Surgical treatment of acute gastroduodenal perforation

Surgical paper IV

Surgical treatment of acute gastroduodenal perforation 

Abstract

This study examines 76 cases of acute gastroduodenal perforation, categorized into digestive ulcer perforations (60 cases), perforations due to gastric cancer (10 cases), and traumatic duodenal ruptures (6 cases). Of these, 37 underwent gastrectomy, while 39 received perforation repair. Clinical outcomes favored gastrectomy, which displayed fewer postoperative complications such as re-perforation and bleeding. The study recorded 5 mortalities. The findings suggest that gastrectomy is the preferred surgical intervention for both immediate relief and long-term cure. Even palliative gastrectomy for malignant conditions can alleviate symptoms and improve quality of life. Perforation repair, although life-saving in certain situations, has significant drawbacks. For traumatic duodenal ruptures, post-repair treatment should include Berne-style diverticulization.

1. Clinical Data

The study involved 76 patients, comprising 69 males and 7 females, ranging in age from 14 to 73 years with an average age of 42 years. Among these patients, 32 were diagnosed with duodenal ulcer perforation with an average age of 35 years; 28 had gastric ulcer perforation with an average age of 54 years; 9 had perforations due to gastric cancer with an average age of 58 years; one case was identified as gastric malignant lymphoma aged 73; and 6 cases involved duodenal rupture due to trauma with an average age of 34 years. Concurrent conditions in the cohort included 7 cases of bleeding, 15 cases of shock, and 3 instances of additional visceral injuries among the 6 trauma-induced perforations. Comorbidities included hypertension in 12 cases, coronary artery disease in 8, diabetes in 6, and pulmonary tuberculosis in 4. Among the 18 cases that underwent surgery within 12 hours of perforation, 13 underwent gastrectomy and 5 received perforation repair. Of the 30 cases operated on between 13 and 24 hours post-perforation, 12 had a gastrectomy and 18 had perforation repair. Finally, among the 28 cases (including 6 trauma cases) who were operated on after 24 hours from perforation, 12 underwent gastrectomy.

2. Results

Gastrectomy

A total of 37 patients underwent gastrectomy, all of which were performed using the Billroth-I technique, with no immediate postoperative fatalities. Of the 10 gastrectomies performed for malignant conditions, 7 were palliative resections with survival periods ranging from 6 to 14 months. Three were curative resections, with survival periods ranging from 2 to 5 years; notably, one 73-year-old patient with gastric malignant lymphoma remained alive and symptom-free five years post-curative resection. Among the 23 patients who underwent gastrectomy for perforated peptic ulcers, all but one patient with a pancreatic-origin ulcer—who required three surgeries culminating in a total gastrectomy—were successfully treated. During an 8 to 10-year follow-up, only two cases exhibited mild symptoms of alkaline reflux gastritis but were otherwise healthy.

Perforation Repair

Out of 39 cases that underwent perforation repair, two patients died due to re-perforation or leakage on the fourth postoperative day, while another two experienced postoperative bleeding on the second and fifth days, resulting in one fatality. In cases involving duodenal trauma, two patients underwent simple repair but did not survive. Among the 34 surviving patients, one experienced re-perforation due to active ulceration at 2 years post-surgery and another at 5 years post-surgery. Additionally, 7 patients underwent subsequent gastrectomies due to persistent symptoms.

3. Discussion

Acute perforation of the stomach and duodenum presents an urgent clinical challenge, irrespective of the underlying etiology or disease progression. The immediate concern is the spillage of luminal contents, leading to acute peritonitis and a cascade of pathophysiological changes that require prompt intervention.

3.1 Evaluation of Non-Surgical Treatments

For cases where the perforation is small and quickly sealed by adhesion, symptoms and signs are mild, systemic disturbances are minimal, or high-risk factors such as advanced age and comorbidities are present, non-surgical treatment may be considered. However, most surgeons are reluctant to take this risk for several reasons:

1. A passive and negative mindset is prevalent, demanding rigorous and continuous observation and monitoring. The criteria for transitioning to surgical intervention are difficult to gauge, and the risk of delayed surgery could come at a significant cost.

2. Precise diagnosis in terms of localization and quantification is challenging. It is generally believed that duodenal ulcer perforations may self-seal, while conservative treatment for gastric ulcer perforations tends to be less effective.

3. Perforations due to gastric cancer necessitate further surgical intervention.

4. The underlying condition requires systematic examination and treatment after the acute phase, with at least half of the cases eventually requiring surgery. Additionally, the rate of re-perforation stands at 8.5%.

5. Post-treatment complications such as intra-abdominal abscesses and adhesions are possible.

Given these considerations, the majority of surgeons opt for surgical intervention.

