Surgical Treatment of Perforated Peptic Ulcer 

With the success of medical therapy, surgery has a very limited role in the management of peptic ulcer disease (PUD). Elective peptic ulcer surgery has been virtually abandoned. In the 1980s, the number of elective operations for peptic ulcer disease dropped more than 70%, and emergent operations accounted for more than 80% of these.^[1]

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In general, 5% of bleeding ulcers eventually require operative management. The indications for urgent surgery include the following:

• Failure to achieve hemostasis endoscopically
• Perforation
• Recurrent bleeding despite endoscopic attempts at achieving hemostasis

With regard to the third item, many advocate surgery after 2 failed endoscopic attempts.Several studies have demonstrated that some perforated peptic ulcers can be treated nonoperatively. Each study has used different indications for surgery; however, the general consensus is that any patient with a perforated peptic ulcer who has peritoneal signs should undergo exploratory laparotomy.

Wangensteen et al reported that in a patient with perforation but without evidence of pneumoperitoneum, one can safely assume that perforation has sealed off on its own.^[2] They advocated a nonoperative approach for such patients. However, they too supported operative treatment in patients with perforated ulcer and evidence of pneumoperitoneum.

Berne and Donovan emphasized the use of a water-soluble upper GI study to demonstrate spontaneous sealing of the perforation.^[3] They demonstrated that as many as 40% of perforated peptic ulcers had no evidence of leak on upper GI contrast studies. Berne and Donovan concluded that these patients can be observed safely as long as peritonitis does not develop. Mortality rates were 6% and 3% in the operative and nonoperative groups, respectively.

Donovan et al proposed dividing patients based on their Helicobacter pylori infection status and recommended nonoperative treatment in all patients except those without H pylori infection and those in whom prior treatment of H pylori infection had failed.^[4]

Despite strong arguments favoring nonoperative treatment of patients with perforated PUD, delaying the initiation of surgery more than 12 hours after presentation was demonstrated to worsen the outcome. Therefore, when definitely indicated, a laparotomy should be performed as soon as possible.^[5]

The appropriate surgical procedure depends on the location and nature of the ulcer. Many authorities recommend simple oversewing of the ulcer, with treatment of the underlying H pylori infection or cessation of nonsteroidal anti-inflammatory drugs (NSAIDs) for bleeding PUD. Additional surgical options for refractory or complicated PUD include vagotomy and pyloroplasty, vagotomy and antrectomy with gastroduodenal reconstruction (Billroth I) or gastrojejunal reconstruction (Billroth II), or a highly selective vagotomy.

Only 1 prospective, randomized trial has compared laparoscopic surgery with open surgery for perforated ulcer. The study found that the only differences between the 2 groups were a reduced need for analgesia and an increased operative time in the laparoscopic group.^[6] Contraindications for laparoscopic repair of a perforated peptic ulcer include large perforations, a posterior location of the perforation, and a poor general state of health.

Fluid resuscitation should be initiated as soon as the diagnosis of peptic ulcer disease (PUD) is made. Essential steps include insertion of a nasogastric tube to decompress the stomach and a Foley catheter to monitor urine output. Intravenous infusion of fluids is begun, and broad-spectrum antibiotics are administered. In select cases, insertion of a central venous line or a Swan-Ganz catheter may be necessary for accurate fluid resuscitation and monitoring. As soon as the patient has been adequately resuscitated, emergent exploratory laparotomy should be performed.

Application of well-known guidelines similar to the "Surviving Sepsis" treatment protocol to the resuscitation algorithm along with prompt surgical intervention is demonstrated to improve survival.^[7]

The patient is placed in the supine position. A midline incision provides the most expeditious entry into the abdominal cavity. The incision can be extended to the symphysis pubis if necessary.

Once the abdomen is entered, the stomach and duodenum are carefully examined to determine the site of perforation. If the anterior surfaces of the stomach and duodenum show no abnormalities, the gastrocolic ligament is serially divided between clamps to allow entrance into the lesser sac and inspection of the posterior surface of the stomach.

