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WeBSurg, the e-surgical reference of Laparoscopic surgery

Clinical Case

PERFORATED PEPTIC ULCER


M Smith, MD, F Jamali, MD, Hôpitaux Universitaires de Strasbourg, Strasbourg, France

1. Description


This case report gives the typical clinical course of a perforated gastroduodenal ulcer with radiologic studies and clinical course. The initial treatment is medical (Taylor's method). The failure of conservative treatment necessitated surgical treatment of the ulcer, performed by laparoscopy.

2. Keywords


Emergency, gastroduodenal ulcer, peritonitis, stomach

3. Patient


Male, 45-year-old

4. Previous medical history


Medical:
- primary TB in infancy;
- pleurisy;
- allergy to Hymenoptera venom.

Surgical:
- appendectomy via a McBurney incision in infancy;
- open Nissen fundoplication via midline laparotomy 6 years ago;
- laparoscopic left inguinal hernia repair (9/97);
- complicated by a symptomatic pneumomediastinum (retrosternal chest pain) at 24 hours.

5. Clinical history


Spontaneous abdominal and chest pain radiating to the left shoulder, and dyspnea.

6. Physical examination


- afebrile;
- hemodynamically stable;
- tenderness in right upper quadrant.

7. Laboratory workup


- WBC 11300/mm3;
- Hgb: 10g/dL;
- ECG: normal.

8. CXR and KUB


Pneumoperitoneum and pneumomediastinum

9. CT scan


Pneumoperitoneum and pneumomediastinum

10. Clinical course


Different solutions can be considered:
1. No therapeutic intervention (Taylor's procedure)
2. Diagnostic and therapeutic laparoscopy
3. Laparotomy

Conservative treatment is attempted:
After several hours with a nasogastric tube with gentle aspiration and antibiotics, the clinical exam worsens:
- physical examination shows generalized peritonitis with diffuse guarding;
- WBC: 15500/mm3;
- KUB: decreased pneumoperitoneum.

11. Surgical intervention


Exploratory laparoscopy:
Findings of intra-abdominal GI content spillage, adhesions in the midline and right lower quadrant: liquid is aspirated and adhesions are lysed.
video
Video 11.a
A perforated ulcer is revealed opposite the anterior surface of the pylorus. Suture repair of the ulcer is performed.
video
Video 11.b
Biologic glue is applied.
video
Video 11.c

12. Discussion


Perforated peptic ulcer disease remains a common surgical emergency despite the widespread use of anti-secretory medications. Laparoscopic techniques have successfully been applied in its management as is illustrated in this case, despite the lack of solid evidence in the literature to support such an approach. Benefits of the laparoscopic approach to perforated ulcer disease include fewer analgesics requirement, shorter hospital stay, and a quicker recovery although these findings are not confirmed by all studies. The laparoscopic approach to perforated ulcer disease does not appear to worsen the outcome of the chemical peritonitis but remains contraindicated in the setting of septic shock. Results from prospective randomized trials to resolve this issue are awaited.

13. References


  1. Bergamaschi R, Marvik R, Johnsen G, et al. Open vs. laparoscopic repair of perforated peptic ulcer. Surg Endosc 1999;13:679-82.
  2. Katkhouda N, Mavor E, Mason RJ, et al. Laparoscopic repair of perforated duodenal ulcers: outcome and efficacy in 30 consecutive patients. Arch Surg 1999;134:845-8; discussion 849-50.
  3. Khoursheed M, Fuad M, Safar H, et al. Laparoscopic closure of perforated duodenal ulcer. Surg Endosc 2000;14:56-8.
  4. Robertson GS, Wemyss-Holden SA, Maddern GJ. Laparoscopic repair of perforated peptic ulcers. The role of laparoscopy in generalised peritonitis. Ann R Coll Surg Engl 2000;82:6-10.