Trends and outcomes of hospitalizations for peptic ulcer disease in the United States, 1993 to 2006. Ann Surg. 2010;251:51-58. [PMID: 20009753 DOI: 10.1097/sla.0b013e3181b975b8]

Laparoscopic repair of perforated peptic ulcer is not prognostic factor for 30-day mortality (a nationwide prospective cohort study)

BACKGROUND

Laparoscopic surgery has become increasingly popular in treating perforated peptic ulcer (PPU). However, currently it is not recognized as a prognostic factor for mortality within this group of patients. The aim of this study was to investigate whether laparoscopic surgery was an independent mortality risk factor in patients treated surgically for perforated peptic ulcer.

MATERIALS AND METHODS

This was a Danish nationwide cohort study based on prospectively collected data of 1008 patients treated surgically for PPU between September 2011 and December 2015. A propensity score matching analysis, considering most of the known prognostic factors for mortality and baseline characteristics, was used to adjust mortality estimates in patients treated with open and laparoscopic surgery. The primary outcome was postoperative 30-day mortality.

RESULTS

The study population comprised 1008 patients; 507 were treated laparoscopically and 501 by open surgery. There was significantly higher mean age, and higher ASA scores, as well as other mortality risk factors in the open surgery group. The unadjusted 30-day mortality was significantly lower in patients undergoing laparoscopic surgery compared to open surgery (HR = 0.48, 95% CI: 0.36-0.65). After matching and weighting controls, the adjusted difference in mortality was reduced and was not significant (HR = 0.82, 95% CI: 0.59-1.15). The 30-day mortality was 13.1% for laparoscopy and 14.7% for the matched controls in the open surgery group.

CONCLUSIONS

Compared to open surgery, laparoscopic surgery in patients with PPU does not reduce short term mortality. More well powered randomized clinical trials are needed to investigate the role of laparoscopic surgery in treatment of patients with PPU.

Trends in Major Gastrectomy for Cancer: Frequency and Outcomes

BACKGROUND

Declining incidence of gastric cancer in the USA has presumably resulted in lower rates of major gastrectomy for cancer. The impact on perioperative outcomes remains undefined. The aims of this study were to characterize national trends in frequency of major gastrectomy for cancer, identify factors associated with in-hospital mortality, and examine outcome disparities by race/ethnicity.

METHODS

Nationwide inpatient sample data from 1993 to 2013 were queried for procedural and diagnostic codes (ICD-9) relating to total and partial gastrectomy procedures. Gastric resections for cancer were compared to those for peptic ulcer disease for reference. Patient demographics, comorbidity score, mortality, and hospital characteristics were recorded as covariates.

RESULTS

A significant decrease in annual rates of partial and total gastrectomy was observed from 1993 to 2013 (p < 0.0001). The change in absolute number and percent decline was greater for partial gastrectomy (- 39.3%) than total gastrectomy (- 19%). There was a 34.0% decrease in gastrectomy for cancer in Whites and a 61.2% increase among Hispanic patients over two decades. In-hospital mortality also significantly decreased over the study period (7.7% to 2.7%). Factors associated with lower mortality rates included male sex and treatment at urban teaching hospitals. Analysis of trends revealed that gastrectomy for cancer was performed with increasing frequency at urban teaching hospitals.

CONCLUSIONS

The frequency of major gastric resections in the USA has declined over two decades. Overall, in-hospital mortality rates also have decreased significantly. Declining in-hospital mortality after gastrectomy for cancer is associated with more frequent treatment at urban teaching hospitals.

Perforated Peptic Ulcer Surgery: Decreased Length of Stay but No Difference in Mortality with Laparoscopic Repair

BACKGROUND

Perforated peptic ulcer (PPU) surgery mortality ranges 1% to 24%. We hypothesized a decrease in length of stay (LOS) with laparoscopic surgical repair (LSR) compared with open surgical repair (OSR).

METHODS

Patients undergoing PPU surgery 2005 to 2015 were identified in NSQIP. LSR was compared with OSR 2005 to 2015. LSR 2005 to 2010 was compared with 2011 to 2015. OSR 2005 to 2010 was compared with 2011 to 2015. The primary outcome was LOS. Secondary outcomes were mortality and morbidity.

RESULTS

Between 2005 and 2015, LSR had a decreased LOS, was more likely to wean from the ventilator, but had no significant difference in mortality compared with OSR. There was no significant difference in mortality for LSR or OSR over time.

CONCLUSIONS

When patients are appropriately selected, LSR for PPU is a viable alternative to OSR, decreasing LOS and pulmonary complications. This demonstrates significant benefit to patients and hospital throughput.

Surgical repair of perforated peptic ulcers: laparoscopic versus open approach

INTRODUCTION

Perforated peptic ulcers are a surgical emergency that can be repaired using either laparoscopic surgery (LS) or open surgery (OS). No consensus has been reached on the comparative outcomes and safety of each approach.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, we conducted a 12-year retrospective review (2005-2016) and identified 6260 adult patients who underwent either LS (n = 616) or OS (n = 5644) to repair perforated peptic ulcers. To mitigate selection bias and adjust for the inherent heterogeneity between groups, we used propensity-score matching with a case (LS):control (OS) ratio of 1:3. We then compared intraoperative outcomes such as operative time, and 30-day postoperative outcomes including infectious and non-infectious complications, and mortality.

RESULTS

Propensity-score matching created a total of 2462 matched pairs (616 in the LS group, 1846 in the OS group). Univariate analysis demonstrated successful matching of patient characteristics and baseline clinical variables. We found that OS was associated with a shorter operative time (67.0 ± 28.6 min, OS versus 86.9 ± 57.5 min, LS; P < 0.001) but a longer hospital stay (8.6 ± 6.2 days, OS versus 7.8 ± 5.9 days, LS; P = 0.001). LS was associated with a lower rate of superficial surgical site infections (1.5%, LS versus 4.2%, OS; P = 0.032), wound dehiscence (0.3%, LS versus 1.6%, OS; P = 0.030), and mortality (3.2%, LS versus 5.4%, OS; P = 0.009).

CONCLUSION

Fewer than 10% of patients with perforated peptic ulcers underwent LS, which was associated with reduced length of stay, lower rate of superficial surgical site infections, wound dehiscence, and mortality. Given our results, a greater emphasis should be provided to a minimally invasive approach for the surgical repair of perforated peptic ulcers.

