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Kim JS, Park SM, Kim BW. Endoscopic management of peptic ulcer bleeding. Clin Endosc 2015; 48:106-111. [PMID: 25844337 PMCID: PMC4381136 DOI: 10.5946/ce.2015.48.2.106] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 03/06/2015] [Accepted: 03/11/2015] [Indexed: 01/14/2023] Open
Abstract
Acute upper gastrointestinal bleeding is a common medical emergency around the world and the major cause is peptic ulcer bleeding. Endoscopic treatment is fundamental for the management of peptic ulcer bleeding. Despite recent advances in endoscopic treatment, mortality from peptic ulcer bleeding has still remained high. This is because the disease often occurs in elderly patients with frequent comorbidities and are taking ulcerogenic medications. Therefore, the management of peptic ulcer bleeding is still a challenge for clinicians. This article reviews the various endoscopic methods available for management of peptic ulcer bleeding and the techniques in using these methods.
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Affiliation(s)
- Joon Sung Kim
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Sung Min Park
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Byung-Wook Kim
- Division of Gastroenterology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
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102
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Kim JH, Chin HM, Bae YJ, Jun KH. Risk factors associated with conversion of laparoscopic simple closure in perforated duodenal ulcer. Int J Surg 2015; 15:40-4. [PMID: 25644542 DOI: 10.1016/j.ijsu.2015.01.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Revised: 01/23/2015] [Accepted: 01/26/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Precise patient selection criteria are necessary to guide the surgeon in selecting laparoscopic repair for patients with perforated peptic ulcers. The aims of this study are to report surgical outcomes after surgery for perforated duodenal ulcers and identify risk factors for predicting failure of laparoscopic simple closure for perforated duodenal ulcer. METHODS In total, 77 patients who underwent laparoscopic simple closure for perforated duodenal ulcers from January 2007 to September 2013 were retrospectively analyzed. Patients were divided into totally laparoscopic and conversion groups. The characteristics of patients, intraoperative findings, postoperative complications, conversion rates and suture leakage rates of each group were investigated. RESULTS Laparoscopic repair was completed in 69 (89.6%) of 77 patients, while 8 (10.4%) underwent conversion to open repair. Patients in the conversion group had longer perforation time, larger perforation size, more suture leakage, longer hospital stay, and higher 30-day mortality rate than those in the totally laparoscopic group. The size of perforation was the only risk factor for conversion in multivariable analysis. Patients with an ulcer perforation size of ≥9 mm or with perforation duration of ≥12.5 h had a significantly increased risk for conversion and suture leakage. CONCLUSIONS Ulcer size of ≥9 mm is a significant risk factor for predicting conversion in laparoscopic simple closure. Suture leakage is associated with ulcer size (9 mm) and duration of perforation (12.5 h).
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Affiliation(s)
- Ji-Hyun Kim
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Republic of Korea
| | - Hyung-Min Chin
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Republic of Korea
| | - You-Jin Bae
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Republic of Korea
| | - Kyong-Hwa Jun
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Republic of Korea.
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Quan S, Frolkis A, Milne K, Molodecky N, Yang H, Dixon E, Ball CG, Myers RP, Ghosh S, Hilsden R, van Zanten SV, Kaplan GG. Upper-gastrointestinal bleeding secondary to peptic ulcer disease: Incidence and outcomes. World J Gastroenterol 2014; 20:17568-17577. [PMID: 25516672 PMCID: PMC4265619 DOI: 10.3748/wjg.v20.i46.17568] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Revised: 05/08/2014] [Accepted: 05/26/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the incidence, surgery, mortality, and readmission of upper gastrointestinal bleeding (UGIB) secondary to peptic ulcer disease (PUD).
METHODS: Administrative databases identified all hospitalizations for UGIB secondary to PUD in Alberta, Canada from 2004 to 2010 (n = 7079) using the International Classification of Diseases Codes (ICD-10). A subset of the data was validated using endoscopy reports. Positive predictive value and sensitivity with 95% confidence intervals (CI) were calculated. Incidence of UGIB secondary to PUD was calculated. Logistic regression was used to evaluate surgery, in-hospital mortality, and 30-d readmission to hospital with recurrent UGIB secondary to PUD. Co-variants accounted for in our logistic regression model included: age, sex, area of residence (i.e., urban vs rural), number of Charlson comorbidities, presence of perforated PUD, undergoing upper endoscopy, year of admission, and interventional radiological attempt at controlling bleeding. A subgroup analysis (n = 6356) compared outcomes of patients with gastric ulcers to those with duodenal ulcers. Adjusted estimates are presented as odds ratios (OR) with 95%CI.
