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ORIGINAL ARTICLE
Year : 2015  |  Volume : 28  |  Issue : 1  |  Page : 62-68

Laparoscopic versus open repair of perforated duodenal peptic ulcer: a randomized controlled trial


General Surgery Department, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission08-May-2014
Date of Acceptance16-Jun-2014
Date of Web Publication29-Apr-2015

Correspondence Address:
Adel S Zedan
General Surgery Department, Faculty of Medicine, Menoufia University, Yassin Abdel Ghaffar Street, Gamal Abdel Nasser Street, Shebin El-Kom, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.155945

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  Abstract 

Objective
The aim of this study was to compare between laparoscopic and laparotomy repair of perforated duodenal ulcer in terms of operative time, postoperative pain, postoperative complication, hospital stay, and resuming normal activity.
Background
Laparoscopic surgery has become a standard of care in many of the elective procedures; however, it is still gaining popularity in conditions associated with peritonitis, such as perforated duodenal ulcer.
Materials and methods
This is a prospective study that included 50 patients with perforated duodenal peptic ulcer admitted to the General Surgery Department in Menoufia University Hospitals from October 2012 to April 2014. The patients were divided by random serial number method into two groups: group A consisted of 25 patients for laparoscopic procedure, and group B consisted of 25 patients for open repair.
Results
In group A, 21 patients underwent successful laparoscopic surgery, and four patients were converted to laparotomy, and in group B, 24 patients were evaluable, and one patient died on the fourth postoperative day not related to surgical cause. Operating time was significantly longer in the laparoscopy group, 145 ± 8.4 versus 110 ± 13 min. Patients who underwent laparoscopic repair were associated with lower morbidity, with P-value less than 0.05. No significant difference was found regarding leak or intra-abdominal abscess. Hospital stay was significantly shorter in the laparoscopic group, 6.9 ± 2.2 versus 8.9 ± 3.3 days. Patients who underwent laparoscopic procedure resumed normal activity earlier than the patients in the laparotomy group, 14 ± 1.9 versus 20.5 ± 3.9 days, with P-value less than 0.001.
Conclusion
Laparoscopic correction of perforated peptic ulcer causes less postoperative pain, postoperative complications, and hospital stay.

Keywords: Duodenal ulcer, laparoscope, peptic ulcer, peritonitis


How to cite this article:
Zedan AS, Lolah MA, Badr ML, Ammar MS. Laparoscopic versus open repair of perforated duodenal peptic ulcer: a randomized controlled trial. Menoufia Med J 2015;28:62-8

How to cite this URL:
Zedan AS, Lolah MA, Badr ML, Ammar MS. Laparoscopic versus open repair of perforated duodenal peptic ulcer: a randomized controlled trial. Menoufia Med J [serial online] 2015 [cited 2019 Jun 16];28:62-8. Available from: http://www.mmj.eg.net/text.asp?2015/28/1/62/155945


  Introduction Top


Since the late 1980s, laparoscopy has become increasingly popular. In the beginning, laparoscopy was mainly used for elective surgery, as the influence of the pneumoperitoneum on the acute abdomen with peritonitis was not clear. However, the benefits of laparoscopy with regard to the acute abdomen as a diagnostic tool have been established, and since then its therapeutic possibilities also seem to be advantageous [1].

Perforated peptic ulcer (PPU) is a condition in which laparoscopic repair is an attractive option. Not only is it possible to identify the site and pathology of the perforation, but the procedure also allows closure of the perforation and peritoneal lavage, just like in open repair but without a large upper abdominal incision [2]. Laparoscopic repair confers benefits including reduced postoperative pain, less pulmonary infection, shorter hospital stay, and earlier return to normal activities [3].

The drawbacks of this surgery are prolonged operating time, higher incidence of reoperations owing to leakage at the repair site, and a higher incidence of intra-abdominal collection secondary to inadequate lavage, and as not all patients are suitable for laparoscopic repair, it is therefore important to preselect patients who are good candidates for laparoscopic surgery [4].

