Gastroduodenal Ulcer

  • Antonino Mirabella
  • Massimo Lupo
  • Fausto Di Marco
  • Vincenzo Mandalà
Part of the Updates in Surgery book series (UPDATESSURG)


The advent of more effective and tolerable drugs (H2 antagonists, proton pump inhibitors, antibiotics for Helicobacter pylori, HP, infection) in the treatment of the peptic ulcer has brought about a radical change in the surgical approach to ulcer disease. In fact we can observe an increasing election for minor surgery and a progressive increase in the treatment in emergency for perforating complications. This figure is likely to be attributed on the one hand to the number of surgical indications and on the other to the increasingly widespread use of nonsteroid anti-inflammatory drugs (NSAIDs), especially in the elderly, where surgery has progressively increased in recent years. The peptic ulcer remains the most common cause of gastroduodenal perforation with an incidence ranging from 2% to 10% of the patients with a peptic ulcer [1] and, consequently, the treatment of a perforated peptic ulcer (PPU) remains today the most frequent indication for gastric emergency surgery [2]. The progress of medical treatment, and in particular the radical treatment of HP, has gradually decreased the use of major gastric surgery. Resective treatment (so-called acid-reduction treatment) has decreased as have recurrences of ulcerative disease, and consequently the need for re operation. Considering these conditions the mini-invasive technique, as in other fields, has been adopted to treat a perforated peptic ulcer.