[Emergency surgery in Russian Federation (in Russian only)]

In the following article, we present the key trends in emergency surgical care in the Russian Federation between 2000 and 2017. The study used data from federal statistical observations and a survey of state medical institutions in 80 regions encompassing 99.3% of the country's population. We discovered a change in the correlation between acute abdominal diseases, particularly a significant reduction in the occurrence of acute appendicitis and perforated peptic ulcer. Reduction in the number of emergency surgeries by 27.8% annually was also observed. Mortality rate decreased in cases of strangulated hernia, acute cholecystitis and acute pancreatitis, while it is stable for bowel obstruction and acute appendicitis and increasing in perforated peptic ulcer cases. The total annual number of lethal outcomes due to acute abdominal diseases was decreased by 1900 cases. Significant changes were observed in mortality rate and minimally invasive surgeries proportions between federal districts and individual regions of the country. The range of administrative measures was proposed.

Disparities in peptic ulcer disease: A nationwide study

BACKGROUND

While advances in diagnosis and treatment of peptic ulcer disease have led to a decrease in hospital admissions the socioeconomic distribution of these benefits is unknown.

METHODS

We designed a retrospective cohort study using the National Inpatient Sample from 2012 to 2013 including all patients that were admitted for peptic ulcer disease. We compared the types of ulcer related complications, the rates of intervention and the outcomes based on race and insurance status.

RESULTS

Of 42,046 patients admitted for peptic ulcer disease 80.25% had an ulcer related complication. Black patients had the lowest rates of bleeding and highest rates of perforation and were less likely to undergo surgery for their complication but mortality was not different from white patients. Uninsured patients also had lower rates of bleeding and higher rates of perforation and they were at increased risk for death.

CONCLUSIONS

Unlike other surgical conditions insurance status, not race, predicts mortality in peptic ulcer disease.

End Stage Renal Disease is Associated with Increased Mortality in Perforated Gastroduodenal Ulcers

Patients with end stage renal disease (ESRD) represent a growing subset of surgical candidates and ESRD status has been associated with increased morbidity and mortality in other operations. Using a national database, we examined outcomes and risk factors for patients presenting with perforated gastroduodenal ulcers undergoing omentopexy. We identified adult and emergent patients with perforated duodenal and gastroduodenal ulcers that underwent omentopexy using the 2005 to 2012 Nationwide Inpatient Sample. We identified patients with ESRD status and assessed comorbidity status using the Elixhauser–van Walraven score. Univariate and multivariable logistic regression analyses were performed. Inpatient mortality was the primary outcome. Six thousand five hundred and twenty-one patients were identified. Median age was 59.0 years, majority were male (55.56%), 79 (1.21%) patients had ESRD, 367 (5.63%) patients died during admission. Multivariable logistic regression showed age (OR 2.71, P < 0.0001), Elixhauser–van Walraven score (OR 2.69, P < 0.0001), and ESRD status (OR 3.88, P < 0.0001) as independent risk factors for mortality. ESRD was associated with increased mortality in patients undergoing omentopexy for perforated gastroduodenal ulcers. Future studies are necessary to identify methods to increase perioperative survival.

Transcatheter Arterial Embolization for Bleeding Peptic Ulcers: A Multicenter Study

PURPOSE

To investigate the outcomes of transcatheter arterial embolization (TAE) for the treatment of peptic ulcer bleeding (PUB).

MATERIALS AND METHODS

This is a retrospective, multicenter study, which investigated all patients who underwent TAE for the treatment of severe upper gastrointestinal hemorrhage from peptic ulcers in five European centers, between January 1, 2012 and May 1, 2017. All patients had undergone failed endoscopic hemostasis. Forty-four patients (male; mean age 74.0 ± 11.1 years, range 49-94), with bleeding from duodenum (36/44; 81.8%) or gastric ulcer (8/44; 18.2%) were followed up to 3.5 years (range 2-1354 days). In 42/44 cases, bleeding was confirmed by pre-procedural CT angiography. In 50% of the cases, coils were deployed, while in the remaining glue, microparticles, gel foam and combinations of the above were used. The study's outcome measures were 30-day survival technical success (occlusion of feeding vessel and/or no extravasation at completion DSA), overall survival, bleeding relapse and complication rates.

RESULTS

The technical success was 100%. The 30-day survival rate was 79.5% (35/44 cases). No patients died due to ongoing or recurrent hemorrhage. Re-bleeding occurred in 2/44 cases (4.5%) and was successfully managed with repeat TAE (one) or surgery (one). The rate of major complications was 4.5% (2/44; one acute pancreatitis and one partial pancreatic ischemia), successfully managed conservatively. According to Kaplan-Meier analysis survival was 71.9% at 3.5 years.

CONCLUSIONS

TAE for the treatment of PUB was technically successful in all cases and resulted in high clinical success rate. Minimal re-bleeding rates further highlight the utility of TAE as the second line treatment of choice, after failed endoscopy.

Short-term outcomes after emergency surgery for complicated peptic ulcer disease from the UK National Emergency Laparotomy Audit: a cohort study

OBJECTIVES

This study used national audit data to describe current management and outcomes of patients undergoing surgery for complications of peptic ulcer disease (PUD), including perforation and bleeding. It was also planned to explore factors associated with fatal outcome after surgery for perforated ulcers. These analyses were designed to provide a thorough understanding of current practice and identify potentially modifiable factors associated with outcome as targets for future quality improvement.

DESIGN

National cohort study using National Emergency Laparotomy Audit (NELA) data.

SETTING

English and Welsh hospitals within the National Health Service.

PARTICIPANTS

Adult patients admitted as an emergency with perforated or bleeding PUD between December 2013 and November 2015.

INTERVENTIONS

Laparotomy for bleeding or perforated peptic ulcer.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was 60-day in-hospital mortality. Secondary outcomes included length of postoperative stay, readmission and reoperation rate.

RESULTS

2444 and 382 procedures were performed for perforated and bleeding ulcers, respectively. In-hospital 60-day mortality rates were 287/2444 (11.7%, 95% CI 10.5% to 13.1%) for perforations, and 68/382 (17.8%, 95% CI 14.1% to 22.0%) for bleeding. Median (IQR) 2-year institutional volume was 12 (7-17) and 2 (1-3) for perforation and bleeding, respectively. In the exploratory analysis, age, American Society of Anesthesiology score and preoperative systolic blood pressure were associated with mortality, with no association with time from admission to operation, surgeon grade or operative approach.

