Improvement of Russian clinical guidelines and reduction of mortality in perforated ulcers / O perspektivakh sovershenstvovaniya rossiiskikh klinicheskikh rekomendatsii i snizheniya letal'nosti pri probodnoi yazve.

OBJECTIVE: To analyze the results of laparoscopic surgery in patients with perforated ulcers using evidence-based medicine approaches. MATERIAL AND METHODS: We compared the efficacy and effectiveness of laparoscopic and open surgeries in patients with perforated ulcers. Meta-analysis of mortality after laparoscopic surgeries (randomized controlled trials) and trial sequential analysis were carried out. RESULTS: We clarified the differences between the efficacy and effectiveness of laparoscopic surgeries regarding postoperative mortality. In the Russian Federation, mortality after laparoscopic surgery is 9-11 times lower compared to open procedures. According to evidence-based researches (efficacy of laparoscopic interventions in 10 meta-analyses), these differences are less obvious (1.4-3.0 times) and not significant. The diversity-adjusted required information size to draw reasonable conclusions about differences in mortality in trial sequential analysis was 68 181 participants. Meta-analyses of RCTs also demonstrate lower incidence of wound complications (1.8-5.0% after laparoscopic surgery and 6.3-13.3% after laparotomy), shorter hospital-stay (mean difference from -0.13 to -2.84) and less severe pain syndrome (mean difference in VAS score from -2.08 to -2.45) after laparoscopic technologies. CONCLUSION: The obvious advantage of laparoscopic surgery in patients with perforated ulcers is fast-truck recovery following shorter hospital-stay, mild pain and rarer wound complications. Comparison of postoperative mortality regarding efficacy and effectiveness is difficult due to insufficient introduction of laparoscopic technologies in clinical practice and diversity-adjusted required information size.

Assessment of risk factors for leakage after repair of perforated peptic ulcer with omental patch. Retrospective study / Evaluación de factores de riesgo de fuga después de la reparación de una úlcera péptica perforada con parche de epiplón. Estudio retrospectivo

Introduction. Perforated peptic ulcer remains one of the critical abdominal conditions that requires early surgical intervention. Leakage after omental patch repair represents one of the devastating complications that increase morbidity and mortality. Our study aimed to assess risk factors and early predictors for incidence of leakage. Methods. Retrospective analysis of data of the patients who underwent omental patch repair for perforated peptic ulcer in the period between January 2019 and January 2022 in Mansoura University Hospital, Egypt. Pre, intra and postoperative variables were collected and statistically analyzed. Incriminated risk factors for leakage incidence were analyzed using univariate and multivariate analysis. Results. This study included 123 patients who met inclusion criteria. Leakage was detected in seven (5.7%) patients. Although associated comorbidities (p=0.01), postoperative intensive care unit admission (p=0.03), and postoperative hypotension (p=0.02) were significant risk factors in univariate analysis, septic shock (p=0.001), delayed intervention (p=0.04), preoperative hypoalbuminemia (p=0.017), and perforation size >5mm (p= 0.04) were found as independent risk factors for leakage upon multivariate analysis. Conclusion. Delayed presentation in septic shock, preoperative hypoalbuminemia, prolonged perforation, operation interval, and large perforation size > 5mm were detected as independent risk factors for leakage. Postoperative tachypnea and tachycardia with increased levels of C-reactive protein and total leucocytic count are alarming signs for incidence of leakage