The Boey's score is based on three criteria: (a) shock at admission, (b) American Society of Anesthesiologists (ASA III-V), and (c) delayed presentation (duration of symptoms >24 h). The patient is given one point for each positive criterion, with possible scores of 0-3. Patients with scores of 0, 1, 2, and 3 were noted to have mortality rates of 0, 10, 45.5, and 100%, respectively [5].

Laparoscopic repair is reported to be safe with Boey's scores 0 and 1. Boey's scores 2 and 3 are associated with high morbidity and mortality rate, independent of the type of surgery [6].


  Materials and methods Top


This is a prospective study that included 50 patients with perforated duodenal peptic ulcer admitted to the General Surgery Department in Menoufia University Hospitals from October 2012 to April 2014. The patients were divided by random serial number method into two groups: group A included 25 patients for laparoscopic procedure, and group B included 25 patients for open repair.

Inclusion criteria

The inclusion criteria were patients with suspected perforated duodenal ulcer based on clinical assessment, investigation, and confirmed by exploration, either male or female of any age with Boey's score 0 or 1.

Exclusion criteria

The exclusion criteria were patients with Boey's score 2 or 3, gastric outlet obstruction, bleeding ulcer, and previous abdominal exploration.

Conversion criteria

Patients with perforation more than 10 mm, difficult identification of the perforation, cardiovascular instability, and iatrogenic injury that could not be managed laparoscopically were converted to laparotomy.

The procedure followed is in accordance with ethical standards of the responsible institutional committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 1983.

All the patients were assessed through patient's history, clinical evaluation, radiological evaluation (plain radiography and abdominal ultrasound), and laboratory investigations (complete blood picture, liver function test, kidney function test, sodium, and potassium) for routine preoperative evaluation.

Preoperative resuscitation (fluids and electrolyte correction), intravenous antibiotic therapy, and proton-pump inhibitor injection should be administered before surgery.

Surgical technique for laparoscopy procedure

Patient position

0At the beginning of the procedure, the patient is placed in the supine position with the legs straight and spread out. The patient's position is changed in the anti-Trendelenburg position during suture, and in the Trendelenburg position during peritoneal lavage.

Team position

The surgeon stands between the patient's legs and the assistant to the patient's left. This position is changed during peritoneal lavage with the surgeon to the left of the patient and assistant between the patient's legs.

Equipments' position

The laparoscopic unit is placed on the patient's left side toward the shoulder. The instrument table is placed at the patient's legs.

Trocar site

An optical trocar of 10-12 mm is introduced in the periumbilical region. One operating trocar of 5 mm is placed in the inferior aspect of the right upper quadrant on the midclavicular line for the atraumatic grasper. A trocar of 5 mm is placed in the left side at the transpyloric level on the midclavicular line for the needle holder. A fourth trocar of 5 or 10/11 mm is placed in the epigastric region and accomodates one or several means of liver and viscera retraction.

First step

The Veress needle or an open technique was used to enter the abdomen. Intra-abdominal pressure between 8 and 12 mmHg is usually sufficient to realize enough room to work properly. The abdomen is explored to identify the perforation and to assess the magnitude of peritonitis. Once the liver is retracted, the exposed area is carefully checked, and the perforation is usually clearly identified as a small hole on the anterior aspect of the first portion of the duodenum.

Second step

The next step is cleaning the abdomen. The whole abdomen must be irrigated and aspirated with warm saline solution; about 4-6 l of warm saline is necessary to clean the abdomen.

Third step

For direct closure of the perforation by interrupted PDS sutures, usually three stitches are placed in a transversal manner over the perforation focused on the pyloroduodenal axis. A big bite of 0.5-1 cm from the perforation edge required to avoid cutting through of the friable ulcer edges. The knot is tied using the intracorporeal knotting. Once the perforation is closed, a small fragment of the greater omentum can be fixed over the suture line.