CONCLUSIONS

Patients undergoing surgery for complicated PUD face a high 60-day mortality risk. Exploratory analyses suggested fatal outcome was primarily associated with patient rather than provider care factors. Therefore, it may be challenging to reduce mortality rates further. NELA data provide important benchmarking for patient consent and has highlighted low institutional volume and high mortality rates after surgery for bleeding peptic ulcers as a target for future research and improvement.

Propensity score-matching analysis to compare clinical outcomes of endoscopic submucosal dissection for early gastric cancer in the postoperative and non-operative stomachs

Background

Endoscopic submucosal dissection (ESD) of the postoperative stomach (ESD-P) for early gastric cancer (EGC) is considered a technically difficult procedure. However, it is difficult to compare the outcomes of ESD-P and ESD of the non-operative stomach (ESD-N) because their baseline characteristics are different. Therefore, we aimed to compare the technical outcomes of ESD-P with those of ESD-N using a propensity score-matching analysis to compensate for the differences.

Methods

The chart records of 1046 patients with EGC who were treated with ESD between January 2004 and July 2016 at Kitakyushu Municipal Medical Center in Japan were reviewed in this retrospective study. Multivariate analyses and propensity score-matching were performed for age, sex, lesion location, lesion size, tumor invasion, tumor size, ulcer (scar), and operator skill. The primary outcome was procedure time. Secondary outcomes were percentages of en bloc, complete, and curative resections, and percentages of adverse events, which were evaluated between the two groups.

Results

Forty-one patients were in the ESD-P group and 1005 patients were in the ESD-N group. Propensity score-matching created 41 matched pairs. According to the adjusted comparisons, ESD-P required a significantly longer procedure time (85 min vs 51 min, p < 0.001). Other treatment outcomes showed an en bloc resection rate of 100% for both groups (p = 1) and complete resection rates of 95.1 and 97.6% (p = 1), curative resection rates of 90.2 and 90.2% (p = 1), perforation during ESD rates of 2.4 and 0% (p = 1), and postprocedure bleeding rates of 2.4 and 2.4% (p = 1) for the ESD-P and ESD-N groups, respectively. For the ESD-P group, lesions on the suture line or anastomotic site were significantly associated with longer procedure times (p = 0.038).

Conclusions

ESD-P was a more time-consuming procedure than ESD-N. However, ESD-P and ESD-N achieved high rates of curative resection with a low rate of adverse events for the treatment of EGC. ESD could be selected as the treatment for EGC even in the postoperative stomach provided that careful attention is given to lesions on the suture line or anastomotic site.

The Acute Upper Gastrointestinal Bleed

Upper gastrointestinal bleeding (UGIB), defined as intraluminal hemorrhage proximal to the ligament of Treitz, can range from mild and asymptomatic to massive life-threatening hemorrhage. For the purposes of this article, the authors define an acute UGIB to be one that results in new acute symptoms and is, therefore, potentially life-threatening. UGIB requires a systematic approach to evaluation and treatment, similar to the management of a trauma patient. Surgeon involvement in UGIBs remains integral despite the rare need for operative management. Endoscopy is the primary tool for diagnosis and treatment.

Pre-Operative Anti-Fungal Therapy Does Not Improve Outcomes in Perforated Peptic Ulcers

BACKGROUND

With the advent of anti-Helicobacter pylori therapy, hospital admissions for peptic ulcer disease (PUD) have declined significantly since the 1990s. Despite this, operative treatment of PUD still is common. Although previous papers suggest that Candida in peritoneal fluid cultures may be associated with worse outcomes in patients with perforated peptic ulcers (PPUs), post-operative anti-fungal therapy has not been effective. We hypothesized that pre-operative anti-fungal drugs improve outcomes in patients with PPUs undergoing operative management.

PATIENTS AND METHODS

A prospectively maintained Acute and Critical Care Surgery (ACCS) database spanning 2008-2015 and including more than 7,000 patients was queried for patients with PPUs. Demographics and clinical outcomes were abstracted. Pre-operative anti-fungal use, intra-operative peritoneal fluid cultures, and infectious outcomes were abstracted manually. We compared outcomes and the presence of fungal infections in patients receiving peri-operative anti-fungal drugs in the entire cohort and in patients with intra-operative peritoneal fluid cultures. Frequencies were compared by the Fisher exact or χ2 test as appropriate. The Student's t-test was used for continuous variables.

RESULTS

There were 107 patients with PPUs who received operative management; 27 (25.2%) received pre-operative anti-fungal therapy; 33 (30.8%) received peritoneal fluid culture, and 17 cultures (51.5%) were positive for fungus. The presence of fungus in the cultures did not affect the outcomes. There were no differences in length of stay (LOS), intensive care unit (ICU) LOS, ventilator days, 30-day re-admission rates, or rates of intra-abdominal abscess formation or fungemia in patients who received pre-operative anti-fungal drugs regardless of the presence of fungi in the peritoneal fluid.

CONCLUSION

Candida has been recovered in 29%-57% of peritoneal fluid cultures in patients with PPUs. However, no studies have evaluated pre-operative anti-fungal therapy in PPUs. Our data suggest that pre-operative anti-fungal drugs are unnecessary in patients undergoing operative management for PPU.

The influence of payor status on outcomes associated with surgical repair of upper gastrointestinal perforations due to peptic ulcer disease in the United States

BACKGROUND

An association between lack of insurance and inferior outcomes has been well described for a number of surgical emergencies, yet little is known about the relationship of payor status and outcomes of patients undergoing emergent surgical repair for upper gastrointestinal (UGI) perforations. We evaluated the association of payor status and in-hospital mortality for patients undergoing emergency surgery for UGI perforations in the United States.

METHODS

Nationwide Inpatient Sample (NIS) was queried to identify patients between 18 and 64 years of age who underwent emergent (open or laparoscopic) repair for UGI perforations secondary to peptic ulcer disease (2010-2014). Primary outcome was in-hospital mortality. Secondary outcomes were major and minor postoperative complications. The main predictor outcome was insurance status (Private, Medicaid, Uninsured). Univariate and multivariable regression analyses were performed. Data were weighted to provide national estimates.

