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Background: The incidence of peptic ulcers has decreased during the last decades; the COVID-19 pandemic may have influenced the peptic ulcer hospitalizations. The study aimed to assess the admissions and mortality for complicated and uncomplicated peptic ulcers and the influence of the pandemic period. Material and Methods: We performed an observational study at a tertiary academic center, including all patients admitted for peptic ulcers between 2017-2021. We evaluated the admissions for complicated and uncomplicated ulcers and risk factors for mortality. Results: 1416 peptic ulcers were admitted, with an equal proportion of gastric and duodenal ulcers; most patients were admitted for bleeding (66.7%), and perforation (17.3%). We noted a decreasing trend for peptic bleeding ulcer (PUB) and uncomplicated ulcer admissions during 2020-2021, while for perforation no significant variation was recorded; a decreasing mortality in PUB was noted from 2017 to 2020. Admissions for bleeding peptic ulcer have decreased by 36.6% during the pandemic period; the mortality rate was similar. Admissions for perforated peptic ulcer have decreased by 14.4%, with a higher mortality rate during the pandemic period (16.83 versus 6.73%). Conclusion: A decreasing trend for PUB admissions but not for perforated ulcers was noted. Admissions for PUB have decreased by more than 1/3 during the pandemic period, with a similar mortality rate. Admissions for perforated peptic ulcers have decreased by 1/7, with significantly higher mortality rates during the pandemic period., (Celsius.)

Duodenal ulcer perforation in patients undergoing gastric bypass surgery is a rare late complication, occurring in less than 1% of cases. It carries a high mortality risk, particularly in cases of delayed diagnosis. The challenge lies in an unspecific clinical presentation and laboratory findings, as well as a CT scan not very helpful in almost half of cases. These features may lead to the consideration of other differential diagnoses, such as pancreatitis or cholecystitis. A multidisciplinary approach in collaboration with digestive surgeons is essential to enable rapid exploratory laparoscopy in presence of diagnostic uncertainty, and appropriate therapeutic management.

Abstract: Gastroduodenal perforation commonly due to spontaneous perforation of a pre-existing peptic ulcer is a surgical emergency. On laparotomy, approximately 60%-70% perforations are duodenal and 15%-20% gastric. The most prevalent etiology are Helicobacter pylori infection in 65%-70% and non-steroidal anti-inflammatory drugs (NSAIDS) abuse in 30%-50% cases depending on the prevalence of H. pylori infection. We report here the autopsy findings in a 29-year-old male who collapsed suddenly in the emergency room of our hospital after a bout of massive hematemesis., (Copyright © 2024 Copyright: © 2024 Indian Journal of Pathology and Microbiology.)

Objective: To compare clinical and operative results between laparoscopic primary repair (LPR) alone and LPR with highly selective vagotomy (LPR-HSV) in patients with duodenal ulcer perforation., Methods: Clinical data from patients who underwent either LPR or LPR-HSV by resecting both sides of the neurovascular bundle using an ultrasonic or bipolar electrosurgical device for duodenal ulcer perforations, between 2010 and 2020, were retrospectively collected. Between-group differences in continuous and categorical variables were statistically analysed., Results: Data from 184 patients (mean age, 49.6 years), who underwent either LPR ( n  = 132) or LPR-HSV ( n  = 52) were included. The mean operation time was significantly longer in the LPR-HSV group (116.5 ± 39.8 min) than in the LPR group (91.2 ± 33.3 min). Hospital stay was significantly shorter in the LPR-HSV group (8.6 ± 2.6 days) versus the LPR group (11.3 ± 7.1 days). The mean postoperative day of starting soft fluid diet was also significantly shorter in the LPR-HSV group (4.5 ± 1.4 days) than in the LPR group (5.6 ± 4 days). No between-group difference in morbidity rate was observed. The learning curve of the HSV procedure showed a stable procedure time after 10 operations., Conclusions: LPR with HSV may be a safe and feasible procedure for selective cases who are at high risk for ulcer recurrence., Competing Interests: Declaration of conflicting interestsThe authors declare that there are no conflicts of interest.

Peptic ulcer disease causing perforation is extremely rare in children and primarily affects teenagers. We present a case of a perforated peptic ulcer in a 6-year-old with abdominal pain and emesis with CT findings of moderate pneumoperitoneum and pelvic free fluid without a distinct cause. He was emergently transferred, found to be peritonitic, and taken to the operating room for diagnostic laparoscopy revealing an anterior duodenal ulcer, and underwent laparoscopic Graham patch repair. Postoperatively, the child had positive fecal antigen for H. pylori. He was treated with triple therapy and underwent subsequent testing to confirm eradication. Perforated peptic ulcer is an uncommon pediatric surgical problem, and imaging may not be diagnostic as in the case presented here. Thus, clinicians need to maintain a high index of suspicion when evaluating children with free air and a surgical abdomen in the setting of long-standing abdominal pain.

