Open surgery vs laparoscopy
The number of patients who needed surgical intervention for complications of peptic ulcer, such as perforation, remained relatively unchanged [
45,
46].
Limiting surgical delay is of paramount importance in treating patients with PPU. In fact from the Danish Clinical Register of Emergency Surgery, a cohort study including 2668 patients showed that every hour of delay from admission to surgery was associated with an adjusted 2 · 4 per cent decreased probability of survival compared with the previous hour [
47].
Perforated peptic ulcer disease is a common abdominal disease and laparoscopic surgery has changed the way such emergencies are managed. Perforated peptic ulcer disease is a condition for which the laparoscopic approach has significant attractions. Laparoscopy allows the confirmation of the diagnosis and furthermore allows the identification of the position, site, and size of the ulcer [
27,
48,
49]. The procedure also allows closure of the perforation and adequate peritoneal toilette without the need for a large abdominal incision.
In the rare occurrence of large perforation with a severe contamination with food debris that can not be adequately removed laparoscopically, conversion may be required for complete peritoneal toilette. In such cases the perforation may be extensive and a resectional surgery may be needed.
Evidence for laparoscopic repair is equivocal [
50]. In available evidence, the results after laparoscopic repair are not clinically different from open surgery, and no difference is found in abdominal septic complications, pulmonary complications, or abdominal collections [
50]. The first randomized trial comparing laparoscopic and open repair of perforated peptic ulcer showed that the total operative time for laparoscopic repair was significantly increased but did result in a reduced requirement for postoperative analgesia [
50]. However, in the same study there was no significant difference found in NG tube drainage, intravenous fluid usage, hospital stay, and return to normal diet [
51]. More recent randomized, controlled trials have shown that laparoscopic repair is associated with shorter operative time, decreased postoperative abdominal drain use, reduced analgesic requirement, reduced hospital stay, earlier return to normal diet, and reduced morbidity [
27]. Laparoscopic repair allows a earlier removal of the abdominal drain, NG tube, and an earlier return to normal diet and mobilization. Even in recent studies, authors have noted an increased operative time [
52]; however, a recent study show, with experience, the time taken for laparoscopic repair can be comparable to open repair. Previous studies have shown a suture leak rate of 7% with laparoscopic repair; however, recent study demonstrate that this can be completely abolished and can be superior to open surgery, for which a leak rate of 2% has been reported [
52,
53]. In addition, the decrease in tissue dissection and the lack of large abdominal incision reduced the amount of opiate analgesia needed by patients. Lau et al. [
51] showed similar results in 100 patients, in whom there was a reduced requirement for opiate analgesia. In contrast to previous studies, there’s a significant decrease in hospital stay in patient who underwent laparoscopic surgery [
54] as well as a reduction in overall morbidity. Many authors have concluded that both open and laparoscopic repair of peptic ulcer are both effective treatments [
52].
Some authors state that laparoscopy is more dangerous in a situation of prolonged peritonitis [
55]. This is supported by the finding that pneumonia occurred more often in the laparoscopy group, although the duration of perforation was similar in both groups [
55]. Experimental animal studies [
56,
57] have revealed that the increased intra-abdominal pressure of carbon dioxide pneumoperitoneum is associated with an increased risk of bacteraemia and sepsis when the duration of peritonitis exceeds 12 h 27. Pneumonia may also be caused by increased bacterial translocation from the peritoneal cavity into the bloodstream, but there is no evidence to support this concept from clinical studies [
58]. There is not yet sufficient information about the outcome after open and laparoscopic repair in high-risk patients. Although risk levels (for example Boey score, Acute Physiology And Chronic Health Evaluation II) for perforated peptic ulcer affect the outcome after both open and laparoscopic repair, any outcome might still be improved by taking (or avoiding) one or other of the interventions. Some surgical centres [
59] have suggested choosing the more familiar open repair for high-risk patients, although there is no hard evidence that this is necessarily the better option. Lunevicius et al. suggest that laparoscopic repair is at least as safe and effective as open repair in terms of wound infection and mortality rates, and shorter hospital stays. The minimally invasive method is associated with a less painful recovery (balanced by a higher leak rate) and better cosmesis, fewer adhesions and incisional hernias, and better diagnostic potential. Patients with no Boey risk factors (prolonged perforation for more than 24 h, shock on admission and confounding medical conditions, defined as ASA grade III–IV) should benefit from laparoscopic repair [
33].