RESULTS

21,005 patients underwent surgical repair for UGI perforations. Patients with private insurance represented the largest payor group (47%). After adjustment of other factors, payor status was not a statistically significant predictor of in-hospital mortality (Medicaid vs. Private: [OR] 1.1; 95% [CI] 0.67-1.81; Uninsured vs. Private: OR 0.9, 95% CI 0.52-1.61). However, payor status remained a statistically significant predictor of major postoperative complications (Medicaid vs. Private [OR] 1.4; 95% CI 1.1, 1.8; Uninsured vs. Private [OR]1.2, 95% CI 0.9, 1.5) and minor postoperative complications (Medicaid vs. Private [OR] 1.4; 95% CI 1.1, 1.9; Uninsured vs. Private [OR]1.2, 95% CI 0.9, 1.6).

CONCLUSIONS

Emergency surgery for UGI perforations is associated with high mortality and morbidity across all payor classes; however, Medicaid is a predictor for both major and minor postoperative complications. Preventing perforation through preventative measures will be key to reducing the burden of peptic ulcer disease across all populations.

Management of a postbulbar duodenal ulcer and stricture causing gastric outlet obstruction: A case report

INTRODUCTION

Peptic ulcer disease has significantly decreased over the past several decades making the need for definitive surgical intervention an infrequent occurrence.

PRESENTATION OF CASE

A 44-year-old Caucasian female was sent to the emergency department by her primary care physician for right upper quadrant abdominal pain which had been intermittent for the past two months but acutely worsened over the last five days. During this time, she was unable to tolerate oral intake with intractable nausea and vomiting. Upper GI endoscopy revealed a tight stricture in the second part of the duodenum and antral biopsy was Helicobacter pylori negative. Patient underwent two rounds of balloon dilation with short lived symptomatic relief. An open pylorus-preserving duodenal stricturoplasty using a Heineke-Mikulicz technique was then performed. The operation was successful and the patient has had no reoccurrence of her symptoms.

DISCUSSION

Gastric outlet obstruction is an uncommon complication of peptic ulcer disease in respect to chronic nonsteroidal anti-inflammatory drug use. The unique location of the patient's stricture and her desire to minimize post-operative GI alterations demanded a review of surgical options and identified the benefits of maintaining the patient's original anatomy versus choosing an extra-anatomic approach.

CONCLUSION

This case presented a unique challenge and demonstrated the need for definitive surgical interventions in the treatment of peptic ulcer induced gastric outlet obstruction. This case adds support for the direct anatomic treatment of duodenal strictures when conservative measures fail and perhaps promotes further development of laparoscopic management of gastric outlet obstruction in the future.

Feasibility of a novel laparoscopic technique with unidirectional knotless barbed sutures for the primary closure of duodenal ulcer perforation

BACKGROUND

Laparoscopic primary repair is one of the main procedures used for perforated gastric ulcers, and this technique requires reproducible and secure suturing. The aim of this study was to investigate the safety and efficacy of a novel continuous suture method with barbed sutures during laparoscopic repair for perforated peptic ulcers.

PATIENTS AND METHODS

Clinical data from 116 consecutive patients undergoing laparoscopic repair for perforated peptic ulcers were collected between November 2009 and October 2015. Continuous suturing with 15-cm-long unidirectional absorbable barbed sutures was used for laparoscopic repair in the study group, termed group V (n = 51). Patients who underwent laparoscopic repair with conventional interrupted sutures were defined as group C (n = 65). The complication and operative data were compared between groups.

RESULTS

Although there was no difference between group V and group C in the overall complication rate (15.7% vs. 24.6%; p = 0.259), the complication rate related to suturing was lower (3.9% vs. 15.4%; p = 0.04) in group V. Group V showed rates of 0% for leakage, 2% for intra-abdominal fluid collection, and 2% for stricture; the corresponding rates in group C were 3.1, 7.7, and 4.6%, respectively. Regarding operative data, the total operation time (V vs. C, 87.7 min vs. 131.2 min), total suture time (7.1 min vs. 25.3 min), and suture time per stitch (1.2 min vs. 6.2 min) were significantly shorter in group V than in group C (p < 0.001).

CONCLUSION

The use of a continuous suture technique with unidirectional barbed sutures is as safe as the conventional suture technique and allows easier and faster suturing in the repair of perforated peptic ulcers.

Imaging Manifestations of Peptic Ulcer Disease on Computed Tomography

Although the overall prevalence of peptic ulcer disease (PUD) has decreased in modern times, its actual incidence may be underestimated owing to the nonspecific clinical presentations patients' manifest. The potential lethal complications that can result from PUD include life-threatening abdominal hemorrhage and bowel perforation that result in significant morbidity and mortality. Computed tomography (CT) imaging historically lacks specificity in detecting PUD-related pathology in the stomach and proximal small bowel segments. Therefore, these are potential pitfalls in the radiologist's search pattern on abdominopelvic CT imaging. This article highlights imaging features of uncomplicated PUD on CT imaging in order to allow for early detection of this disease process on imaging and the prevention of potential high-grade complications by recommending esophagogastroduodenoscopy.

Surgical outcome evaluation of perforated gastric cancer: from the aspects of both acute care surgery and surgical oncology

BACKGROUND

Perforated gastric cancer (PGC) is a rare condition of gastric cancer (GC). In this study, we sought to assess the outcome of PGC from the aspects of both acute care surgery and surgical oncology at a single institute, Chang Gung Memorial Hospital (CGMH).

METHODS

From 1997 to 2013, 6864 patients were diagnosed with GC and 2738 were diagnosed with gastroduodenal perforation at CGMH. In total, 29 patients with PGC were identified. Immediate surgical and long-term oncologic outcomes were evaluated after an appropriate matching process was performed.

RESULTS

The immediate surgical outcome of PGC, i.e., the hospital mortality rate within 30 d after surgery, did not significantly differ from that of non-cancer related gastroduodenal perforation. The long-term oncologic outcome, with matching by age, gender, year of surgery and AJCC 7th stage grouping, also did not significantly differ from that of GC without perforation.

CONCLUSIONS

Aggressive surgical treatment, including an initial emergency procedure for containing peritonitis and radical surgery for GC, may benefit PGC patients in terms of both the immediate and oncologic outcomes.

Hepatointestinal complications in polycystic kidney disease

Background

The objective of this study was to determine the incidence of major hepatointestinal complications in patients with polycystic kidney disease (PKD).

