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

The "Birmingham stitch"--avoiding slippage in laparoscopic gastric banding.

BACKGROUND Slippage rates of 1.4-24 % are frequently quoted after adjustable gastric banding. This complication can be extremely serious and has contributed to many units offering more invasive interventions in the surgical management of morbid obesity. We present results of the first 1,140 Laparoscopic Bands performed in our unit. METHODS Between April 2003 and June 2007, 1140 consecutive patients, mean weight 121.5 kg (range 73-268 kg), mean body mass index (BMI) 44.3 kg/m(2) (range 35-88) underwent laparoscopic adjustable gastric banding (LAGB). An identical surgical technique of one gastropexy suture in addition to the two routine gastro-gastro tunnel sutures was used in all cases. Fluoroscopy-guided adjustments were performed at 3 and 6 months and fluoroscopic evaluations were performed later if clinically indicated. RESULTS There was no mortality and only one major septic complication of gastric perforation 1 week postoperatively which was managed conservatively. The mean stay was 1.02 days (range 0-30 days). Excess percent BMI loss in these patients at 3, 6, 12, 18, 24, 30, and 36 months were 25.4%, 34.7%, 38.3%, 41.1%, 43.7%, 44.4%, and 58.9%, respectively. Slippage with urgent readmission occurred in one patient (0.08%) at 5 months. Two partial slippages were noticed at 12 and 18 months, respectively. One patient had the band removed and the other was treated by band deflation and repositioning 6 months later. CONCLUSION These results demonstrate that in our unit, laparoscopic gastric band insertion is successful in producing weight loss and at the same time has a very low slippage and pouch dilatation rate. This difference is most probably secondary to operative technique