Magen- und Duodenalperforation: Welchen Stellenwert hat die laparoskopische Chirurgie?

Zusammenfassung

Einleitung: Die Magen- und Duodenalperforation stellt eine lebensbedrohliche Komplikation der Ulkuskrankheit mit der sofortigen Indikation zur operativen Versorgung dar. Inwieweit die Laparoskopie in dieser Akutsituation ein geeignetes Verfahren darstellt, soll die vorliegende Untersuchung zeigen.
Material und Methoden: Die Daten aller Patienten, die innerhalb eines Zeitraums von 15 Jahren (01/1996–12/2010) wegen eines perforierten Magen- oder Duodenalulkus laparoskopisch operiert worden waren, wurden prospektiv erfasst und hinsichtlich Alter, Geschlecht, Perforationslokalisation, Diagnostik, Klinik, Operationsverfahren, intra- und postoperativen Komplikationen sowie postoperativem Verlauf retrospektiv analysiert.
Ergebnisse: Im Beobachtungszeitraum wurden 45 Patienten mit einer Magen- oder Duodenalperforation laparoskopisch operiert. Das mediane Lebensalter bei Operation betrug 58 (18–91) Jahre. Eine NSAR-Medikation bestand bei 11 (24,4 %) Patienten. Die Perforation lag bei 12 (26,7 %) Patienten präpylorisch, bei 10 (22,2 %) postpylorisch, bei je 1 (2,2 %) Patienten an der kleinen und an der großen Kurvatur, bei 18 (40,0 %) an der Vorder- und 3 (6,7 %) an der Hinterwand. In 2 Fällen bestand eine vorangegangene operative Versorgung im Oberbauch. Nach primärer diagnostischer Laparoskopie wurde bei 20 (44,4 %) Patienten die Indikation zur Konversion gestellt. Im Verlauf der laparoskopisch beendeten Operationen wurden bei 18/25 (72,0 %) Patienten eine Übernähung und bei 7/25 (37,8 %) Patienten eine Ulkusexzision durchgeführt. Nach Konversionen wurde bei 7/20 (35,0 %) Patienten eine Übernähung, bei 10/20 (50,0 %) Patienten eine Ulkusexzision und bei 3/20 (15,0 %) Patienten ein resezierender Eingriff durchgeführt. Die mediane Operationszeit betrug 105 (40–306) Minuten und die mittlere Verweildauer 11 (4–66) Tage. Der Intensivaufenthalt lag im Median bei 2 (0–37) Tagen. Majorkomplikationen bestanden bei 11 (24,4 %) Patienten. Hierbei sind im Wesentlichen Relaparotomien (n = 7; 15,6 %) und Nachblutungen (n = 4; 8,9 %) zu nennen. Minorkomplikationen waren in 8 (17,8 %) Fällen zu beobachten. Die Letalität betrug 11,1 % (n = 5).
Schlussfolgerung: Die laparoskopische Versorgung von Magen- und Duodenalperforationen stellt eine minimalinvasive therapeutische Option für die definitive Versorgung dieser lebensbedrohlichen Erkrankung dar. Die Indikation für ein laparoskopisches Vorgehen ist jedoch individuell zu stellen und wird in entscheidendem Maß von der laparoskopischen Erfahrung des Operateurs bestimmt.

Abstract

Introduction: The gastric and duodenal perforations are a life-threatening complication of peptic ulcer disease with the indication for immediate surgical intervention. To which extent laparoscopy is a suitable method in an acute situation was examined in the present investigation. Materials and Methods: The data of all patients within a period of 15 years (01/1996–12/2010) who were operated laparoscopically because of a perforated gastric or duodenal ulcer, were collected prospectively in terms of age, gender, localisation of perforation, diagnostics, symptoms, surgical procedures, intraoperative and postoperative complications and postoperative course, and were analysed retrospectively. Results: During the observation period 45 patients were operated laparoscopically due to gastric or duodenal perforation. The median age at operation was 58 (18–91) years. An NSAID medication was present in 11 (24.4 %) patients. The perforation was juxtapyloric in 12 (26.7 %) patients, postpyloric in 10 (22.2 %) patients, one (2.2 %) patient in each small and greater curvature, in 18 (40.0 %) at the front and in three (6.7 %) patients on the rear wall. In two cases, previous surgical treatment in the upper abdomen was performed. After primary diagnostic laparoscopy, an indication for conversion was seen in 20 (44.4 %) patients. During laparoscopically completed operations simple suturing was done in 18/25 (72.0 %) patients and excision and suturing was performed in 7/25 (37.8 %) patients. After conversion simple suturing was observed in 7/20 (35.0 %) patients, whereas in 10/20 (50.0 %) patients excision and suturing was performed. 3/20 (15.0 %) patients underwent a resective operation. The median operative time was 105 (40–306) minutes and mean hospitalisation 11 (4–66) days. The ICU stay was in median 2 (0–37) days. Major complications were seen in 11 (24.4 %) patients, namely re-laparotomy (n = 7; 15.6 %) and haemorrhage (n = 4; 8.9 %). Minor complications were observed in 8 (17.8 %) of cases. The mortality rate was 11.1 % (n = 5).
Conclusion: The laparoscopic treatment of gastric and duodenal perforations is a minimally invasive therapeutic option for the definitive treatment of this life-threatening disease. The indication for a laparoscopic approach has to be considered individually and depends to a decisive extent on the experience of the laparoscopic surgeon.