Duodenal ulcer perforation, a frequent surgical emergency, needs simple closure with indirect Graham's Omentopexy which is effective with excellent results in majority of cases despite patients' late presentation. The objective of the study was to determine the frequency of postoperative complications of perforated duodenal ulcer, conducted in the Surgery Department, Jinnah Postgraduate Medical Centre, Karachi, from March 20, 2018 to September 20, 2018. The study was a descriptive case series of 108 patients of both genders with perforated duodenal ulcer > 1 week old with ASA score I & II. Patients with trauma and comorbidities were excluded. The patients underwent laparotomy and peritoneal toilet, and after noting the site of perforation indirect Graham's Omentopexy was performed. Complications like duodenal fistula, peritonitis, and paralytic ileus, and patient's death within 10 days of surgery were noted. Age ranged from 18 to 50 years with mean age of 35.027±5.13 years, mean weight 71.120±12.77 kg, mean height 1.541 ±0.09 metres, mean BMI 29.975±4.99 kg/m2, and the mean duration of complaint was 4.194±1.30 weeks. Male predominance in 75 (69.4%) patients. Duodenal fistula was seen in 10 (9.3%) patients, peritonitis 12 (11.1%), paralytic ileus 14 (13%) and mortality was in 11 (10.2%) patients.

Rapunzel syndrome is a rare clinical entity in which a trichobezoar is produced by the ingestion of hair at the gastric level, extending in the form of a tail towards the duodenum. It occurs in young patients with trichotillomania and trichophagia. We present the case of a 24-year-old woman with a history of anxiety without treatment, who for 10 years presented trichotillomania and trichophagia, producing a picture of intestinal obstruction that required surgical intervention, evidencing a giant Trichobezoar throughout the gastric cavity and one jejunum associated with diastatic perforation. duodenal.

Aims: Duodenal ulcer perforations are frequently encountered but there is limited literature regarding risk factors for leak after omentopexy., Methodology: The record of 100 patients of duodenal ulcer perforation undergoing omentopexy by open approach was prospectively maintained to identify any significant factors contributing towards leak., Results: Out of 100 patients undergoing omentopexy, 9 (9%) developed leak; when leak occurred, the mortality was very high (44.4%). Patients who developed leak (09) were compared against those who did not (91), and it was seen that seen that duration of symptoms before surgery (> 3 days), amount of intra-abdominal contamination (> 2 L), low body mass index (BMI < 19.35 kg/m 2 ), serum creatinine (> 1.5 mg/dl), and deranged International Normalized Ratio (INR) were found to be significant on univariate analysis; however, multivariate analysis revealed only low BMI and high creatinine to be contributory towards leak., Conclusion: Leak after omentopexy carries a high morbidity and mortality. Identification of risk factors may help in optimizing patients at risk and reduce the incidence of leak and its sequelae., Trial Registration Number: CTRI/2020/03/023798., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Background: This study aims to summarize our experience in diagnosis and treatment of pediatric duodenal ulcer perforation in a National Center for Children's Health., Methods: Fifty-two children with duodenal perforation hospitalized in Beijing Children's Hospital Affiliated to Capital Medical University from January 2007 to December 2021 were retrospectively collected. According to the inclusion and exclusion criteria, patients with duodenal ulcer perforation were included in the group. They were divided into the surgery group and the conservative group according to whether they received surgery., Results: A total of 45 cases (35 males and 10 females) were included, with a median age of 13.0 (0.3-15.4) years. Forty cases (40/45, 88.9%) were over 6 years old, and 31 (31/45, 68.9%) were over 12 years old. Among the 45 cases, 32 cases (32/45, 71.1%) were examined for Helicobacter pylori (HP), and 25 (25/32, 78.1%) were positive. There were 13 cases in the surgery group and 32 cases in the conservative group, without a significant difference in age between the two groups (P = 0.625). All cases in the surgery group and the conservative group started with abdominal pain. The proportion of history time within 24 h in the two groups was 6/13 and 12/32 (P = 0.739), and the proportion of fever was 11/13 and 21/32 (P = 0.362). The proportion of pneumoperitoneum in the surgery group was higher than that in the conservative group (12/13 vs. 15/32, P = 0.013). The fasting days in the surgery group were shorter than those in the conservative group (7.7 ± 2.92 vs. 10.3 ± 2.78 days, P = 0.014). There was no significant difference in the total hospital stay (13.6 ± 5.60 vs14.8 ± 4.60 days, P = 0.531). The operation methods used in the surgery group were all simple sutures through laparotomy (9 cases) or laparoscopy (4 cases). All patients recovered smoothly after surgery., Conclusion: Duodenal ulcer perforation in children is more common in adolescents, and HP infection is the main cause. Conservative treatment is safe and feasible, but the fasting time is longer than the surgery group. A simple suture is the main management for the surgery group., (© 2023. The Author(s).)

Background: Gastroduodenal perforation stands out as one of the complications in cancer patients. Despite its high mortality, its characteristics are still poorly described. This study aimed to evaluate the characteristics and outcomes of cancer patients who had gastroduodenal perforation, and the influence of chemotherapy (CMT) in these cases., Method: A retrospective analysis of patients who underwent emergency surgery with an intraoperative finding of gastroduodenal perforation. Patients who performed CMT within 60 days before perforation were considered as the CMT group., Results: Among 45 patients included, 16 (35.5%) were classified as the CMT group and the remaining 29 (64.5%) patients as the non-CMT group. There was no difference between the groups regarding sex, age, BMI, comorbidity, and laboratory exams. ECOG 2-3 was significantly more frequent in the CMT group (68.8% vs. 34.5% p = 0.027). Major postoperative complications were similar between both groups (75% vs. 58.6%, p = 0.272). The sepsis of abdominal focus was the main postoperative complication. The 30-day mortality was 55.6%, with no difference between non-CMT and CMT groups (62.5% vs. 51.7%, respectively; p = 0.486). A multivariate analysis of risk factors showed that only an age of ≥65 years was related to 30-day mortality., Conclusions: Patients with gastroduodenal perforation and oncologic treatment present high mortality, regardless of receiving recent CMT.