When it is difficult to approximate the edges of the ulcer, as is the case with chronic callous ulcers and large perforation, direct closure of perforation should be avoided and closure of the perforation with an omental patch only, as in the open technique, must be used to avoid cutting the duodenal wall.

Finally

Before ending the operation, routine drainage of the peritoneal cavity is performed, and the abdomen must be examined for any possible bowel injury or hemorrhage.

Surgical technique for open procedure

The patient was placed in the supine position and general anesthesia was administered. An exploratory upper midline incision was made. After formal exploration and identification of perforation, we used the Graham patch technique in which three interrupted sutures were used. A piece of omentum was laid over these sutures, which were then tied just sufficiently tight to hold the omental graft in situ. Peritoneal toilet with warm saline until become clear, drains are inserted, and closure of abdomen.

Postoperative care

Nothing by mouth, giving intravenous fluids, broad spectrum antibiotic, proton-pump inhibitor, opioid analgesic, and prophylactic heparin to prevent deep vein thrombosis. After return of intestinal movement usually by the third or fourth day, removal of Ryle and starting gradually oral fluid with adding triple therapy for Helicobacter pylori.

Follow-up

Patients with a history of chronic ulcer, continued use of NSAIDs, and infection with H. pylori were more likely to have persistent signs, symptoms, and complications of peptic ulcer. Therefore, the postoperative follow-up of patients with perforated duodenal ulcers included the following: combination of antibacterial and antisecretory therapy to eradicate H. pylori should be administered to all patients, and after 6 weeks postoperatively, endoscopy with confirmation of both ulcer healing and eradication of H. pylori was performed in all patients.


  Results Top


This study was carried out on 50 patients who had perforated duodenal ulcer. All patients were divided into two groups: group A, with 21 patients undergoing successful laparoscopic surgery, and four patients being converted to laparotomy; and group B, with 25 patients undergoing laparotomy, of which 24 patients were evaluable and one patient died on the fourth postoperative day owing to extensive myocardial infarction.

Results were collected in a database, tabulated, and statistical analyses were performed with the Statistical Package for Social Sciences for Windows, version 16.0 (IBM SPSS Inc., Chicago, Illinois, USA). Analysis was performed using t-test for quantitative variable, and c2 -test was used where appropriate for qualitative data. P-value less than 0.05 was considered statistically significant.

Demographic characteristics of patients regarding risk factor for ulceration and perforation and preoperative risk factor are illustrated in [Table 1]. Comparison between groups A and B regarding operative time, postoperative pain, patient recovery, cosmetic result, and conversion are illustrated in [Table 2]. Comparison between groups A and B regarding postoperative complication, leak, intraperitoneal abscess, wound infection, respiratory complication, and sepsis are demonstrated in [Table 3] [Figure 1] and [Figure 2].
Figure 1: Diagram showing rate of conversion.

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Figure 2: Diagram showing cosmetic results in groups A and B.

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Table 1: Characteristics of patient regarding sex, risk factor for ulceration and perforation, and preoperative risk factor

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Table 2: Comparison between group A and group B regarding operative time, postoperative pain, patients' recovery, cosmetic result, and conversion

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Table 3: Comparison between group A and group B regarding postoperative complication

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  Discussion Top


In 2010, data collected by Bertleff and Lange [7] from 29 studies on 2784 patients showed that patient demography data (age and sex), risk factors for perforation (NSAIDs, history of peptic ulcer, and H. pylori), and risk factors influencing outcome after surgery for PPU (delayed treatment >24 h, shock at admission, and concomitant diseases) were very similar to the data in this study.

Data collected by Bertleff and Lange [7] also showed that, with regard to surgical technique, there seems to be no consensus on how to perform the surgical procedure, which probably means that the perfect setup has not yet been found. The number, the site, size of trocars, and sutures differed between surgeons; however, all surgeons agree that perforation more than 10 mm should be managed by open laparotomy. In our study, the mean of perforation size was similar to data collected by Bertleff and Lange [7].