Fibrin Glue Intraabdominal Abscess Perforated Peptic Ulcer Omental Flap Traditional Surgery 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Lui FY, Davis KA (2010) Gastroduodenal perforation: maximal or minimal intervention? Scand J Surg 99:73–77PubMedGoogle Scholar
  2. 2.
    Lagoo S, McMahon RL, Kalkharu M et al (2002) The sixth decision regarding perforated duodenal ulcer. JSLS 6:359–368PubMedGoogle Scholar
  3. 3.
    Mouret J, Francois Y, Vignal J et al (1990) Laparoscopic treatment of perforated duodenal ulcer. Br J Surg 77:1006PubMedCrossRefGoogle Scholar
  4. 4.
    Nathanson LK, Easter DW, Cuschieri A (1990) Laparoscopic repair peritoneal toilette of perforated duodenal ulcer. Surg Endosc 4:232–233PubMedCrossRefGoogle Scholar
  5. 5.
    Sanabria AE, Morales CH, Villegas MI (2005) Laparoscopic repair for perforated peptic ulcer disease. Cochrane Database Syst Rev 4:CD004778PubMedGoogle Scholar
  6. 6.
    Sanabria AE, Morales CH, Villegas MI (2005) Laparoscopic repair for perforated peptic ulcer disease. The Cochrane Library 4[Last assessed as up-to-date: March 9 2010] DOI: 10.1002/14651858.CD004778.pub2Google Scholar
  7. 7.
    Lau H (2004) Laparoscopic repair of perforated peptic ulcer. A meta-analysis. Surg Endosc 18:1013–1021PubMedGoogle Scholar
  8. 8.
    Lunevicius R, Morkevicius M (2005) Systemic review comparing laparoscopic and open repair for perforated peptic ulcer. Br J Surg 92:1195–1207PubMedCrossRefGoogle Scholar
  9. 9.
    Bertleff M, Halm JA, Bemelman WA et al (2009) Randomized clinical trial of laparoscopic versus open repair of the perforated peptic ulcer: the LAMA trial. World J Surg 33:1368–1373PubMedCrossRefGoogle Scholar
  10. 10.
    Siu WT, Leong HT, Law BKB et al (2002) Laparoscopic repair for perforated peptic ulcer: a randomized controlled trial. Ann Surg 235:313–319PubMedCrossRefGoogle Scholar
  11. 11.
    Lau WY, Leung KL, Kwong KH et al (1996) A randomized study comparing laparoscopic versus open repair of perforated peptic ulcer using suture or sutureless technique. Ann Surg 224:131–138PubMedCrossRefGoogle Scholar
  12. 12.
    Lunevicius R, Morkevicius M (2005) Management strategies, early results, benefits and risk factors of laparoscopic repair of perforated peptic ulcer. World J Surg 29:1299–1310PubMedCrossRefGoogle Scholar
  13. 13.
    Bertleff M, Lange JF (2010) Laparoscopic correction of perforated peptic ulcer: first choice? A review of literature. Surg Endosc 24:1231–1239PubMedCrossRefGoogle Scholar
  14. 14.
    Kakhry S, Watts D, Daley B et al (2001) Current diagnostic approach lack sensitivity in the diagnosis of perforating blunt small bowel injury (SBI): findings from a large multi-institutional trial. J Trauma 51:1232Google Scholar
  15. 15.
    Schein M (2010) Perforated peptic ulcer. In: Schein M, Rogers PN, Assalia A (eds) Schein’s common sense emergency abdominal surgery, Springer, Berlin Heidelberg, pp 157–166CrossRefGoogle Scholar
  16. 16.
    Miller RE, Nelson SW (1971) The roentgenologic demonstration of tiny amounts of free intarperitoneal gas: experimental and clinical studies. AJR Am J Roentgenol 112:574–585Google Scholar
  17. 17.
    Chen SC, Wang HP, Chen WJ (2002) Selective use of ultrasonography for the detection of pneumoperitoneum. Acad Emerg Med 9:643–645PubMedCrossRefGoogle Scholar
  18. 18.
    Phatak Mg, Frank SJ, Ellis JJ (1984) Computed tomography of bowel perforation. Gastrointest Radiol 9:133–135PubMedCrossRefGoogle Scholar
  19. 19.
    Cho KC, Baker SR (1994) Extraluminal air: diagnosis and significance. Radiol Clin North Am 32:829–844PubMedGoogle Scholar
  20. 20.
    Stapakis JC, Thickman D (1992) Diagnosis of pneumoperitoneum: abdominal CT vs upright chest film. J Comput Assist Tomogr 16:713–716PubMedCrossRefGoogle Scholar
  21. 21.
    Earls JP, Dachaman AH, Colon E et al (1993) Prevalence and duration of postoperative pneumoperitoneum: sensitivity of CT vs left lateral decubits radiography. AJR 161:781–785PubMedGoogle Scholar
  22. 22.
    Chen CH, Huang HS, Yang CC, Yeh YH (2001) Features of perforated peptic ulcers in conventional computed tomography. Hepatogastroenterology 48:1393–1396PubMedGoogle Scholar
  23. 23.
    Fultz PJ, Skucas J, Weiss SL (1992) CT in upper gastrointestinal tract perforations secondary to peptic ulcer disease. Gastrointest Radiol 17:5–8PubMedCrossRefGoogle Scholar
  24. 24.
