Atakan SAÇLI, Erkan OYMACI, Deniz UÇAR, Savaş YAKAN, Ali COŞKUN, Nazif ERKAN, Erdem SARI

PEPTİK ÜLSER PERFORASYONLARINDA TEDAVİ SEÇENEKLERİMİZ

Peptik ülser tedavisindeki gelişmeler sayesinde elektif ülser operasyonlarının sayısı azalırken, özellikle non-steroid ağrı kesiciler, siklooksijenaz inhibitörleri, selektif serotonin geri alım inhibitörleri ve steroidler gibi ilaçların kullanımının yaygınlaşması nedeniyle acil komplikasyonlara bağlı operasyonların sayısında ise azalma olmamıştır. Postoperatif asit baskılayıcı tedaviler sayesinde son yıllarda definitif ülser cerrahisine gereksinim azalmıştır. Biz de bu çalışmamızda peptik ülser perforasyonları konusunda kliniğimizin deneyimlerini yeni yaklaşımlar ışığında irdelemeyi amaçladık. İzmir Bozyaka Eğitim ve Araştırma Hastanesi 2. Genel Cerrahi Kliniği’nde son 5 yılda peptik ülser perforasyonları nedeniyle opere edilen 61 hastanın dosyaları retrospektif olarak incelendi. Hastaların 9’u %14,7 kadın, 52’si %85,2 erkekti ve yaş ortalaması 49,6 idi. Preoperatif tanı, 47 %77 hastada akciğer grafisinde diyafragma altında serbest hava görülmesi ile, 8 hastada %13,1 ise abdominal tomografide intraperitoneal serbest hava görülmesi ile konuldu. 6 hastada ise %9,8 tanı intraoperatif olarak konuldu. Perforasyonların 37’si %60,7 bulbusta, 18’i %29,5 prepilorik alanda, 2’si %3,3 mide küçük kurvaturda, 1’i %1,6 mide korpusta ve 1’i %1,6 duodenum 2. kıtada lokalizeydi. Ülser cerrahisi öyküsü olan 2 %3,3 hastada da gastroenterostomi hattında perforasyon saptandı. Hastaların 50’sine %82 primer tamir+omentoplasti, 4’üne %6,6 omental yama ile tamir, 2’sine %3,3 sadece primer tamir, 3’üne %4,9 subtotal gastrektomi ve Roux en Y anastomoz, 2’sine %3,3 antrektomi ve Billroth-II prosüdürleri uygulandı. Mortalite saptanmazken morbidite olarak 8 %13,1 hastada postoperatif yara yeri enfeksiyonu gelişti. Peptik ülser perforasyonlarında non-operatif tedaviden geniş rezeksiyonlara kadar pek çok tedavi seçeneği mevcuttur. Bu seçeneklerden hangisini tercih edeceğimiz hastaların genel durumuna ve perforasyonların çeşidine göre değişmektedir. Erken tanı ve doğru müdahalenin yapılması morbidite ve mortalite riskini azaltmak açısından önemlidir

Anahtar Kelimeler:

peptik ülser, perforasyon, cerrahi

OUR TREATMENT ALTERNATIVES FOR PERFORATED PEPTIC ULCER DISEASE

Even though elective operation number has been decreasing for perforated peptic ulcer disease, increasing use of non-steroidal anti-inflammatory pain killer drugs, cyclooxygenase inhibitors, selective serotonin uptake inhibitors and steroids prevented likewise decrease in peptic ulcer disease complication related emergency operation frequency. The need for definitive ulcer surgery had decreased owing to postoperative acid suppressive therapies. We tried to examine the experience of our peptic ulcer perforation with the light of new approaches. The files of 61 patients which operated for peptic ulcer perforation were examined retrospectively during the last five years in İzmir Bozyaka Education and Research Hospital. There were 9 %14.7 female, 52 85.2% male patients with the mean age of 49.6 . Preoperative diagnosis was established with the air under the diaphragm on chest x-ray in 47 77% patients whereas intraperitonealfree air on abdominal computed tomography was the diagnostic finding in 8 13.1% patients. Six patients 9.8% have had the definitive diagnosis intraoperatively. The number of perforation sites were 37 60.7% for bulbus; 18 29.5% for prepyloric area; 2 3.3% for lesser curvature; 1 1.6% for corpus and 1 1.6% for duodenum 2nd portion. There were 2 3.3% patient with ulcer surgery in past medical history in whom perforation detected at gastroenterostomy site. 50 82% patients underwent primary repair and omentoplasty; 4 6.6% mending with omental patch; 2 3.3% only primary suturing; 3 4.9% subtotal gastrectomy and Roux & Y anastomosis and 2 3.3% antrectomy and Billroth II procedure were applied. There was no mortality observed whereas 8 13.1% surgical site infection had developed as morbidity. There is a wide range of treatment alternatives for peptic ulcer perforation starting from nonoperative observation to wide excisions. The choice of treatment depends on the patient’s general condition and the type of perforation. It is important to establish early diagnosis and appropriate therapy in order to reduce the morbidity and mortality

