Other techniques and future developments Self-expandable metal stents Primary stenting and drainage has been shown to be an effective and safe way to treat esophageal perforations or anastomotic leaks after gastric bypass surgery. M. Bergstrom et al. present a case series of eight patients with perforated duodenal selleck compound ulcers treated with covered self-expandable metal stents (SEMS). Two patients received
their stents because of postoperative leakage after initial traditional surgical closure. Six patients had SEMS placed as primary treatment due to co-morbidities or technical surgical difficulties. Gilteritinib cost Endoscopy and stent treatment in these six patients was performed at a median of 3 days (range, 0–7 days) after initial symptoms. Six patients had percutaneous abdominal drainage. Early oral intake, 0–7 days after stent placement, was possible. All patients except one recovered without complications and were discharged 9–36 days after selleck products stent placement. This study indicates that in cases where surgical closure will be difficult,
gastroscopy with stent placement can be performed during the laparoscopy, followed by laparoscopic drain placement. In patients with severe co-morbidity or delayed diagnosis, gastroscopy and stent placement followed by radiologically guided drain placement can be an alternative to conservative treatment . Natural orifice transluminal endoscopic surgery (NOTES) A NOTES approach may reduce the physiologic impact of therapeutic intervention after peptic ulcer perforation and provide a technically less challenging procedure. Experimental data suggest that the NOTES repair may be possible with lower intraabdominal
pressure . Preclinical trials of endoscopic omental patch closures for upper gastrointestinal viscus perforations have been published . A retrospective review suggested that up to 50% of patients presenting with perforated ulcer might be candidates for a NOTES repair . Bingener et al.  present a pilot clinical study evaluating the feasibility of endoscopic transluminal omental patch closure for perforated peptic selleck chemicals llc ulcers, with the hypothesis that the technique will be successful at closing ulcer perforations, as evidenced by intraoperative leak test and post operative water-soluble contrast studies. After induction of general anesthesia, pneumoperitoneum (12–14 cm H2O) has been established using a periumbilical trocar in Hasson technique. This served to confirm the diagnosis of ulcer perforation and for surveillance of the endoscopic procedure. A standard diagnostic upper endoscope with CO2 insufflation has been introduced through the oropharynx into the stomach and duodenum. The site of perforation was identified and measured. The endoscope was carefully advanced through the perforation when possible. Once in the peritoneal cavity, the endoscopist proceeded with inspection and irrigation.