    Hainaux B, Agneessen E, Bertinotti R et al (2006) Accuracy of MDCT in predicting site of gastrointestinal tract perforation. AJR 187:1179–1183PubMedCrossRefGoogle Scholar
  25. 25.
    Imuta M, Awai K, Nakayama Y et al (2004) Multidetector CT findings suggesting a perforation site in the gastrointestinal tract: analysis in surgical confirmed 155 patients. Imaging 28:334–339Google Scholar
  26. 26.
    Rice RP, Thompson WM, Gedgaudas RK (1982) The diagnosis and significance of extraluminal gas in the abdomen. Radiol Clin North Am 20:819–837PubMedGoogle Scholar
  27. 27.
    Cho HS, Yoon SE, Park SH et al (2009) Distinction between upper and lower gastrointestinal perforation. Usefulness of the periportal free air sign on computed tomography. Eur J Radiol 69:108–113PubMedCrossRefGoogle Scholar
  28. 28.
    Ghekiere O, Lesnik A, Hoa D et al (2007) Value of computed tomography in the diagnosis of the cause of non traumatic gastrointestinal tract perforation. J Comput Assist Tomogr 31:169–176PubMedCrossRefGoogle Scholar
  29. 29.
    Maniatis V, Chryssikopoulos H, Roussakis A et al (2000) Perforation of the alimentary tract: evaluation with computed tomography. Abdom Imaging 25:373–379PubMedCrossRefGoogle Scholar
  30. 30.
    Brenner DJ, Hall EJ (2007) Computed tomography: an increasing source of radiation exposure. N Engl J Med 357:2277–2284PubMedCrossRefGoogle Scholar
  31. 31.
    Moriwaki Y, Sugiyama M, Toyoda H (2009) Ultrasonography for the diagnosis of the intraperitoneal free air on chest-abdominal-pelvic blunt trauma and critical acute abdominal pain. Arch Surg 144:137–141PubMedCrossRefGoogle Scholar
  32. 32.
    Singh JP, Steward MJ, Booth TG et al (2010) Evolution of imaging for abdominal perforation. Ann R Coll Surg Engl 92:182–188PubMedCrossRefGoogle Scholar
  33. 33.
    Agresta F, Mazzarolo G, Ciardo LF, Bedin N (2005) The laparoscopic approach in abdominal emergiencies: has the attitude changed? A single-center review of a 15 year experience. Surg Endosc 22:1255–1262CrossRefGoogle Scholar
  34. 34.
    Bhogal R, Athwal R, Durkin D et al (2008) Comparison between open and laparoscopic repair of perforated peptic ulcer disease. Worl J Surg 32:2371–2374CrossRefGoogle Scholar
  35. 35.
    Ates M, Coban S, Sevil S, Terzi A (2008) The efficacy of laparoscopic surgery in patients with peritonitis. Surg Laparosc Endosc Percutan Tech 18:453–456PubMedCrossRefGoogle Scholar
  36. 36.
    Boey J, Wong J (1987) Perforated duodenal ulcers. World J Surg 11:319–324PubMedCrossRefGoogle Scholar
  37. 37.
    Lunevicius R, Morkevicius M (2005) Comparison of laparoscopic versus open repair for perforated duodenal ulcers. Surg Endosc 19:1565–1571PubMedCrossRefGoogle Scholar
  38. 38.
    Katkhouda N, Mavor E, Mason RJ et al (1999) Laparoscopic repair of perforated duodenal ulcers: outcome and efficacy in 30 consecutive patients. Arch Surg 134:845–850PubMedCrossRefGoogle Scholar
  39. 39.
    Robertson GS, Wemyss-Holden SA, Maddern GJ (2000) Laparoscopic repair of perforated duodenal ulcers. The role of laparoscopy in generalized peritonitis. Ann R Coll Surg Engl 82:6–10PubMedGoogle Scholar
  40. 40.
    Vaidya BB, Garg CP, Shah JP (2009) Laparoscopic repair of perforated peptic ulcer with delayed presentation. J Laparosc Adv Surg Tech 19:153–156CrossRefGoogle Scholar
  41. 41.
    Lee FY, Leung KL, Lai BS et al (2001) Predicting mortality and morbility of patients operated on for perforated peptic ulcers. Arch Surg 136:90–94PubMedCrossRefGoogle Scholar
  42. 42.
    Walsh CJ, Khoo DE, Motson RW (1993) Laparoscopic repair of perforated peptic ulcer. Br J Surg 80:127PubMedGoogle Scholar
  43. 43.
    Wemyss-Holden S, White SA, Robertson G, Lloyd D (2002) Color coding of sutures in laparoscopic perforated duodenal ulcer: a new concept. Surg Laparosc Endosc Percutan Tech 12:177–179PubMedCrossRefGoogle Scholar
  44. 44.
    Matsuda M, Nishiyama M, Hanai T et al (1995) Laparoscopic omental patch repair for perforated peptic ulcer. Ann Surg 221:236–240PubMedCrossRefGoogle Scholar
  45. 45.
    Guglielminotti P, Bini R, Fontana D, Leli R (2009) Laparoscopic repair for perforated peptic ulcers with U-CLIP. World J Emerg Surg 4:28PubMedCrossRefGoogle Scholar
  46. 46.
    Darzi A, Chesire NJ, Somers SS (1993) Laparoscopic omental patch repair with an automated stapler. Br J Surg 80:1552PubMedCrossRefGoogle Scholar
  47. 47.
    Costalat G, Alquier Y (1995) Combined laparoscopic and endoscopic treatment of perforated gastroduodenal ulcers using the ligamentum teres hepatis. Surg Endosc 9:677–679PubMedCrossRefGoogle Scholar