Sanabria A. et al. in collaboration with the Cochrane library has made a review in 2010. They showed that there was a tendency to a decrease in septic intra-abdominal complications, surgical site infection, postoperative ileus, pulmonary complications and mortality with laparoscopic repair compared with open surgery, none of these were statistically significant. However, there was a tendency to an increase in the number of intra-abdominal abscesses and re-operations, but without statistical significance. This finding could be related to surgeon experience in laparoscopic surgery. It is not possible to draw any conclusions about suture dehiscence and incisional hernia with the two procedures [
60]. Recently Guadagni et al. suggests that laparoscopic repair for PPU is feasible but skill in laparoscopic abdominal emergencies are required. Perforations 1.5 cm or larger, posterior duodenal ulcers should be considered the main risk factors for conversion [
61].
Comparing laparoscopic versus open repair for PPU, Byrge N et al. has showed that in the laparoscopic group the rates of wound complications, organ space infections, prolonged ventilation, postoperative sepsis, return to the operating room, and mortality tended to be lower for the LA, although not significantly. Length of hospital stay was, however, significantly shorter for the laparoscopic repair. The authors concluded that laparoscopy is safe in mild to moderately ill patients with perforated peptic ulcer and may allow a reduced use of hospital resources [
62].
Laparoscopy allows the surgeon to explore and wash out the entire peritoneal cavity and it is therefore a powerful diagnostic tool. The benefits of less postoperative pain, shorter length of hospital stay and earlier return to work after laparoscopic surgery for perforated peptic ulcer may offset the costs needed for performing laparoscopic repair.
Laparoscopic repair also offers the advantage of better cosmesis.
We recommend laparoscopic approach to hemodynamically stable patients with free air at X-ray and/or CT for diagnostic purposes.
We suggest laparoscopic repair of PPU in stable patients with PPU <5 mm in size and in presence of appropriate laparoscopic skills.
We recommend laparoscopy for achieving a better intraperitoneal lavage, even in presence of diffuse peritonitis.
We suggest that laparoscopy may improve patients’ outcome with significantly lower morbidity.
We recommend open surgery in presence of septic shock or in patients with absolute contraindications for pneumoperitoneum.
We suggest open surgery in presence of perforated and bleeding peptic ulcers, unless in stable patients with minor bleeding and in presence of advanced laparoscpic suturing skills (Additional file
1
: Video 1).
We suggest use of intra-operative methylene blue via NG tube for precise localization of microscopic perforations (Additional file
2
: Video 2).
Primary repair vs sutureless
Laparoscopic sutureless repair was shown to take a significantly shorter time than laparoscopic suture repair. Laparoscopic sutureless repair has the advantage over laparoscopic suture repair because is technically much less demanding. The technique can be easily performed by those who have limited experience with laparoscopic surgery [
63].
It is arguable if there are standard laparoscopic procedures to treat PPU. Sutureless repair was once considered as safe as suture repair [
63] but it carried extra-costs such as the use of fibrin glue. Although the rationale of this sutureless technique was to simplify the procedure and shorten operative time, it did not gain wide acceptance owing to its high leakage rate as compared to suture repair (16–6%) [
64]. Siu et al. [
65] proposed a technique of closing the ulcer with a single stitch plus omental patch for small perforations (i.e. \10 mm). They obtained satisfactory results with a conversion rate of only 7.4% [
66,
27]. Song et al. [
67] further simplified the method by suturing the perforation without knotting followed by tying the suture over an omental patch. Although simple and effective by avoiding applying suture on fragile edge, the draw back was that no further rescue maneuver could be made if the single stitch was tied without good security. Ates et al. [
68] compared the results of laparoscopic simple closure without omental patch with that of conventional open repair in patients with small perforated duodenal ulcer and prove that is was as safe and as effective. On the other hand, Turner et al. [
69] reported that suture without an omental patch would result in a significantly higher mortality rate than with a patch. However, most cases in their series were perforated gastric ulcers instead of juxta-pyloric perforation. Finally, Lunevicius et al. [
70] reviewed 13 prospective and 12 retrospective studies and concluded that repair method should best be judged by the properties of the ulcer edge. In short, although it seems that no single method is considered being the standard, the literature showed that there were no differences between these two most common adopted procedures in terms of postoperative recovery and incidence of surgical complications. To summarize, laparoscopic simple closure alone without adding an omental patch is a safe procedure for juxtapyloric perforation in low risk patients. In terms of leakage rate and surgical outcome, the manoeuver to cover an omental patch on the repaired PPU did not show any additional advantage [
71].