Introducción. La úlcera péptica perforada es una de las afecciones abdominales críticas que requiere una intervención quirúrgica temprana. La fuga después de la reparación con parche de epiplón representa una de las complicaciones más devastadoras, que aumentan la morbilidad y la mortalidad. Nuestro estudio tuvo como objetivo evaluar los factores de riesgo y los predictores tempranos de fugas. Métodos. Análisis retrospectivo de los datos de los pacientes sometidos a reparación con parche de epiplón por úlcera péptica perforada, en el período comprendido entre enero de 2019 y enero de 2022, en el Hospital Universitario de Mansoura, Egipto. Se recogieron y analizaron estadísticamente variables pre, intra y postoperatorias. Los factores de riesgo asociados a la incidencia de fugas se analizaron mediante análisis univariado y multivariado. Resultados. Este estudio incluyó 123 pacientes que cumplieron con los criterios de inclusión. Se detectó fuga en siete (5,7 %) pacientes. Aunque las comorbilidades asociadas (p=0,01), el ingreso postoperatorio a la unidad de cuidados intensivos (p=0,03) y la hipotensión postoperatoria (p=0,02) fueron factores de riesgo en el análisis univariado, el shock séptico (p=0,001), el retraso en la intervención (p=0,04), la hipoalbuminemia preoperatoria (p=0,017) y el tamaño de la perforación mayor de 5 mm (p=0,04) se encontraron como factores de riesgo de fuga independientes en el análisis multivariado. Conclusión. Se detectaron como factores de riesgo independientes de fuga la presentación tardía en shock séptico, la hipoalbuminemia preoperatoria, la perforación prolongada, el intervalo operatorio y el tamaño de la perforación mayor de 5 mm. La taquipnea posoperatoria y la taquicardia con niveles elevados de proteína C reactiva y recuento leucocitario total son signos de alarma sobre la presencia de fuga.

Perforated peptic ulcer disease in transferred patients is associated with significant increase in length of stay.

BACKGROUND: Perforated peptic ulcer disease (PPUD) has a prevalence of 0.004-0.014% with mortality of 23.5% (Tarasconi et al. in World J Emerg Surg 15(PG-3):3, 2020). In this single center study, we examined the impact associated with patient transfer from outside facilities to our center for definitive surgical intervention (exploratory laparotomy). METHODS: Using EPIC report workbench, we identified 27 patients between 2018 and 2021 undergoing exploratory laparotomy with a concurrent diagnosis of peptic ulcer disease, nine of which were transferred to our institution for care. We queried this population for markers of disease severity including mortality, length of stay, intensive care unit (ICU) length of stay, and readmission rates. Manual chart reviews were performed to examine these outcomes in more detail and identify patients who had been transferred to our facility for surgery from an outside hospital. RESULTS: A total of 27 patients were identified undergoing exploratory laparotomy for definitive treatment of PPUD. The majority of patients queried underwent level A operations, the most urgent level of activation. In our institution, a Level A operation needs to go to the operating room within one hour of arrival to the hospital. Average mortality for this patient population was 14.8%. The readmission rate was 40.1%, and average length of ICU stay post-operatively was 16 days, with 83% of non-transfer patients requiring ICU admission and 100% of transfer patients requiring ICU admission, although this was not found to be statistically significant. Average length of hospital stay was 27 days overall. For non-transfer patients and transfer patients, LOS was 20 days and 41 days, respectively, which was statistically significant by one-sided t-test (p = 0.05). CONCLUSION: Patients transferred for definitive care of PPUD in a population otherwise notable for high mortality and high readmission rates: their average length of stay compared to non-transfer patients was over twice the length, which was statistically significant. Transferred patients also had higher rates of ICU care requirement although this was not statistically significant. Further inquiry to identify modifiable variables to facilitate the care of transferred patients is warranted, especially in the context of improving quality metrics known to enhance patient outcomes, satisfaction, and value.

Spectrum of perforated peptic ulcer disease in a tertiary care hospital in South India: predictors of morbidity and mortality.

