Moshe Schein
– There’s a hole in my bucket…How should I mend it?
– Just patch it! (a folk song)
“Every doctor, faced with a perforated ulcer of the stomach or intestine, must consider opening the abdomen, sewing up the hole, and averting a possible or actual inflammation by careful cleansing of the abdominal cavity.”
(Johan Mikulicz-Radecki, 1850–1905)
Thanks to effective, modern anti-ulcer drug management the incidence of perforated peptic ulcers has decreased drastically, but not everywhere. Perforated ulcers are still common in the socio-economically disadvantaged or stressed popu- lations worldwide. Usually perforations develop against the background of chronic symptomatic ulceration but de novo presentation without previous history is not uncommon. In the Western World perforated duodenal ulcers (DU) are much more common than perforated gastric ulcers (GU), which are seen more in lower socio- economic groups.
Natural History
Classically, the abdominal pain caused by a peptic perforation develops very suddenly in the upper abdomen. Most patients can accurately time the dramatic onset of symptoms. The natural history of such an episode can be divided into three phases:
Chemical peritonitis/contamination. Initially, the perforation leads to chem- ical peritonitis,with or without contamination with micro-organisms.(Note that the presence of acid sterilizes gastroduodenal contents; it is when gastric acid is reduced by treatment or disease (e.g. gastric cancer) that bacteria and fungi are present in the stomach and duodenum). Spillage of gastroduodenal contents is usually diffuse but may be localized in the upper abdomen by adhesions or the omentum. Spillage along the right gutter into the right lower quadrant, mimicking acute appendicitis, is mentioned in every textbook but almost never seen in clinical practice.
Intermediate stage. After 6 to 12 hours many patients obtain some sponta- neous relief of the pain. This is probably due to the dilution of the irritating gastro- duodenal contents by the ensuing peritoneal exudate.
Intra-abdominal infection.Should the patient escape the scalpel initially,after 12 to 24 hours intra-abdominal infection supervenes. The exact point in time in the individual patient when contaminating micro-organisms become invasive-infective,
is unknown.Therefore, you should consider any perforation operated upon with a delay of more than 12 hours as infection rather than contamination.This bears on your postoperative antibiotic therapy as discussed below. Neglected patients may present a few days after the perforation in septic shock. Shock in the earlier stages is very rare although quoted commonly by medical students,but when confronted with a combination of shock and abdominal pain think about ruptured aortic aneurysm, mesenteric ischemia or severe acute pancreatitis. Untreated perforation can lead eventually to an early “septic” death from peritonitis or the development of an intra-abdominal abscess.
Diagnosis
The vast majority of patients present with signs of diffuse or localized perito- neal irritation; most lie still, groaning, and have a board-like abdomen as in the textbook. Spontaneous “sealing off ” of the perforation or localization of the spill or leakage into the lesser sac causes atypical and delayed presentation. We had a pa- tient who re-perforated his duodenal ulcer a few years after receiving an omental patch. The second perforation was thus diverted backwards into the retroperi- toneum – behind the pancreas, the left colon and into the scrotum – while the abdomen remained soft.
In a patient with an abrupt onset of upper abdominal pain and diffuse peri- tonitis the diagnosis is simple. It can be summarized in the following formulas:
Sudden onset peritonitis + free gas = perforated viscus
Sudden onset peritonitis + no free gas + normal amylase = perforated viscus
There is free gas under the diaphragm in about two-thirds of perforated patients. Remember, free gas is visualized better on upright chest X-ray than on plain abdominal radiographs (> Chaps. 4 and 5). If your patient can’t stand, or sit up, order a left lateral decubitus abdominal film. Free gas is diagnostic, although it is not always due to a perforated peptic ulcer. But so what? It signifies a per- forated viscus, and a laparotomy is almost always indicated. But “almost always”
means not “always”: free gas without clinical peritonitis is NOT an absolute indication for an emergency laparotomy. As mentioned in > Chap. 4 there is a long list of “non-operative” conditions that may produce free intra-peritoneal gas. Free gas in a “soft” abdomen may also mean that the perforation has been spontaneously sealed and is amenable to non-operative therapy as discussed below.
In the absence of free air, acute pancreatitis – the “great simulator” – should be considered and excluded(> Chap. 18). Normal serum amylase levels support
a diagnosis of a perforation, while very elevated amylase levels in a “susceptible”
patient (e.g.,alcohol,gallstones) suggest acute pancreatitis.The “border line”patient with atypical presentation and marginal elevation of amylase remains a problem because perforated ulcer may cause hyperamylasemia. In the good old days, before imaging techniques replaced clinical skills,our decision to operate or observe would have depended on the whole clinical picture. Rarely, a gastrografin contrast study was performed to demonstrate or exclude leakage. Faced with such a patient today we would advise you to obtain a CT scan of the abdomen, looking for free gas, extra- luminal gastrografin and free peritoneal fluid. CT is excellent at picking up minute amounts of free intraperitoneal gas and is thus a valuable tool in clarifying the diagnosis in patients with an ambiguous clinical picture.
