Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (27 page)
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Authors: Simon Paterson-Brown MBBS MPhil MS FRCS
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Enders K.W. Ng
Foregut perforations are challenging surgical emergencies and the keys to success in managing these potentially life-threatening situations are timely diagnosis and appropriate intervention. This chapter summarises the latest evidence and clinical experience concerning the investigation and therapeutic options for perforation in different parts of the upper gastrointestinal tract. Owing to the potential implications for prognosis and management planning, perforations are conventionally classified according to the anatomical position and causative mechanism.
The estimated lifetime risk of perforation in peptic ulcer disease ranges from 2% to 10%.
1
–
3
Typical presentation includes a sudden onset of epigastric pain, which rapidly generalises to other parts of the abdomen. Some patients may report a history of dyspepsia or peptic ulcer, but such findings are absent in about one-third of the patients.
4
‘Board-like rigidity’ is the most commonly mentioned physical sign, referring to the diffuse peritonitis revealed on abdominal examination. However, in the elderly and the critically ill who develop ulcer perforation during hospitalisation, the presentation can often be atypical and subtle. Diagnosis under such circumstances requires a high index of suspicion. Though subdiaphragmatic free gas on a plain erect chest X-ray (
Fig. 6.1
) is diagnostic, it is seen in no more than 70% of patients.
5
A lateral decubitus X-ray, water-soluble contrast meal, ultrasound scan and computed tomography (CT) of the abdomen are thus invaluable additional investigations when the diagnosis is in doubt (see also
Chapter 5
). However, it is noteworthy that the role of CT may be limited if the onset of symptoms is less than 6 hours.
6
Pneumogastrogram was once advocated for being able to increase the diagnostic yield from 66% on plain erect X-ray to 91%.
7
However, such a practice is now abandoned because forceful intragastric air insufflation is likely to reopen some of the spontaneously sealed-off perforations. For patients with profound peritoneal signs and a serum amylase level not diagnostic of acute pancreatitis, a laparoscopy or laparotomy after resuscitation is indeed the most time-saving and efficient investigation. It has the advantage of being able to execute immediate therapeutic intervention, either laparoscopically or via an open laparotomy, once the pathology is verified.
Figure 6.1
Erect chest radiograph showing right subphrenic free gas shadow associated with a perforated peptic ulcer.
Perforation accounts for the majority of deaths related to peptic ulcer disease.
8,
9
Spillage of gastroduodenal contents through the perforation initiates a chemical peritonitis, which will rapidly be superimposed by bacterial infection if left untreated. This leads in turn to the systemic inflammatory response syndrome and multi-organ dysfunction associated with the bacterial translocation across the peritoneal surface. Despite surgical intervention, mortality rates remain around 5–15%.
9
–
11
The prognostic indicators for ulcer perforation have been widely studied, yet most published series consist of relatively small numbers of patients with marked heterogeneity in both demographics and treatment methods.
Before the era of laparoscopic surgery, significantly higher rates of mortality were reported by Boey et al. in patients with an ulcer perforation who were admitted with major medical illness, preoperative shock and long-standing perforation (more than 24 hours). Those with no, one, two and all three risk factors at presentation were noted to have mortality rates of 0%, 10%, 45.5% and 100%, respectively.
12
This study underscores the importance of stratifying patients with ulcer perforation according to their risk of mortality, which is of relevance to the prognosis and choice of surgical intervention.
Similar findings have been reported by other multivariate analyses. Some also identified that age > 65 years and perforation during hospital stay are additional predictive factors of death.
13,
14
In 2001, Lee et al. compared the APACHE II score with the Boey parameters in a cohort of over 400 patients.
15
An APACHE II score > 5 was found to have predictive value for increasing postoperative complications and death, whereas the Boey score only predicted mortality but not morbidity. Interestingly, in the same study, a higher Boey score was found to be associated with an increased chance of conversion when laparoscopic repair was attempted. Albeit a precise and useful tool for research purposes, the APACHE II system is cumbersome to employ in daily practice, not to mention that the calculated score may vary with different time points of assessment.
It is widely accepted that patient comorbidity, age > 65 years, the presence of preoperative shock and long-standing perforation are associated with an increase in mortality and morbidity following perforated peptic ulcer.
A Danish group has recently published a revised prediction model, the Peptic Ulcer Perforation (PULP) score, based on a multicentre study including more than 2600 patients with perforated gastric or duodenal ulcers treated surgically over a 6-year period.
