Gastrointestinal perforation surgery
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Abdelwahed M.D[2]
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Gastrointestinal perforation Microchapters |
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Differentiating gastrointestinal perforation from other diseases |
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Diagnosis |
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Overview
Indications for abdominal exploration
Many patients will require urgent surgical intervention.
Patients with the following clinical signs:
- Abdominal sepsis or worsening or continuing abdominal pain and/or signs of diffuse or extensive peritonitis.
- Complete or closed-loop bowel obstruction
- Bowel ischemia: Main initial management is recommended except vasoconstricting agents and digitalis should be avoided since they can exacerbate mesenteric ischemia.
- If vasopressors are needed, dobutamine, low-dose dopamine, or milrinone are preferred since they have less of an effect on mesenteric perfusion as compared with other vasopressors.
- Pain control and systemic anticoagulation are recommended to prevent thrombus formation and propagation unless patients are actively bleeding. Specific organs management
Esophagus
- Open surgery is the mainstay of treatment.
- Surgical options include primary repair, repair over a drain. [51,117]
- Primary repair of the perforation site is the optimal procedure, even if the diagnosis is delayed greater than 24 hours. A primary repair is performed when the closure can heal.
- Endoscopically-placed-stents can be used to manage some patients with esophageal perforation.
- Complications associated with stents include bleeding, fistula, and injury to adjacent structures. [119] 12-14].
- When there has been a delay in diagnosis greater than 24 hours, a vascularized pedicle flap can be used to overcome the lack of integrity in the mucosa. The most common flap used is the intercostal muscle flap.
- A laparotomy is the preferred approach to repair a perforation of an intra-abdominal esophagus.
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Stomach and duodenum
- A major decision when treating patients with ulcer perforation is whether and when to operate. {123-131]
- With any free perforation, if the patient's status is deteriorating, urgent surgery is indicated. Emergent operation and closure with a piece of omentum is the standard of care for patients with an acute perforation and a rigid abdomen with free intraperitoneal air.
- If the patient is stable or improving, especially if spontaneous sealing of the perforation has been demonstrated, nonoperative management with close monitoring is a reasonable option.
- Surgery is indicated in circumstances where the cause of an acute abdomen has not been established or the patient's status cannot be closely monitored.
- Currently, the standard of care for such patients is surgery. [84].
- an initial period of nonoperative treatment with careful observation was safe in patients under age 70 years. If patients did not show clinical improvement after 24 hours, surgery was performed.
- Factors associated with surgery included the size of the pneumoperitoneum, abdominal distension, heart rate >94 beats per minute, pain on digital rectal examination, and age >59 years. Overall mortality in the study was 1 percent. If spontaneous sealing occurs, patients do well without surgery. [77]
- over 50 percent of patients with perforated duodenal ulcers have sealed spontaneously when first examined.
- Nonoperative management may also be considered for patients with delayed presentations. [87]
- Patients with perforated ulcers should have an upper endoscopy to look for evidence of malignancy. It is important to obtain a biopsy of the ulcer margins in all patients with a gastric perforation to rule out gastric carcinoma. If the procedure does not need to be done urgently, we prefer to wait six to eight weeks to allow for ulcer healing.
- Antral and duodenal ulcers can penetrate into the pancreas.
- Pyloric or prepyloric ulcers can penetrate the duodenum. Gastrocolic fistulae are seen with greater curvature gastric ulcers. [72,94]
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Small intestine
- Treatment of small intestinal perforation is performed by closing the perforation in one or two layers.
- A small bowel resection is performed in case:
- Long-standing perforation
- Indurated tissues
Appendix
- The management of perforated appendicitis depends on the condition of the patient:[69]
Unstable patients
- A free perforation of the appendix can cause intraperitoneal dissemination of pus and fecal material and generalized peritonitis.
- These patients are typically quite ill and may be septic or hemodynamically unstable, thus requiring preoperative resuscitation. The diagnosis is not always appreciated before exploration.
- For patients who are septic or unstable, and for those who have a free perforation of the appendix or generalized peritonitis, emergency appendectomy is required, as well as drainage and irrigation of the peritoneal cavity.
- Emergency appendectomy in this setting can be accomplished open or laparoscopically; the choice is determined by surgeon preference with consideration of patient condition and local resources.
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Stable patients
- Stable patients with perforated appendicitis who have symptoms localized to the right lower quadrant can be treated with immediate appendectomy or initial nonoperative management. [70].
