Stent treatment or surgical closure for perforated duodenal ulcers: a prospective randomized study

Abstract

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.

Experience in diagnosis and treatment of duodenal ulcer perforation in children

“…If the perforation diameter is large, omental tamponade repair [ 13 , 16 , 17 ] or distal gastric plus bulbar resection and gastrojejunostomy can be performed [ 18 ]. In addition, with the development of endoscopy, more and more endoscopic treatment and endoscopic combined surgery have been reported to treat duodenal ulcer perforation [ 19 – 21 ]. In our study, the diameters of perforation in the surgery group were all less than 1 cm.…”

Operative versus non-operative management for perforated peptic ulcer disease

“…A prospective randomised study of 43 patients by Vazquez et al [ 16 ] demonstrated that, a safe alternative to conventional surgical closure for perforated duodenal ulcers is stent treatment in conjunction with laparoscopic lavage and drainage. Stent treatment is also a good alternative in cases of suture-line leakage.…”

Approaches for the treatment of perforated peptic ulcers: a network meta-analysis of randomised controlled trials – study protocol

“…Moreover, a combined approach using laparoscopy and endoscopy can be employed for treating a PPU. In such instances, the perforation is closed endoscopically through stent placement, while lavage and drainage procedures are conducted laparoscopically 19…”

“…In such instances, the perforation is closed endoscopically through stent placement, while lavage and drainage procedures are conducted laparoscopically. 19 …”