Methods

We analyzed the Taiwan National Health Insurance claims data (2000-2010) of 6031 patients with PKD and 23,976 non-PKD hospitalized controls. The control cohort was propensity score matched with the PKD cohort at a 1:4 ratio. All patients were followed up from the index date to the first inpatient diagnosis of hepatointestinal complications, death, or 31 December, 2011. Cox proportional hazard regression models were used to identify the risk of outcome after adjustment for potential confounders.

Results

The incidence rates of acute pancreatitis, cholangitis, peptic ulcer bleeding, and cirrhosis were 5.72, 4.01, 19.9, and 5.46 per 1000 person-years, respectively, in the PKD cohort. Compared with the non-PKD controls, patients with PKD exhibited an increased risk of hospitalization for acute pancreatitis, cholangitis, peptic ulcer bleeding, and cirrhosis (adjusted subhazard ratio [aSHR]: 2.36, 95% confidence interval [95% CI], 1.95-2.84]; 2.36, [95% CI, 1.95-2.84]; 2.41, [95% CI, 1.93-3.01]; 2.41, [95% CI, 2.17-2.67]; and 1.39, [95% CI, 1.16-1.66], respectively; all p < 0.001). PKD, chronic kidney disease, and alcoholism were independent predictors of all these hepatointestinal complications. Kaplan-Meier analysis revealed an increased overall mortality in patients with PKD who developed acute pancreatitis and peptic ulcer bleeding (log-rank p < 0.05).

Conclusion

PKD is associated with clinically significant extrarenal complications including acute pancreatitis, cholangitis, peptic ulcer bleeding, and cirrhosis.

Continuing use of antithrombotic medications for patients with bleeding gastroduodenal ulcer requiring endoscopic hemostasis: a case-control study

OBJECTIVE

The aim of this study was to compare clinical characteristics and outcomes of bleeding gastroduodenal ulcer between patients taking antithrombotic medications and those not taking antithrombotic medications.

METHODS

We performed a case-control study of 346 patients with endoscopically verified bleeding gastroduodenal ulcer, which included 173 cases taking antithrombotic medications throughout peri-bleeding period and 173 age- and sex-matched controls not taking antithrombotic medications.

RESULTS

The cases showed less frequent Helicobacter pylori (H. pylori) infections (45.1% versus 60.7%, p = .005), more frequent duodenal location (31.8% versus 19.1%, p = .009), and more frequent rebleeding (13.9% versus 5.8%, p = .02) than the controls. Multivariate analysis revealed that duodenal location (odds ratio [OR] 3.01, 95% confidence interval [CI] 1.37-6.65) and use of antithrombotic medications (OR 2.47, 95% CI 1.13-5.77) were independent factors for rebleeding. However, there were no differences in clinical outcomes, including final successful endoscopic hemostasis, need for surgical intervention, and mortality between cases and controls. Thromboembolic events did not occur in any cases and controls during the periendoscopic period.

CONCLUSIONS

Low prevalence of H. pylori infection, frequent duodenal location, and high rebleeding rate are characteristics of patients with bleeding gastroduodenal ulcer under antithrombotic medications. Continuation of antithrombotic medications can be accepted for bleeding gastroduodenal ulcer.

The natural history of perforated foregut ulcers after repair by omental patching or primary closure

BACKGROUND

The treatment of perforated foregut ulcers by omental patching (OP) or primary closure has mostly replaced vagotomy and pyloroplasty/antrectomy (VPA). We sought to determine the natural history and recurrence rate of ulceration in patients treated by omental patching or primary closure.

STUDY DESIGN

An 11-year retrospective study.

RESULTS

From 2004 through 2015, 94 patients had perforated foregut ulcers, 53 gastric, and 41 duodenal. 77 (82%) were treated by OP alone (study group) and 17 (18%) were treated with VPA (comparison group). All OP patients were discharged on PPIs, but only 86% took the drugs for a median of 22 months (1-192, SD 40). Endoscopy in the OP group showed recurrent ulcers in nine (12% recurrence rate) and gastritis in three (4%) This group also had three later recurrent perforations. Another recurrent ulcer hemorrhaged causing death (3% late mortality). Two other patients required non-emergent re-do ulcer operations for recurrent disease/symptoms (surgical re-intervention rate 4%). Total length of follow-up was median 44 months (1-192, SD 40) and was complete in 82 (87%). 18 (23%) patients in the OP group developed recurrent abdominal pain attributed to ulcer disease during follow-up, compared to 2 (12%) in the VPA group (p = 0.15). No patient in the VPA group had an endoscopic recurrence or re-intervention.

CONCLUSION

Omental patching does not correct the underlying disease process which causes foregut perforation, and has a 12% endoscopically proven recurrent ulceration rate and a 23% incidence of recurrent symptoms within 44 months. Patients tend to stop taking PPIs after 22 months at which time their risk increases.

Gastric Ulcer Complications after the Introduction of Proton Pump Inhibitors into Clinical Routine: 20-Year Experience

BACKGROUND

The aim of this study was to analyze the admissions and the management of peptic ulcer disease (PUD) in a tertiary care surgical center.

METHODS

We evaluated the medical records of all patients admitted to the University Hospital of Tübingen, Germany, for treatment of PUD during 1989-2008. Patients were included into the study if the diagnosis was verified endoscopically or surgically. Annual number of admissions, length of hospitalization, mortality rate, age, rate of non-steroidal anti-inflammatory drugs (NSAIDs) and proton pump inhibitor (PPI) medication, rate of Helicobacter pylori infection, and complications of PUD and surgery performed were recorded. Data were analyzed by descriptive analyses, Pearson's chi-square test, and regression analysis.

RESULTS

This study included 614 admissions. The number of annual admissions (31 ± 12), the length of hospitalization (9 ± 3 days), and the mortality rate (5 ± 4% per year) remained constant, whereas the age increased (1989: 52 ± 14 years vs. 2008: 67 ± 16 years). The rates of patients with H. pylori infection (47 ± 28% per year), NSAIDs treatment (29 ± 15% per year), and PPI treatment (31 ± 27% per year) remained constant. The most frequent PUD complication was hemorrhage (42 ± 16% per year), followed by perforation (9 ± 8% per year). During 1999-2008, more hemorrhages (125 vs. 121; p < 0.05) and perforations (40 vs. 21; p < 0.05) were registered than during 1989-1998. The rate of emergency surgery increased from 70% during 1989-1998 to 87% during 1999-2008. In contrast, elective surgery decreased from 21% during 1989-1998 to 7% during 1999-2008. Ulcer excision and oversewing was the most frequent surgical procedure performed (59%), with decreasing rates of acid-reducing surgery.