  48. 48.
    Tate JJT, Dawson JW, Lau WY et al (1993) Sutureless laparoscopic treatment of perforated duodenal ulcer. Br J Surg 80:235PubMedCrossRefGoogle Scholar
  49. 49.
    Tate JJT, Dawson JW, Lau WY et al (1993) Sutureless laparoscopic treatment of perforated duodenal ulcer. Br J Surg 80:235PubMedCrossRefGoogle Scholar
  50. 50.
    Bertleff M, Stegmann T, Liem R et al (2009) Comparison of closure of gastric perforation ulcers with biodegradable lactide-glycolide-caprolactone or omental patches. JSLS 13:550–554PubMedCrossRefGoogle Scholar
  51. 51.
    Druart ML, Van Hee R, Etienne J et al (1997) Laparoscopic repair of perforated duodenal ulcer. A prospective multicenter clinical trial. Surg Endosc 11:1017–1020PubMedCrossRefGoogle Scholar
  52. 52.
    Siu WT, Chau CH, Law BKB et al (2004) Routine use of laparoscopic repair for perforated peptic ulcer. Br J Surg 91:481–484PubMedCrossRefGoogle Scholar
  53. 53.
    Cellan-Jones CJ (1929) A rapid method of treatment in perforated duodenal ulcer. BMJ 1:1076–1077.PubMedCrossRefGoogle Scholar
  54. 54.
    Petrowsky H, Demartines N, Rousson V, Clavien PA (2004) Evidence-based value of prophylactic drainage in gastrointestinal surgery. A systematic review and meta-analyses. Ann Surg 240:1074–1085PubMedCrossRefGoogle Scholar
  55. 55.
    Naegaard JM, Edwin B, Reiertsen O et al (1999) Laparoscopic and open operation in patients with perforated peptic ulcer. Eur J Surg 165:209–214CrossRefGoogle Scholar
  56. 56.
    Adachi Y, Mori M, Maehara Y et al (1997) Surgical results of perforated gastric carcinoma: an analysis of 155 Japanese patients. Am J Gastroenterol 92:516–548PubMedGoogle Scholar
  57. 57.
    Roviello F, Rossi S, Marrelli D et al (2006) Perforated gastric carcinoma: a report of 10 cases and review of the literature. World J Surg Oncol 4:19PubMedCrossRefGoogle Scholar
  58. 58.
    Miserez M, Eypasch E, Spangenberger W et al (1996) Laparoscopic and conventional closure of perforated peptic ulcer: a comparison. Surg Endosc 10:831–836PubMedCrossRefGoogle Scholar
  59. 59.
    Pappas TN, Lagoo SA (2002) Laparoscopic repair for perforated peptic ulcer. Ann Surg 235:320–321PubMedCrossRefGoogle Scholar
  60. 60.
    Aird I (1935) Perforation of carcinoma of the stomach into the general peritoneal cavity. Br J Surg 22:545–554CrossRefGoogle Scholar
  61. 61.
    Lee HJ, Park DJ, Yang HK et al (2006) Outcome after emergency surgery in gastric cancer patients with free perforation or severe bleeding. Dig Surg 23:217–223PubMedCrossRefGoogle Scholar
  62. 62.
    Lehnert T, Buhl K, Dueck M et al (2000) Two-staged radical gastrectomy for perforated gastric cancer. Eur J Surg Oncol 26:780–784PubMedCrossRefGoogle Scholar
  63. 63.
    Kitakado Y, Tanigawa N, Muraoka R (1997) A case report perforated early gastric cancer. Nippon Geka Hokan 66:86–90PubMedGoogle Scholar
  64. 64.
    Kasakura Y, Ajai JA, Mochizuki F et al (2002) Outcomes after emergency surgery for gastric perforation or severe bleeding in patients with gastric cancer. J Surg Oncol 7:219–224Google Scholar
  65. 65.
    So JB, Yam A, Cheah WK et al (2000) Risk factors related to operative mortality and morbility in patients undergoing emergency gastrectomy. Br J Surg 87:1702–1707PubMedCrossRefGoogle Scholar
  66. 66.
    Gertsch P, Yip SK, Chow LW, Launder IJ (1995) Free perforation of gastric carcinoma. Arch Surg 130: 177–181PubMedCrossRefGoogle Scholar
  67. 67.
    Taylor H (1957) The non-surgical treatment of perforated peptic ulcer. Gastroenterology 33:353–368PubMedGoogle Scholar
  68. 68.
    Croft TJ, Kenneth GM, Park MB (1989) A randomized trial of non operative treatment for perforated duodenal ulcer. N Engl J Med 320:970–973CrossRefGoogle Scholar
  69. 69.
    Marshall C, Ramanswamy P, Bergin FG et al (1999) Evaluation of a protocol for the nonoperative management of perforated peptic ulcer. Br J Surg 86:131–134PubMedCrossRefGoogle Scholar
  70. 70.
    Bucher P, Oulbaci W, Morel P et al (2007) Results of conservative treatment for perforated gastroduodenal ulcer in patients not eligible for surgical repair. Swiss Med WKLY 137:337–340PubMedGoogle Scholar
  71. 71.
    Notashi AY, Salimi J, Rahimian H et al (2005) Evaluation of Mannheim Peritonitis Index and multiple failure score in patients with peritonitis. Ind J Gastroenterol 24:197–200Google Scholar