- Patients with an appendiceal abscess should be treated with intravenous antibiotics and percutaneous, image-guided drainage of the abscess. Patients who fail initial antibiotic therapy clinically or radiographically require rescue appendectomy, whereas those who respond to initial antibiotic therapy can be discharged with oral antibiotics to complete a 7- to 10-day course (in total) and return for follow-up in six to eight weeks.
Colon and rectum
- Most cases of diverticulitis with contained perforation or small abscess can be treated nonoperatively with antibiotics with or without percutaneous drainage.
- Colon perforations can be treated by simple suture if the perforation is small, often using a laparoscopic approach [152].
- If the perforation is larger and devascularizing the colonic wall, colon resection will be necessary [153].
- Patients with a perforated colon due to neoplasm also require resection [154].
- Laparoscopic treatment of complicated disease is feasible but has a higher rate of conversion to open operation compared with uncomplicated disease [155].
- A primary anastomosis is preferred, whenever feasible [139,156]. Primary anastomosis may be combined with proximal "protective" ostomy in those with complicated diverticulitis or malignancy. Colonic perforation due to Ehlers-Danlos syndrome is best treated with resection or exteriorization, or subtotal colectomy.
- Since most patients with diverticulitis are treated medically, surgery is only indicated when the diverticular disease is either not amenable or refractory to medical therapy (algorithm 1) [5,7-9].
- Acute diverticulitis with free perforation is a life-threatening condition that mandates emergency surgery. [5,9-11]
- Patients who deteriorate or fail to improve after three to five days of inpatient intravenous antibiotics may require urgent surgery, as further medical therapy is unlikely to resolve their diverticulitis.
Colonic obstruction
- Patients who present with colonic obstruction should undergo surgical resection of the involved colonic segment.
- It is difficult to differentiate between obstruction due to cancer and diverticulitis. Surgery is required to rule out cancer and also to relieve symptoms of obstruction.
- Endoluminal stenting may not be helpful for colonic obstruction caused by diverticulitis due to high rates of failure, perforation, or migration.
- Diverticular abscess is treated with percutaneous image-guided drainage or with intravenous antibiotics. In case of failed conservative therapy, urgent surgery is indicated.
Fistula
- Diverticular fistulas rarely close spontaneously, and therefore require surgical correction.
Chronic smoldering diverticulitis
- Patients with acute diverticulitis who initially respond to medical treatment but subsequently develop recurrent symptoms, such as left lower quadrant abdominal pain, alteration in bowel movements, and/orrectal bleeding, are described as having chronic smoldering diverticulitis.
- If the symptoms persist for longer than six weeks, patients should be referred for surgical evaluation.
Asymptomatic but high-risk patients
- Elective surgery is indicated for patients who had a previous episode of complicated diverticulitis. [13,14].
- For immunocompromised patients, elective surgery should be offered after a single attack of diverticulitis.
Techniques
- For patients who require surgery for diverticulitis, the choice of technique depends upon the patient's hemodynamic stability, the extent of peritoneal contamination, and surgeon experience [15].
- The primary goal of surgery is to remove the diseased colonic segment.
- For too ill patients to tolerate a definitive colon resection and reconstruction, a laparotomy with limited resection of the diseased colonic segment should be performed. [16
- A one-stage colon resection for diverticulitis can be performed open or laparoscopically. The laparoscopic approach is preferred when feasible. Growing evidence suggests that laparoscopic surgery in this setting can be performed safely with superior short-term outcomes and comparable long-term outcomes [25-35].
- A two-stage procedure is primarily used for patients with Hinchey III or IV diverticulitis, and for those with Hinchey I or II diverticulitis who have excessive contamination or inflammation of the surrounding tissues or other risk factors for anastomotic leakage.
- Hartmann's procedure is the most commonly performed two-stage procedure and the preferred approach for patients with Hinchey III or IV diverticulitis.
- A Hartmann's procedure involves resecting the diseased colonic segment, creating an end colostomy and a rectal stump, followed by a reversal of the colostomy three months later [18].
- Colonic resection with primary anastomosis and protective ostomy
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Reconstruction
The choice of reconstructive techniques largely depends upon the extent of peritoneal contamination as assessed by the Hinchey classification system [22]:
- Stage I – Pericolic or mesenteric abscess
- Stage II – Walled-off pelvic abscess
- Stage III – Generalized purulent peritonitis
- Stage IV – Generalized fecal peritonitis