Certainly, opting for surgical intervention carries risks associated with perioperative anesthesia, surgical trauma, and hemodynamic changes. However, the advantages often outweigh these concerns. Open surgery allows for a more accurate assessment of the nature and extent of the pathological changes, the status of intra-abdominal infection, as well as the location and size of the perforation. This enables a more targeted and proactive choice of surgical procedures. Furthermore, advancements in surgical techniques, improved monitoring measures, and the progress in antibiotics contribute to increasingly encouraging surgical outcomes.

3.2 Subtotal or Radical Gastrectomy

Whenever feasible, this should be the treatment of choice, boasting excellent therapeutic outcomes of 90%-95% for perforated ulcer diseases and a surgical mortality rate of less than 1%. It serves both diagnostic and therapeutic purposes. This approach is also suitable for treating perforations caused by gastric cancer. In cases of duodenal trauma followed by diverticulization, gastroenterostomy along with gastric resection is required. Out of the 37 gastrectomies performed in our study group, both short-term and long-term outcomes were favorable, except for cases of advanced gastric cancer where curative resection was not possible. The time elapsed since perforation should not be the sole criterion for selecting the surgical approach; rather, factors like the extent of edema and inflammation at the lesion site, as well as intra-abdominal infection, should also guide the choice. During gastrectomy, the lesion is removed, allowing for anastomosis on healthy tissue. In our group, four cases underwent this procedure 48 hours post-perforation and had smooth postoperative recoveries.

Of course, suturing techniques and comprehensive perioperative management are also crucial factors.

3.3 Perforation Repair

Since its inception by Von Heusner in 1892 and Bennett in 1896, perforation repair remains clinically valuable for life-saving measures even today. The procedure is characterized by its simplicity, minimal invasiveness, and safety, making it indispensable for high-risk patients. However, the technique is not without its drawbacks. Apart from the risks of postoperative bleeding and leakage, 50%–70% of patients ultimately require further surgical intervention or experience symptom recurrence. Illingworth reported that 40% of patients experienced symptom recurrence within one year and 70% within five years following perforation repair. Shi Huang reported that, in a long-term follow-up of 141 cases, 20% experienced bleeding, 9.2% had pyloric stenosis, and 4.7% suffered re-perforation. All five fatalities in our study group underwent this procedure. Moreover, perforation repair for gastric cancer provides only temporary relief and does not alter the disease course, with most patients succumbing to cancer within a year post-surgery.

The authors believe that this procedure should be strictly limited to the following conditions:

1. Severe peritonitis accompanied by shock.
2. Extensive edema around the perforation site, which could hinder the healing of anastomosis following gastrectomy.
3. Lost opportunity for palliative resection of the tumor.
4. Presence of other severe comorbidities or frailty due to advanced age, where any increase in surgical trauma would elevate the mortality risk.

Three technical aspects warrant special attention during perforation repair:

1. Care must be taken to avoid excessive inverting sutures, particularly in the pylorus and duodenum, to prevent iatrogenic stenosis.

2. Effective repair to prevent re-leakage is crucial. The first layer of sutures should be loosely approximated, followed by a second layer of seromuscular sutures for coverage, and then supplemented by an omental patch with an adequate blood supply.

3. In cases of traumatic duodenal rupture, if repair proves challenging, nearby organs such as the stomach, intestine, or gallbladder can be used, or a vascularized patch may be applied for suturing and sealing. However, this must be accompanied by thorough diverticulization to ensure proper drainage [5].  

References

[1] Shen Hongxun. Current Status and Progress in Surgical Treatment of Peptic Ulcers: Transportation Medicine 1991, 5(1): 26~

[2] Berne CT. Duodenal Diverticularization for Duodenal and Pancreatic Injury. Am J Surg. 1974, 127:503~

[3] Rodney Maingot. Abdominal Surgery. Shanghai: Science and Technology Press, 1965, pp. 244-247.

[4] Shi Huang. Simple Repair for Acute Gastric and Duodenal Ulcer Perforation. Chinese Journal of Surgery, 1964, 12:646.

[5] Jiang Kai, Pan Youlan, Li Mingjie.  Diagnosis and Treatment of Closed Retroperitoneal Injury of the Duodenum. Wuhu Medicine, 1997, 3(2): 9~

Li Mingjie
Changhang Hospital, Wuhu, Anhui Province, China
Surgical Department, Zip Code: 241000
Received: June 5, 1995; Revised: October 21, 1997
Originally published in the Chinese Journal of General Surgery, Supplement to Volume 6, December 6, 1997, pp. 22-23.

【李名杰从医66年论文专辑】（电子版）

【李名杰从医66年论文专辑（英语电子版）】