Background: Duodenal defects are complex clinical situations, and their management is challenging and associated with high mortality. Besides surgery, endoscopic treatment options exist, but the size and location of the perforation can limit their application. We present a retrospective study, demonstrating a successful application of endoscopic vacuum therapy (EVT) for duodenal leaks., Methods: We performed a retrospective study of all patients who underwent EVT for duodenal perforations between 2016 and 2021 at two tertiary centers. We analyzed demographic and clinical patient characteristics, surgical outcomes, leak characteristics, sponge-related complications, and success rate., Results: Indications for treatment with EVT in the duodenum consisted of leak after duodenal suture of a perforated ulcer (n = 4), iatrogenic perforation after endoscopic resection (n = 2), iatrogenic perforation during surgery (n = 2), and anastomotic leak after upper gastrointestinal surgery (n = 2). EVT was used as a first-line treatment in seven patients and as a second-line treatment in three patients. EVT was successfully applied in all interventions (n = 10, 100%). Overall, EVT lead to definitive closure of the defects in eight out of ten patients (80%). No severe EVT-related adverse events occurred., Conclusion: EVT is safe and technically feasible, so it emerges as a promising endoscopic treatment option for duodenal leaks. However, multidisciplinary collaboration and management are important to reduce the occurrence of postoperative complications, and to improve recovery rates., (© 2022. The Author(s).)

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is an endoscopic study in which the duodenum is observed laterally, and the bile duct is instrumented. There are several indications and complications in the procedure., Objective: To determine the incidence of duodenal perforations, using the Stapfer classification in the Hospital Juárez de Mexico over a period of 5 years, as well as the management implemented in such cases., Method: The study was carried out at the Hospital Juárez de Mexico of the Ministry of Health. All patients who underwent ERCP between January 1, 2017, to May 30, 2022 were included., Results: 485 ERCP were performed in the study period. Incidence of 1.6% post-ERCP duodenal perforation. The average age of the subjects 56.37 years. In-hospital stay of post-ERCP perforations averaged 9.37 days. The time of the endoscopic study at the time of the surgical procedure is 10 h on average., Conclusions: Post-ERCP duodenal perforation is a complication that occurs with a low incidence, it tends to increase the number of days of in-hospital stay and increases morbimortality of patients; therefore, it is important to be always alert., (Copyright: © 2023 Permanyer.)

Background: Peptic ulcer perforation is a common surgical emergency and a major cause of death especially in elderly patients, despite the fact of the presence of effective drug treatments and an increased understanding of its etiology. Giant duodenal perforations, in particular, pose a significant challenge and there is scarce data regarding their optimal management. Laparoscopic surgery is advocated in the surgical treatment of perforated duodenal ulcer disease, in experienced hands., Methods: Herein we present an 84-year-old man with past medical history of type II diabetes mellitus and hypertension who was admitted to our Department due to epigastric pain and diffuse peritonitis. CT scan revealed the presence of a significant amount of free air and fluid in the upper abdomen secondary to a duodenal perforation., Results: The patient was taken immediately to the theater for an urgent laparoscopy. Methylene blue via the NG tube better defined the extent of the duodenal perforation which was not amenable to a primary repair. Consequently, a decision was made for a laparoscopic pancreas-sparing, ampulla preserving gastroduodenectomy with intracorporeal Billroth II gastrojejunal anastomosis. The postoperative period was uneventful and the patient was discharged on the 13th postoperative day. Histopathology revealed a large benign duodenal ulcer., Conclusions: Although the incidence of peptic ulcer disease is decreasing, it appears that the incidence of complications is rising. Laparoscopic approach, especially when performed by laparoscopic surgery experts, could be a treatment option for difficult duodenal ulcer perforations with less pain, shorter hospital stay and reduced morbidity., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Peptic ulcer disease (PUD), once primary a surgical problem, is now medically managed in the majority of patients. The surgical treatment of PUD is now strictly reserved for life-threatening complications. Free perforation, refractory bleeding and gastric outlet obstruction, although rare in the age of medical management of PUD, are several of the indications for surgical intervention. The acute care surgeon caring for patients with PUD should be facile in techniques required for bleeding control, bypass of peptic strictures, and vagotomy with resection and reconstruction. This video procedures and techniques article demonstrates these infrequently encountered, but critical operations., Content Video Description: A combination of anatomic representations and videos of step-by-step instructions on perfused cadavers will demonstrate the key steps in the following critical operations. Graham patch repair of perforated peptic ulcer is demonstrated in both open and laparoscopic fashion. The choice to perform open versus laparoscopic repair is based on individual surgeon comfort. Oversewing of a bleeding duodenal ulcer via duodenotomy and ligation of the gastroduodenal artery is infrequent in the age of advanced endoscopy and interventional radiology techniques, yet this once familiar procedure can be lifesaving. Repair of giant duodenal or gastric ulcers can present a challenging operative dilemma on how to best repair or exclude the defect. Vagotomy and antrectomy, perhaps the least common of all the aforementioned surgical interventions, may require more complex reconstruction than other techniques making it challenging for inexperienced surgeons. A brief demonstration on reconstruction options will be shown, and it includes Roux-en-Y gastrojejunostomy., Conclusion: Surgical management of PUD is reserved today for life-threatening complications for which the acute care surgeon must be prepared. This presentation provides demonstration of key surgical principles in management of bleeding and free perforation, as well as gastric resection, vagotomy and reconstruction., Level of Evidence: Video procedure and technique, not applicable., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Surgical therapy of duodenal perforation into the retroperitoneum entails high morbidity. Conservative treatment and endoscopic negative pressure therapy have been suggested as promising therapeutic alternatives. We aimed to retrospectively assess outcomes of patients treated for duodenal perforation to the retroperitoneum at our department. A retrospective analysis of all patients that were treated for duodenal perforation to the retroperitoneum at our institution between 2010 and 2021 was conducted. Different therapeutic approaches with associated complications within 30 days, length of in-hospital stay, number of readmissions and necessity of parenteral nutrition were assessed. We included thirteen patients in our final analysis. Six patients underwent surgery, five patients were treated conservatively and two patients received interventional treatment by endoscopic negative pressure therapy. Length of stay was shorter in patients treated conservatively. One patient following conservative and surgical treatment each was readmitted to hospital within 30 days after initial therapy whereas no readmissions after interventional treatment occurred. There was no failure of therapy in patients treated without surgery whereas four (66.7%) of six patients required revision surgery following primary surgical therapy. Conservative and interventional treatment were associated with fewer complications than surgical therapy which involves high morbidity. Conservative and interventional treatment using endoscopic negative pressure therapy in selected patients might constitute appropriate therapeutic alternatives for duodenal perforations to the retroperitoneum., (© 2022. The Author(s).)

