Based on Morkevicius M and Lunevicius R papers. Do it, and discuss the experience.

1. Open Versus Laparoscopic Repair
for Perforated Peptic Ulcer:
from personal experience to systematic review /
meta-analysis
Raimundas Lunevicius MD, PhD
22 Jul 2011
King’s College Hospital NHS Foundation Trust

2.  Occurs in 5-10 % of
duodenal ulcer patients1
 Accounts for >70 % of
deaths associated with peptic
ulcer disease1
 The incidence is 7-10
cases/100,000 per year2
Perforated duodenal ulcer
1. Druart ML et al., Surg Endosc 1997;11:1017.
2. Rodrigues A. Surg Clin North Am 1997;77:1291.
Duodenal Ulcer Perforation

3. Perforated duodenal ulcer
The mainstay in the management of PPU is
surgical repair
Laparoscopic versus open repair?
Lap: 1996 in ASU 1 and 2: 120 beds (60+60)
First laparoscopic repair for perforated peptic
ulcer:
1989 - Mouret: sutureles technic - fibrin glue and
omental patch repair1
1990 - Nathanson: suture repair2
1. Mouret P et al. Br J Surg 1990;77:1006.
2. Nathanson LK et al. Surg Endosc 1990;4:232.
Introduction

4. Objective
 To compare the early outcome results after
laparoscopic and open repair for perforated
duodenal ulcer
Perforated duodenal ulcer

5. Methods
 Design: retrospective study (1996 October – 2004 May)
 Setting: tertiary care academic center
 Patients: patients treated for PPU
 222 out of 365 patients entered the final analysis
Perforated duodenal ulcer

6. Methods
 Intervention(s):
Laparoscopic suture repair of PDU
with or without omentopexy (n= 60)
Open suture repair
with or without omentopexy (n = 162)
 Selection of patients:
Based on the surgeon’s expertise and choice
Higher risk patients tended to be selected for open
repair
Perforated duodenal ulcer

7. Perforated peptic ulcer

8. Perforated peptic ulcer

9. Perforated peptic ulcer
Boey score definition
(Boey J, Choi SKY, Alagaratnam TT, Poon A: Risk stratification in perforated duodenal ulcers. Ann Surg 1987, 205:22-26)
Boey score (0 – 3) is the count of Boey factors:
 Shock on admission
 ASA grade III – V (confounding medical conditions)
 Prolonged perforation (for more then 24 hours)
 A Boey score of 0 means low surgical risk
 Otherwise, it is considered a high surgical risk

10. Perforated peptic ulcer

11. Perforated peptic ulcer

12. Perforated peptic ulcer
Conclusions
 Higher priority should be given to the minimal
invasive approach in low risk patients
 Advantages of lap over open repair for PPU are
not as obvious as they may seem
 Further: systematic review (meta-analysis method)

13. Perforated peptic ulcer

14. Perforated peptic ulcer

15. Perforated peptic ulcer

16. Perforated peptic ulcer

17. Perforated peptic ulcer

18. Perforated peptic ulcer

19. Perforated peptic ulcer

20. Perforated peptic ulcer
Conclusions
 The data on low risk patients (majority of patients included
in this metaanalysis) suggest that lap repair is at least as
safe as and effective as open repairs in terms of
 wound infection,
 mortality rates,
 shorter hospital stays.
 Patients with no Boey risk factors should benefit
from lap repair

21. Perforated peptic ulcer
Take – homes
1. DO IT
2. Share your knowledge / discuss practise