The choice of operative procedure depends on variables such as the presence of shock, the presence of life-threatening comorbid conditions, the degree of contamination of the upper abdomen, the amount and duration of perforation, and whether the patient has a history of, or currently has intraoperative evidence of, chronic peptic ulceration.

In the presence of life-threatening comorbid conditions and severe intra-abdominal contamination, the safest technique for an acute anterior duodenal perforation is a simple closure with a Graham patch, using omentum. Several full-thickness simple sutures are placed across the perforation, using 2-0 or 3-0 silk sutures. A segment of omentum is placed over the perforation. The silk sutures are secured.

If contamination of the upper abdomen is minimal and the patient is stable, a definitive ulcer procedure can be performed. For a perforated duodenal ulcer, this may include a highly selective vagotomy, a truncal vagotomy and pyloroplasty, or vagotomy and antrectomy.

For a perforated gastric ulcer, the procedure performed depends on the patient's condition. If the patient is moribund, the ulcer is best excised by grasping it with multiple Allis clamps and using a GIA-60 linear stapler. Alternatively, the ulcer can be excised with electrocautery; the defect is approximated with a 2-layer closure with inner continuous 3-0 absorbable sutures and outer interrupted Lambert sutures using 2-0 or 3-0 silk sutures.

In a stable patient, the ulcer is excised and sent for frozen section analysis to exclude malignancy. For a benign gastric ulcer, a distal gastrectomy with either a Billroth I gastroduodenostomy or a Billroth II gastroduodenostomy is performed.

To obtain access to the esophageal hiatus, the left triangular ligament is sharply divided with electrocautery, and the left lateral lobe of the liver is carefully retracted or folded. A transverse incision is made in the peritoneum overlying the esophagus at the hiatus in the diaphragm. This opening is then widened on each side of the esophagus by sharply dividing the adjacent lesser omentum and the esophagophrenic ligament. Blunt dissection is continued until 2 or 3 fingers can be comfortably passed around the esophagus.

Using a large, right-angle Mixter clamp, a one-half-inch Penrose is passed around the esophagus. The anterior (left) vagal trunk is then sought. The anterior trunk is separated from the esophagus with the aid of a right-angle Mixter clamp or a nerve hook.

The posterior vagus is usually felt as a stout cord lying behind and to the right of the esophagus. The nerve is carefully freed.

After the vagal trunks are transected, the distal 5-6 cm of the esophagus must be cleared by meticulously dissecting and dividing all strands of nerve fibers, small blood vessels, and fascia.

The criminal nerve of Grassi, which is a branch of the posterior vagus to the fundus, must be sought diligently and divided in the usual fashion. After completion of this extensive periesophageal dissection, only the longitudinal esophageal fibers should be visible. Such meticulous dissection is essential to ensure complete vagotomy and subsequent low incidence of recurrent ulceration. If a selective vagotomy is to be performed, the hepatic branch of the anterior vagus nerve and the celiac division of the posterior vagus nerve are preserved.

The type of drainage procedure performed depends on the condition of the duodenum. Typically, a pyloroplasty is considered standard practice; however, if the duodenum is scarred and inflamed, a gastrojejunostomy is a suitable alternative.

A Kocher maneuver is first performed to mobilize the second part of the duodenum. Two 2-0 silk stay sutures are placed at the superior and inferior aspects of the pylorus. A 6- to 10-cm transverse incision is made, starting from the antrum and extending across the pylorus and into the first part of the duodenum. This incision is closed longitudinally with an inner layer of interrupted 3-0 absorbable sutures encompassing all layers, followed by a seromuscular layer of 3-0 silk Lembert sutures.

Alternatively, a stapled closure can be performed. In this case, the edges of the incision are grasped in a longitudinal fashion with several Allis clamps. The incision is closed with a TA-55 stapler containing 4.8-mm staples.

