Page 14 - 53-Peptic ulcer diseases (Loét dạ dày)

818 PART VI Stomach and Duodenum

surgery within 6 hours, mortality was 17% in 117 hospitals prognosis less favorable. As with perforated DUs, there has been
with strict management protocols and was 27% in 512 hospitals a debate regarding the choice of surgery for perforated GUs.
without protocols. Other measures include goal-directed fluid Simple closure should be offered to small perforations at the
therapy, general respiratory and circulatory support, intravenous prepyloric area. The optimal treatment of an angular notch GU
broad-spectrum antibiotics, and insertion of a double-barreled along the lesser curvature should entail an antrectomy and lesser
NG tube, and a urinary catheter. An intravenous PPI is given curve ulcer excision, followed by either a Billroth type I or II
routinely after surgery. reconstruction. The role of vagotomy is unclear. The advocates
Nonoperative management of ulcer perforation should sel- for primary resection in perforated GUs argue that mortality
dom be practiced. It involves NG suctioning, parenteral antibi- rates after gastrectomy are not increased and that the rate of post-
otics, and IV fluids. In a RCT, Crofts and associates 138 assigned operative ulcer-related complications is reduced. The arguments
patients with the presumptive diagnosis of perforated peptic for primary resection also include the possibility that the ulcer is
ulcers to either conservative treatment or prompt surgery. Over- malignant. Malignancy is seen in approximately 6% of perforated
all morbidity and mortality rates (5%) were low and similar in the GUs. 143 In a retrospective series comprising 287 perforated GUs,
medical and surgical groups. Of the 40 patients assigned to con- death occurred in 21.5% of patients who underwent patch closure
servative treatment, 11 showed no improvement within 12 hours alone and in 24.3% of those who underwent gastric resections. 144
and underwent operation. Three of these 11 patients were found In Hp-associated ulcers, Hp eradication reduces the relapse
to have perforated carcinomas (2 gastric and 1 sigmoid colon). of ulceration after patch repair. In a RCT from Hong Kong, 99
Findings of the study highlight common objections to the use of patients after patch repairs for perforated ulcers, were assigned
non-operative management: uncertainty of the site of perforation, to Hp eradication or a course of PPI. At 1 year, there were fewer
the possibility of a perforated GI tumor, and atrophic momentum relapses in those given Hp eradication (4.8% vs. 38.1%). 145
making spontaneous sealing unlikely. Older adults tolerate sepsis A meta-analysis of 5 RCTs that compared simple closure plus
poorly. Any delay in definitive treatment leads to poor outcomes. Hp eradication to closure alone in patients with perforated DU
showed that the pooled incidence of ulcer relapse in the year after
Surgical Therapy Hp eradication was 5.2% compared to 35.2% in those without
eradication. These data support the use of simple closure in the
Perforated gastroduodenal ulcer carries a high mortality rate. In a majority of perforated DUs. 146
review of surgery for perforated ulcers between 2011 and 2013 in
Denmark, the 90-day mortality was 25.5% among 726 patients. Obstruction
Re-operation was required in 124 patients (17.1%), approxi-
mately one third of them caused by persistent leaks. 139 Gastric outlet obstruction is now an infrequent complication of
Boey and associates 140 identified preoperative shock, major PUD. Its clinical manifestations—nausea and postprandial vom-
medical illnesses, and perforation longer than 12 hours as impor- iting, abdominal fullness, pain, and early satiety—are discussed
tant adverse prognostic factors. The PULP score was recently in Chapters 15 and 50, as is the diagnostic approach to patients
developed from a cohort of 2668 patients who received surgery in presenting with possible gastric outlet obstruction. Gastric out-
11 hospitals across Denmark. Variables included were age greater let obstruction should alert clinicians to possible malignancy (see
than 65 years, active malignant disease or acquired immunodefi- Chapter 54).
ciency, cirrhosis, glucocorticoid use, perforation more than 24
hours, shock, raised serum creatinine level, and American Soci- Medical Therapy
ety of Anesthesiologists (ASA) score greater than 1. The PULP
score was accurate in predicting mortality from ulcer perforation Patients with obstructing peptic ulcers are often volume depleted.
(AUROC of 0.83). 141 The score, however, has not been validated The loss of fluid, hydrogen ions, and chloride ions in the vomitus
in centers outside Denmark. leads to hypochloremic, hypokalemic metabolic alkalosis. The
The controversies in the operative management of perfo- patient should be volume resuscitated with normal saline fol-
rated peptic ulcers have revolved around the choice between lowed by potassium replacement once urine output is adequate.
laparoscopic and open repair and the need for a definitive ulcer In severely malnourished patients, parenteral nutrition should be
operation after closure of the perforation (and which definitive considered. Decompression of the stomach by a large-bore NG
operation to perform). Treatment also differs for duodenal and tube relieves vomiting, helps to monitor fluid loss, and allows the
gastric perforations. Simple closure of a perforated duodenal or stomach to regain its tone. A high-volume, non–bile-stained aspi-
a juxta-pyloric ulcer with the use of an omental patch is widely rate can help distinguish gastric outlet obstruction from a high
practiced. small bowel obstruction. Use of an IV PPI reduces gastric acid
Meta-analyses of 3 RCTs (2 from Hong Kong and the Dutch output, making fluid and electrolyte management easier. PPI
LAMA Study) that compared laparoscopic to open surgical treat- therapy also initiates ulcer healing, ameliorates inflammatory
ment of perforated peptic ulcers tends to favor laparoscopic repair edema, and assists in resolving obstruction. Approximately half of
with respect to rates of abdominal septic complications (OR 0.66; patients respond to this management. Improvement is especially
95% CI, 0.3 to 1.47), and pulmonary complications (OR 0.43; noticeable in patients with active ulceration and edema. Surgery
95% CI, 0.17 to 1.12) 142 ; thus, laparoscopic repair should, at the is, therefore, deferred until after an adequate trial of conserva-
least, be considered not inferior to open repair. There may, how- tive management. Other factors that may influence the decision
ever, have been selection bias in these RCTs. Poor risk patients to proceed to surgery are chronicity, a history of previous ulcer
(those with delayed presentations, shock, and with significant complication, and the patient’s age and general medical condi-
comorbidities) may be better suited for a laparotomy. Large per- tion. Furthermore, many authorities argue for initial endoscopic
forations (>10 mm) suggest sizable ulcerations and should also be dilation before surgery.
managed by laparotomy; often, gastric resections are required in
such patients. Endoscopic Therapy
GU accounts for approximately 20% of perforated peptic
ulcers. Epidemiologic data suggest a rising proportion of GUs Endoscopic balloon dilation has been used successfully in patients
among perforated ulcers, especially in older adult patients who with gastric outlet obstruction from PUD (Fig. 53.6). 147-149
use NSAIDs. Patients with perforated GUs are more likely to During endoscopic examination, the stenosis is traversed by means
be older and to have significant comorbid illnesses, making their of a biliary-type guidewire with a flexible tip. A low-compliance