RESULTS: The positive predictive value and sensitivity of ICD-10 coding for UGIB secondary to PUD were 85.2% (95%CI: 80.2%-90.2%) and 77.1% (95%CI: 69.1%-85.2%), respectively. The annual incidence between 2004 and 2010 ranged from 35.4 to 41.2 per 100000. Overall risk of surgery, in-hospital mortality, and 30-d readmission to hospital for UGIB secondary to PUD were 4.3%, 8.5%, and 4.7%, respectively. Interventional radiology to control bleeding was performed in 0.6% of patients and 76% of these patients avoided surgical intervention. Thirty-day readmission significantly increased from 3.1% in 2004 to 5.2% in 2010 (OR = 1.07; 95%CI: 1.01-1.14). Rural residents (OR rural vs urban: 2.35; 95%CI: 1.83-3.01) and older individuals (OR ≥ 65 vs < 65: 1.57; 95%CI: 1.21-2.04) were at higher odds of being readmitted to hospital. Patients with duodenal ulcers had higher odds of dying (OR = 1.27; 95%CI: 1.05-1.53), requiring surgery (OR = 1.73; 95%CI: 1.34-2.23), and being readmitted to hospital (OR = 1.54; 95%CI: 1.19-1.99) when compared to gastric ulcers.
CONCLUSION: UGIB secondary to PUD, particularly duodenal ulcers, was associated with significant morbidity and mortality. Early readmissions increased over time and occurred more commonly in rural areas.
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104
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Wright GP, Davis AT, Koehler TJ, Scheeres DE. Cost-efficiency and outcomes in the treatment of perforated peptic ulcer disease: laparoscopic versus open approach. Surgery 2014; 156:1003-7. [PMID: 25239359 DOI: 10.1016/j.surg.2014.06.047] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 06/23/2014] [Indexed: 02/06/2023]
Abstract
PURPOSE Laparoscopic treatment of perforated peptic ulcer disease (perfPUD) has demonstrated comparable operative outcomes with an open approach though the cost-efficiency of this method has not been studied. METHODS Data were obtained from the Nationwide Inpatient Sample (2007-2010). Patients who underwent operation for perfPUD were divided on the basis of laparoscopic or open approach. The primary outcome measures were hospital duration of stay, mortality, and total charges. RESULTS A total of 5,361 patients with perfPUD were identified: 5,219 in the open group and 142 in the laparoscopic group. Patients in the laparoscopic group were younger (50.5 vs 60.0, P < .001) and had a lesser incidence at presentation of sepsis (8.5 vs 14.8%, P = .034) and shock (2.1 vs 7.7%, P = .012). On univariate analysis, the laparoscopic group had decreased duration of stay (7.0 vs 8.0 days, P < .001), lesser rates of mortality (3.5 vs 8.1%, P = .048), and were discharged to home more frequently (79.6 vs 68.1%, P = .025). Mean total charges were less in the laparoscopic group ($44,095 vs $52,055, P = .019). Multivariate analyses failed to show a difference between groups for any of the outcome variables. CONCLUSION The laparoscopic treatment of perfPUD is associated with equivalent costs and outcomes compared with the open technique when we corrected for presentation variables.