BACKGROUND: Perforated peptic ulcer remains one of the most common surgical emergencies in India with significant morbidity and mortality. The aim of this study was to identify the perioperative risk factors influencing the post-operative morbidity and mortality in patients with perforated peptic ulcer disease. METHODS: Five-hundred patients who underwent surgery for perforated peptic ulcer in our institution in the preceding 8 years were included in this observational retrospective study. Their clinical presentations, peri-operative managements were studied and analysed. RESULTS: Five hundred cases were analysed of which 96% were males. Mean age was 46.5 years. A total of 160 patients had duodenal perforation and 328 had gastric perforation with a mean size of 8.6 mm. Most patients (96.2%) underwent omental patch closure of the perforation with mean length of hospitalization being 14 days. The most common major and minor postoperative complications were prolonged intubation and pulmonary complaints respectively. Re-exploration was needed in 6.2% of cases with a post-operative leak rate of 5.8%. Age >60 years, presence of comorbid illnesses, shock at presentation and perforation size >1 cm were identified as independent predictors of postoperative morbidity. Overall mortality was 11.6% while specific mortality among males and females were 11.8% and 5% respectively. Age >60 years, shock at presentation, presence of abdominal rigidity and size of perforation >1 cm were independent predictors of mortality. CONCLUSION: Old age, comorbidities, shock at presentation, perforation size >1 cm, higher ASA grade, prolonged surgery and biliopurulent contamination >500 mL were independent predictors of both increased post-operative morbidity and mortality.

Methamphetamine-related peptic ulcer perforation: a growing medical concern.

BACKGROUND: Many studies have been done in the literature on perforations due to substance abuse, and there are limited publications on perforations related to inhaled methamphetamine. Recently, in our clinic, we observed an increase in the number of patients with perforated peptic ulcer, which we think is secondary to a significant increase in the consumption of this drug. The main purpose of this study is to determine whether the use of inhaled methamphetamine known as 'fire and ice' is a factor directly related to peptic perforation and its complications and also to determine the demographic variables of patients with peptic ulcer perforation due to this substance use, in the context of the literature. METHODS: A retrospective study was conducted by examining the medical records of 29 gastric perforation patients who underwent surgical treatment in our clinic in 2021. Data were transferred to SPSS.23 (IBM Inc., Chicago, IL, USA) program and evaluated with statistical analysis. Normality assumptions of continuous variables were examined with Kolmogorov-Smirnov test, and variance homogeneity was examined with Levene's test. Bi-level comparisons, t-test if the data are normally distributed and Mann-Whitney U-test for bi-level comparisons where the data are not normally distributed were used. Relationships between categorical variables were examined by Chi-square test analysis. P<0.05 was accepted as the level of significance in all analyzes. RESULTS: Twenty-nine patients were divided into two groups as methamphetamine users (n=13) and non-users (n=16). There was a statistically significant difference according to the lower age in the group using methamphetamine (31.69-48.8-P=0.025). The pres-ence of PU history differed significantly between the groups (P=0.009). Interestingly, aspartate transaminase alanine aminotransferase values were lower in substance dependents (P=0.020). Furthermore, there was a significant difference in localization between groups (P<0.001). There was no statistically significant difference between the two groups in terms of gender, clinical presentation, and other laboratory values. CONCLUSION: Methamphetamine consumption, known as fire and ice, is an important risk factor for ulcer development and subsequent perforation, especially in young patients and long-term consumption of this narcotic substance. It has been determined that this risk factor, which is currently considered rare, has been seen in a very large number in a short time in our clinic. The use of this substance, which is considered a major social threat, is becoming more and more widespread, and this study is only a small part of the iceberg reflected in the general surgery clinic of a hospital.

Management of post-ERCP duodenal perforations: experience at Hospital Juárez de México.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is an endoscopic study in which the duodenum is observed laterally, and the bile duct is instrumented. There are several indications and complications in the procedure. OBJECTIVE: To determine the incidence of duodenal perforations, using the Stapfer classification in the Hospital Juárez de Mexico over a period of 5 years, as well as the management implemented in such cases. METHOD: The study was carried out at the Hospital Juárez de Mexico of the Ministry of Health. All patients who underwent ERCP between January 1, 2017, to May 30, 2022 were included. RESULTS: 485 ERCP were performed in the study period. Incidence of 1.6% post-ERCP duodenal perforation. The average age of the subjects 56.37 years. In-hospital stay of post-ERCP perforations averaged 9.37 days. The time of the endoscopic study at the time of the surgical procedure is 10 h on average. CONCLUSIONS: Post-ERCP duodenal perforation is a complication that occurs with a low incidence, it tends to increase the number of days of in-hospital stay and increases morbimortality of patients; therefore, it is important to be always alert.