CONCLUSION

Despite recent advances in PUD management, ulcer hemorrhage and perforation remain a significant health burden and a surgical disease.

A Five-Year Review of Perforated Peptic Ulcer Disease in Irrua, Nigeria

Background

Peptic ulcer perforation is a common cause of emergency admission and surgery. This is the first study that documents the presentation and outcome of management in Irrua, Nigeria.

Patients and Method

This is a prospective study of all patients operated on for perforated peptic ulcer between April 1, 2010, and March 31, 2015. A structured questionnaire containing patients' demographics, operation findings, and outcome was filled upon discharge or death.

Results

There were 104 patients. 81 males and 23 females (M : F = 3.5 : 1). The age range was between 17 years and 95 years. The mean age was 48.99 years ± SD 16.1 years. The ratio of gastric to duodenal perforation was 1.88 : 1. Perforation was the first sign of peptic ulcer disease in 62 (59.6%). Pneumoperitoneum was detectable with plain radiographs in 95 (91%) patients. 72 (69.2%) had Graham's Omentopexy. Death rate was 17.3%.

Conclusion

We note that gastric perforation is a far commoner disease in our environment. Perforation is often the first sign of peptic ulcer disease. We identify fasting amongst Christians as a risk factor for perforation.

Postgastrectomy Syndromes and Nutritional Considerations Following Gastric Surgery

Postgastrectomy syndromes result from altered form and function of the stomach. Gastrectomy disrupts reservoir capacity, mechanical digestion and gastric emptying. Early recognition of symptoms with prompt evaluation and treatment is essential. Many syndromes resolve with minimal intervention or dietary modifications. Re-operation is not common but often warranted for afferent and efferent loop syndromes and bile reflux gastritis. Preoperative nutritional assessment and treatment of common vitamin and mineral deficiencies after gastrectomy can reduce the incidence of chronic complications. An integrated team approach to risk assessment, patient education, and postoperative management is critical to optimal care of patients with gastric cancer.

Predictors of mortality in the elderly after open repair for perforated peptic ulcer disease

BACKGROUND

As the U.S. population ages and the number of emergent surgical repairs for perforated peptic ulcer disease (PUD) rise, contemporary national data evaluating operative outcomes for open surgical repair for perforated PUD among the elderly are lacking.

MATERIALS AND METHODS

The National Surgical Quality Improvement Program (2007-2014) was queried for patients ≥65 y who underwent open surgical repair for perforated PUD. The primary outcome was 30-d mortality. Secondary outcomes included 30-d postoperative complications. Univariate and multivariable regression analyses were performed.

RESULTS

Overall, 2131 patients underwent open surgical repair for perforated PUD. Among those who died, more used steroids preoperatively (15% versus 9%, P = 0.001) and fewer were independent preoperatively (55% versus 83%, P < 0.0001) compared to those who were alive 30-d postoperatively. Common postoperative complications were septic shock (15%) and pneumonia (12%). The overall 30-d mortality rate was 17.7%, with more deaths in subsequent decades of life (65-75 y 13% versus 75-84 y 18% versus >85 y 24%, P < 0.0001). After adjustment for other factors, mortality was significantly associated with older age (85+ versus 65-74 y) (odds ratio [OR], 1.5; 95% confidence interval [CI], 0.8, 1.7), dependent functional status preoperatively ([OR], 0.2; 95% CI, 0.2, 0.3), and American Society of Anesthesiologist classification ≥4 (OR, 3.2; 95% CI, 2.4, 4.3).

CONCLUSIONS

At U.S. hospitals, open surgical repair, the accepted treatment of perforated PUD, among the elderly is associated with significant 30-d morbidity and mortality rates that are unacceptably high in our contemporary era. Furthermore, mortality rates are associated with older age. Therefore, as the elderly population continues to increase in the United States, preoperative, perioperative, and postoperative measures must be taken to reduce this high morbidity and mortality rates.

Valentino's Syndrome: A Life-Threatening Mimic of Acute Appendicitis

Perforated ulcers are a rare cause of abdominal pain, and may not be considered when pain is localized to the right lower quadrant (RLQ). This case highlights an unusual presentation of a perforated duodenal ulcer that presented with RLQ pain, which has been described as Valentino’s syndrome. Valentino’s syndrome occurs when gastric or duodenal fluids collect in the right paracolic gutter causing focal peritonitis and RLQ pain. This case highlights that perforated ulcers, while an uncommon cause of RLQ pain, must remain on the differential of any patient that has an abdominal examination consistent with peritonitis.

Laparoscopic Repair of Perforated Peptic Ulcer: Outcome and Associated Morbidity and Mortality

INTRODUCTION

The mainstay of treatment for perforated peptic ulcer is Omental patch closure. With the advent of laparoscopic surgery, this approach is being used for the treatment of perforated peptic ulcer. The aim of this study was to evaluate the outcome of laparoscopy in Firoozgar general hospital over a period of 18 months. The outcome of the laparoscopic approach and the associated morbidity and mortality, operation time, conversion rate and hospital stay were assessed.

METHODS

A prospective analysis of 29 consecutive patients (mean age 37.5 years; 23 men) with perforated peptic ulcers and who had undergone laparoscopic surgery was carried over a period of 18 months from March 2014 until September 2015. Pre-operative, intra-operative, and post-operative clinical data were collectively analyzed by SPSS 19 for Windows.

RESULTS

Seventeen patients had a history of cigarette smoking, 11 patients had a history of opium consumption, 19 were chronic NSAID users, 26 had Helicobacter pylori infections, and six had a co-morbid condition. Previous surgical history included laparotomy for pancreatic cancer in two patients, for sigmoid colon cancer in one patient, and for acute appendicitis in four patients. The average operating time for all cases was 47.5 + 20 min. The mean lag time between onset of symptoms and surgery was 20.4 hours. All patients underwent laparoscopic closure of the perforation with Omental patch closure. No morbidity was observed, and none of the patients needed conversion to open surgery. One patient died after 11 months of follow-up due to the progression of underlying pancreatic cancer. The mean postoperative hospital stay was 4.2 days.

