Choosing the appropriate patch repair based on the duodenal perforation size

Poris S, et al. Routine versus selective upper gastrointestinal contrast series after omental patch repair for gastric or duodenal perforation. Surg Endosc. 2018 Jan; 32(1):400-404.

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“Age greater than 60 years (p-0.0470, CI-0.76-31.54), pulse rate greater than 110/minute (p-0.0217, CI-1.04-34.48), systolic blood pressure less than 90 mm Hg (p-0.0016, CI-2.04-71.9), haemoglobin level less than 10 g/dl (p-0.0009, CI-2.25-135.02), serum albumin less than 2.5 grams/dl (p-0.0145, CI-1.21-38.31), total lymphocyte count less than 1800 cells/mm-3 (p-0.0003, CI-8.9-42.2), size of perforation greater than 5 mm (p-0.0011, CI-1.09-36.13) were identified as risk factors for releak. Serum albumin, hemoglobin and size of perforation were independent risk factors for prediction of releak on multivariate analysis. The anthropometric parameters namely mean triceps skin fold thickness, mean mid arm circumference and mean body mass index were all significantly less in cases as compared to controls. Releak was found to be a significant cause of death in patients with perforated duodenal ulcer. A total of 8 patients died in both the groups. The mortality rate in the releak group was 55.6% (5 out of 9 patients) compared to 2.7% (3 out of 110 patients) in the control group [p-0.0001].”

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Article of interest: Volvulus of the Small Bowel and Colon

Kapadia MR. Volvulus of the Small Bowel and Colon. Clin Colon Rectal Surg. 2017 Feb; 30(1):40-45.

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“Volvulus of the intestines involves twisting around a fixed point. It may occur anywhere along the gastrointestinal tract where there is a long, mobile intestinal segment with a narrow mesenteric attachment. Volvulus leads to luminal obstruction and can compromise intestinal blood flow. For this reason, it tends to be a surgical emergency which requires prompt attention. Failure to recognize the signs and symptoms of intestinal volvulus may lead to bowel ischemia and perforation.”

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Stomal necrosis

Murken DR, Bleier JIS. Ostomy-Related Complications. Clin Colon Rectal Surg. 2019 May;32(3):176-182.

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“Stomal necrosis has been reported to occur in up to 20% of ostomates in the immediate postoperative period ([Fig. 1]).[3] Specific risk factors for stoma necrosis include emergent operation, inadequate mobilization of the bowel, excessive mesenteric resection resulting in inadequate arterial blood supply to or venous drainage from the bowel, and constriction in the abdominal wall due to excessively small openings in the fascia, abdominal wall mesh, or skin.[10] [20] Importantly, the obese patient is seven times more likely to experience stoma necrosis than the nonobese patient.[21] Stoma necrosis is much less common for loop stomas given the dual blood supply to both the afferent and efferent limbs.”

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The management of perforated duodenal ulcers: operative vs non-operative?

Chung KT, Shelat VG. Perforated peptic ulcer – an update. World J Gastrointest Surg. 2017 Jan 27;9(1):1-12. doi: 10.4240/wjgs.v9.i1.1.

Mortality is a serious complication in PPU. As we mentioned before, PPU carries a mortality ranging from 1.3% to 20%[9,10]. Other studies have also reported 30-d mortality rate reaching 20% and 90-d mortality rate of up to 30%[11,12].

Significant risk factors that lead to death are presence of shock at admission, co-morbidities, resection surgery, female, elderly patients, a delay presentation of more than 24 h, metabolic acidosis, acute renal failure, hypoalbuminemia, being underweight and smokers[11,127-131]. The mortality rate is as high as 12%-47% in elderly patients undergoing PPU surgery[132-134]. Patients older than 65 year-old were associated with higher mortality rate when compared to younger patients (37.7% vs 1.4%)[131]. A study involving 96 patients with PPU also showed that there was a ninefold increase in postoperative complications in patients with comorbidities[119]. In another large population study, patients with diabetes had significantly increased 30-day mortality from PPU[135]. (Chung, 2017, p. 8)

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Open Mesh Vs. Lap Mesh Repair of Inguinal Hernia

Bullen NL, Massey LH, Antoniou SA, Smart NJ, Fortelny RH. Open versus laparoscopic mesh repair of primary unilateral uncomplicated inguinal hernia: a systematic review with meta-analysis and trial sequential analysis. Hernia. 2019; 23(3):461–472.

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RESULTS: This study included 12 randomised controlled trials with 3966 patients randomised to Lichtenstein repair (n = 1926) or laparoscopic repair (n = 2040). There were no significant differences in recurrence rates between the laparoscopic and open groups (odds ratio (OR) 1.14, 95% CI 0.51-2.55, p = 0.76). Laparoscopic repair was associated with reduced rate of acute pain compared to open repair (mean difference 1.19, CI - 1.86, - 0.51, p ≤ 0.0006) and reduced odds of chronic pain compared to open (OR 0.41, CI 0.30-0.56, p ≤ 0.00001). The included trials were, however, of variable methodological quality. Trial sequential analysis reported that further studies are unlikely to demonstrate a statistically significant difference between the two techniques.

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Article of interest: Long-term Results of a RCT of a Nonoperative Strategy (Watchful Waiting) for Men With Minimally Symptomatic Inguinal Hernias

This week’s discussion included what are the best treatment options for asymptomatic and symptomatic inguinal hernias.

Fitzgibbons RJ Jr, Ramanan B, Arya S, et al. Long-term results of a randomized controlled trial of a nonoperative strategy (watchful waiting) for men with minimally symptomatic inguinal hernias. Ann Surg. 2013;258(3):508–515.

Results: Eighty-one of the 254 men (31.9%) crossed over to surgical repair before the end of the original study, December 31, 2004, with a median follow-up of 3.2 (range: 2-4.5) years. The patients have now been followed for an additional 7 years with a maximum follow-up of 11.5 years. The estimated cumulative CO rates using Kaplan-Meier analysis was 68%. Men older than 65 years crossed over at a considerably higher rate than younger men (79% vs 62%). The most common reason for CO was pain (54.1%). A total of 3 patients have required an emergency operation, but there has been no mortality.

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