Duodenal diverticulum perforation is a rare and life-threatening pathology. Perforation secondary to iatrogenic causes is rare, with only 14 cases previously reported. This paper explores a world-first case report on iatrogenic duodenal diverticulum perforation during right laparoscopic nephroureterectomy and a systematic review of all reported cases of duodenal diverticulum perforation in the literature., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

A 78-year-old woman presenting with severe acute liver failure was admitted to our hospital. On screening for the etiology of acute liver failure, it was diagnosed as being due to idiopathic hypereosinophilic syndrome (eosinophil count reported as 4766/μL; 33.8% of the white blood cells). Her medical history included marked eosinophilia, as observed six months prior to this admission. Corticosteroid therapy was initiated. During the clinical course, duodenal perforation occurred but was managed promptly by appropriate surgery. A liver biopsy, following the initiation of corticosteroid therapy, revealed degenerating hepatic cells with mild eosinophilic infiltration. With corticosteroid therapy, the liver function improved.

Background: Gastroduodenal perforation is potentially life threatening and requires early diagnosis and treatment. Urgent endoscopy facilitates detecting bleeding sites and achieving hemostasis. However, there is no consensus on urgent endoscopy for gastroduodenal perforation in Japan., Methods: We evaluated the effectiveness and safety of urgent endoscopy for gastroduodenal perforation. We compared clinical characteristics between 140 patients who underwent urgent endoscopy (urgent endoscopy group) and 16 patients did not (no urgent endoscopy group) at Hiroshima City Asa Citizens Hospital between December 2005 and December 2018., Results: Endoscopic diagnosis was possible in all urgent endoscopy group. In contrast, correct diagnosis of the perforation site was made on CT in 99 cases (63%). Furthermore, the proportion of cases with correct diagnosis of the perforation site by CT findings differed significantly between the urgent endoscopy group and the no urgent endoscopy group (66% vs. 38%, p < 0.05). No complications of urgent endoscopy were observed. Primary perforation site was gastric in 42 cases and duodenal in 114. In the 42 gastric perforation cases, 12 gastric perforation cases (29%) were managed conservatively, successfully in 9 (75%); 2 cases (17%) required delayed emergency surgery for worsening peritonitis. In the 114 duodenal perforation cases (duodenal ulcer in all cases), 52 cases (46%) were managed conservatively, successfully in 48 (92%); 3 cases (6%) required delayed emergency surgery for worsening peritonitis. A significantly higher proportion of gastric perforation cases than duodenal perforation cases required surgical treatment (76% vs. 57%, p < 0.05). Multivariate analysis revealed localized abdominal pain (no peritonism) (OR 0.25; 95% CI 0.08-0.75; p < 0.01) and perforation diameter ≤ 5 mm (OR 0.13; 95% CI 0.04-0.36; p < 0.01) as significant independent clinical factors for successful conservative management of duodenal ulcer perforation., Conclusions: Urgent endoscopy in gastroduodenal perforation enabled primary diagnosis and perforation site identification, and facilitated deciding the management strategy., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: To compare the results of endoscopic and open treatment of perforated gastroduodenal ulcers., Material and Methods: There were 445 patients with perforated gastroduodenal ulcers between 2013 and 2021. Endoscopic suturing of perforation was performed in 172 patients (38.7%), 273 ones underwent open surgery., Results: Among 172 patients scheduled for endoscopy, 160 (93.6%) ones underwent laparoscopic suturing of perforation. Morbidity rate was 5.0% ( n =8), postoperative mortality rate - 1.3% ( n =2). Comparison of the outcomes after laparoscopic suturing of ulcers in 160 patients and open surgery in 134 patients showed that laparoscopy was followed by 2.5 times lower incidence of complications and 3 times lower postoperative mortality., Conclusion: Diagnostic laparoscopy is advisable in patients with perforated ulcers and no contraindications. In most cases, surgery can be successfully and effectively completed without conversion to laparotomy. Endoscopic closure of ulcerative defect is preferable since this procedure has certain advantages over traditional intervention, contributes to significant reduction in morbidity, mortality and hospital-stay.