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Affiliation(s)
- G Paul Wright
- General Surgery Residency Program, Grand Rapids Medical Education Partners, Grand Rapids, MI; Department of Surgery, Michigan State University College of Human Medicine, Grand Rapids, MI.
| | - Alan T Davis
- Department of Surgery, Michigan State University College of Human Medicine, Grand Rapids, MI; Research Department, Grand Rapids Medical Education Partners, Grand Rapids, MI
| | - Tracy J Koehler
- Research Department, Grand Rapids Medical Education Partners, Grand Rapids, MI
| | - David E Scheeres
- General Surgery Residency Program, Grand Rapids Medical Education Partners, Grand Rapids, MI; Department of Surgery, Michigan State University College of Human Medicine, Grand Rapids, MI; Division of Surgical Specialties, Spectrum Health Medical Group, Grand Rapids, MI
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Sverdén E, Sondén A, Leinsköld T, Lagergren J, Lu Y. Minimal versus definitive surgery in managing peptic ulcer bleeding: a population-based cohort study. Dig Surg 2014; 31:276-282. [PMID: 25322774 DOI: 10.1159/000365336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 06/15/2014] [Indexed: 12/10/2022]
Abstract
OBJECTIVE To compare radical surgery with a minimal approach for peptic ulcer bleeding in relation to survival. DESIGN A Swedish nationwide population-based cohort study from 1987-2008 compared survival after minimal surgery and definitive surgery. The cohort was also stratified into calendar year before and after the year 2000 for subgroup analyses. Data were collected from the Swedish Patient Register. The two surgical groups were matched based on the propensity score to mimic a randomized trial design. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox regression models adjusted for potential confounders. RESULTS 4,163 patients were included. There were no differences in survival in patients who underwent definitive surgical procedures compared to those who underwent minimal surgery for a bleeding peptic ulcer during the full study period. Using minimal surgery group as the reference, the HRs for death in the definitive surgery group within 30 days, 90 days, 1 year, and 5 years were 0.87 (95% CI 0.72-1.05), 0.93 (0.80-1.09), 1.00 (95% CI 0.87-1.14), and 1.05 (95% CI 0.95-1.16), respectively. The corresponding HRs during the calendar period after the year 2000 were 1.05 (95% CI 0.65-1.69), 1.18 (95% CI 0.81-1.73), 1.17 (0.84-1.62), and 1.27 (95% CI 0.99-1.63), respectively. CONCLUSION This study found no worse overall survival after minimal surgery compared to more extensive surgery for refractory peptic ulcer bleeding, and indicated better long-term survival in the minimal surgery group during the more recent study period. A minimal approach is probably sufficient in most cases.
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Affiliation(s)
- Emma Sverdén
- Unit of Upper Gastrointestinal Research, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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106
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Brzozowski T. Role of renin-angiotensin system and metabolites of angiotensin in the mechanism of gastric mucosal protection. Curr Opin Pharmacol 2014; 19:90-8. [PMID: 25238456 DOI: 10.1016/j.coph.2014.08.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 08/29/2014] [Accepted: 08/29/2014] [Indexed: 12/29/2022]
Abstract
Angiotensin II, the main effector of the renin-angiotensin system (RAS), is generated from the precursor angiotensinogen by the actions of renin, angiotensin-converting enzyme, chymase and various peptidases. RAS is essential in the control of blood pressure and body fluid homeostasis but their involvement in the mechanism of the protection of gastric mucosa has not been extensively studied. On the other hand, angiotensin-(1-7) which acts on the Mas receptor, exhibits a potent vasodilatory activity and attenuates the gastric lesions induced by various ulcerogens. In this review, the mechanism of RAS, the antagonists of angiotensin AT1 and AT2 receptors and angiotensin-(1-7) in formation of gastric damage is discussed with possible translating relevance to treatment modalities in the protection against gastric mucosal injury.
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Affiliation(s)
- Tomasz Brzozowski
- Department of Physiology, Jagiellonian University Medical College, Cracow, Poland.