Philosophy of Treatment
The primary goal of treatment is to save the patient’s life by eliminating the source of infection and cleaning the abdominal cavity. The secondary goal is to cure, if possible, the ulcer diathesis. The former goal may be achieved by simple closure of the ulcer; the latter requires a definitive ulcer operation.When to do what?
Before telling you what to do we must answer a few other questions.
Who Are the Patients who Require a Definitive Procedure?
Twenty years ago the reply was simpler. The “law of thirds” maintained that after a simple closure of perforation one-third of the patients are cured permanently, another third would require long-term medical anti-ulcer therapy,and the last third would require definitive ulcer surgery because of intractability or further compli- cations. This provided us with a rationale to add a definitive procedure in order to cure the ulcer in two-thirds of the patients. With the emergence of modern anti- ulcer agents we were told that definitive ulcer procedures are not necessary as all perforated patients could be maintained indefinitely and effectively on proper anti- ulcer drugs. Our counter-argument was then that an ulcer operation is more cost- effective than a life-long commitment to drugs; that patients often are not compliant with the latter, and, in fact perforate while taking anti-ulcer drugs. Now, with the availability of anti-Helicobacter pylori treatment of peptic ulcers we are told: “why do you want to add an anti-ulcer procedure? Close the perforation and give a course of anti-Helicobacter antibiotics – the ulcer will be cured and never recur”. This may be true, but in patients acutely operated for a perforated ulcer we do not know whether Helicobacter is or is not involved. Furthermore, the very patients who are susceptible to perforation also suffer from substandard access to medical care and
reduced compliance, both adversely affecting successful medical anti-ulcer thera- pies. Consequently, if the operation for a perforated ulcer can kill two birds using one bullet (especially if the environment around you cannot ensure optimal medi- cal management and follow up of your patient) why not do it?
This appears initially to be a reasonable argument, but after a few moments’ thought one realizes that it is obviously just the ravings of a committed peptic ulcer surgeon who laments the passing of interesting anti-ulcer surgery. Modern surgeons know that duodenal ulcers are due to acid hypersecretion and H. pylori infection and that elimination of this infection will cure the disease. Thus, definitive anti-ulcer surgery is nowadays indicated in only the most unusual of situations and should not even be considered in the routine perforation. [Paul Rogers, Co-editor].
Rebuttal: I agree with this comment in the Western World settings but there are places where follow-up and effective anti-ulcer therapy are not available. And there are patients who perforate while allegedly on such “effective” therapy and those whose ulcers are asso- ciated with non-steroidal anti-inflammatory drug intake. Thus, while I agree that the role of definitive surgery for perforated and bleeding (see > Chap. 16) ulcers has drastically declined, surgeons still need to know how to do these procedures and when. [Moshe Schein]
In What Patients is a Definitive Procedure Safe?
Surely you do not want to embark on a lengthy definitive procedure in a critically ill and “septic”patient. Over the years we encountered surgeons who omit- ted a definitive procedure because of “severe contamination”, often quoting a myth that vagotomy in a perforated patient may “spread the infection into the mediastinum”. The Hong Kong group showed that when the following three factors are present an anti-ulcer procedure can be safely performed: blood pressure
>90 mmHg, operation within 48 hours of perforation, and lack of associated medi- cal illnesses.We found the APACHE II scoring system (p. 57) useful in this situation as patients with perforated ulcers with scores less than 11 can tolerate a definitive procedure of any magnitude. Conversely, in patients with higher APACHE II scores the simplest operation should be performed.
Operative Treatment: Simple Closure (>Fig. 17.1)
Classically,simple closure of the ulcer is best achieved by an omental Graham’s patch also called omentopexy. A few “through-all-layers” interrupted sutures are placed through both edges of the perforation (transversely – not vertically – in order not to narrow the lumen), and are left untied; a pedicle of the greater omentum is created and flipped over the perforation; the sutures are then gently tied over the omentum in order not to strangulate it (> Fig. 17.2).At this stage the anesthetist may
Fig. 17.1. “How should we mend it?”
Fig. 17.2. Simple closure. Note the omental patch should “plug” the hole with the sutures tied over it.First suturing the hole and then sticking omentum over the repair is wrong
be asked to inject water through the nasogastric tune to ascertain that the patch is waterproof.
Not a few surgeons misunderstand this operation; they initially suture-close the perforation and only then cover the suture line with the omentum. However, the approximation of the edematous, friable edges of perforation can be troublesome.
In all cases of postoperative duodenal fistula witnessed by us the simple suture- closure of perforated DU was the causative mechanism.Remember, you do not stitch the perforation but plug it with viable omentum.
Omentopexy can be easily performed for most perforated DUs. Rarely, a giant perforated DU creates a huge anterior bulbar-pyloric defect, which is not amenable to safe closure and thus mandates partial gastrectomy. Perforated GUs are usually larger than the duodenal ones. For those positioned on the greater curvature of the stomach, a wedge resection of the ulcer, hand sutured or stapled, may be easier and safer than omentopexy. For chronic and large lesser curvature ulcers, omentopexy is notoriously difficult and unsafe; partial gastrectomy may serve the patient better.
