Small Bowel: The Problematic Duodenal Perforation

Abstract

While the overall incidence of acid-peptic ulcer disease continues to decrease, perforated duodenal ulcers continue to occur. This is particularly true in elderly patients where the incidence of infection with Helicobacter pylori is the highest, and there is increasing usage of NSAIDs. Small (<1 cm) soft perforated ulcers of the anterior duodenum are closed primarily or with a viable omental plug by a laparoscopic approach in the modern era. When there are contraindications to laparoscopy, when anti-Helicobacter therapy has failed, or when a large (2 cm) anterior perforation is present, an exploratory laparotomy is usually performed. Excision of the ulcer locally and closure as a pyloroplasty is a simple definitive approach, with or without truncal vagotomy. Another definitive operation is antrectomy, partial duodenectomy, and a gastroduodenostomy or gastrojejunostomy. Either primary closure or the insertion of a duodenostomy tube is performed, as well