Laparoscopic repair of perforated duodenal ulcer: a comparison with the open surgical technique

INTRODUCTION

A duodenal ulcer is a form of peptic ulcer that occurs in the duodenum towards the beginning of the small intestine. Peptic ulcer is portions of the stomach and duodenum lining that have eroded, resulting in abdominal soreness, potential hemorrhage, as well as other gastrointestinal symptoms. A stomach infection caused by the Helicobacter pylori bacteria is the most prevalent cause of duodenal ulcers.¹

Despite the usage of numerous anti-ulcer agents and eradication treatments, duodenal ulcer perforation remains a prevalent consequence of duodenal ulcer illness. It is among the most prevalent reasons for admittance to a hospital in the world, especially in developing countries.²

Perforated duodenal ulcer is primarily an illness of young males, but due to increased smoking in females as well as the usage of nonsteroidal anti-inflammatory drugs (NSAIDs) across all age categories, it is now prevalent in the entire adult population.³

The prevalence of peptic ulcer illness and concomitant complications has reduced considerably since the invention of curative medicinal therapy for H. pylori, and final operative treatments are now rarely undertaken. Interestingly, the rate of perforation has not been reduced, implying that the pathogenesis of perforated peptic ulcer illness may be complicated by multiple causes. Infection with H. pylori, smoking, usage of NSAIDs, and a history of peptic ulcer are all recognized statistically significant risk factors for perforation.⁴

Peptic ulcers commonly occur in the duodenum's first section and the stomach's lesser curvature, but they can also appear in the stoma following stomach surgery, esophagus, and even Meckel’s diverticulum. Duodenal ulcer perforation is the third most prevalent abdominal emergency, following acute appendicitis and acute intestinal blockage.⁵

Duodenal ulcer symptoms could be constant or sporadic, and the disease's progression differs from person to person. If H. pylori is responsible for the ulcer, the symptoms will last as long as the infection is not treated. Some individuals with duodenal ulcers experience no symptoms at all, whereas others experience severe nausea and vomiting, as well as scorching pain.⁶

The mainstay of therapy for a perforated duodenal ulcer is surgery, which involves sealing the perforation with or without the use of omental patches. The surgical intervention for a perforated duodenal ulcer is without controversy, but the optimum surgical strategy is still up for debate. The aim of the research would have been to look at the viability of laparoscopic treatment of duodenal perforation and make a comparison between it and traditional open repair in aspects of operational time, postsurgical pain, stay in hospital, and postsurgical complications in our set-up.⁷

PATIENTS AND METHODS

This is a prospective study in which 30 patients having perforated duodenal peptic ulcers have been admitted to the General Surgery Department at Al-Azhar University Hospitals (Al-Hussein and Sayed Galal) between January and July 2021. All patients were given a full assessment that included a detailed medical history, a thorough physical exam, laboratory tests, and an imaging study Chest X-ray erect was performed to all patients.

All patients had pre-operative Abdominal X-ray Erect and Abdominal Ultrasound. Patients were excluded if they were < 15 years old and > 70 years old, had a clinical presentation that lasted more than two days, were in shock, or had a systolic BP of < 90 mm Hg that won't be enhanced following hydration. Patients with clinically sealed perforations, contraindications to laparoscopy, prior upper abdominal operations, and perforations other than the duodenum were converted to open surgery intraoperatively.

The patients were randomized into two groups using a random serial number method: group A included 15 patients for laparoscopic surgery, while group B included 15 patients for open repair. Laparoscopic repair was done in all patients by the same surgical team using the standard technique of operation. The operative time was calculated from the start of the incision until placement of the last suture. The outcome and complications of laparoscopic repair, the conversion rate to an open operation, the surgical time, as well as the duration of stay in the hospital have all been recorded. All patients were followed up and instructed to notify the surgeon if there were any complications.

Statistical methods

SPSS version 15 has been utilized to analyze the data gathered (SPSS Inc., Chicago, IL, USA). Quantitative data has been expressed as mean ± SD, whereas qualitative data has been expressed as number and percentage (%). The independent student test has been utilized to identify the significance of the difference in quantitative data, whereas the Chi square or Fisher's exact test has been utilized to identify the significance of the difference in qualitative data. A statistically significant p-value of

RESULTS

In terms of sex, history of PU disease, NSAID intake, & smoking, there were no statistically significant differences (p-value > 0.05) among the groups studied (Table 1).

In terms of clinical presentation, this table reveals that there is no statistically significant difference (p-value > 0.05) among the studied groups (Table 2).

In terms of operative time and post-operative pain score, this table shows a highly statistically significant difference (p-value < 0.001) among the studied groups (Table 3).

In terms of post-operative hospital stay and post-operative start of oral intake, this table reveals a highly statistically significant difference (p-value < 0.001) among the studied groups (Table 4).

This table shows results of post-operative complications. In terms of suture leakage, intra-abdominal collections, and incisional hernia, there was no statistically significant difference (p-value > 0.05) among the studied groups. In terms of post-operative wound infection and post-operative chest infection, there were statistically significant differences (p-value 0.05) among the studied groups. (Table 5).

DISCUSSION

In the immediate or acute post-operative phase, a seroma is an accumulation of serous fluid formed after the development of skin flaps during mastectomy or in the axillary dead space .¹⁰

The prevalence and treatment of peptic ulcers have evolved dramatically since the initial surgical operations were performed less than a decade earlier.

First, the identification of H. pylori, which is now known to be related to 95% of instances of duodenal ulcers, has made significant progress in understanding the disease process etiology.

Second, the development of pharmaceutical H2-receptor antagonists as well as proton pump inhibitors implies that acid secretion in the stomach can now be controlled without invasive and frequently debilitating surgical operations. ⁸

Despite such advancements, emergency presentations with bleeding or perforation still happen on a regular basis, and it is the surgical trainee's responsibility to master the basics of patient treatment in such instances.

Table 4: Comparison of the study groups' post-operative hospital stays and oral intake start times.

Table 5: Comparison between studied groups as regard post-operative complications.