16
It comprises eight variables including (1) age over 65 years, (2) active malignancy or human immunodeficiency virus (HIV) infection, (3) cirrhosis, (4) steroid use, (5) presentation more than 24 hours after symptom onset, (6) preoperative shock, (7) serum creatinine higher than 130 μM/L and (8) the four levels of ASA score (2–5). In the study, PULP score was reported to predict postoperative 30-day mortality with an area under curve (AUC) of 0.83, which was significantly better than the conventional Boey score (AUC = 0.70) and ASA score alone (AUC = 0.78).
Some 50% of perforated peptic ulcers have spontaneously sealed at the time of admission to hospital.
17
Such an observation has led to the sporadic advocacy of non-operative management, especially for older patients with poor premorbid status.
18
However, the non-operative approach has not been widely accepted, with the exception of a few centres. Donovan et al. were among the first to advocate use of diatrizoate meglumine (Hypaque) water-soluble contrast meal for confirmation of spontaneous sealing of the perforation.
19
In the absence of duodenal scarring and contrast extravasation, patients with subphrenic free gas were managed non-operatively with nasogastric suction and intravenous antibiotics. By implementing this preset policy, these authors were able to report an overall mortality rate of only 4.6% in a series of 249 patients.
20
The non-operative approach to the treatment of perforated peptic ulcers has been studied in a randomised trial consisting of 83 patients, of whom 40 were assigned to non-operative management while the rest underwent immediate laparotomy.
21
After 12 hours, 28% of the patients in the non-operative group failed to improve and required surgery. Though mortality rates were comparable between the two approaches, the incidence of intra-abdominal collections and sepsis was much higher in the non-operative group. Most strikingly, patients over 70 years of age were found to be less responsive to the non-operative approach when compared to the younger patients. In concluding the study, the authors did not recommend routine use of non-operative management for peptic ulcer perforation. However, they recognised that the results suggested that patients (a) did not need to be rushed to the operating theatre and time could be more usefully spent in better preoperative resuscitation, and (b) in selected patients the non-operative approach has a role to play.
Though the majority of surgeons now advocate immediate surgical intervention for perforated peptic ulcers, there remains debate as to what constitutes the most appropriate operation. The omental repair technique first described by Graham in 1937 involves patching the perforation with a piece of detached omentum.
22
It is no longer a common practice nowadays and has been largely replaced by the pedicle omentopexy which is usually secured in place by two to three tie-over sutures (
Fig. 6.2a, b
). For a time such a simple omentopexy repair was associated with a high subsequent ulcer relapse rate.
23
–
25
This resulted in the popularity of adding a definitive acid-reducing procedure, such as distal gastrectomy or vagotomy, to lower ulcer recurrence.
26
–
29
In a prospective follow-up study, 107 selected patients with perforated pyloroduodenal ulcers undergoing omental patch closure and parietal cell vagotomy were evaluated up to 21 years later. The operative mortality was only 0.9% and the recurrent ulcer rate by life table analysis was 7.4%, with a re-operative rate of only 1.9%.
30
As a result, emergency vagotomy was once a standard of care recommended for peptic ulcer perforation.
Figure 6.2
(a)
A small perforation at the juxtapyloric area.
(b)
Pedicle omental patch repair on the perforation site secured with absorbable sutures.
The addition of a truncal or highly selective vagotomy may cause little early morbidity or mortality apart from prolonging the time of anaesthesia. However, resectional surgery in the form of emergency antrectomy or distal gastrectomy has been shown to increase mortality in patients with perforated peptic ulcers, and therefore should be avoided wherever possible.
31
All these ‘definitive’ surgical approaches, however, have changed over the last two decades following better understanding about the pathogenesis of peptic ulcer disease; most surgeons now prefer a much less aggressive ‘damage control’ tactic when treating ulcer perforations.
32,
33
The availability of
Helicobacter pylori
eradication regimens and potent proton-pump inhibitors provides excellent means to alleviate patients' ulcer diathesis without the need for a definitive acid-reducing procedure. A simple omental patch repair and thorough peritoneal toileting are the only key manoeuvres needing to be done during the emergency operation. The only exception is probably those suffering from giant duodenal perforations (> 2 cm), which may not be amenable to a simple patch repair (see below).
34