ANTECEDENTES: La colangiopancreatografía retrógrada endoscópica (CPRE) es un estudio endoscópico en el cual se observa lateralmente el duodeno y se instrumenta la vía biliar. Existen diversas indicaciones y complicaciones en el procedimiento. OBJETIVO: Determinar la incidencia de perforaciones duodenales utilizando la clasificación Stapfer para ubicación anatómica en el Hospital Juárez de México en un periodo de 5 años, así como el manejo implementado en dichos casos. MÉTODO: El estudio se realizó en el Hospital Juárez de México de la Secretaría de Salud. Se incluyeron todos los pacientes sometidos a CPRE entre el 1 de enero de 2017 y el 30 de mayo de 2022. RESULTADOS: Se realizaron 485 CPRE en el periodo de estudio. Hubo una incidencia del 1.6% de perforación duodenal post-CPRE. El promedio de edad de los sujetos fue de 56.37 años. La estancia hospitalaria de los pacientes con perforación post-CPRE fue en promedio de 9.37 días. El tiempo del estudio endoscópico al momento de realizar el procedimiento quirúrgico fue de 10 h en promedio. CONCLUSIONES: La perforación duodenal post-CPRE es una complicación que ocurre con una baja incidencia, suele aumentar los días de estancia intrahospitalaria y aumenta la morbimortalidad de los pacientes, y por ello es importante estar siempre alerta.

A comparative study on laparoscopic and open surgical approaches for perforated peptic ulcer repair: efficacy and outcomes analysis.

PURPOSE: This study aimed to compare the clinical outcomes of the clinical outcomes of laparoscopic and open sutures for peptic ulcer perforation (PPU). MATERIALS AND METHODS: PubMed, EMBASE, and Cochrane Library databases were searched for eligible studies from inception to March 31, 2023. Odds ratios (OR) and 95% confidence intervals (Cl) were also calculated. The Newcastle-Ottawa Scale (NOS) was used to evaluate the quality of the included studies. This study was performed using the Stata (V.16.0) software. RESULTS: A total of 29 studies involving 17,228 patients were included in this study. In terms of postoperative outcomes, the laparoscopic group had a shorter postoperative hospital stay (MD = -0.29, 95%CI = -0.44 to -0.13, P = 0.00), less blood loss (MD = -0.45, 95%CI = -0.82 to -0.08, P = 0.02), fewer wound infection (OR = 0.20, 95%CI = 0.17 to 0.24, P = 0.00), fewer pneumonia (OR = 0.59, 95%CI = 0.41 to 0.87, P = 0.01), fewer respiratory complications (OR = 0.26, 95%CI = 0.13 to 0.55, P = 0.00) and lower postoperative morbidity (OR = 0.51, 95%CI = 0.33 to 0.78, P = 0.00). The laparoscopic group had a lower mortality rate (OR = 0.36, 95%CI = 0.27 to 0.49, P = 0.00) than the open group. We also found that the laparoscopic group had a higher overall complication rate than the open group (OR = 0.45, 95%CI = 0.34 to 0.60, P = 0.00). CONCLUSION: Laparoscopic repair was associated with a lower risk of mortality than open repair in patients with PPU. Laparoscopic repair may be a better option in patients with PPU.

The feasibility of falciformopexy in the repair of peptic ulcer perforation.

