Gastrointestinal perforation surgery

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Abdelwahed M.D[2]

Gastrointestinal perforation Microchapters
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Overview

Surgery is the mainstay therapy for gastrointestinal tract (GIT) perforation. The main indications are abdominal sepsis, worsening abdominal pain, signs of diffuse peritonitis, complete bowel obstruction, bowel ischemia. In esophageal perforation, surgical options include primary repair, repair over a drain. Primary repair is the best procedure for thoracic esophageal rupture. It is performed when the closure can heal. Endoscopically-placed-stents can be used to manage some patients with esophageal perforation. In perforated stomach, if the patient is unstable or deteriorating, urgent operation and closure with a piece of omentum is the standard of care. If the patient is stable or improving, nonoperative management with close monitoring is a reasonable option. If patients did not show clinical improvement after 24 hours, surgery was performed. In colonic resection, A one-stage colon resection for diverticulitis can be performed open or laparoscopically. The laparoscopic approach is preferred when feasible. 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. In perforated appendix, stable patients with perforated appendicitis who have symptoms localized to the right lower quadrant can be treated with immediate appendectomy or initial nonoperative management. Patients with an appendiceal abscess should be treated with intravenous antibiotics and percutaneous image-guided drainage. 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. 

Gastrointestinal perforation surgery

Indications for abdominal exploration

Many patients will require urgent surgical intervention. Following clinical signs are the main indications:

• Abdominal sepsis
• Worsening abdominal pain 
• Signs of diffuse peritonitis
• Complete 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.

Esophageal perforation management

• Open surgery is the mainstay of treatment.
• Surgical options include primary repair, repair over a drain.
• Primary repair is the best procedure for thoracic esophageal rupture. It is performed when the closure can heal.
• Endoscopically-placed-stents can be used to manage some patients with esophageal perforation.
• A laparotomy is the preferred approach to repair a perforation of an intra-abdominal esophagus.
• Complications associated with stents include bleeding, fistula, and injury to adjacent structures.
• 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.

Video shows endoscopically-placed-stent in esophageal perforation

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Gastric perforation management

• Antral and duodenal ulcers can penetrate into the pancreas.
• Pyloric or prepyloric ulcers can penetrate the duodenum.

• A major decision when treating patients with ulcer perforation is whether and when to operate.
• If the patient is unstable or deteriorating, urgent operation and closure with a piece of omentum is the standard of care.
• If the patient is stable or improving, nonoperative management with close monitoring is a reasonable option. If patients did not show clinical improvement after 24 hours, surgery was performed.
• 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.
• Factors associated with surgery include:
• The size of the pneumoperitoneum
• Abdominal distension
• Heart rate >94 beats per minute
• Pain on digital rectal examination
• Age >59 years

Follow-up

• Fifty percent of patients with perforated duodenal ulcers have sealed spontaneously when first examined.
• Nonoperative management may also be considered for patients with delayed presentations.
• 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.

Video shows endoscopical surgery in gastric perforation

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Small intestine perforation management

• 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:

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.
• Patients with an appendiceal abscess should be treated with intravenous antibiotics and percutaneous image-guided drainage.
• The complete 7- to 10-day course and return for follow-up in six to eight weeks is sufficient for theses patients.
• Patients who fail initial conservative therapy require rescue appendectomy.

Unstable patients

• 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, and drainage and irrigation of the peritoneal cavity. They require preoperative resuscitation before surgery.

Video shows endoscopic surgery in appendical perforation

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Colon and rectum perforation management

•  Most cases of diverticulitis with perforation or small abscess can be treated nonoperatively with antibiotics with or without percutaneous drainage.
• If the perforation is small, simple suture using a laparoscopic approach can be an ideal approach. Patients who deteriorate or fail to improve after three to five days of inpatient intravenous antibiotics may require urgent surgery.
• If the perforation is larger, colon resection will be necessary. Acute diverticulitis with free perforation is a life-threatening condition that mandates emergency surgery.
• Patients with a perforated colon due to neoplasm also require resection.
• A primary anastomosis is preferred if applicable.
• Since most patients with diverticulitis are treated medically, surgery is only indicated in medically refractory cases.

Colonic obstruction

• Patients who present with colonic obstruction should undergo surgical resection of the involved colonic segment.
• 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 stent 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

• Fistulas due to diverticulitis do not close spontaneously and require surgical correction.

Chronic smoldering diverticulitis

• Patients with acute diverticulitis who initially respond to medical treatment but subsequently develop recurrent symptoms 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.
• For immunocompromised patients, elective surgery should be offered after a single attack of diverticulitis.

Techniques

• 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.
• 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.
• 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.
• Colonic resection with primary anastomosis and protective ostomy.

Video shows {{#ev:youtube|b0msKgqTjDU}}

Reconstruction 

The choice of reconstructive techniques largely depends upon the extent of peritoneal contamination as assessed by the Hinchey classification system:

Stages	Description
I	Pericolic or mesenteric abscess
IIa	Distant abscess amendable to percutaneous drainage
IIb	Complex abscess associated with fistula
III	Generalized purulent peritonitis
IV	Fecal peritonitis