Suggested Readings

  1. Sauerland S, Agresta F, Bergamaschi R, Borzellino G, Budzynski A, Champault G, Fingerhut A, Isla A, Johansson M, Lundorff P (2006) Laparoscopy for abdominal emergencies. Evidencebased guidelines of the European Association for Endoscopic Surgery. Surg Endosc 20:14–29PubMedCrossRefGoogle Scholar
  2. Agresta F, Ansaloni L, Baiocchi L, Bergamini C, Campanile FB, Carlucci M, Cocorullo G, Corradi A, Franzato B, Lupo M, Mandalà V, Mirabella A, Pernazza G, Piccoli M, Staudacher C, Vettoretto N, Zago M, Lettieri E, Levati A, Pietrini D, Scaglione M, De Masi S, De Placido G, Francucci M, Rasi M, Scaramuzza G, Del Favero AL (2011) Consensus Development Conference of the Società Italiana Chirurgia Endoscopica e nuove tecnologie (SICE); Associazione Chirurghi Ospedalieri Italiani (ACOI); Società Italiana di Chirurgia (SIC); Società Italiana Chirurgia d’Urgenza e Trauma (SICUT), Società Italiana Chirurghi dell’Ospedalità Privata (SICOP) and the European Association for Endoscopic Surgery (EAES). In pressGoogle Scholar

Copyright information

© Springer-Verlag Italia 2012

Authors and Affiliations

  • Antonino Mirabella
    • 1
  • Massimo Lupo
  • Fausto Di Marco
  • Vincenzo Mandalà
  1. 1.Department of General and Emergency Surgery“Villa Sofia — Cervello” Hospital TrustPalermoItaly

Personalised recommendations