Trends in Diagnosis and Surgical Management of Patients with Perforated Peptic Ulcer

Introduction While the laparoscopic treatment of perforated peptic ulcers (PPU) has been shown to be feasible and safe, its implementation into routine clinical practice has been slow. Only a few studies have evaluated its overall utility. The aim of this study was to investigate changes in surgical management of PPU and associated outcomes. Material and Methods The study was a retrospective, single institution, population-based review of all patients undergoing surgery for PPU between 2003 and 2009. Patient demographics, diagnostic evaluation, management, and outcomes were evaluated. Results Included were 114 patients with a median age of 67 years (range, 20–100). Women comprised 59% and were older (p<0.001), had more comorbidities (p=0.002), and had a higher Boey risk score (p=0.036) compared to men. Perforation location was gastric/pyloric in 72% and duodenal in 28% of patients. Pneumoperitoneum was diagnosed by plain abdominal x-ray in 30 of 41 patients (75%) and by abdominal computerized tomography (CT) in 76 of 77 patients (98%; p<0.001). Laparoscopic treatment was initiated in 48 patients (42%) and completed in 36 patients (75% of attempted cases). Laparoscopic treatment rate increased from 7% to 46% during the study period (p=0.02). Median operation time was shorter in patients treated via laparotomy (70 min) compared to laparoscopy (82 min) and those converted from laparoscopy to laparotomy (105 min; p=0.017). Postoperative complications occurred in 56 patients (49%). Overall 30-day postoperative mortality was 16%. No statistically significant differences were found in morbidity and mortality between open versus laparoscopic repair. Conclusion This study demonstrates an increased use of CT as the primary diagnostic tool for PPU and of laparoscopic repair in its surgical treatment. These changes in management are not associated with altered outcomes

Comparison of Closure of Gastric Perforation Ulcers With Biodegradable Lactide-Glycolide-Caprolactone or Omental Patches

Results of both methods of gastric closure (omental and biodegradable patch) were similar suggesting that a biodegradable patch glued to the outside of the stomach may be a viable alternative for closure of perforations of the digestive tract

Randomized Clinical Trial of Laparoscopic Versus Open Repair of the Perforated Peptic Ulcer: The LAMA Trial

Background: Laparoscopic surgery has become popular during the last decade, mainly because it is associated with fewer postoperative complications than the conventional open appr

Laparoscopic correction of perforated peptic ulcer: first choice? A review of literature

Background Perforated peptic ulcer (PPU), despite antiulcer medication and Helicobacter eradication, is still the most common indication for emergency gastric surgery associated with high morbidity and mortality. Outcome might be improved by performing this procedure laparoscopically, but there is no consensus on whether the benefits of laparoscopic closure of perforated peptic ulcer outweigh the disadvantages such as prolonged surgery time and greater expense. Methods An electronic literature search was done by using PubMed and EMBASE databases. Relevant papers written between January 1989 and May 2009 were selected and scored according to Effective Public Health Practice Project guidelines. Results Data were extracted from 56 papers, as summarized in Tables 1-7. The overall conversion rate for laparoscopic correction of perforated peptic ulcer was 12.4%, with main reason for conversion being the diameter of perforation. Patients presenting with PPU were predominantly men (79%), with an average age of 48 years. Onethird had a history of peptic ulcer disease, and one-fifth took nonsteroidal anti-inflammatory drugs (NSAIDs). Only 7% presented with shock at admission. There seems to be no consensus on the perfect setup for surgery and/or operating technique. In the laparoscopic groups, operating time was significant longer and incidence of recurrent leakage at the repair site was higher. Nonetheless there was significant less postoperative pain, lower morbidity, less mortality, and shorter hospital stay. Conclusion There are good arguments that laparoscopic correction of PPU should be first treatment of choice. A Boey score of 3, age over 70 years, and symptoms persisting longer than 24 h are associated with higher morbidity and mortality and should be considered contraindications for laparoscopic intervention

2013 WSES guidelines for management of intra-abdominal infections

Peer reviewe

Use of environmental isotopes to define the capture zone of a drinking water supply situated near a dredge lake.

Lake&ndash;ground water interactions in the vicinity of a dredge lake (Lake Leis; SW Germany) were studied by means of the stable isotopes (18O, 2H) mainly to determine the capture zone of a pumping well for the drinking water supply to the nearby town of Baden-Baden. The water supply is situated in a Quaternary gravel aquifer of the Rhine Valley. Numerical simulation performed using a two-dimensional water flow model was not able to characterise the capture zone uniquely. Several best fit options were possible by applying the values of hydraulic conductivities obtained from the pumping tests. As a result it was not possible to define whether Lake Leis is situated either completely inside or fully outside of the capture zone. To overcome this problem and to define the shape of the catchment area of the water supply precisely, a two-dimensional water flow and tracer transport model was established using both hydraulic heads and isotope data. The isotope data were applied to determine the proportion of lake water in down-gradient pumping and observation wells. Additionally, the isotope compositions of lake water and those in observation wells, measured as a function of time, were used to determine the mean water velocity (v = 0.6 m/d) along some selected 200 m long flow-paths. Based on known porosity and hydraulic gradient values, a hydraulic conductivity of about k = 6 &times; 10-4 m/s was determined for the central area down-gradient of the lake. This hydraulic conductivity and the proportion of lake water in the groundwater were used to calibrate a numerical two-dimensional regional scale transport model. The study demonstrates that it is possible to calibrate a water flow model in the vicinity of a dredge lake uniquely, only when stable isotope signals measured in a time series in both the lake and groundwater are taken into consideration. The calibrated model finally enables the capture zone of the production well to be precisely defined

Comparative study of different aquifer types in central Europe using environmental isotopes.

From 1976 to 1983, water samples were taken from about 300 wells and springs for hydrochemical and isotope analyses (2H, 3H, 13C, 14C, 18O). It was possible to approximately determine a coherent zone of young, tritium-containing groundwater in the porous Younger Tertiary aquifer. Locally, tritium was found at great depths of the fractured aquifers of the Frankisches Albvorland and Oberschwaben, revealing a rather inhomogeneous flow pattern. In all three areas investigated, low 14C contents of groundwater are associated with low d2H and d18O values which are considered to be due to the colder climate during recharge in the glacial period