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107
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Diagnosis and treatment of perforated or bleeding peptic ulcers: 2013 WSES position paper. World J Emerg Surg 2014; 9:45. [PMID: 25114715 PMCID: PMC4127969 DOI: 10.1186/1749-7922-9-45] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 06/26/2014] [Indexed: 12/11/2022] Open
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108
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Di Saverio S, Bassi M, Smerieri N, Masetti M, Ferrara F, Fabbri C, Ansaloni L, Ghersi S, Serenari M, Coccolini F, Naidoo N, Sartelli M, Tugnoli G, Catena F, Cennamo V, Jovine E. Diagnosis and treatment of perforated or bleeding peptic ulcers: 2013 WSES position paper. World J Emerg Surg 2014. [PMID: 25114715 DOI: 10.1186/1749-7922-9-451749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Salomone Di Saverio
- Emergency and General Surgery Dept, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Marco Bassi
- Department of Gastroenterology and Operative Endoscopy, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Nazareno Smerieri
- Emergency and General Surgery Dept, Maggiore Hospital- Bologna Local Health District, Bologna, Italy.,Liver and Multivisceral Transplantation Unit, University of Modena&Reggio Emilia - Policlinico Hospital, Modena, Italy
| | - Michele Masetti
- Emergency and General Surgery Dept, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Francesco Ferrara
- Department of Gastroenterology and Operative Endoscopy, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Carlo Fabbri
- Department of Gastroenterology and Operative Endoscopy, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Luca Ansaloni
- General and Emergency and Trauma Surgery, I unit, Ospedali Riuniti, Bergamo, Italy
| | - Stefania Ghersi
- Department of Gastroenterology and Operative Endoscopy, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Matteo Serenari
- Emergency and General Surgery Dept, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Federico Coccolini
- General and Emergency and Trauma Surgery, I unit, Ospedali Riuniti, Bergamo, Italy
| | - Noel Naidoo
- Port Shepstone Regional Hospital, Port Shepstone, South Africa - Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | | | - Gregorio Tugnoli
- Emergency and General Surgery Dept, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery Dept., Maggiore Hospital of Parma, Parma, Italy
| | - Vincenzo Cennamo
- Department of Gastroenterology and Operative Endoscopy, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Elio Jovine
- Emergency and General Surgery Dept, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
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109
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Application of cyanoacrylate in difficult-to-arrest acute non-variceal gastrointestinal bleeding. Wideochir Inne Tech Maloinwazyjne 2014; 9:489-93. [PMID: 25337181 PMCID: PMC4198650 DOI: 10.5114/wiitm.2014.44169] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 05/10/2014] [Accepted: 05/20/2014] [Indexed: 12/20/2022] Open
Abstract
Gastrointestinal bleeding is a common medical emergency. Although endoscopic treatment is effective in controlling non-variceal upper gastrointestinal bleeding, in cases of persistent bleeding radiological or surgical interventions are required. Application of cyanoacrylate for treatment of difficult-to-arrest non-variceal upper gastrointestinal bleeding is poorly investigated. We describe patients in whom cyanoacrylate for acute non-variceal gastrointestinal bleeding was used to stop the bleeding after failure of conventional endoscopic treatment. Five patients were treated with cyanoacrylate application (injection and/or spraying) for persistent bleeding (duodenal ulcer in 3, gastric ulcer in 1 and gastric Dieulafoy's lesion in 1) despite conventional endoscopic therapies. Hemostasis was achieved in all patients (100%). One patient (20%) developed recurrent bleeding 4 days after initial treatment. No complications or adverse events attributed to the cyanoacrylate application during the follow-up period of 57 days were observed. Application of cyanoacrylate is a safe and effective method to achieve immediate hemostasis when conventional endoscopic treatment is unsuccessful. This technique is easy to perform and should be considered in cases of patients with difficult-to-arrest acute non-variceal upper gastrointestinal bleeding.
