What is the surgical management of a perforated duodenal ulcer in the first part of the duodenum (D1) due to acid hypersecretion?

From the Guidelines

Surgical management of a perforated duodenal ulcer in D1 due to acid typically requires a tailored approach, considering the size and location of the ulcer, with options including repair, resection, or pyloric exclusion, as suggested by the most recent guidelines 1. The procedure involves identifying the perforation, debriding the edges if needed, and closing the defect with absorbable sutures. For large duodenal ulcers, resection or repair plus pyloric exclusion/external bile drainage may be considered, as recommended by the WSES guidelines 1.

• The treatment of giant peptic ulcers (diameter > 2 cm) poses different challenges according to the anatomical location, and the proximity of the defect to the common bile duct and ampulla of Vater must be thoroughly investigated 1.
• Intraoperative cholangiography may be necessary to verify common bile duct anatomy, and several different procedures, such as a jejunal serosal patch, Roux en-Y duodenojejunostomy, pyloric exclusion, and omental plugs, have been described for large duodenal defects 1.
• Postoperatively, patients require intravenous antibiotics and acid suppression with proton pump inhibitors, as well as Helicobacter pylori eradication therapy if the bacterium is detected, as suggested by previous guidelines 1.
• Early surgical intervention is crucial, as mortality increases significantly with delays beyond 24 hours, and the choice of operative intervention should be influenced by the patient's condition, including the presence of septic shock or peritonitis 1.

From the Research

Surgical Management of Perforated Duodenal Ulcer

• The surgical management of perforated duodenal ulcer can be performed through laparoscopic or open repair, with or without an omental patch 2, 3, 4, 5.
• Laparoscopic repair has been shown to be a safe and effective method for treating perforated duodenal ulcers, with a shorter hospital stay and lower morbidity rate compared to open repair 2, 3, 4, 5.
• The use of an omental patch in laparoscopic repair has been reported to be a simple and easy procedure, with an acceptable morbidity rate and a low conversion rate 2, 4.
• The Boey score has been investigated as a predictor of outcomes in patients with perforated duodenal ulcers, and has been shown to be a useful tool in selecting patients for laparoscopic or open repair 3.
• Long-term follow-up studies have shown that omental patch repair can provide long-term benefit for patients with perforated duodenal ulcers, particularly those whose perforations are associated with ulcerogenic medications 6.

Comparison of Laparoscopic and Open Repair

• Laparoscopic repair has been shown to have a shorter hospital stay and lower morbidity rate compared to open repair 3, 5.
• The conversion rate from laparoscopic to open repair has been reported to be low, ranging from 0-2.5% 2, 3, 5.
• The operative time for laparoscopic repair has been reported to be longer than for open repair, but this difference has been shown to decrease with increasing experience and expertise 3, 5.

Factors Affecting Outcomes

• The timing of diagnosis and treatment has been shown to be an important factor in outcomes, with delayed diagnosis and treatment associated with a higher risk of mortality 5.
• The use of ulcerogenic medications has been shown to be a risk factor for recurrence of perforated duodenal ulcers, and patients who have not been taking these medications may be better treated with definitive ulcer surgery at the time of perforation 6.
• The experience and expertise of the surgeon have been shown to be important factors in outcomes, with a higher volume of cases associated with improved results 3.