Background: Perforated peptic ulcer is a life-threatening condition. Traditional treatment is surgery. Esophageal perforations and anastomotic leakages can be treated with endoscopically placed covered stents and drainage. We have treated selected patients with a perforated duodenal ulcer with a partially covered stent. The aim of this study was to compare surgery with stent treatment for perforated duodenal ulcers in a multicenter randomized controlled trial., Methods: All patients presenting at the ER with abdominal pain, clinical signs of an upper G-I perforation, and free air on CT were approached for inclusion and randomized between surgical closure and stent treatment. Age, ASA score, operation time, complications, and hospital stay were recorded. Laparoscopy was performed in all patients to establish diagnosis. Surgical closure was performed using open or laparoscopic techniques. For stent treatment, a per-operative gastroscopy was performed and a partially covered stent was placed through the scope. Abdominal lavage was performed in all patients, and a drain was placed. All patients received antibiotics and intravenous PPI. Stents were endoscopically removed after 2-3 weeks. Complications were recorded and classified according to Clavien-Dindo (C-D)., Results: 43 patients were included, 28 had a verified perforated duodenal ulcer, 15 were randomized to surgery, and 13 to stent. Median age was 77.5 years (23-91) with no difference between groups. ASA score was unevenly distributed between the groups (p = 0.069). Operation time was significantly shorter in the stent group, 68 min (48-107) versus 92 min (68-154) (p = 0.001). Stents were removed after a median of 21 days (11-37 days) without complications. Six patients in the surgical group had a complication and seven patients in the stent group (C-D 2-5) (n.s.)., Conclusions: Stent treatment together with laparoscopic lavage and drainage offers a safe alternative to traditional surgical closure in perforated duodenal ulcer. A larger sample size would be necessary to show non-inferiority regarding stent treatment., (© 2020. The Author(s).)

Background: There are limited studies regarding the impact of post-operative leak on perforated peptic ulcer disease (PPUD) and conflicting results regarding routine drain placement in operative repair of PPUD. This study aims to identify risk factors for gastrointestinal leak after operative repair of PPUD to better guide intra-operative decisions about drain placement., Methods: We performed a retrospective cohort study at a tertiary care center from 2008 to 2019, identifying 175 patients who underwent operative repair of PPUD., Results: Patients who developed a leak (17%) were compared to patients who did not. Both hypoalbuminemia (albumin < 3.5 g/dL) ( P = .03) and duodenal ulcers ( P < .01) were identified as significant risk factors for leak. No significant difference was found between leak and no leak groups for AAST disease severity grade, repair technique, or pre-operative use of tobacco, alcohol, or steroids. Post-operative leaks were associated with prolonged hospital stay (29 days compared to 10, P < .01), increased complication rates (77% compared to 48%, P < .01), and increased re-operation rates (73% compared to 26%, <0.01). No difference was identified in patient characteristics or operative leak rates between patients who had drains placed at the index operation and those that did not., Discussion: Leak after operative PPUD repair is associated with significant post-operative morbidity. Hypoalbuminemia and duodenal perforations are significant risk factors for post-operative leaks.

Background: Gastroduodenal ulcer perforation is a common abdominal emergency that may be curable without surgical repair in non-elderly patients with localized and stable symptoms. However, the outcomes of nonoperative approaches have rarely been described., Methods: Using a Japanese national inpatient database, we identified 14,918 patients with gastroduodenal ulcer perforation who were hospitalized and received nonoperative treatment from July 2010 to March 2017. We categorized these patients into three groups according to age: 18 to 64 years (young group, n=8407), 65 to 74 years (old group, n=2616), and ≥75 years (old-old group, n=3895). We investigated the characteristics, treatments, and outcomes in each group., Results: Most of the patients were men (71%), and the median patient age was 62 years (interquartile range, 47-75 years). The old and old-old groups had more comorbidities than the young group. Whereas most patients were administered proton pump inhibitors and various antibiotics (96% and 90%, respectively), only 58% of patients underwent gastric tube placement. Surgical repair >3 days after admission was performed in 7.1% of all patients (6.3% vs. 7.9% vs. 5.5%, P<0.001). The old and old-old groups showed higher mortality (1.4% vs. 8.3% vs. 18%, P<0.001) and morbidity (6.6% vs. 15% vs. 17%, P<0.001) than the young group. The median length of stay was almost 2 weeks (13 vs. 17 vs. 20 days, P<0.001)., Discussion: Unlike previous studies, many patients aged >65 years received nonoperative treatment in this nationwide cohort. Our findings provide useful information for clinicians and patients hospitalized for gastric ulcer perforation., (© 2021. The Society for Surgery of the Alimentary Tract.)