To construct a gastrojejunostomy, a loop of jejunum approximately 12-15 cm from the ligament of Treitz is first selected and brought through an opening in the transverse mesocolon, usually to the left of the middle colic vessels. The stoma should be placed in the prepyloric region or at the most dependent portion of stomach. Using 3-0 silk, a posterior layer of seromuscular Lembert sutures is placed.

Before the bowel is opened, noncrushing Doyen clamps are placed on both sides of the proposed anastomosis to occlude the jejunum. The area of the anastomosis is isolated with moist laparotomy pads in case spillage of jejunal contents occurs. In addition, the suction catheter must be readily available to contain any spillage.

The stomach and the adjacent jejunum are opened. Using 3-0 absorbable sutures, the full-thickness inner layer is started posteriorly and completed anteriorly using inverting Connell sutures. An anterior seromuscular layer of interrupted 3-0 silk Lembert sutures is placed to complete the anastomosis.

For a stapled anastomosis, the jejunum is first aligned to the dependent portion of the stomach with 2-0 silk stay sutures at each end. A stab incision is made in the stomach and jejunum, and the anastomosis is performed using a GIA-60 stapling device. The staple line is inspected for hemostasis. The combined stab incision is closed with an inner layer of continuous 3-0 absorbable sutures and an outer layer of interrupted 3-0 silk Lembert sutures. Finally, the transverse mesocolon is carefully closed around the anastomosis to avoid herniation.

If antrectomy is to be performed as part of the antiulcer procedure, dissection is commenced along the distal half of the greater curvature. First, the greater omentum is separated from the proximal half of the transverse colon. Next, the branches from the gastroepiploic arcade to the greater curvature are divided and ligated. As this dissection proceeds toward the duodenum, the small, fragile vessels are ligated in continuity with 3-0 silk sutures and divided.

With gentle dissection, the posterior wall of the first part of the duodenum is freed from the pancreas and divided with a GIA-60 linear stapler. The right gastric artery is identified above the pylorus, divided, and ligated with 2-0 silk sutures. With electrocautery, the gastrohepatic ligament is divided proximally along the lesser curvature.

Just proximal to the incisura angularis, the left gastric vessels lying along the lesser curvature are carefully isolated with a right-angle Mixter clamp. These vessels are individually ligated in continuity with 2-0 silk sutures and divided. Proximally, these vessels are suture ligated with 3-0 silk sutures. After the nasogastric tube is withdrawn proximally, the stomach is divided with a GIA-90 linear stapler.

Billroth I

If an adequate length of supple duodenum is available, a Billroth I gastroduodenal anastomosis can be constructed. The staple line along the transected duodenum is sharply excised and hemostasis is established.

A 2-layer anastomosis, with an outer layer of interrupted Lembert 3-0 silk sutures and an inner layer of full-thickness continuous 3-0 absorbable sutures, is performed. The gastric staple line from the lesser curvature is inverted with 3-0 silk interrupted Lembert sutures until the angle of sorrow (ie, the junction with the gastroduodenal anastomosis) is reached. A crown suture is placed there.

Billroth II

If a Billroth II gastrojejunostomy (Polya-Hoffmeister type) is to be constructed, a loop of proximal jejunum is selected and brought in an antecolic or retrocolic fashion toward the transected stomach. The loop of jejunum is aligned along the lower half of the gastric staple line with 3-0 silk stay sutures.

For a hand-sewn anastomosis, a posterior layer of interrupted 3-0 silk Lembert sutures is placed, approximating the posterior wall of the stomach and jejunum. Noncrushing bowel clamps are placed on the small bowel.

With electrocautery, a longitudinal enterotomy is made in the loop of jejunum, and the appropriate length of adjacent gastric staple line is sharply excised. An inner layer of continuous 3-0 absorbable sutures is placed. Finally, the anterior interrupted Lembert 3-0 silk sutures are placed to complete the anastomosis.

