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Closing a perforated duodenal ulcer with a stent was feasible and did not appear to differ from surgical closure in outcomes, a small randomized Swedish study suggested.

In the 42-patient study, the median operation time was significantly shorter in the stent group at 68 minutes versus 92 minutes for surgery (P=0.001). Median hospital stay was similar at 7 days for surgery and 8 days for stenting, according to Jorge A. Arroyo Vàsquez, MD, of South Alvsborg Hospital in Boras.

There was no difference in postoperative C-reactive protein levels or white blood cell count, he stated in a presentation at the virtual Society of American Gastrointestinal and Endoscopic Surgeons meeting.

While standard treatment for this serious condition is surgery, treatment with a nasogastric tube and suction is sometimes used in comorbid patients, but has shown poor results with high mortality, Arroyo Vàsquez's group noted. They added that they have used stent treatment in selected patients with high comorbidity with good results since 2009, and outcomes at the 2017 SAGES meeting.

For the current study, 28 surgical candidates with laparoscopically diagnosed perforated duodenal ulcer were enrolled from December 2014 to August 2018. Of those, 15 were randomized to surgical closure and 13 to treatment with a partially covered stent (Hanaro, MI-tech) placed over the perforation with a guide wire via gastroscope. Surgical suturing was performed with open or laparoscopic techniques according to surgeons' preferences and was removed after 2 or 3 weeks.

The median patient age was 75 in the surgical group and 80 in the stent group. American Society of Anesthesiologists pre-surgery classification was similar in both groups but tended to be somewhat higher in the older group receiving stents (range 1-4 vs 1-3). All patients received abdominal lavage and intravenous proton pump inhibitors (PPI), drainage for leakage control, antibiotics, and intravenous PPI. Stents were endoscopically removed after 2 to 3 weeks.

In terms of complications, six surgical patients overall had a complication ( classification range 2-4). Two required ICU care with inotropic support; one had a suture-line leakage on post-op day 1 treated with a duodenal stent; two had non-specific fever; one had pneumonia; and one had a postoperative duodenal stricture. One required total parenteral nutrition.

In the stented group, seven patients overall had a complication (Clavien-Dindo range 2-5) and three needed ICU care with inotropic support. Two had intra-abdominal abscesses requiring percutaneous drainage; one patient with several days' delayed diagnosis and preoperative deterioration developed multi-organ failure and died. Another developed a leakage after stent placement, which was treated by inserting a new stent.

The one patient who died had experienced symptoms for a week before treatment, and in their previous report, the group found the most important factor for a good outcome without complications was the time factor from onset to treatment.

"Stent treatment seems to be an efficient alternative to treatment with surgery and treat suture line leakage after surgical closure," Arroyo Vasquez said in an audio presentation. "A larger sampling size would be needed to show non-inferiority regarding stent treatment."

Other European GI surgeons have found a semi-covered stent to be a for intervention or rescue in perforated ulcers.

George Van Buren II, MD, of Baylor College of Medicine in Houston, highlighted that complications in the stent arm were substantial, including two intra-abdominal abscesses and a leakage requiring stent replacement.

Van Buren, who was not involved in the study, also pointed out that the stent procedure is a more expensive option than standard surgery. "And if you have a large perforation, you may have to replace the stent, and from experience in esophageal surgery, we know these sometimes wear out and have to be replaced over time," he said.

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