Background: There is no consensus on optimal surgical treatment of large duodenal defects arising from perforated ulcers, even though such defects are challenging to repair and inadequate repair is associated with high morbidity and mortality. The aim of this study was to carry out a systematic literature review of different surgical techniques used to treat large duodenal perforations, provide a narrative description of these techniques, and propose a framework for approaching this pathology., Methods: PubMed/MEDLINE database was searched for articles published in English between January 1, 1970, and December 1, 2020. Studies describing surgical techniques used to treat giant duodenal ulcer perforation and their outcomes in adult patients were included. No quantitative analysis was planned because of the heterogeneity across studies., Results: Out of 960 identified records, 25 studies were eligible for inclusion. Two randomized controlled trials, one case-control trial, three cohort studies, 14 case series, and 5 case reports were included. Eight main surgical approaches are described, ranging from simple damage-control operations, such as the omental plug and triple-tube techniques, all the way to complex resections, such as gastrectomy., Conclusion: Evidence on surgical treatment of large duodenal defects is of poor quality, with the majority of studies corresponding to Oxford levels 3b-4. Current evidence does not support any single surgical technique as superior in terms of morbidity or mortality, but choice of technique should be guided by several factors including location of the perforation, degree of duodenal tissue loss, hemodynamic stability of the patient, as well as expertise of the operating surgeon., Level of Evidence: SR with more than two negative criteria, Level IV., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Perforated peptic ulcer (PPU) is a surgical emergency needing swift operative resolution. While laparoscopic and open approaches are viable options, it remains unclear whether laparoscopic repair has significantly improved outcomes. We use a national surgical database to compare perioperative and 30-d postoperative (30POP) outcomes., Materials and Methods: The 2016-2018 ACS-NSQIP database was used to create the patient cohort, using ICD-10 and CPT codes. An unmatched analysis identified factors that likely contributed to the laparoscopic versus open treatment allocation. Propensity score matching (PSM) was used to identify outcomes that were not explained by underlying differences in the patient cohorts., Results: A total of 3475 patients were included: 3135 in open group (OG), 340 (~10%) in laparoscopic group (LG). After PSM to control for comorbidities and illness severity that differed between groups on univariate analysis, 288 patients remained in each group. Analysis of the matched cohorts revealed no statistically significant difference in mortality (5.9% OG versus 3.8% LG, P = 0.245). The LG had significantly longer operative times (92 versus 79 min, P = 0.003), shorter hospital stays (8.2 versus 9.4 d, P = 0.044) and higher probability of being discharged home (81% versus 73%, P = 0.017). 30POP outcomes were largely equivalent, except that OG had higher risk for bleeding (14.6% versus 8%, P = 0.012) and pneumonia (8.7% versus 4.5%, P = 0.044)., Conclusions: While laparoscopic repairs take longer, they lead to shorter hospital stays and higher likelihood of discharge home. Further study to identify patients that are candidates for this technique is warranted., (Copyright © 2021. Published by Elsevier Inc.)

Background: Perforated peptic ulcer is a life-threatening complication with a high morbidity and mortality. It is the most common indication for emergency operation in peptic ulcer disease (PUD) patients. This study aimed to describe the pattern of presentation, management and early outcome in patients with perforated PUD., Methods: This was a prospective study of patients who had operation for perforated PUD at Ekiti State University Teaching Hospital (EKSUTH), Ado-Ekiti, Southwestern Nigeria from June 2015 to May 2020., Results: Forty-six patients were studied with their ages ranging from 21-85 years. Their mean age was 49.9±16.3 years while the median was 54 years. Males outnumbered females by a ratio of 5.5:1. Majority (56.5%) of the patients were farmers and artisans. Duration of symptoms was 6 hours to 9 days (mean 2.7±1.9 days). Non-steroidal anti-inflammatory drugs use, herbal concoction, alcohol and smoking was found in 54.3%, 52.2%, 30.4% and 21.7% respectively. More duodenal perforations (63.0%) were recorded. Graham's patch closure was done for 27 (58.7%) while the remaining (41.3%) had primary closure with omentoplasty. Sixteen (34.8%) had postoperative complications with wound infection predominating. Overall postoperative mortality was 17.4%. Age ≥ 60 years (p=0.04), premorbid illness (p=0.01), delayed presentation ≥ 48 hours (p=0.01), shock (p=0.01) and intraperitoneal effluent ≥ 2000ml (p=0.03) were associated with mortalities., Conclusion: Perforated PUD accounts for high morbidities and mortalities in our setting. Abuse of NSAIDs and herbal concoction ranked highest among the risk factors. Efforts at curtailing indiscriminate sales of NSAIDs and herbal concoction will reduce the menace., (© 2021 Olaogun J.G., et al.)

Objective: To study the effectiveness of pharmacotherapy for perforated gastric ulcer in a surgical hospital., Material and Methods: A retrospective analysis of the treatment of 693 patients with perforated gastric and duodenal ulcers was carried out. Laparoscopic and open surgeries were performed. Statistical analysis was performed using the Statistica and MS Excel software packages. Student t-test was applied for independent samples and Fisher's F-test was calculated., Results: Combined therapy included surgical treatment (suturing of the ulcer as a rule) and medication with proton pump inhibitors, antibacterial drugs. Over the past 5 years, postoperative quality of life has been significantly improved in patients with perforated ulcers. Stomach resection and vagotomy for perforated ulcers will become historical in the near future. Laparoscopic and open procedures ensure similar periods of ulcer closure., Conclusion: Currently, successful treatment of perforated gastric and duodenal ulcers requires an integrated approach at all levels of specialized care and is impossible without modern pharmacotherapy.

