Treatment

General surgical principles apply to the treatment of a perforated viscus. As soon as the diagnosis has been made and the patient has been resuscitated, no further delay should be allowed. A perforated viscus is always an emergency. Conservative treatment by means of gastric suction and resuscitation may be considered in patients with a perforated peptic ulcer. However, the patient's condition must improve within 6 to 12 h; if not, laparotomy should follow immediately. Treatment of intra-abdominal abscesses due to a perforated bowel with CT-guided percutaneous puncture and drainage should only be considered if the perforation has been treated appropriately.

In the compromised (e.g. septic) patient, surgery should be aimed at the most reliable treatment strategy. The first aim of the laparotomy is removal of all foreign material, drainage of all abscesses, and extensive peritoneal lavage. There is no place for primary anastomosis of the bowel in the severely contaminated abdomen.

Particularly in the large bowel, the affected part should be exteriorized, if necessary with multiple stomata. Usually, this also holds true for the small bowel; however, primary anastomosis is possible in selected cases. Resection of the perforation site should be performed when the perforation is caused by an inflammation or a tumor (perforated appendix, diverticulitis, perforated colonic carcinoma, etc.).

In the case of a perforated gallbladder, the affected organ should be removed. However, when a dense inflammatory mass prevents recognition of important anatomic structures, partial resection and placement of drains in the remaining gallbladder lumen is a treatment option.

A perforated peptic ulcer is sutured and the perforation is covered with an omental patch. Extensive surgery to reduce acid production (e.g. highly selective vagotomy or antrum resection and vagotomy) increases the operative risk and is not indicated, since modern medication (H 2 receptor antagonists, proton pump inhibitors) is equally effective in healing and preventing peptic ulcers. Exceptions to this rule are the large perforated duodenal ulcer that cannot be closed by suture and the severely deformed pyloric region with obvious outlet obstruction, in which case a resection is necessary.

After adequate surgical debridement there are three options: close the abdomen with a resorbable mesh to allow drainage of the abdominal cavity, the so-called 'open abdomen' where the abdominal wall is left open, or primary suture of the abdominal wall. In the latter case a thorough follow-up and a very low threshold for relaparotomy (within 24-48 h) are the secrets to successful treatment. In the case of an open abdomen, the use of a wound manager will facilitate proper care of the patient. Repeat exploration of the abdominal cavity in these patients can be performed in the ICU. When the abdomen is closed with a resorbable mesh, placement of a large self-adhesive plastic sheet prevents excessive fluid loss and dehydration of the underlying bowel loops. The strategy adopted depends largely on the experience and preference of the surgeon.

A very difficult category of patients are those with a perforation of the esophagus. The perforation should be treated aggressively and as soon as possible. Depending on the cause, the location, and the size of the perforation, different treatment strategies are possible. A small perforation as a result of an endoscopy can be treated conservatively with suction in the esophagus and antibiotics, if necessary combined with drainage of the thoracic cavity. A large distal perforation (e.g. after dilatation) can be treated by suture of the perforation and plication with the gastric fundus. In cases of a large perforation or in the presence of a tumor, primary resection may be necessary. This should only be performed by a surgeon with long experience in esophageal surgery and preferably in a referral hospital. In patients with severe sepsis (multiple organ failure) due to esophageal perforation, deviation of the esophagus to the neck and local debridement and drainage of the perforation may be a suitable treatment option to get the patient through the first stage of the therapy.

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