Most of the patients with suspected PPU received immediate surgery as an initial treatment [3, 9]. Recently, the possibility of non-operative management has been assessed in the WSES and JSGE guidelines for PPU [11, 12]. The WSES recommended against a routinely use of non-operative management, but non-operative management could be considered in extremely selected cases where perforation has sealed as confirmed on water-soluble contrast (weak recommendation based on low-quality evidence, 2C) [11]. The JSGE proposed that mild localized peritonitis could be an indication of nonoperative treatment for PPU. The criteria for conservative treatment include; onset within 24 hours, onset at hunger, stable condition without severe complication, symptoms of peritoneal irritation localized in the upper quadrant, and a small amount of ascites (Recommendation 2, 100% agreed, evidence level D) [12]. In our study, all patients, who were successfully cured by conservative treatment, were under 70 years of age, presented the perforation less than 12 hours earlier, were in a stable condition without severe complications, and had no or localized peritonitis and ascites located in the upper quadrant. Moreover, there were significant differences in these factors between surgery patients and non-surgery patients. On the other hand, nine patients who underwent surgery also matched the criteria of conservative treatment as laid out in the JSGE guidelines before surgery. Only one of them had postoperative complications with CD Grade Ⅱ (aspiration pneumonia), but other patients were entirely cured without any postoperative complications. These results suggest that these patients might have had the potential to be cured without surgery, although careful observation should be needed during conservative treatment. The prospective study of conservative therapy for the PUGT based on the above guidelines should be pursued in future research.
The JSGE guidelines propose that patients with PPU should be surgically treated when clinical and imaging findings show no improvement after 24 hours of conservative treatment (Recommendation 2, 100% agreed, evidence level D) [12]. In our study, two patients were converted to surgery because clinical and imaging findings showed no improvement 24 hours after non-surgical treatment. One patient was 33 years of age and presented the perforation within 6 hours, localized peritonitis, and ascites only at the perforated area. He was discharged 11 days after surgery without any postoperative complications. Another patient showed no peritonitis and no ascites, but he was older (79 years of age), and had a longer perforation-to-treatment time (more than 24 hours). He stayed at the hospital 61 days after surgery with CD Grade Ⅱ. The WSES and JSGE guidelines both recommend performing surgery as soon as possible, especially in patients older than 70 years old and instances where hospital admission was delayed [11, 12, 15, 16]. Buck et al. have shown that elderly patients may experience higher mortality. Every hour of delay from admission to surgery was associated with an adjusted 2.4% decreased probability of survival compared with the previous hour if non-operative management fails. Furthermore, caution is advised in patients > 70 years of age [17]. Based on the guidelines and our own experiences, immediate surgery should be selected as an initial treatment for older patients and those whose treatment has been delayed.
In 2010, a systematic review including 50 studies was performed. Thirty-seven prognostic factors were assessed in a total of 29,782 patients who underwent surgery for PPU. The review provided strong evidence for an association of shock upon admission, preoperative metabolic acidosis, tachycardia, acute renal failure, low serum albumin level, high ASA score, and preoperative delay > 24 h with poor prognosis [18]. In our study, we compared the postoperative complications for surgical patients and examined the predictors of postoperative complications (Grade Ⅱ ≦). Older age, high ASA-PS, longer perforation-to-surgery duration, stomach perforation, tachycardia, abnormal coagulation, anemia, and elevated CRP and lactate levels were associated with postoperative complications. Moreover, the multivariable analyses also identified lactate (18 ≦), which is one of the septic shock criteria [19], as an independent risk factor for postoperative complications. These results support the appropriate targets for resuscitation, which include: MAP ≥ 65 mmHg, urine output ≥ 0.5 ml / kg / h, and lactate normalization, as suggested by the WSES guidelines [11]. In addition, the aforementioned systematic review reported that mortality was associated with older age, comorbidity, and use of NSAIDs or steroids [18]. In this study, the rate of mortality was 4% (N = 2). One patient with abdominal symptoms approximately 2 days before surgery was elderly (79 years of age), and another patient with stomach perforation caused by advanced gastric cancer was in an unstable condition. They had not used NSAIDs or steroids, but both had preoperatively elevated lactate (80 mg / dL, 19 mg / dL, respectively), which was identified as an independent risk factor for postoperative complications in this study.