BACKGROUND: Modified Graham omentopexy is the most commonly used operative technique in the repair of peptic ulcer perfo-ration (PUP); however, there is little data on falciformopexy in the literature. The aim is to investigate the feasibility of falciformopexy in the repair of PUP, comparing with modified Graham omentopexy. METHODS: Data of 471 patients who were operated for PUP were retrospectively analyzed. Patients' demographics, pre-operative basic laboratory findings, American Society of Anesthesiologists (ASA) status, operative findings, and post-operative complications were recorded. The patients were classified into two groups modified Graham omentopexy and falciformopexy, and then compared with each other in terms of clinical characteristics, operative findings, and post-operative complications. RESULTS: Modified Graham omentopexy and falciformopexy were performed in 425 (90.2%) and 46 (9.8%) patients, respectively. The two groups were similar in terms of basic patient characteristics and pre-operative laboratory findings (P>0.05). ASA physical status was significantly different between the groups (P=0.001). No statistically significant difference was found between the groups in terms of complications, except for an anastomotic leak. Anastomotic leak was observed more frequently in patients who underwent falciformopexy than in patients with modified Graham omentopexy (P=0.017). CONCLUSION: Although falciformopexy technique has a higher rate of leak compared to the modified Graham omentopexy method, it should be kept in mind as an alternative method for repair of PUP, especially in cases where omentopexy cannot be applied for various reasons such as the presence of unavailable or unsuitable omentum.

Concurrent laparoscopic highly selective vagotomy with closure of duodenal ulcer perforations show good clinical results as primary repair alone.

OBJECTIVE: To compare clinical and operative results between laparoscopic primary repair (LPR) alone and LPR with highly selective vagotomy (LPR-HSV) in patients with duodenal ulcer perforation. METHODS: Clinical data from patients who underwent either LPR or LPR-HSV by resecting both sides of the neurovascular bundle using an ultrasonic or bipolar electrosurgical device for duodenal ulcer perforations, between 2010 and 2020, were retrospectively collected. Between-group differences in continuous and categorical variables were statistically analysed. RESULTS: Data from 184 patients (mean age, 49.6 years), who underwent either LPR (n = 132) or LPR-HSV (n = 52) were included. The mean operation time was significantly longer in the LPR-HSV group (116.5 ± 39.8 min) than in the LPR group (91.2 ± 33.3 min). Hospital stay was significantly shorter in the LPR-HSV group (8.6 ± 2.6 days) versus the LPR group (11.3 ± 7.1 days). The mean postoperative day of starting soft fluid diet was also significantly shorter in the LPR-HSV group (4.5 ± 1.4 days) than in the LPR group (5.6 ± 4 days). No between-group difference in morbidity rate was observed. The learning curve of the HSV procedure showed a stable procedure time after 10 operations. CONCLUSIONS: LPR with HSV may be a safe and feasible procedure for selective cases who are at high risk for ulcer recurrence.

Gastric, Duodenal, and Small Bowel Emergencies.

Gastric and small bowel emergencies are often seen in the emergency department and require rapid assessment and intervention as patients can deteriorate quickly. Some of the more frequently seen gastric emergencies include gastric volvulus and peptic ulcer disease, which can present with ischemia, strangulation, perforation, or severe bleeding. Swift diagnosis is crucial to ensuring the proper management whether that is endoscopic or with surgical exploration. Perforated peptic ulcers that are not contained will require surgical intervention, whereas bleeding ulcers can often be controlled with endoscopic interventions.

A simple and effective technique for laparoscopic gastrorrhaphy: modified Graham's patch with barbed suture.

INTRODUCTION: Peptic ulcers are caused by unbalanced acid production, and proton pump inhibitors (PPIs) in recent decades have helped to treat peptic ulcers effectively. Meanwhile, the incidence of perforated peptic ulcer (PPU) persists and has a high mortality rate if there is no adequate management. Primary closure with a modified Graham's patch was well performed in early detected PPU with a small size < 2 cm. A laparoscopic approach for PPU was prescribed for decades with proven feasibility and safety. We introduced an effective technique combined with barbed suture and modified Graham's patch, which can significantly reduce the surgical time without significantly increasing morbidity and mortality compared with traditional interrupted suture. PATIENTS AND METHOD: We retrospectively collected data from January 2014 to December 2020 in Keelung Change Gung Memorial Hospital, and a total of 154 patients receiving laparoscopic repair of PPU were included. There were 59 patients in the V-loc group (V group) and 95 patients in the laparoscopic primary repair group (P group). RESULTS: The V group had a significantly shorter operation time than the P group (96.93 ± 22.14 min vs. 123.97 ± 42.14, P < 0.001). Ten patients suffered from morbidity greater than the Clavien‒Dindo classification 4 (5 from V group, and 5 from P group). Three patients with leakage were reported. Two patients were in the V group, and one patient was in the P group (p = 0.432). CONCLUSION: Laparoscopic repair with barbed suture and modified Graham's patch provides a simple and effective technique in the management of acute abdomen. This technique can be easily performed by experienced surgeons and trainees in minimally invasive surgery without affecting patient safety.