CONCLUSIONS

The results of the laparoscopic approach for perforated peptic ulcer were promising, with no conversion to open surgery, no morbidity, and mortality.

Increased short- and long-term mortality in 8146 hospitalised peptic ulcer patients

BACKGROUND

Incidence and complications of peptic ulcer disease (PUD) have declined, but mortality from peptic ulcer bleeding has remained unchanged. The few recent studies on mortality associated with both uncomplicated and complicated patients with peptic ulcer disease provide contradictory results.

AIMS

To evaluate short- and long-term mortality, and the main causes of death in peptic ulcer disease.

METHODS

In this retrospective epidemiologic cohort study, register data on 8146 adult patients hospitalised with peptic ulcer disease during 2000-2008 were collected in the capital region of Finland. All were followed in the National Cause of Death Register until the end of 2009. The data were linked with the nationwide Drug Purchase Register of the Finnish Social Insurance Institution.

RESULTS

Mean follow-up time was 4.9 years. Overall mortality was substantially increased, standardised mortality ratio 2.53 (95% CI: 2.44-2.63); 3.7% died within 30 days, and 11.8% within 1 year. At 6 months, the survival of patients with perforated or bleeding ulcer was lower compared to those with uncomplicated ulcer; hazard ratios were 2.06 (1.68-2.04) and 1.32 (1.11-1.58), respectively. For perforated duodenal ulcers, both the short- and long-term survival was significantly impaired in women. The main causes of mortality at 1 year were malignancies and cardiovascular diseases. Previous use of statins was associated with significant reduction in all-cause mortality.

CONCLUSIONS

One-year mortality in patients hospitalised with peptic ulcer disease remained high with no change. This peptic ulcer disease cohort had a clearly decreased survival rate up to 10 years, especially among women with a perforated duodenal ulcer, most likely explained by poorer survival due to underlying comorbidity.

Clinical patterns of presentation and attenuated inflammatory response in octo- and nonagenarians with perforated gastroduodenal ulcers

BACKGROUND

Perforated gastrodudenal ulcer (PGDU) is an operative emergency with high mortality rates. The growing elderly population increasingly presents with need for geriatric acute operative care. Current knowledge of age-specific characteristics in presentation, diagnosis, and outcome for PGDU in the elderly is scarce.

METHODS

We reviewed a consecutive, population-based cohort of patients with PGDU, octa- and nonagenarians were compared with younger patients for variation in patterns of presentation and outcomes. Patterns and outcomes observed included 30-day mortality, serious complications (Clavien-Dindo 3 and 4), and duration of stay.

RESULTS

Of the 244 patients, 127 were women (52%); median age was 68 years; and 59 patients (24.2%) were ≥80 years. Two thirds had gastric ulcers (n = 168; 67.2%). On admission, hemoglobin levels, white blood cell count, and serum levels of C-reactive protein, bilirubin, and albumin differed significantly between the age groups. Diagnosis, treatment, and the occurrence of severe complications did not differ with age. The median hours of delay to definitive treatment did not differ significantly for all ages, but patients ≥80 years had a greater proportion (44.1% compared with 25.8%) of delay >12 hours (odds ratio 2.26, 95% confidence interval 1.22-4.17; P = .008). Overall mortality was 38 (15.6%); no deaths occurred in patients <55 years. Over one half of deaths occurred in those ≥80 years (odds ratio 4.76, 2.30-9.83; P < .001). Duration of hospital stay was significantly greater in elderly survivors, and fewer were discharged within a week.

CONCLUSION

Octa- and nonagenarians with PGDU present with fewer signs of peritonitis and have an attenuated inflammatory response. The very elderly have twice the risk of long delays to definitive treatment and almost 5 times increased risk of mortality.

Per-Oral Pyloromyotomy (POP): An Emerging Application of Submucosal Tunneling for the Treatment of Refractory Gastroparesis

A growing body of literature supports the use of laparoscopic pyloroplasty as a minimally invasive treatment of refractory gastroparesis that has failed conservative measures and for benign gastric outlet obstruction. Endoscopic pyloric dilation, stent placement, and Botox have been described for similar indications, but often with transient or mixed results. Per-oral pyloromyotomy has recently been proposed as an endoscopic alternative to surgical pyloroplasty or pylormyotomy because it is less invasive by its nature and potentially more durable than current endoscopic treatments.

Surgery for Peptic Ulcer Disease in sub-Saharan Africa: Systematic Review of Published Data

INTRODUCTION

Peptic ulcer disease is a significant cause of morbidity and mortality worldwide, with a significant burden in low- and middle-income countries. However, there is limited information regarding management of peptic ulcer disease in these countries. This study describes surgical interventions for peptic ulcer disease in sub-Saharan Africa.

MATERIALS AND METHODS

A systematic review was performed using PubMed, EMBASE, and African Index Medicus for studies describing surgical management of peptic ulcer disease in sub-Saharan Africa.

RESULTS

From 55 published reports, 6594 patients underwent surgery for peptic ulcer disease. Most ulcers (86%) were duodenal with the remainder gastric (14%). Thirty-five percent of operations were performed for perforation, 7% for bleeding, 30% for obstruction, and 28% for chronic disease. Common operations included vagotomy (60%) and primary repair (31%). The overall case fatality rate for peptic ulcer disease was 5.7% and varied with indication for operation: 13.6% for perforation, 11.5% for bleeding, 0.5% for obstruction, and 0.3% for chronic disease.

CONCLUSION

Peptic ulcer disease remains a significant indication for surgery in sub-Saharan Africa. Recognizing the continued role of surgery for peptic ulcer disease in sub-Saharan Africa is important for strengthening surgical training programs and optimizing allocation of resources.

Laparoscopic approach in gastrointestinal emergencies

This review focuses on the laparoscopic approach to gastrointestinal emergencies and its more recent indications. Laparoscopic surgery has a specific place in elective procedures, but that does not apply in emergency situations. In specific emergencies, there is a huge range of indications and different techniques to apply, and not all of them are equally settle. We consider that the most controversial points in minimally invasive procedures are indications in emergency situations due to technical difficulties. Some pathologies, such as oesophageal emergencies, obstruction due to colon cancer, abdominal hernias or incarcerated postsurgical hernias, are nearly always resolved by conventional surgery, that is, an open approach due to limited intraabdominal cavity space or due to the vulnerability of the bowel. These technical problems have been solved in many diseases, such as for perforated peptic ulcer or acute appendectomy for which a laparoscopic approach has become a well-known and globally supported procedure. On the other hand, endoscopic procedures have acquired further indications, relegating surgical solutions to a second place; this happens in cholangitis or pancreatic abscess drainage. This endoluminal approach avoids the need for laparoscopic development in these diseases. Nevertheless, new instruments and new technologies could extend the laparoscopic approach to a broader array of potentials procedures. There remains, however, a long way to go.