Keywords:

Peptic ulcer, perforation, surgery,

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) Paimela H, Paimela L, Myllykangas-Luosujarvi R, et al. Current features of peptic ulcer disease in Finland: incidence of surgery, hospital admissions and mortality for the disease during the past twenty-five years. Scandinavian Journal of Gastroenterology. 2002; 37:399–403.
) Schwesinger WH, Page CP, Sirinek KR, et al. Operations for peptic ulcer disease: paradigm lost.Journal of Gastrointestinal Surgery. 2001; :438–43.
) Wang YR, Richter JE, Dempsey DT. Trends and outcomes of hospitalizations for peptic ulcer disease in the United States, 1993 to 2006. Ann Surg. 2010;251:51–8.
) Ahsberg K, Ye W, Lu Y, et al. Hospitalisation of and mortality from bleeding peptic ulcer in Sweden: a nationwide time-trend analysis. Aliment Pharmacol Ther. 2011;33:578–84.
) Lau JY, Sung J, Hill C, Henderson C, Howden CW, Metz epidemiology of complicated peptic ulcer disease: incidence, recurrence, risk factors and mortality. Digestion 2011; 84: –13. review of the ) Lozano R, Naghavi M, Foreman K, Lim
S, Shibuya K, Aboyans V et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Lancet 2012; 380: 2095–128. of Disease Study
) Bertleff MJ, Lange JF. Perforated peptic ulcer disease: a review of history and treatment. Dig Surg 2010; 27: 161–9.
) Mİller MH, Adamsen S, Thomsen RW, Mİller AM. Preoperative prognostic factors for mortality in peptic review. Scand J Gastroenterol 2010; 45: 785–805. a systematic
) Van der Hulst RWM, Rauws EAJ, Hoycu B, et al: Prevention of ulcer recurrence after eradication of Helicobacter pylori: a prospective long-term follow- up study. Gastroenterol 1997;113 (Suppl 1 ) 082– S1086
) Blomgren LGM: Perforated peptic ulcer: long- term results of simple closure in the elderly. World J Surg 1997;21:412–5.
) Svanes C, Lie RT, Svanes K, et al. Adverse effects of delayed treatment for perforated peptic ulcer. Ann Surg. 1994; 220:168–175.
) Marshall BJ, Warren JR. Unidentified curved bacilli in the stomach of patients with gastritis and peptic ulceration. Lancet. 1984; :1311–1315.
) NIH Consensus Conference. Helicobacter pylori in peptic ulcer disease. NIH Consensus Development Panel on Helicobacter pylori in Peptic Ulcer Disease. JAMA. 1994;272:65–69.
) Gisbert JP, Legido J, García-Sanz I, Pajares JM. Helicobacter pylori and perforated peptic ulcer prevalence of the infection and role of non- steroidal anti-inflammatory drugs. Dig Liver Dis 2004; 36: 116–120.
) Christensen S, Riis A, Nİrgaard M, Thomsen RW, Sİrensen HT. Introduction of newer selective cyclo-oxygenase-2 inhibitors and rates of hospitalization with bleeding and perforated peptic ulcer. Aliment Pharmacol Ther 2007; 25: 907–912.
) Lanza FL. A guideline for the treatment and prevention of NSAID-induced ulcers. Members of the Ad Hoc Committee on Practice Parameters of the American College of Gastroenterology. Am J Gastroenterol. ;93:2037–2046.
) Mort JR, Aparasu RR, Baer RK. Interaction between selective serotonin reuptake inhibitors and nonsteroidal antiinflammatory drugs: review of the literature. Pharmacotherapy. 2006;26:1307–1313.
) Lanas A, Serrano P, Bajador E, et al. Evidence of aspirin use in both upper and lower gastro intestinal perforation. Gastroenterology. ;112:683–689. ) Thorsen K, Glomsaker TB, von Meer A, Sİreide K, Sİreide JA. Trends in diagnosis and surgical management of patients with perforated peptic ulcer. J Gastrointest Surg 2011; 15: 1329–35.
) Suriya C, Kasatpibal N, Kunaviktikul W, Kayee T. Diagnostic indicators for peptic ulcer perforation at a tertiary care hospital in Thailand. Clin Exp Gastroenterol 2011; 4: 283–89.
) Grassi R, Romano S, Pinto A, Romano L. Gastro-duodenal perforations: conventional plain film, US and CT findings in 166 consecutive patients. Eur J Radiol 2004; 50: 30–6.
) Hainaux B, Agneessens E, Bertinotti R, De Maertelaer E et al. Accuracy of MDCT in predicting site of gastrointestinal tract perforation. AJR Am J Roentgenol 2006; 187: 1179–83. E, Capelluto
) Furukawa A, Sakoda M, Yamasaki M, Kono N, Tanaka T, Nitta N et al. Gastrointestinal tract perforation: CT diagnosis of presence, site, and cause. Abdom Imaging 2005; 30: 524–34.