We suggest that Laparoscopic sutureless repair may be a viable option in presence of limited laparoscopic experience, only in presence of small size perforations (i.e. microscopic or <2 mm perforations) without significant peritoneal contamination and for low risk patients.
We recommend primary repair in case of perforated peptic ulcer larger than 5 mm and smaller than 2 cm (Additional file
3
: Video 3).
We suggest routine use omental patch to further protect the suture line (see Additional file
3
: Video 3).
We recommend avoiding use of glue as only method of closure of PPU.
We suggest use of glue only as an adjunctive measure to protect suture line or the omental patch.
We suggest avoiding use of glue because of increased costs and risks of complications if serious doubts exist on the efficacy of primary closure.
We suggest conversion to open procedure if the primary repair is deemed to be done not efficaciously.
Resectional surgery
The resection surgery is a viable option for giant peptic ulcers, commonly defined as having a diameter greater than 2 cm. These lesions have a higher risk of perforation. In gastric lesions, although the risk of malignancy is less than historically predicted, the incidence is still around 10% [
72,
73]. There are no specific surgical treatment recommendations since the site of perforation and the secondary effects on the surrounding anatomical structures must direct the necessary interventions. These patients are also frequently in septic shock upon presentation when the amount of peritoneal spillage is large. This factor alone should significantly influence the choice of operative intervention. Giant gastric ulcers are most commonly located on the lesser curvature and will often require an antrectomy and reconstruction. For perforated giant duodenal ulcers, the defect is often too large to perform a primary repair. Leak rates of up to 12% have been reported from attempted closure with an omental patch procedure [
74]. The proximity of the defect and its relation to the common bile duct and ampulla of Vater must also be thoroughly investigated. Intraoperative cholangiography may even be necessary to verify common bile duct anatomy. There are several different procedures that have been described for duodenal defects such as a jejunal serosal patch, tube duodenostomy, and several variations of omental plugs antrectomy with diversion is the classic and most commonly described intervention, if the ampullary region is not involved. Affected patients are often in extremis at the time of presentation, and therefore a damage control procedure will likely be the safest and most appropriate operation for the patient. An antrectomy, with resection of the duodenal defect for duodenal ulcers proximal to the ampulla, will allow a definitive control of the spillage. Depending upon the location of the duodenal defect, closure and diversion via antrectomy may be the safest method for damage control.
The proximal gastric remnant should be decompressed with a nasogastric tube placed intraoperatively with verification of its correct position. Anastomoses should be avoided in presence of hypotension or hemodynamic instability, especially if the patient requires vasopressors. After copious abdominal irrigation, a temporary abdominal closure device can be placed. The patient can then be resuscitated appropriately in the ICU. The surgeon can return to the OR for re-exploration, restoration of continuity, possible vagotomy, and closure of the abdomen once the patient is hemodynamically stable [
75].
We suggest resectional surgery in case of perforated peptic ulcer larger than 2 cm (Additional file
4
: Video 4)
We suggest resectional surgery in presence of malignant perforated ulcers or high risk of malignancy (e.g. large ulcers, endoscopic features of malignancy, presence of secondary lesions or suspected metastases, etc.) (Additional file
4
: Video 4).
We suggest resectional surgery in presence of concomitant significant bleeding or stricture.
We suggest use of techniques such as jejunal serosal patch or Roux en-Y duodenojejunostomy or pyloric exclusion to protect the duodenal suture line, in case of large post-bulbar duodenal defects not amenable to resection (i.e. close to or below the ampulla).
Whenever possible (i.e. stable patient), in case of repair of large duodenal ulcer, we suggest to perform a cholecistectomy for external bile drainage (e.g. via trans-cystic tube).
We suggest duodenostomy (e.g. over Petzer tube) only as an extreme option, in presence of giant duodenal ulcers with severe tissue inflammation and when mobilization of the duodenum is not possible and the patient is in severe septic shock/hemodynamic instability.