Data collected by Lau [2], from 13 publications comprising 658 patients met the inclusion criteria. Lau's meta-analysis [2] showed several studies that demonstrated a significantly longer operative time for laparoscopic repair. Meta-analysis by Matsuda et al. [8] showed that the mean of operative time in laparoscopic and open patients was 135 and 94 min, respectively. Meta-analysis by So et al. [9] showed that the median of operative time in laparoscopic and open patients was 80 and 65 min, respectively.

In this study, there is a significant longer operation time in the laparoscopic group that agrees with the results of Lau's meta-analysis [2]; however, the relative longer time in both the groups could be attributed to generous peritoneal toilet and the experience of operative teams.

Data collected by Lau's meta-analysis [2] reported that rates of conversion to open repair ranged from 0 to 29.1%; the overall success rate of laparoscopic repair was 84.7%. The rate of conversion by Siu et al. [10] was 14.2%, and by Lau et al. [11] it was 23%. The reasons for the conversion included difficulty identifying the site of ulcer perforation, large perforation, technical problems, cardiovascular instability, ileal perforation, bleeding, gallbladder perforation, injury to the stomach, omental adhesion, and other unspecified factors.

Conversion to open surgery was required in four patients, representing 16%. Reasons for conversion are two patients with severe purulent peritonitis, making identification of perforation difficult and hazardous, and one patient owing to the large size of perforation, which was more than 10 mm, and the other due to hemodynamic instability. There was no bleeding, ileal perforation, gallbladder perforation, nor injury to the stomach. The rate of conversion in this study was within the range of conversion rate by Lau's meta-analysis [2].

The meta-analysis by Lau [2] showed 10 trials that compared the amount of analgesic consumption by the laparoscopic and open repair groups. A significant reduction in the dosage of opiate analgesic required in the laparoscopic group was observed in eight of the studies. In a study by Robertson et al. [12], it was 15 mg morphine in the laparoscopic group and 100 mg morphine in the open group. Siu et al. [10] showed that the number of opioid injections in the laparoscopic group was zero, and in the open group the number was six. In a study by Katkhouda et al. [13], opioid analgesics in the laparoscopic group was three doses, and in the open group it was nine doses, whereas the other two studies by Naesgaard et al. [14] and Johansson et al. [15] showed comparable results.

With regard to opioid requirement, the amount required per day showed significant lower opioid analgesic requirement in the laparoscopic group over 5 days. Our result was very close to Lau's meta-analysis.

Katkhouda et al. [13] showed significantly earlier resumption of the oral diet after laparoscopic repair, whereas Siu et al. [10] showed comparable results, starting oral feeding on day 4 for laparoscopy and open repair. In this study, oral feeding was started earlier in the laparoscopic patients and was well tolerated. This is caused by the less postoperative ileus in the laparoscopic group, and this result was similar to that published by Katkhouda et al. [13].

Chest infection is the most common postoperative morbidity. In the randomized trial by Siu et al. [10], there was a significant reduction in chest infection after laparoscopic repair; infection rate was 0% for the laparoscopic group, and 12% for the open group. In this study, the respiratory complication in the form of pneumonia, lung atelectasis, pleural effusion, and pneumothorax were significantly less in the laparoscopic patient and this agreed with the result of the study by Siu et al. [10]. This may be attributed to less postoperative pain, as there is no upper abdominal wound, allowing the patient to take deep breaths and expectorate efficiently, and early ambulation.

After chest infection, wound infection is the next most common morbidity after open repair of the PPU. In the study by Siu et al. [10], a significant reduction in wound infection rate was noted; it occurred in 3% of the patients in the laparoscopic repair group, and in 12% of the patients who underwent open repair. In this study, wound infection occurred in one (4.7%) patient in the laparoscopic group in the form of port site infection, in the laparotomy patient it occurred in seven (29%) patients, in four of them the wound burst. Wound infection is significantly less in the laparoscopic patient and this agrees with the result of the study by Siu et al. [10]; however, the relative high incidence in the open group may be attributed to resistant bacteria and patient ignorance of wound care.