Upper gastrointestinal bleeding due to peptic ulcer disease is not associated with air pollution: a case-crossover study

Background

Recent studies have demonstrated an association between short-term elevations in air pollution and an increased risk of exacerbating gastrointestinal disease. The objective of the study was to evaluate if day-to-day increases in air pollution concentrations were positively associated with upper gastrointestinal bleeding (UGIB) secondary to peptic ulcer disease (PUD).

Methods

A time-stratified case-crossover study design was used. Adults presenting to hospitals with their first UGIB secondary to PUD from 2004–2010 were identified using administrative databases from Calgary (n = 1374; discovery cohort) and Edmonton (n = 1159; replication cohort). Daily concentrations of ozone, nitrogen dioxide, sulfur dioxide, carbon monoxide, and particulate matter (PM₁₀ and PM_2.5) were estimated in these two cities. Conditional logistic regression models were employed, adjusting for temperature and humidity. Odds ratios (OR) with 95 % confidence intervals (CI) were expressed relative to an interquartile range increase in the concentration of each pollutant.

Results

No statistically significant associations were observed for any of the individual pollutants based on same-day, or 1-day lag effects within the Calgary discovery cohort. When the air pollution exposures were assessed as 3-, 5-, and 7-day averages, some pollutants were inversely associated with UGIB in the discovery cohort; for example, 5-day averages of nitrogen dioxide (OR = 0.68; 95 % CI: 0.53–0.88), and particulate matter <2.5 μm (OR = 0.75; 95 % CI: 0.61–0.90). However, these findings could not be reproduced in the replication cohort.

Conclusion

Our findings suggest that short-term elevations in the level of ambient air pollutants does not increase the incidence of UGIB secondary to PUD.

Electronic supplementary material

The online version of this article (doi:10.1186/s12876-015-0363-6) contains supplementary material, which is available to authorized users.

MDCT diagnosis of gastroduodenal ulcers: key imaging features with endoscopic correlation

Although the overall prevalence of peptic ulcer disease (PUD) and related hospitalizations are decreasing, the initial presentation of complicated PUD on CT remains common. It, therefore, remains critical for radiologists to recognize the findings of PUD at CT for initial diagnosis. While the CT findings of complicated PUD have been previously described in the literature, the CT findings of uncomplicated PUD have not been well documented. Furthermore, although CT is certainly not the diagnostic evaluation of choice for patients with suspected uncomplicated PUD, many patients with PUD will nonetheless present to the emergency department with unexplained abdominal pain and undergo MDCT evaluation as the initial diagnostic test. Therefore, recognizing the MDCT findings of uncomplicated PUD can help appropriately direct patient management, and help prevent the development of complications. To facilitate improved recognition of PUD on abdominal CT, we present an overview of the CT findings of both uncomplicated and complicated PUD, as well as several diagnostic pitfalls which can result in misdiagnosis from peptic ulcer mimics.

Perforated peptic ulcer

Perforated peptic ulcer is a common emergency condition worldwide, with associated mortality rates of up to 30%. A scarcity of high-quality studies about the condition limits the knowledge base for clinical decision making, but a few published randomised trials are available. Although Helicobacter pylori and use of non-steroidal anti-inflammatory drugs are common causes, demographic differences in age, sex, perforation location, and underlying causes exist between countries, and mortality rates also vary. Clinical prediction rules are used, but accuracy varies with study population. Early surgery, either by laparoscopic or open repair, and proper sepsis management are essential for good outcome. Selected patients can be managed non-operatively or with novel endoscopic approaches, but validation of such methods in trials is needed. Quality of care, sepsis care bundles, and postoperative monitoring need further assessment. Adequate trials with low risk of bias are urgently needed to provide better evidence. We summarise the evidence for perforated peptic ulcer management and identify directions for future clinical research.

The relationship between computed tomography findings and the locations of perforated peptic ulcers: it may provide better information for gastrointestinal surgeons

BACKGROUND

Computed tomography (CT) plays an important role in diagnosing gastrointestinal perforation. This study explored the relationship between CT findings and the locations of perforated peptic ulcers (PPUs), which may help further surgical planning.

METHODS

During a 34-month period, 175 patients had CT scans. We categorized those 175 patients into 2 groups: patients with and without a PPU at a difficult ulcer site for a laparoscopic approach. Both clinical data and the CT images were reviewed and analyzed.

RESULTS

Based on the univariate analysis results, we conducted multivariate analyses of 3 factors: age, American Society of Anesthesiologists classification of 3 or more, and positive lesser sac image findings. The positive lesser sac findings in CT were the only independent factor that was correlated to the PPU site.

CONCLUSIONS

Positive lesser sac CT findings may help to predict PPUs in sites where a laparoscopic approach might be difficult. Our study re-evaluates the additional value of CT scanning in diagnosing PPU, and the results may assist with surgical planning in clinical practice.

Chronic subclinical perforation of a duodenal ulcer presenting with an abdominal abscess in a patient with seronegative rheumatoid arthritis

Peptic ulcer disease has been a major problem since the turn of this century with high morbidity and mortality. Perforation is less common, with an estimated incidence of 7-10 per 100 000. We present a young woman with rheumatoid arthritis presenting with anaemia. On work up, she was found to have a chronic abdominal abscess secondary to subclinical perforation of a duodenal ulcer. After undergoing percutaneous drainage, she became haemodynamically unstable and was taken for surgical washout and jejunostomy tube placement. A week later she had a decrease in the size of the abscess and was discharged home with drain and tube feeds. At her follow-up a few weeks later, she was tolerating goal tube feeds.

Gastrointestinal causes of abdominal pain

Gastrointestinal causes of abdominal pain are numerous. These causes are reviewed in brief here, divided into 2 categories: acute abdominal pain and chronic abdominal pain. They are further subcategorized by location of pain as it pertains to the abdomen.