Operative Treatment: Definitive Procedure
Ideally, in emergency you should choose the anti-ulcer procedure with which you are most familiar in the elective situation. The problem is that today you and other young surgeons are deprived of experience with elective anti-ulcer operations.
Based on our philosophy to avoid, if possible, a gastric resection for a benign
Table 17.1. Selection of procedures in perforated ulcers
Ulcer type Textbook options We recommend
Good risk Poor risk Good risk Poor risk Duodenal Omentopexy Omentopexy Omentopexy Omentopexy
±TV+D or plus HSV
HSV or TV+A
Prepyloric Omentopexy Omentopexy Omentopexy Omentopexy
±TV+D or plus HSV+D
TV+A
Gastric Omentopexy or Omentopexy Omentopexy Omentopexy wedge excision or partial plus HSV+D or partial or partial gastrectomy or partial gastrectomy
gastrectomy gastrectomy
TV+D truncal vagotomy and drainage procedure; TV+A truncal vagotomy and antrectomy;
HSV highly selective vagotomy; HSV+D highly selective vagotomy and drainage.
process, and on results of elective ulcer operations, we recommend an operative policy which tailors the definitive procedure to the specific ulcer (> Table 17.1).
Whatever you do please remember that if your patient is “sick” and you are not a skilled gastroduodenal surgeon – forget about the definitive procedure. Just patch the hole and get out!
Special Problems
“Kissing” ulcers: any evidence of a preceding or co-existing UGI hemorrhage (e.g. finding of “coffee ground” or fresh blood in the nasogastric tube or at the perforation site or peritoneal cavity) suggests the presence of “kissing” ulcers – the anterior perforated, the posterior bleeding. Simple closure of the former, without hemostasis for the latter, could lead to a severe postoperative hemorrhage. In such circumstances enlarge the duodenal perforation into a duodenotomy and explore the inside of the duodenum. If posterior ulcer is found suture-transfix its base as described in > Chap. 16.
Laparoscopic Management of Perforated Ulcers
Omentopexy and peritoneal toilet can be executed laparoscopically (> Chap.
49). A large experience has been accumulated in the treatment of perforated DUs with conflicting results. We suggest that laparoscopic procedure is a reasonable option in stable and well-resuscitated patients and when the perforation can be promptly and securely closed. Conversely, a prolonged pneumoperitoneum will be poorly tolerated in the high risk or severely “septic” patients. The addition of a laparoscopic anti-ulcer procedure could lengthen the operation beyond what is reasonable in an emergency situation.
Non-operative Management of Perforated Ulcers
A non-operative approach consisting of nil per mouth, nasogastric suction, systemic antibiotics,and acid secretion inhibitors,has been proven effective by a few enthusiastic groups. The sine qua non for success is the spontaneous sealing of the perforation by the omentum or other adjacent structures; if this occurs, a non- operative approach would be successful in the majority of cases.
Non-operative treatment may be of particular value for two types of patients:
the “late presenter” and the “extremely sick”.The “late presenter”presents to you a day or more after the perforation occurred, with an already improving clinical-
picture and minimal abdominal findings.This,together with radiographic evidence of free air, hints at a localized and spontaneously sealed perforation. Non-operative treatment, following a gastrografin UGI study, or contrast CT, to document that the perforation is sealed, should be successful in most instances. The “extremely sick”are the other candidates for conservative therapy: those in whom the risk of any operation could be prohibitive, such as the early post-massive myocardial infarct patient, the COPD (chronic obstructive pulmonary disease) grade IV, or the patient with an APACHE II score over 25. Also in this group, however, conservative treatment may be successful only if the perforation is sealed and radiographically proven to be so. When sealing did not occur, in desperate situations we have successfully carried out omentopexy under local anesthesia.
Antibiotics
As soon as the diagnosis of perforation is made, and the patient is “booked”
for a laparotomy, administer a dose of wide spectrum antibiotics. The vast majority of patients presents for treatment within 12 hours of perforation and suffer, there- fore, from peritoneal contamination rather than infection. In many of them, in fact, the peritonitis is chemical and does not contain any microorganisms.Antibiotics in this group will serve for prophylaxis. Postoperative therapeutic antibiotics are not needed in these patients. Those who present later than 12 hours may suffer from intra-abdominal infection; here antibiotics should be continued in the postoperative phase (> Chap. 42). The antibiotics given, either in the form of monotherapy or combination therapy, should “cover”, empirically, Gram-negatives and anaerobes.
Routine culturing of the peritoneal fluid in perforated patients is not indicated
(> Chap. 12). Those who practice it (unnecessarily, we believe) often grow Candida,
which represents a contaminant and does not need specific therapy.
Conclusions
Patch a perforated ulcer if you can, if you cannot, then you must resect. Con- sider adding a definitive anti-ulcer procedure on a very selective basis, and do not forget that a non-operative approach is possible,beneficial and indicated in selected patients.
“We have no responsibility to such patients but to save their lives. Any proce- dure, which aims to do more than this, can quite significantly be considered meddle- some surgery. We have no responsibility during the surgery to carry out any procedure to cure the patient of his original duodenal ulcer.”(Roscoe. R Graham, 1890–1948)