[Laparoscopic treatment of perforated gastroduodenal ulcers]. / Laparoskopicheskaya tekhnologiya lecheniya probodnykh yazv zheludka i dvenadtsatiperstnoi kishki.

The review is devoted to laparoscopic technology in the treatment of perforated gastroduodenal ulcers. Searching for literature data was performed in the PubMed, Google, Springer Link online library, Cochrane Systematic Review databases. We analyzed reviews, prospective and retrospective studies devoted to various strategies in the treatment of perforated peptic ulcers. Demographic, clinical and epidemiological features of these patients, indications and contraindications for endoscopic suturing of perforations, features of laparoscopic procedures and causes of conversions to open surgery were studied. Finally, we compared the results of laparoscopic and open surgeries.

Duodenal ulcer perforation and its consequences.

Duodenal ulcer perforation, a frequent surgical emergency, needs simple closure with indirect Graham's Omentopexy which is effective with excellent results in majority of cases despite patients' late presentation. The objective of the study was to determine the frequency of postoperative complications of perforated duodenal ulcer, conducted in the Surgery Department, Jinnah Postgraduate Medical Centre, Karachi, from March 20, 2018 to September 20, 2018. The study was a descriptive case series of 108 patients of both genders with perforated duodenal ulcer > 1 week old with ASA score I & II. Patients with trauma and comorbidities were excluded. The patients underwent laparotomy and peritoneal toilet, and after noting the site of perforation indirect Graham's Omentopexy was performed. Complications like duodenal fistula, peritonitis, and paralytic ileus, and patient's death within 10 days of surgery were noted. Age ranged from 18 to 50 years with mean age of 35.027±5.13 years, mean weight 71.120±12.77 kg, mean height 1.541 ±0.09 metres, mean BMI 29.975±4.99 kg/m2, and the mean duration of complaint was 4.194±1.30 weeks. Male predominance in 75 (69.4%) patients. Duodenal fistula was seen in 10 (9.3%) patients, peritonitis 12 (11.1%), paralytic ileus 14 (13%) and mortality was in 11 (10.2%) patients.

The role of multidetector computed tomography in predicting the site of gastroduodenal perforation.

OBJECTIVE: This study aims to evaluate the value of multidetector computed tomography (MDCT) in detecting the location of gastroduodenal perforation. PATIENTS AND METHODS: This cross-sectional descriptive study was conducted with 47 patients who underwent contrast-enhancing MDCT and were diagnosed with gastroduodenal perforation during surgery between July 2021 and June 2022. Radiologic findings included pneumoperitoneum (distribution and quantity) and analyzed the image findings for localizing the site of gastroduodenal perforation. RESULTS: Pneumoperitoneum was the most common finding [95.74% (45 out of 47 patients)]. Regarding air distribution, the sensitivity (Se) and negative predictive value (NPV) of abdominal free air and supramesocolic free air were the highest (100% for both). The accuracy (Acc) of supramesocolic free air was the highest (93.6%), followed by abdominal free air (89.4%). Subphrenic free air also had a high Acc value (89.4%), with Se, specificity (Sp), and positive predictive value (PPV) being 90%, 85,7%, and 97.3%, respectively. The Sp PPV of falciform ligament/ligamentum teres sign, and periportal free air were also high (100% for both). In contrast, retroperitoneal free air was valuable in determining retroperitoneal duodenal perforation with an Sp, Se of 100%, and Acc of 89.4%. The thickness of abdominal free air was ≥5.5 mm, suggesting gastroduodenal perforation with a Se, Sp, PPV, NPV, and Acc of 82.5%, 100%, 100%, 50%, and 85.1%, respectively. CONCLUSIONS: Subphrenic free air, periportal free air, falciform ligament sign, and the air above transverse mesocolon were correlated to gastric and duodenal bulb perforation. Retroperitoneal air indicates the perforation at the retroperitoneal duodenum. The thickness of abdominal free air ≥5.5 mm indicates gastric and duodenal bulb perforation.

