Ates et al [68] compared the results of laparoscopic simple clos

Ates et al. [68] compared the results of laparoscopic simple closure without omental patch with that of conventional open repair in patients with small perforated duodenal ulcer and prove that is was as safe and as effective. On the other hand, Turner et al. [69] reported that suture without an omental patch would result in a significantly higher mortality rate than with a patch. However, most cases in their series were perforated gastric ulcers instead of juxta-pyloric perforation. Finally, Lunevicius et al. [70] reviewed 13 prospective and 12 retrospective studies and concluded that repair method should best be judged

by the properties of the ulcer edge. In short, although it seems that no single method is considered being the standard, the literature showed that there were no differences between these two most common adopted procedures in terms of postoperative recovery and incidence of surgical complications. To summarize, laparoscopic simple closure alone without adding an omental patch is a safe procedure for juxtapyloric QNZ supplier perforation in low risk patients. In terms of leakage rate and surgical outcome, the manoeuver to cover an omental patch on the repaired PPU did not show any additional advantage [71]. We suggest that Laparoscopic sutureless repair may

be a viable option in presence of limited laparoscopic experience, only in presence of small size perforations (i.e. microscopic or <2 mm perforations) without significant peritoneal contamination and for low risk patients. We recommend primary repair in case of perforated peptic ulcer larger than 5 mm and smaller than 2 cm (Additional file 3 : Video 3). We suggest routine use omental patch to further protect the suture line (see Additional file 3 : Inositol monophosphatase 1 Video 3). We recommend avoiding use of glue as only method of closure

of PPU. We suggest use of glue only as an adjunctive measure to protect suture line or the omental patch. We suggest avoiding use of glue because of increased costs and risks of complications if serious doubts exist on the efficacy of primary closure. We suggest conversion to open procedure if the primary repair is deemed to be done not efficaciously. Resectional surgery The resection surgery is a viable option for giant peptic ulcers, commonly defined as having a diameter greater than 2 cm. These lesions have a higher risk of perforation. In gastric lesions, although the risk of malignancy is less than historically predicted, the incidence is still around 10% [72, 73]. There are no specific surgical treatment recommendations since the site of perforation and the secondary effects on the surrounding anatomical structures must direct the necessary interventions. These patients are also frequently in septic shock upon presentation when the amount of peritoneal spillage is large. This factor alone should significantly influence the choice of operative intervention.

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