Treatment of perforated peptic ulcer

Treatment policy in patients with perforated pepticulcer is surgical.

Conservative treatment is temporary measure when surgery is impossible. Conservative treatment includes the following (Taylor’s method):

– nasogastric decompression;

– replacement of fluid and electrolytes;

– proton pump inhibitor;

– broad-spectrum antibiotics;

– hypothermia of abdominal wall.

Conservative treatment is associated with high risk of septic complications (formation of abscess, peritonitis).

Surgical treatment

Preoperative details. Fluid resuscitation should be initiated as soon as the diagnosis is made. Essential steps include insertion of a nasogastric tube to decompress the stomach and a Foley catheter to monitor urine output. Intravenous infusion of fluids is begun, and broad-spectrum antibiotics are administered. In select cases, insertion of a central venous line may be necessary for accurate fluid resuscitation and monitoring. As soon as the patient has been adequately resuscitated, emergent surgery should be performed.

Simple closure of perforation. Simple closure of perforation may be performed by laparotomy or laparoscopy.

The 1st step of the operation is the exploration of the abdominal cavity, which allows confirming the diagnosis of generalized peritonitis. In addition, it allows differentiating between the septic and the clinical peritonitis, and especially it permits to determine the possibility of the laparoscopic repair.

A very important step of the operation is the aspiration of peritoneal fluid, which should be as complete as possible. This is followed by extensive irrigation of the abdominal cavity.

The next step is the exact localization of the perforation, which sometimes may be covered by the liver, gallbladder or omentum. In this case, the perforation is identified on the anterior aspect of the duodenum.

Ideal repair of the perforation is direct closure by absorbable or non-absorbable sutures. Treatment of perforation may include also an epiploplasty in addition to the closure. An omental flap is chosen and is placed over the suture and fixed with 1 or 2 absorbable stitches. When a reliable direct suture of the opening cannot be achieved, closure can be completed by application of biological glue. The operation is completed by final extensive abdominal irrigation.

Ulcer excision, pyloroduodenoplasty

Ulcer excision and pyloroduodenoplasty is the simplest open surgical treatment for duodenal ulcer and in selected instances it can be used in the treatment of bleeding, obstruction, perforation. The operation carries low morbidity and mortality rates.

The operation usually consists of a Judd procedure. A longitudinal excision is made around the ulcer defect beginning from distal stomach to the proximal duodenum and closed transversely, so that the action of the pyloric valve is obliterated.

In other cases, when the proximal duodenum is badly deformed by scar, a Finney procedure (essentially a side-to-side gastroduodenostomy) or a Jaboulay procedure (gastric resection plus side-to-side gastroduodenostomy) is used after ulcer excision.

Various types of vagotomy

Three types of vagotomy require consideration. Bilateral truncal vagotomy denervates the entire stomach and the gastrointestinal tract to the left colon. When combined with other operations it is extremely effective in reducing the number of recurrent ulcers.

However it does carry some deleterious side effects, reducing the ability of the stomach to empty and being followed by other late motility disturbances, occasional vagus diarrhoea, and reflux alkaline gastritis.

Selective vagotomy denervates the entire stomach but leaves nerves to the gallbladder, pylorus, and bowel intact. From a practical point of view this operation is more difficult and time-consuming than truncal vagotomy, appears to have nearly equivalent results, and has attracted few supporters. Proximal gastric vagotomy can be used without pyloroplasty.

Partial gastrectomy

The usual procedure involves resection of the distal two-thirds of the stomach followed by either a Billroth I or a Billroth II anastomosis. In our opinion the operation is neater and more accurate when sutures are inserted by hand, although stapling instruments can be used. Partial gastrectomies are usually performed for type 1 gastric ulcer and for combination of duodenal ulcer perforation with decompensate stenosis.

Postoperative treatment

Administer intravenous antibiotics postoperatively. The length of administration is based on the operative findings and the recovery of the patient.

Antiemetics and analgesics are administered to patients experiencing nausea and wound pain.

A liquid diet may be started when bowel function returns.

To prevent gastric and duodenal ulcer recurrence and their complications proton pump inhibitor or H2 – receptors antagonist is administered.

Follow-up care

After hospital discharge, patients must have a light diet and limit their physical activity for a period of 4 weeks – 3 months based on the surgical approach (i.e., laparoscopic or open procedure).

The patient should be evaluated by the surgeon in the clinic to determine improvement and to detect any possible complications.

Continuous supportive therapy (for a month or even years) with half the dose of proton pump inhibitors or H2 receptors antagonists is administered.

Prognosis

For uncomplicated surgery, the prognosis is excellent, with a very low mortality rate.