Comparison of 'primary repair' and 'placing a drain without repair' methods in duodenum perforations.

BACKGROUND: Duodenal ulcer perforation is a serious condition. A number of methods have been defined and used in surgical treatment. In this study, it was aimed to compare the effectiveness of 'primary repair' and 'drain placement without repair' methods in duodenal perforations using an animal model. METHODS: Three equivalent groups of ten rats each were formed. Perforation was created in the duodenum in the first (primary repair/sutured group) and the second group (drain placement without repair/sutureless drainage group). In the first group, the per-foration was repaired with sutures. In the second group, only a drain was placed in the abdomen without sutures. In the third group (control group), only laparotomy was performed. Neutrophil count, sedimentation, serum C-reactive protein (CRP), serum total an-tioxidant capacity (TAC), serum total thiol, serum native thiol, and serum myeloperoxidase (MPO) analyses were performed on animal subjects in the pre-operative period and on the post-operative 1st and 7th days. Histological and immunohistochemical (transforming growth factor-beta 1 [TGF-ß1]) analyzes were performed. Blood analysis, histological, and immunohistochemical findings obtained from the groups were compared statistically. RESULTS: There was no significant difference between the first and second groups, except for the TAC on the post-operative 7th day and MPO values on the post-operative 1st day (P>0.05). Although tissue healing was more pronounced in the second group than in the first group, there was no significant difference between the groups (P>0.05). TGF-ß1 immunoreactivity observed in the second group was found to be significantly higher than in the first group (P<0.05). CONCLUSION: We think that the sutureless drainage method is as effective as the primary repair method in the treatment of duo-denal ulcer perforation and can be safely applied as an alternative to the primary repair method. However, further studies are needed to fully determine the efficacy of the sutureless drainage method.

Perforated Stress Ulcer of the Duodenum: a Case of an Unexpected Diagnosis in a COVID-19 Patient Following Dilatation and Curettage Procedure.

Background: Stress ulcers in the upper gastrointestinal tract can arise from pathologies related to erosive or inflammatory insults in critically ill patients. The relationship between stressful bodily events and the ischemia and perforation of stress ulcers is poorly understood. Objective: We present a case of perforated stress ulcer following an abortion that was treated by dilatation and curettage (D&C) and complicated by a coronavirus disease 2019 (COVID-19) infection. Case presentation: A 40-year-old lady presented to the emergency room complaining of diffuse abdominal pain, she was recently diagnosed with an incomplete abortion and managed via a D&C procedure in an external hospital. A computed tomography (CT) scan was done at our center for the abdomen and pelvis, showing extensive pneumoperitoneum, which brought the radiologist's attention to suspect a small bowel perforation presumably accompanying a uterine perforation secondary to the D&C. There were no obvious signs of pelvic small bowel perforation in the initial CT images. The perforated duodenal stress ulcer was diagnosed the next day by a new CT scan following oral contrast ingestion and managed surgically by repair and omental patch, and no other bowel perforations were found upon surgical exploration. After the surgery, the patient was diagnosed with COVID-19, and her clinical status deteriorated gradually during the following week, and she passed away from a cardiac arrest. Conclusion: It is unclear whether septic abortion or COVID-19 has resulted in stress ulcer perforation in our patient. This case report highlights the importance of raising early suspicion in the diagnosis of stress ulcer perforation in critically ill patients to reduce the risk of morbidity and mortality.