) Yeung KW, Chang MS, Hsiao CP, Huang JF. CT evaluation of gastrointestinal tract perforation. Clin Imaging 2004; 28: 329–333.
) Silen W. Cope’s early diagnosis of the acute abdomen. 19. New York: Oxford University Press; ) Lee SC, Fung CP, Chen HY, et al. Candida peritonitis due to peptic ulcer perforation: incidence rate, risk factors, prognosis and susceptibility to fluconazole and amphotericin B. Diagn Microbiol Infect Dis.2002;44:23–27.
) Shan YS, Hsu HP, Hsieh YH, et al. Significance of intraoperative peritoneal culture of fungus in perforated peptic ulcer. Br J Surg. 2003;90:1215–
) Wong PF, Gilliam AD, Kumar S, Shenfine J, O'Dair GN, Leaper DJ. Antibiotic regimens for secondar28peritonitis of gastrointestinal origin in adults. Cochrane CD004539. Syst Rev 2005
) Sartelli M, Catena F, Coccolini F, Pinna AD. Antimicrobial management of intra-abdominal infections: literature's guidelines. World J Gastroenterol 2012; 18: 865–871.
) Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases (Larchmt) 2010; 11: 79–109. America. Surg Infect
) Augustin P, Kermarrec N, Muller-Serieys C, Lasocki S, Chosidow D, Marmuse JP et al. Risk factors for multidrug resistant bacteria and optimization of empirical antibiotic therapy in postoperative peritonitis. Crit Care 2010; 14: R20.
) Eggimann P, Francioli P, Bille J, Schneider R, Wu MM, Chapuis G et al. Fluconazole prophylaxis prevents intra-abdominal candidiasis in high-risk surgical patients. Crit Care Med 1999; 27: 1066–
) Yıldırım M, Engin O, Ilhan E, Coskun A. Risk factors and Mannheim Peritonitis Index for the prediction of morbidity and mortality in patients with peptic ulcer perforation. Nobel Med 2009; 5: 81.
) Sillakivi T, Lang A, Tein A, Peetsalu A. Evaluation of risk factors for mortality in surgically treated perforated peptic ulcer. Hepatogastroenterology 2000;47:1765-8.
) Chao TC, Wang CS, Chen MF. Gastroduodenal perforation in cancer patients. Hepatogastroenterology 1999;46:2878-81.
) Kujath P, Schwandner O, Bruch HP. Morbidity and mortality of perforated peptic gastroduodenal ulcer following emergency surgery. Langenbecks Arch Surg 2002;387:298-302
) Gilliam AD, Speake WJ, Lobo DN, Beckingham IJ. Current practice of emergency vagotomy and Helicobacter pylori eradication for complicated peptic ulcer in the United Kingdom. Br J Surg 2003; 90: 88–90.
) Jani K, Saxena AK, Vaghasia R. Omental plugging for large-sized duodenal peptic perforations: A prospective randomized study of patients. South Med J. 2006;99:467–71.
) Lal P, Vindal A, Hadke NS. Controlled tube duodenostomy in the management of giant duodenal ulcer perforation: a new technique for a surgically challenging condition. Am J Surg. 2009;198:319–23.
) Gupta S, Kaushik R, Sharma R, et al. The management of large perforations of duodenal ulcers.BMC Surg. 2005;5:15.
) Lehnert T, Buhl K, Dueck M, et al. Two-stage radical gastrectomy for perforated gastric cancer. Eur J Surg Oncol. 2000; 26:780–4.
) Swahn F, Arnelo U, Enochsson L, Löhr M, Agustsson T, Gustavsson K et al. Endoscopic closure Endoscopy 2011; 43(Suppl 2 UCTN): E28–E29. peptic ulcer.
) Moran EA, Gostout CJ, McConico AL, Michalek J, Huebner M, Bingener J et al. Assessing the invasiveness of NOTES perforated viscus repair: a comparative study of NOTES and laparoscopy. Surg Endosc 2012; 26: 103–9.
) Bonin EA, Moran E, Gostout CJ, McConico AL, Zielinski transluminal endoscopic surgery for patients with J. Natural orifice peptic ulcer. Surg ) Saber A, Gad MA, Ellabban GM. Perforated duodenal ulcer in high risk patients: is percutaneous drainage justified? N Am J Med Sci 2012; 4: 35–9.
) Bucher P, Oulhaci W, Morel P, Ris F, Huber O. Results of conservative treatment for perforated gastroduodenal ulcers in patients not eligible for surgical repair. Swiss Med Wkly 2007; 137: 337–
) Oida T, Kano H, Mimatsu K, Kawasaki A, Kuboi Y, Fukino conservative therapy for perforated gastroduodenal ulcers. Hepatogastroenterology 2012; 59: 168–70 drainage in
Yazının alınma tarihi: 07.03.2014 Kabül tarihi: 18.04.2014 Online basım: 24.04.2014