Perforated Peptic Ulcer: new insights

textabstractMuch has been written on perforated peptic ulcer (PPU) during the last hundred years. In 1500, when necropsies were first allowed, often a small hole was found in the anterior wall of the stomach, giving an explanation for symptoms of acute abdominal pain, nausea, vomiting which often led to death within a few hours or days. Laparoscopic surgery, also called minimal invasive surgery or keyhole surgery is a surgical technique in which operations are performed through small incisions as compared to the larger incision needed in traditional surgical procedures. Georg Kelling performed the !rst laparoscopic procedure in dogs in 1902 and in 1910 Hans Christian Jacobaeus was responsible for the first laparoscopic procedure in humans, but it took till the 80s of the last century before laparoscopic procedures became popular. Benefits of laparoscopic surgery are less postoperative pain, minimal scarring and lower morbidity and mortality. A review of the history of perforated peptic ulcer disease (PUD) has been written in chapter 1 and a review on laparoscopic correction for PPU has been written in Chapter 2. The aim of this thesis was to demonstrate if laparoscopic correction of PPU was feasible and if it was superior to the routine correction of PPU by upper laparotomy. For this a Dutch multicenter trial, the LAMA trial, was performed. During this trial several questions raised, which led to more research. First of all, reviewing literature on this topic, it became clear that consensus on several topics was lacking (Chapter 3, 4). A European questionnaire was sent to get an impression of the current preferred methods of choice (Chapter 5). During the LAMA trial it was discovered that the laparoscopic suture procedure sometimes led to problems. Therefore an alternative technique for closure of the perforation without the need for suturing was tested in rats (Chapter 6 and 7). Finally, during surgery for PPU routinely a biopsy is taken for testing on Helicobacter pylori (H.pylori), one of the main causes for the occurrence of peptic ulcer disease. It was questioned if testing the abdominal fluid or serum could replace the need for a biopsy, but also it was evaluated if there was one genetic type of the H.pylori responsible for the emergence of PPU, which could be an important factor in the prevention of PPU (Chapter 8)