Laparoscopic Repair for Perforated Peptic Ulcer

Great strides in the medical management of peptic ulcer disease have resulted in a radical change in the indications for surgical intervention. Elective surgery for peptic ulcer disease has markedly declined, although there has been no decrease in the incidence of perforation secondary to peptic ulcer disease. Perforation of a peptic ulcer is the development of a complication in acute or chronic preexisting peptic ulcer diathesis. In the past, surgical management of a perforated peptic ulcer included treatment of the local complication; i.e., omental patch closure of the perforated ulcer, ¹ as well as definitive management of the disease process. Pharmacological advances, with highly effective H₂ antagonists and proton pump inhibitors, have made it possible to successfully inhibit acid production, obviating the need for acid-reducing surgery. Also, with the discovery of H. pylori, the pathogenesis of peptic ulcer disease has become more clearly defined. Of even greater significance, the ease of diagnosis, treatment, and eradication of H.Pylori infection have resulted in a marked decline in ulcer recurrence.

In 1992, Feliciano questioned the need for acid decreasing surgical procedure for perforated duodenal ulcer. ² The concomitant rise in the use of laparoscopic techniques led to the first description of a laparoscopic approach in the management of a perforated peptic ulcer. ³ Since then, there has been wide acceptance of this approach. Some studies concluded that the laparoscopic repair did not yield additional benefits over the open repair ⁴ or that the objective benefits were small, while other studies reported excellent results and documented advantages such as decreased need for postoperative analgesics ⁵ and decreased operating times in the laparoscopic group. ⁶ The first randomized trial in 1996 ⁷ showed increased operating times and decreased postoperative analgesic use. Increasing familiarity with laparoscopic techniques, and innovative ways of repairing the perforation ranging from sutureless closure or single suture closure to use of fibrin glue have all enabled surgeons to decrease operating time. More recent prospective randomized studies are needed to re-enforce the findings of the earlier trial and to establish the laparoscopic approach as the gold standard for management of a perforated peptic ulcer.

In this issue, Siu et al. ⁸ have filled this need. In an elegantly designed and meticulously executed prospective randomized trial, the laparoscopic approach in the management of perforated peptic ulcer disease has been compared to the open approach. Their study validates the findings of earlier studies in proving the laparoscopic approach to be safe, feasible, and with morbidity and mortality comparable to that of the open approach. Enrollment of a large group of patients in this trial reduces the chance of a Type II statistical error and gives us conclusive evidence of the advantages of the laparoscopic repair over an open repair. Their observations are critical in the decisions that a general surgeon has to make in the care of a patient with a perforated peptic ulcer. New knowledge about the pathogenesis of the disease and advances in medical management have made the surgical procedure a shorter one. This makes a strong case for a minimally invasive laparoscopic approach. Although previous studies have proved the safety and efficacy of the procedure, the surgeon’s dilemma has been, “Does the patient benefit when I choose the laparoscopic approach?” Siu’s study resolves that dilemma. The authors show decreased operating times in the laparoscopic group. The patients’ pain perception postoperatively is reduced in the laparoscopic group, as is the need for postoperative analgesia. This leads to earlier ambulation and, as shown in the study, a significantly lower incidence of respiratory infections, lower median length of hospital stay, and earlier return to normal activities. Documentation of a multitude of these findings in a randomized prospective trial will have a tremendous impact on patient care and has the potential to markedly reduce hospital costs.

As always, it is critical that we identify factors that would caution us against a laparoscopic suture repair of a peptic ulcer. As Roscoe Graham ¹ very succinctly put it, it is extremely unlikely to encounter a carcinoma in a duodenal ulcer, whereas it is the bête noir of every patient who suffers from a gastric ulcer. Siu and colleagues have accurately determined exclusion criteria for the laparoscopic repair – namely a non-juxtapyloric gastric ulcer, an ulcer greater than 10mm in diameter, and technical difficulties. Additional factors that must be taken into account include a hostile abdomen, concomitant hemorrhage, and the inability to tolerate pneumoperitoneum.

It is important for the surgeon to remember that although the surgical treatment of a perforated peptic ulcer today addresses mainly the management of a complication of the disease process (namely the closure of the perforation with an omental patch and thorough irrigation of the peritoneal cavity) it is the surgeon’s responsibility to determine the etiology of the disease process in each individual and tailor the subsequent medical management accordingly. The basic tenets of surgery must be adhered to. As in the open approach, delayed presentation, hemodynamic instability, and preexisting comorbidities necessitate aggressive resuscitation prior to surgery and close peri-operative monitoring in order to benefit from the advantages offered by laparoscopic intervention. Prospective randomized trials will be necessary to determine whether laparoscopic surgery is safe in patients with generalized peritonitis and whether it is more advantageous than the open approach in the presence of sepsis.