cover’,empirically,Gram-negatives and
anaerobes.Routineculturingoftheperitonealfluidinperforatedpatients
isnotindicated( Chapter13).
Butyoumaybecrucifiedbytheinfectiondiseasespecialistandprobablybyyourbossifyoufail
tocomplywiththeirguidelines.Danny
Candida,oftenculturedfromtheperitoneuminthesecases,isa
contaminantanddoesnotneedspecifictherapy.
Operativetreatment
Opensurgeryversuslaparoscopy?
Omentopexy and peritoneal toilet can be executed laparoscopically.
Wesuggestthatalaparoscopicprocedureisareasonableoptionin
stableandwell-resuscitatedpatients andwhenthe perforationcan
be promptly and securely closed. Conversely, a prolonged
pneumoperitoneum will be poorly tolerated in the high-risk or severely
septicpatients.And, of course, you must beaskilledlaparoscopist (do
you know any surgeon who does not consider himself ‘skilled in
everything’?) to be able to perform a safe, watertight laparoscopic
omentopexy.
Figure18.1.“Howshouldwemendit?”
By the way, the laparotomy for omentopexy need not always be a
macrolaparotomy.Instead,with accuratepre-operativediagnosisonCT,
you can repair the perforation and suck out the free peritoneal fluid
through a limited transverse right subcostal incision or a short midline
epigastricincisionwhichareeasieronthepatientthanthetraditionallong
midlineapproach( Chapter10).
Some surgeons would opt for a ‘lap-assisted’ procedure: the
diagnosisisconfirmedatlaparoscopy,theperitonealcavityiscleansed;a
smallincisionisthenplacedjustontopoftheperforationandtheholeis
fixed.
In sum, do what is absolutely safe in your hands — even if open
surgeryseemstoyounotso‘sexy’itisstillconsidered‘OK’.
Simpleclosureoftheperforation( Figure18.1)
ThekeywordisOMENTOPEXY!Classically,simpleclosureofthe ulcerisbestachievedby
anomentalpatch(termedGraham’spatch,althoughdescribedearlierin1929by
Cellan-Jones — well, the Russians claim that it was V. A. Oppel who first described the
operationin1925),alsocalledomentopexy.Placeafew‘through-all-layers’interruptedsutures
(we use 2-0 Vicryl®, but monofilament is OK) through both edges of the perforation
(longitudinalto the axisof the duodenumin order not to narrow the lumen),and leave them
untied;fashionafatpedicleofthegreateromentumandflipitupandovertheperforation;then
gentlytiethesuturesovertheomentuminordernot to strangulate it ( Figure18.2). At this
stageasktheanesthetist toinjectsaline,withorwithout dye, throughthenasogastrictubeto
ascertainthatthepatchiswaterproof.Ifitisnotthendoitagain!Iftheomentumisflimsyor
absent for some reason, you can do the same with a mobilized falciform ligament,
flippingitdownovertheperforation.
More than a few surgeons misunderstand this operation; they
initially suture-close theperforation and only then cover the suture line
with the omentum. Some, mainly inexperiencedlaparoscopic surgeons,
‘cutcorners’andavoidthepatchaltogether—itis easierintheirhands
tosuture-closetheperforation.Butthisisarecipefordisaster!Thisis
howpostoperativeleaksoccur!Theapproximationoftheedematous,
friableedgesofperforationcanbetroublesome.Itmaybesuccessfulin
smallperforationswhentheedgesofthedefectarefresh,butinallcases
of postoperative duodenal fistula witnessed by us, simple sutureclosureofa perforated DU was thecausativemechanism. Besmarter,
donotstitchtheperforationbutplugitwithviableomentum.
Figure 18.2. Simple closure. Note: the omental patch should ‘plug’ the hole with the
suturestiedover it. Suturingtheholefirstandthen stickingomentumovertherepairis
wrong.
Shouldyouleaveadrainbehind?Somesurgeonsdo.Wedon’t—a
perfect, tested omental patch does not leak and makes drains
obsolete.
Ileaveaperiduodenaldrainafteropenrepairwhenthereismorethan24hours’delayfromthe
onset of pain to surgery. This detects early leaks and sometimes is sufficient to keep the
ensuingfistula‘controlled’.Ari
Itappearsthatdrainsareleftmore oftenafterlaparoscopicrepairs—
thismakessense:thelapsurgeonssuspectthattheirrepairisnotalways
fantastic…
Simplesurgicaldrainage(in‘difficult’circumstances)
In the absence of basic anesthetic facilities (e.g. somewhere in the
bush or remote India) and when confronted with a patient who clearly
needsanoperation,there isaviable(andwell-described)option.Under
local anesthesia theupper abdomen may be entered through a limited
incision and, after aspiration of as much muck and pus as possible, a
largedrain can be left undertheliver in the regionofthe duodenum. If
the perforation seals spontaneously the drain helps to control the
associatedabscess;ifnot,thenitformsalife-savingcontrolledduodenal
fistula, to be dealt with — conservatively or operatively — later and
elsewhere(notinthebush!).Ourfriend,Dr.KuldipPandey,asurgeonin
rural India told us: “In moribund patients, if conditions don’t permit for
laparotomy, I generally put in a drain under vision (under local
anesthesia).QuiteoftenIdoitbedsideorintheminorORcumdressing
roomattachedtomyward.Inquiteanumberofcasesonlythismuchhas
ledtogreatimprovementinthegeneralconditionofthepatientwhowere
lateroperated[upon]anddischargedsuccessfully.”
Operativetreatment:definitivesurgery?
Soisthereanyindicationlefttoaddadefinitiveulcerprocedure?
It is, according to Dr. Alex Berzoy of Odessa, Ukraine: “The patient
whowouldbuyvodkainsteadofaprotonpumpinhibitor.”Andheisright!
The very patients who are susceptible to perforation also suffer from
substandard access to medical care and reduced compliance, both
adversely affecting successful medical anti-ulcer therapies. This is
obviouslymuchmore commoninthe developingworld.Consequently,if
the operation for a perforated ulcer can kill two birds with one stone
(especiallyiftheenvironmentaroundyoucannotensureoptimalmedical
management and follow-up of your patient), why not add a definitive
procedure?—thatis,ifyouknowhowtodoit.Whileintractabilityasa
realissueseemstobelimitedtothedevelopingworld,otherspecial
problems which could indicate a definitive procedure may be
presentanywhere(seebelow).
Inwhichpatientsisadefinitiveproceduresafe?
Well, you certainly do not want to embark on a lengthy definitive
procedureinacriticallyillandsepticpatient.However,overtheyearswe
haveencounteredsurgeonswhoomittedadefinitiveprocedurebecause
of ‘severe contamination’, often quoting a myth that vagotomy in a
perforatedpatient may “spread the infectionintothe mediastinum”. The
Hong Kong group showed that when the following three factors are
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