Gastrointestinal fiberscopic findings after simple closure for perforated duodenal ulcer in the early postoperative phase: from experience to evidence by evaluation of the healing process.
OBJECTIVE
Today, in light of widespread adoption of H2-RA and PPI, the standard surgical procedure for perforated duodenal ulcer (PDU) is simple closure and/or omental patch (SC). However, the healing process after these techniques has not been fully examined. We have not yet confirmed the propriety of simple suture of the bottom of the ulcer. This technique has been performed based only on experience, and there is insufficient evidence to conclude that this procedure can be definitively considered a safe therapeutic technique for the majority of patients with PDU. The aim of this study is to clarify the macroscopic findings of the healing process after SC for PDU.


METHODS
Thirteen patients with PDU who were treated with SC underwent postoperative gastroduodenal fiberscopy (GF) at the 7th-16th postoperative day and the healing process was monitored under sufficient informed consent. Patients with severe preoperative disease were excluded from the study. Healing condition of the ulcer and stitches, deformity, and stenosis were evaluated by postoperative endoscopy. Possible adverse effects that were evaluated included: perforation, rise in fever, worsening of inflammation on laboratory data, gastrointestinal symptoms such as abdominal pain, sense of fullness, and vomiting. The indications for SC were as follows: PDU with 1) no stenosis and 2) no prominent ulcer ridge. The surgical technique was as follows: 1) interrupted simple closure with no trimming and debridement of wound (4-5 stitches) with absorbable monofilament suture, and/or 2) omental patch, 3) administration of H2-RA (or PPI) just after operation, and 4) oral feeding 4-5 days after operation independent of postoperative GF.


RESULTS
GF findings in 2 patients showed active and healing stage, in whom surgical technique was thought to be insufficient; the ulcer had been large and included a descending portion, or a small perforation had occurred in the large ulcer bottom (the distance between the stitches and the edge of the ulcer was insufficient). In the other 11 patients, GF findings showed scar phase. There was no morbidity related to endoscopic procedure.


CONCLUSIONS
Sutured PDU with SC will be in the scar phase in 1 or 2 weeks. Postoperative GF 1 week after SC for PDU is thought to be a safe examination. This study is a primitive study of a small group, and more cases that can adequately show the frequency of complications and indicate the overall safety of the procedure are needed.
Moriwaki
Yoshihiro
Y
Critical Care and Emergency Center, Yokohama City University Medical Center, Japan. qqc3@urahp.yokohama-cu.ac.jp
Sugiyama
Mitsugi
M
Arata
Shinju
S
Yoshida
Kenichi
K
Yamagishi
Shigeru
S
Matsuda
Goro
G
Hasegawa
Satoshi
S
Kanaya
Koji
K
Yamamoto
Toshiro
T
Toyoda
Hiroshi
H
Kosuge
Takayuki
T
Uchida
Keiji
K
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004381:Duodenal Ulcer / Q000601:surgery*; D016099:Endoscopy, Gastrointestinal; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011184:Postoperative Period; D013536:Suture Techniques; D014945:Wound Healing