Spontaneous perforated gastric cancer (PGC) has an incidence ranging from 0.39–9.6% in gastric cancer patients as reported by different studies [4, 20–22]. It is difficult to diagnose PGC preoperatively because its preoperative symptoms are the same as those of a perforated gastric ulcer [4]. Therefore, the outcomes after emergency surgery in patients with free perforation depend on the stage and whether a curative resection can be performed [23]. Surgical management has usually been performed using one-stage or two-stage surgery [24]. In this study, 4 of 6 patients with PGC could be diagnosed after the initial surgery; two patients received two-stage surgery (distal gastrectomy plus lymph node dissection), one patient received chemotherapy for unresectable, and one patient received best supportive care. The other patients were able to be diagnosed before the initial surgery because they received chemotherapy for gastric cancer. One patient underwent gastrectomy as a one-stage surgery. Another patient underwent simple closure with omental patch instead of gastrectomy because of multiple metastases. Five patients were dead within one year after surgery, while one gastrectomy patient (pStage ⅠB) has been alive with no recurrence for more than 5 years.
In terms of surgical procedures, some previous reports showed that the maneuver to cover an omental patch on the repaired PPU did not show additional advantage compared to simple closure alone [25–27]. The WSES suggested performing primary repair in patients with PPU smaller than 2 cm, and no recommendation can be made whether the use of an omental patch can provide further protection of the repair (weak recommendation based on low-quality evidence, 2C) [11]. On the other hand, other research showed low postoperative leak rates with the omental patch technique, even in perforations of up to 2 cm in diameter [28], and suggested the adjunct of an omental patch to reduce the risk of the suture cutting through the edges of the ulcer [29]. The JSGE recommend peritoneal lavage in addition to the closure of the perforated hole with an omental patch as the surgical procedure for gastroduodenal PPU (Recommendation 1, 100% agreed, evidence level A) [12]. In our institute, most of the patients with PUGT received omental plombage and patch (n = 30, 68%) or simple closure plus omental patch (n = 11, 25%). No simple closure alone has performed. The perforation size tended to be bigger in patients with omental plombage and patch than those with simple closure plus omental patch, but the selection of surgical procedures was not associated with postoperative complications.
The WSES recommended a laparoscopic approach in stable patients, but an open approach is recommended in the absence of appropriate laparoscopic skills and equipment (weak recommendation based on moderate-quality evidence, 2B) [5, 30]. However, laparoscopic surgery for PPU is not included in the JSGE guidelines because the extent to which laparoscopic surgery is possible in the emergent setting depends upon the institution [12]. In our institute, laparoscopic surgery has mainly been used to confirm the location of the perforation, then laparoscopic surgery or open surgery was performed depending on the size of the perforation, the degree of peritonitis, and the skills of the surgeon with regards to approaching the perforation. Since 2018, the most frequently used method has been laparoscopy. Our study showed that the use of laparoscopy led to significantly less bleeding during surgery (P = 0.038), but it required a longer operation time (P < 0.001), a finding shared by other reports [30–32]. Patients who received laparoscopies tended to have more postoperative complications (Grade 0–Ⅰ, n = 2 (8%); Grade Ⅱ–Ⅴ, n = 6 (29%), P = 0.077); therefore, more careful and appropriate selection of surgical procedures is warranted.
The clinical presentation of gastroduodenal perforation is usually a sudden onset of abdominal pain. Localized or generalized peritonitis is typical of the perforated upper gastrointestinal tract, but may be present in only two-thirds of the patients [5–7]. Laboratory tests are also non-specific, although leukocytosis, metabolic acidosis, and elevated serum amylase are usually associated with perforation [33]. CT scan is increasingly taking the primary role in the diagnosis of perforation due to its greater sensitivity in detecting free air as well as its ability to characterize the site and size of perforation while excluding other possible causes [6, 10, 34]. Japan currently has over 100 CT scanners per million people, which is much higher than other countries [35]. In our institute, intraperitoneal free air could be identified in all patients by CT scan after their first outpatient visit. The appropriate early diagnosis by CT scan may have contributed to the reduction in mortality rates as compared to previous literature.
This study had some limitations. First, it was retrospective in design and the sample size was relatively small. Second, the survey period was relatively long, and there is a bias based on historical background, such as the induction of laparoscopic surgery and conservative treatment. Therefore, prospective, multicenter studies based on the aforementioned guidelines will be needed in the future.