Outcomes of surgical management of peptic ulcer perforation using the falciform ligament: A cross-sectional study at a single centre in Vietnam

Abstract

Introduction: Peptic ulcer perforation (PUP) is one of the most common critical surgical emergencies. The omentum flap is commonly used to cover a PUP. However, the omentum cannot be used in cases of severe peritonitis or previous surgical removal. This is the first study conducted in Vietnam that was designed to analyse the outcomes of patients with PUPs who were treated using the falciform ligament.

Method: In this study, we retrospectively identified 40 consecutive patients who were treated for PUP at a single high-volume centre in Vietnam from February 2018 to February 2021. Peptic ulcer perforation was measured during diagnostic evaluation based on preoperative imaging, such as X-ray, and CT scan. Patients who had malignancy, laparoscopic surgery, omentopexy and nonoperative treatment were excluded from this research.

Results: Forty patients were included; the mean age of the patients was 66.3 years (range 33-99 years), and some patients had comorbid disease (57.5%), hypertension (30%), diabetes (10%), cirrhosis (7.5%), and chronic renal failure (7.5%). The PUPs were located in the duodenum (80%), or the pyloric (15%) and prepyloric (5%) regions. The procedures used to treat the patients included duodenostomy (32.5%), gastrojejunostomy (37.5%), and antrum resection (2.5%). The average operative time was 88.6 min (45-180 min), hospital stay was 9.6 days (2-35 days), and oral intake was started at 4.1 days (3-8 days); additionally, the 30-day mortality (17.5%) and incidences of pneumonia (25%), multiorgan failure (15%), acute liver failure (5%), wound infection (7.5%), and ulcer peptic fistula (0%) were assessed. Univariate tests showed that an ASA ≥ III and comorbidities, such as pulmonary complications, liver failure and multiorgan failure, were associated with mortality. The multivariate test showed that multiorgan failure was the only factor related to mortality.

Conclusion: The falciform ligament can be efficiently used for the closure of a PUP. Although there were no instances of complication with a reperforated peptic ulcer, the mortality rate was slightly highly related to severe comorbidities and postoperative multiorgan failure.

Keywords: Falciform ligament; Flap; Mortality; Peptic ulcer; Perforation; Round ligament.

Conflict of interest statement

Authors declare no conflict of interest.

© 2021 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd.

Figures

Fig. 1

Duodenal ulcer perforation. The duodenal ulcer perforation was located at D1 (white arrow) below the pyloric ring (blue dot) and measured approximately 10 mm. The unhealthy tissues of the perforated ulcer were dissected to the healthy duodenal wall and then closure of the perforated ulcer was performed with a vertical incision and stitched horizontally. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)

Fig. 2

A T-tube was placed and closure was obtained with full-thickness simple interrupted sutures using only safil 2–0 or 3–0. The T-tube size was 14 or 16 Frankel and was used to drain biliary and pancreatic fluid out of the body. This drainage was allowed to flow freely for 7–14 days, and was withdrawn after 30 days.

Fig. 3

Internal layer with a continuous suture using safil 3–0 connecting the duodenal seromuscosa below the ulcer to the falciform ligament.

Fig. 4

Outer layer with a continuous suture (white arrow) the seam of the duodenal perforation.