Next, the gastric staple line from the lesser curvature is inverted with 3-0 silk interrupted Lembert sutures until the angle of sorrow of the gastrojejunal anastomosis is reached. A corner crown suture is placed there. For additional security at this location, the adjacent jejunal wall can be used to cover the angle of sorrow.

For a stapled Billroth II anastomosis, stay sutures are placed to hold the loop of jejunum adjacent to the gastric remnant. A small stab incision is made in the jejunum and at the adjacent posterior wall along the greater curvature of the stomach. The limbs of the GIA stapler are inserted and fired. At least 2 cm of posterior gastric wall is needed between the gastric staple line and the gastrojejunostomy to avoid necrosis.

The position, incision, and initial exploration are as described for truncal vagotomy and pyloroplasty. First, the anterior nerve of Latarjet is identified, which may be observed leaving the gastroesophageal junction and running downward in the lesser omentum parallel to the lesser curvature and terminating at the incisura angularis (5-7 cm from the pylorus) as several branches, resembling a crow's foot. These terminal branches and the branches from the nerve of Latarjet to the body of the stomach are accompanied by the blood vessels.

The posterior vagal trunk also runs downward within the lesser omentum as the posterior nerve of Latarjet. Its course and distribution to the posterior aspect of the stomach are similar to those of the anterior nerve of Latarjet.

Before beginning the anterior dissection, inspect the lesser sac for adhesions to the pancreas that could be inadvertently avulsed during dissection, which can lead to bleeding. To enter the lesser sac, the gastrocolic ligament is sharply divided, but the gastroepiploic arcade is kept intact. Any avascular congenital adhesions between the stomach and pancreas are divided with electrocautery. A nasogastric tube is placed by the anesthesiologist and should be directed toward the antrum to be used to grasp the greater curvature and provide downward traction.

The dissection commences at the site just proximal to the crow's foot on the anterior aspect of the stomach. The objective is to divide the lesser omentum from the lesser curvature, between the incisura angularis and the esophagus, by dividing all the blood vessels and the accompanying nerves that enter the lesser curvature.

The anterior layer of the lesser omentum, adjacent to the neurovascular bundle, is sharply incised. With the use of a fine Schnidt clamp, the neurovascular branches are carefully dissected, ligated in continuity with 3-0 or 4-0 silk sutures, and divided. This dissection proceeds proximally up along the lesser curvature until the left side of the gastroesophageal junction is reached.

Next, the stomach is turned upward, and again, the nasogastric tube is used to grasp the greater curvature. The posterior denervation is conducted in a similar fashion.

Attention is then turned to careful and meticulous dissection of the lower 5 cm of the esophagus, which involves ligating and dividing all blood vessels and nerve fibers entering the esophagus, particularly on its right lateral and posterior aspects. By dividing close to the wall of the upper stomach and lower esophagus, damage to the main vagal trunk and its celiac and hepatic branches is avoided.

The 2 critical components of achieving a successful, complete highly selective vagotomy are (1) completely separating the lesser curvature of the stomach from the lesser omentum, extending from the incisura angularis to the cardia, and (2) skeletonizing the lower 5-7 cm of the esophagus.

The nasogastric tube can be discontinued on postoperative day 2 or 3, depending on the return of GI function, and diet can be slowly advanced. Patients who are found to have H pylori infection should receive the appropriate antibiotic regimen. Patients with high serum gastrin levels should undergo an evaluation for Zollinger-Ellison syndrome. Patients should undergo upper endoscopy to evaluate the area of ulcer and healing of the perforation site 4-6 weeks after surgery.

Surgical complications include pneumonia (30%), wound infection, abdominal abscess (15%), cardiac problems (especially in those >70 y), diarrhea (30% after vagotomy), and dumping syndromes (10% after vagotomy and drainage procedures).