Schlüsselwörter

Abdominalchirurgie - abdomineller Notfalleingriff - laparoskopische Chirurgie - Perforation von peptischen Ulzera - Magenperforation - Duodenalperforation

Key words

abdominal surgery - abdominal surgery in an emergency setting - laparoscopic surgery - perforation of peptic ulcer - gastric perforation - duodenal perforation

• Literatur

• 1 Mouret P, Francois Y, Vignal J et al. Laparoscopic treatment of perforated peptic ulcer. Br J Surg 1990; 77: 1006
• 2 Nathanson LK, Easter DW, Cuschieri A. Laparoscopic repair/peritoneal toilet of perforated duodenal ulcer. Surg Endosc 1990; 4: 232-233
• 3 Malfertheiner P, Bellutti M. Ulkuskrankheit. Klinische Bewertung 2006. Internist 2006; 47: 588 590–595
• 4 Lagoo S, McMahon RL, Kakihara M et al. The sixth decision regarding perforated duodenal ulcer. JSLS 2002; 6: 359-368
• 5 Lee K, Chang H, Lo C. Endoscope-assisted laparoscopic repair of perforated peptic ulcers. Am Surg 2004; 70: 352-356
• 6 Lunevicius R, Morkevicius M. Systematic review comparing laparoscopic and open repair for perforated peptic ulcer. Br J Surg 2005; 92: 1195-1207
• 7 Sugimoto K, Hirata M, Takishima T et al. Mechanically assisted intraoperative peritoneal lavage for generalized peritonitis as a result of perforation of the upper part of the gastrointestinal tract. J Am Coll Surg 1994; 179: 443-448
• 8 Platell C, Papadimitriou JM, Hall JC. The influence of lavage on peritonitis. J Am Coll Surg 2000; 191: 672-680
• 9 Ruiz-Tovar J, Santos J, Arroyo A et al. Effect of peritoneal lavage with clindamycin-gentamicin solution on infections after elective colorectal cancer surgery. J Am Coll Surg 2012; 214: 202-207
• 10 Hemmer PHJ, de Schipper JS, van Etten B et al. Results of surgery for perforated gastroduodenal ulcers in a Dutch population. Dig Surg 2011; 28: 360-366
• 11 Ates M, Sevil S, Bakircioglu E et al. Laparoscopic repair of peptic ulcer perforation without omental patch versus conventional open repair. J Laparoendosc Adv Surg Tech A 2007; 17: 615-619
• 12 Bhogal RH, Athwal R, Durkin D et al. Comparison between open and laparoscopic repair of perforated peptic ulcer disease. World J Surg 2008; 32: 2371-2374
• 13 Lau H. Laparoscopic repair of perforated peptic ulcer: a meta-analysis. Surg Endosc 2004; 18: 1013-1021
• 14 Schlöricke E, Bader FG, Hoffmann M et al. Offen chirurgische versus laparoskopische Versorgung der iatrogenen Kolonperforation – Ergebnisse nach 13 Jahren Erfahrungen. Zentralbl Chir 2011; Apr 8 [Epub ahead of print]
• 15 Thill V, Simoens C, Mendes da Costa P. Management of latrogenic perforation after gastrointestinal endoscopy. Hepatogastroenterology 2010; 57: 1465-1468
• 16 Ates M, Coban S, Sevil S et al. The efficacy of laparoscopic surgery in patients with peritonitis. Surg Laparosc Endosc Percutan Tech 2008; 18: 453-456
• 17 Bertleff MJOE, Lange JF. Laparoscopic correction of perforated peptic ulcer: first choice? A review of literature. Surg Endosc 2010; 24 (6) 1231-1239
• 18 Bertleff MJOE, Halm JA, Bemelman WA et al. Randomized clinical trial of laparoscopic versus open repair of the perforated peptic ulcer: the LAMA Trial. World J Surg 2009; 33: 1368-1373
• 19 Khoursheed M, Fuad M, Safar H et al. Laparoscopic closure of perforated duodenal ulcer. Surg Endosc 2000; 14: 56-58
• 20 Thompson AR, Hall TJ, Anglin BA et al. Laparoscopic plication of perforated ulcer: results of a selective approach. South Med J 1995; 88: 185-189
• 21 Wullstein C, Koppen M, Gross E. Laparoscopic treatment of colonic perforations related to colonoscopy. Surg Endosc 1999; 13: 484-487