Competing Interests: Competing interests: None declared.

BACKGROUND In the emergency department pain in the right lower quadrant is a frequent finding and is related to a wide variety of diseases, the most common of which is acute appendicitis. An unusual presentation of pain in the right iliac fossa is due to perforation of a duodenal peptic ulcer. The fluid that originates from the perforated ulcer moves through the paracolic sulcus to the right iliac fossa and causes irritation of the peritoneum and even chemical peri-appendicitis, thereby imitating all the usual causes of pain in the right lower quadrant. This condition is known as Valentino's syndrome, named after the Italian actor Rudolph Valentino. CASE REPORT The aim of this case report was to review the current published literature regarding Valentino's syndrome and report on a case involving a 51-year-old male who was admitted to our surgical department with right lower quadrant pain and suspicion of acute appendicitis. An exploratory laparotomy was performed, from which a retroperitoneal perforation of a duodenal ulcer was found; suture closure was then applied. The patient's postoperative course was uncomplicated, and he was discharged 9 days after the operation. CONCLUSIONS Surgeons should be alert for this rare condition imitating acute appendicitis, and the differential diagnosis of right lower quadrant pain should include peptic ulcer perforation.

Competing Interests: Nil.

Background: Laparoscopic single-port surgery has widely been introduced for the treatment of various abdominal conditions. But controversies still exist regarding its potential advantages and risks, especially for emergency surgery. The aim of this study was to evaluate the results of a single-port laparoscopic repair using straight laparoscopic instruments for the treatment of perforated duodenal ulcers., Methods: A prospective consecutive case series was conducted including all patients with a perforated duodenal ulcer who underwent a laparoscopic single-port repair at a single institution from January 2012 to June 2018. The operation was performed through a single port using conventional straight laparoscopic instruments and intra-corporeal knot tying techniques., Results: Out of 75 patients, simple closure of the perforation without omental patch was accomplished in 96% of cases. Conversion to an open operation was required in one patient (1.3%) due to a posterior duodenal perforation, and additional trocar placement was needed in another patient (1.3%). The mean incision length was 2.0 ± 0.2 cm. The mean operation time was 63.0 ± 26.6 min. Meantime a nasogastric tube remained in place was 2.9 ± 0.8 days. Mean duration of analgesic use was 2.8 ± 0.8 days. The rate of postoperative complications was 2.7%, including two patients with wound infections. There were no instances of intestinal leak or abscess. The postoperative hospital stay was 5.7 ± 1.2 days., Conclusion: Laparoscopic single-port repair using conventional straight laparoscopic instruments with intra-corporeal knot tying technique was safe and feasible for patients with perforated duodenal ulcers with low risk factors. This method offers results comparable to those expected with the standard multiport laparoscopic approach with the addition of improved cosmetic outcomes.

A 49-year-old man presented to the nearest emergency department profoundly septic with significantly raised inflammatory markers. He had a background of floor of mouth invasive squamous cell carcinoma for which he underwent complex head and neck surgery followed by adjuvant radiotherapy and insertion of a percutaneous gastrostomy tube for feeding. He experienced 3 weeks of retching, cough and malaise. Imaging revealed both an oesophageal perforation and perforated duodenal ulcer, presumed secondary to oesophageal stricturing from his prior surgery and radiotherapy., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: None

Objective: To study the outcomes of fast-track recovery in patients with perforated duodenal ulcer (PDU)., Material and Methods: There were 138 patients with PDU who underwent surgical treatment for the period from January 1, 2015 to December 31, 2019. Patients were divided into 3 groups: main group, control group 1 (CG-1) and control group 2 (CG-2). The main group (fast-track group, FT-group) included 51 patients who underwent laparoscopic suturing of PDU followed by enhanced recovery (fast-track). CG-1 comprised 44 patients who underwent open suturing of PDU and conventional perioperative treatment. CG-2 consisted of 43 patients who underwent laparoscopic suturing and conventional perioperative treatment. Complications were assessed using Clavien-Dindo grading system., Results: In the FT group, postoperative complications were observed in 2 patients (3.92%). Anemia of mixed genesis (Clavien-Dindo grade II) was diagnosed in 1 patient and left-sided lower lobe pneumonia in another one (grade II). There were no deaths. Mean length of hospital-stay was 3.86 days. In the 1 st control group, the largest number of complications was observed ( n =12, 27.27%) including 9 extra-abdominal complications (pulmonary disorders (II) - 7 patients (15.9%); sepsis (IVB) - 1 (2.27%), delirium (IVA) - 1 patient (2.27%), postoperative wound seroma (IIIA) - 1 (2.27%) patient). Intra-abdominal complications consisted of compensated pyloroduodenal stenosis (II) in 1 (2.27%) case, recurrent bleeding from acute gastric and duodenal ulcers (IIIB) in 1 (2.27%) patient. Mortality rate was 4.54% ( n =2) in this group (progressive multiple organ failure). Mean length of hospital-stay was 7.56 days. In the 2 nd control group, postoperative complications included extra-abdominal (pulmonary disorders (II) - pneumonia in 4 (9.3%) cases, spontaneous pneumothorax (IIIA) in 1 (2.32%) case) and intra-abdominal events (duodenitis (II) in 1 (2.32%) patient and compensated pyloroduodenal stenosis (II) in another 1 (2.32%) patient). There were no lethal outcomes in this group. Mean length of hospital-stay was 6.7 days., Conclusion: Treatment outcomes in patients with perforated duodenal ulcer confirmed an effectiveness of laparoscopic suturing and complete abdominal sanitation. These measures create the prerequisites for fast track recovery in urgent surgical practice. FT-protocol of inpatient management is followed by reduced hospital-stay and less incidence of postoperative complications. Moreover, this approach promotes early and safe discharge of patients.