Lau's meta-analyses [2] found a lower leakage rate and intra-abdominal collection after open repair; the pooled estimate of the effect showed no significant difference between open and laparoscopic repair. In this study, there was no significant difference between two groups with regard to leak. Leak occurred in three patients in the laparoscopic group (14.2%), of whom two patients had leak that was minimal and effectively drained, and in one patient it required reoperation by a small incision in the upper abdomen. In the open group, the leak occurred in two patients (8.3%), of whom one was reoperated upon with the insertion of the duodenostomy tube, and this agreed with the results of Lau's meta-analysis [2].

In this study, intraperitoneal abscess occurred in two patients in the laparoscopic group; of them, one patient was drained of the intraperitoneal abscess by insertion of a ultrasound-guided big tail drain, and the other was reoperated for pelvic abscess laparoscopically. In the laparotomy group, abscess occurred in three patients, of whom one patient was drained by big tail drain, and the other two were reoperated. There was no significant difference between the two groups with regard to the incidence of intra-abdominal collection or abscess formation and this agreed with the results of Lau's meta-analysis [2].

All the studies showed that the length of hospital stay after laparoscopic repair was either shorter than or equal to that associated with open repair. The difference between the laparoscopic and open repair groups was statistically significant in three studies, that is, in the studies of Siu et al. [10], Mehendale et al. [16], and Katkhouda et al. [13]. These studies showed that the median of hospital stay was 6 days in the laparoscopic patients and 7 days in laparotomy patients.

In this study, hospital stay was significantly shorter in laparoscopic patients and this is attributed to early recovery, early oral feeding, early removal of nasogastric, urinary catheter, and abdominals drains and lower morbidity.

Data collected by Lau [2] involved six studies that examined that the time taken to resume normal activity by patients underwent laparoscopic surgery was significantly earlier than the patients who underwent open repair, as shown in the studies conducted by Mehendale et al. [16] and Katkhouda et al. [13]. Siu et al. [10] found that patients returned to normal activities after laparoscopic repair within an average of 10 ± 6.9 days, which was significantly earlier than the return of those who underwent open repair 26 ± 15.1 days, and this agreed with the results of our study.


  Conclusion Top


The results of this study confirm the results of other trials and consist with the World Society of Emergency Surgery (WSES) guidelines for the management of intra-abdominal infections [17], that laparoscopic correction of PPU is safe, feasible for the experienced laparoscopic surgeon, and causes less postoperative pain, postoperative complications, and hospital stay for those with early presentation and small perforation.


  Acknowledgements Top


The author thank all the participants in the study, patients and their family.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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HC Lo, Wu SC, Huang HC. Laparoscopic simple closure alone is adequate for low risk patients with perforated peptic ulcer. World J Surg 2011; 35 :1873-1878.  Back to cited text no. 3
    
4.
Bertleff MJ, Halm JA, Bemelman WA. Randomized clinical trial of laparoscopic versus open repair of the perforated peptic ulcer: the LAMA trial. World J Surg 2009; 33 :1368-1373.  Back to cited text no. 4
    
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7.
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8.
Matsuda M, Nishiyama M, Hanai T, Saeki S, Watanabe T. Laparoscopic omental patch repair for the perforated peptic ulcer. Ann Surg 1995; 221 :236-240.  Back to cited text no. 8
    
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Siu WT, Chau CH, Law BK, Tang CN, Ha PY, Li MK. Routine use of laparoscopic repair for perforated peptic ulcer. Br J Surg 2004; 91 :481-490.  Back to cited text no. 10
    
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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.  Back to cited text no. 12
    
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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