• 22 Veldkamp R, Kuhry E, Hop WCJ et al. Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomised trial. Lancet Oncol 2005; 6: 477-484
• 23 Buunen M, Veldkamp R, Hop WCJ et al. Survival after laparoscopic surgery versus open surgery for colon cancer: long-term outcome of a randomised clinical trial. Lancet Oncol 2009; 10: 44-52
• 24 Rotholtz NA, Montero M, Laporte M et al. Patients with less than three episodes of diverticulitis may benefit from elective laparoscopic sigmoidectomy. World J Surg 2009; 33: 2444-2447
• 25 Siu WT, Chau CH, Law BKB et al. Routine use of laparoscopic repair for perforated peptic ulcer. Br J Surg 2004; 91: 481-484
• 26 Lee FY, Leung KL, Lai BS et al. Predicting mortality and morbidity of patients operated on for perforated peptic ulcers. Arch Surg 2001; 136: 90-94
• 27 Lee FY, Leung KL, Lai PB et al. Selection of patients for laparoscopic repair of perforated peptic ulcer. Br J Surg 2001; 88: 133-136
• 28 Siu WT, Leong HT, Law BKB et al. Laparoscopic repair for perforated peptic ulcer: a randomized controlled trial. Ann Surg 2002; 235: 313-319
• 29 Lau WY, Leung KL, Kwong KH et al. A randomized study comparing laparoscopic versus open repair of perforated peptic ulcer using suture or sutureless technique. Ann Surg 1996; 224: 131-138
• 30 Lee J, Kim D, Kim W. Comparison of laparoscopy-assisted and totally laparoscopic Billroth-II distal gastrectomy for gastric cancer. J Korean Surg Soc 2012; 82: 135-142
• 31 Du J, Shuang J, Li J et al. Totally laparoscopic Billroth II gastrectomy with a novel, safe, simple, and time-saving anastomosis by only stapling devices. J Gastrointest Surg 2012; 16: 738-743
• 32 Jedeikin RJ, Engelberg M, Shapira AL et al. Fecal peritonitis. An approach to its management. Isr J Med Sci 1983; 19: 119-123
• 33 Darzi A, Cheshire NJ, Somers SS et al. Laparoscopic omental patch repair of perforated duodenal ulcer with an automated stapler. Br J Surg 1993; 80: 1552
• 34 So JB, Kum CK, Fernandes ML et al. Comparison between laparoscopic and conventional omental patch repair for perforated duodenal ulcer. Surg Endosc 1996; 10: 1060-1063
• 35 Pescatore P, Halkic N, Calmes JM et al. Combined laparoscopic-endoscopic method using an omental plug for therapy of gastroduodenal ulcer perforation. Gastrointest Endosc 1998; 48: 411-414
• 36 Momtaz H, Souod N, Dabiri H et al. Study of Helicobacter pylori genotype status in saliva, dental plaques, stool and gastric biopsy samples. World J Gastroenterol 2012; 18: 2105-2111
• 37 Madiba TE, Nair R, Mulaudzi TV et al. Perforated gastric ulcer–reappraisal of surgical options. S Afr J Surg 2005; 43: 58-60
• 38 Seelig MH, Seelig SK, Behr C et al. Comparison between open and laparoscopic technique in the management of perforated gastroduodenal ulcers. J Clin Gastroenterol 2003; 37: 226-229
• 39 Watanabe I, Ogawa K, da Silva MCP et al. Ultrastructure of the adhesion of bacteria to the epithelial cell membrane of three-day postnatal rat tongue mucosa: a transmission and high-resolution scanning electron microscopic study. Braz Dent J 2007; 18: 320-323
• 40 Vitkov L, Krautgartner WD, Hannig M et al. Fimbria-mediated bacterial adhesion to human oral epithelium. FEMS Microbiol Lett 2001; 202: 25-30
• 41 Vaid S, Tucker J, Bell T et al. Cost analysis of laparoscopic versus open colectomy in patients with colon cancer: results from a large nationwide population database. Am Surg 2012; 78: 635-641
• 42 Dowson HM, Gage H, Jackson D et al. Laparoscopic and Open Colorectal Surgery: A Prospective Cost Analysis. Colorectal Dis 2012; 14: 1424-1430