Duodenal perforation is a rare, but potentially life-threatening injury. Multiple etiologies are associated with duodenal perforations such as peptic ulcer disease, iatrogenic causes and trauma. Computed tomography with intravenous and oral contrast is the most valuable imaging technique to identify duodenal perforation. In some cases, surgical exploration may be necessary for diagnosis. Specific treatment depends upon the nature of the disease process that caused the perforation, the timing, location and extent of the injury and the clinical condition of the patient. Conservative management seems to be feasible in stable patients with sealed perforations. Immediate surgery is required for patients presenting with peritonitis and/or intra-abdominal sepsis. Minimally invasive techniques are safe and effective alternatives to conventional open surgery in selected patients with duodenal perforations. Here we review the current literature on duodenal perforations and discuss the outcomes of different treatment strategies.

Purpose: Over the last 3 decades, laparoscopic procedures have emerged as the standard treatment for many elective and emergency surgical conditions. Despite the increased use of laparoscopic surgery, the role of laparoscopic repair for perforated peptic ulcer remains controversial among general surgeons. The aim of this study was to compare the outcomes of laparoscopic versus open repair for perforated peptic ulcer., Methods: A systemic literature review was conducted using Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. A search was conducted using MEDLINE, EMBASE, PubMed and Cochrane Database of all randomised controlled trials (RCT) that compared laparoscopic (LR) with open repair (OR) for perforated peptic ulcer (PPU). Data was extracted using a standardised form and subsequently analysed., Results: The meta-analysis using data from 7 RCT showed that LR for PPU has decreased overall post-operative morbidity (LR = 8.9% vs. OR = 17.0%) (OR = 0.54, 95% CI 0.37 to 0.79, p < 0.01), wound infections, (LR = 2.2% vs. OR = 6.3%) (OR = 0.3, 95% CI 0.16 to 0.5, p < 0.01) and shorter duration of hospital stay (6.6 days vs. 8.2 days, p = 0.01). There were no significant differences in length of operation, leakage rate, incidence of intra-abdominal abscess, post-operative sepsis, respiratory complications, re-operation rate or mortality. There was no publication bias and the quality of the studies ranged from poor to good., Conclusion: These results demonstrate that laparoscopic repair for perforated peptic ulcer has a reduced morbidity and total hospital stay compared with open approach. There are no significant differences in mortality, post-operative sepsis, abscess and re-operation rates. LR should be the preferred treatment option for patients with perforated peptic ulcer disease.

Background: Laparoscopic primary repair is one of the main procedures used for perforated gastric ulcers, and this technique requires reproducible and secure suturing. The aim of this study was to investigate the safety and efficacy of a novel continuous suture method with barbed sutures during laparoscopic repair for perforated peptic ulcers., Patients and Methods: Clinical data from 116 consecutive patients undergoing laparoscopic repair for perforated peptic ulcers were collected between November 2009 and October 2015. Continuous suturing with 15-cm-long unidirectional absorbable barbed sutures was used for laparoscopic repair in the study group, termed group V (n = 51). Patients who underwent laparoscopic repair with conventional interrupted sutures were defined as group C (n = 65). The complication and operative data were compared between groups., Results: Although there was no difference between group V and group C in the overall complication rate (15.7% vs. 24.6%; p = 0.259), the complication rate related to suturing was lower (3.9% vs. 15.4%; p = 0.04) in group V. Group V showed rates of 0% for leakage, 2% for intra-abdominal fluid collection, and 2% for stricture; the corresponding rates in group C were 3.1, 7.7, and 4.6%, respectively. Regarding operative data, the total operation time (V vs. C, 87.7 min vs. 131.2 min), total suture time (7.1 min vs. 25.3 min), and suture time per stitch (1.2 min vs. 6.2 min) were significantly shorter in group V than in group C (p < 0.001)., Conclusion: The use of a continuous suture technique with unidirectional barbed sutures is as safe as the conventional suture technique and allows easier and faster suturing in the repair of perforated peptic ulcers.

Context: Patients taking exogenous glucocorticoids are at risk for gastrointestinal (GI) complications, including peptic ulcer disease with perforation and gastric bleeding. However, little is known about the GI comorbidity in patients with endogenous hypercortisolemia., Case Descriptions: We describe six patients with endogenous Cushing syndrome (CS) who developed sudden perforation of colonic diverticula necessitating urgent exploratory laparotomy. Most of these patients shared the following features of CS: skin thinning, severe hypercortisolemia (24-hour urinary free cortisol ≥10 times the upper limit of normal), ectopic secretion of ACTH, and severe hypokalemia. At the time of diagnosis of diverticular perforation (DP), these patients had minimal signs of peritonitis and lacked fever or marked leukocytosis. The diagnosis of DP was established by having a low threshold for obtaining an imaging study for evaluation of nonspecific abdominal pain., Conclusions: Patients with CS can develop spontaneous surgical abdomen with rapid decompensation within hours. Prompt recognition is critical in the successful treatment of these patients.