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110
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The weekend effect in patients hospitalized for upper gastrointestinal bleeding: a single-center 10-year experience. Eur J Gastroenterol Hepatol 2014; 26:715-20. [PMID: 24849766 DOI: 10.1097/meg.0000000000000124] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE This study was conducted to assess the possible weekend effect in patients with upper gastrointestinal bleeding (UGIB) on the basis of a 10-year single-center experience in Serbia. MATERIALS AND METHODS A retrospective analysis of hospital records in the University Clinic 'Dr Dragisa Misovic-Dedinje', Belgrade, Serbia, from 2002 to 2012 was conducted. Patients admitted for UGIB were identified, and data on demographic characteristics, symptoms, drug use, alcohol abuse, diagnosis and treatment were collected. Univariate and multivariate logistic regression were used to assess the association between weekend admission and the occurrence of rebleeding and in-hospital mortality. RESULTS Analyses included 493 patients. Rebleeding occurred significantly more frequently on weekends (45.7 vs. 32.7%, P=0.004). Weekend admission [odds ratio (OR)=1.78; 95% confidence interval (CI): 1.15-2.74], older age (OR=1.02; 95% CI: 1.00-1.03), and the presence of both melaena and hematemesis (OR=2.29; 95% CI: 1.29-4.07) were associated with the occurrence of rebleeding. No difference between weekend and weekday admissions was observed for the in-hospital mortality rate (6.9% vs. 6.0%, P=0.70). Older age (OR=1.14; 95% CI: 1.08-1.20), presentation with melaena and hematemesis (OR=4.12; 95% CI: 1.56-10.90) and need for surgical treatment (OR=5.16; 95% CI: 1.61-16.53) were significant predictors of all-cause mortality. Patients with nonvariceal bleeding had significantly higher rebleeding rates on weekends (44 vs. 32.3%, P=0.013). CONCLUSION There was no significant weekend effect in the mortality of patients admitted for UGIB, irrespective of the source of bleeding. Increased attention to older patients presenting with a more severe clinical picture is needed to prolong survival and prevent rebleeding.
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111
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Vagotomy/drainage is superior to local oversew in patients who require emergency surgery for bleeding peptic ulcers. Ann Surg 2014; 259:1111-8. [PMID: 24368635 DOI: 10.1097/sla.0000000000000386] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare early postoperative outcomes of patients undergoing different types of emergency procedures for bleeding or perforated gastroduodenal ulcers. BACKGROUND Although definitive acid-reducing procedures are being used less frequently during emergency ulcer surgery, there is little published data to support this change in practice. METHODS A retrospective analysis of data for patients from the 2005-2011 American College of Surgeons National Surgical Quality Improvement Program database who underwent emergency operation for bleeding or perforated peptic ulcer disease was performed to determine the association between surgical approach (local procedure alone, vagotomy/drainage, or vagotomy/gastric resection) and 30-day postoperative outcomes. Multivariable regression analysis was used to adjust for a number of patient-related factors. RESULTS A total of 3611 patients undergoing emergency ulcer surgery (775 for bleeding, 2374 for perforation) were included for data analysis. Compared with patients undergoing local procedures alone, vagotomy/gastric resection was associated with significantly greater postoperative morbidity when performed for either ulcer perforation or bleeding. For patients with perforated ulcers, vagotomy/drainage produced similar outcomes as local procedures but required a significantly greater length of postoperative hospitalization. Conversely, vagotomy/drainage was associated with a significantly lower postoperative mortality rate than local ulcer oversew when performed for bleeding ulcers. CONCLUSIONS Simple repair is the procedure of choice for patients requiring emergency surgery for perforated peptic ulcer disease. For patients requiring emergency operation for intractable ulcer bleeding, vagotomy/drainage is associated with lower postoperative mortality than with simple ulcer oversew.
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Abstract
Cirrhosis patients’ comorbidities are their other diseases than cirrhosis. Comorbidities are neither causes nor consequences of cirrhosis, but they can increase mortality and are therefore clinically important. They are also an important source of confounding in epidemiologic studies. Comorbidity scoring systems have been developed as tools to measure the cirrhosis patient’s total burden of comorbidity, and they are useful in the clinic and for epidemiologic studies. The recently developed CirCom score is the only comorbidity scoring system developed specifically for cirrhosis patients, and it may be preferred over the older, generic, and more complex Charlson comorbidity index. Studies of individual comorbid diseases can provide insight into the interactions between cirrhosis and other diseases and thus into the pathophysiology of cirrhosis. This article reviews the literature on comorbidity in cirrhosis.
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113
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Dhakal OP, Dhakal M, Bhandari D. Phytobezoar leading to gastric outlet obstruction in a patient with diabetes. BMJ Case Rep 2014; 2014:bcr-2013-200661. [PMID: 24928925 DOI: 10.1136/bcr-2013-200661] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Gastroparesis is a condition which results in delayed gastric emptying without gastric outflow tract obstruction. Gastrointestinal involvement in diabetes can present in various forms such as oesophageal dysmotility, gastro-oesophageal reflux disease, gastroparesis, enteropathy, non-alcoholic fatty liver disease and glycogenic hepatopathy. Gastroparesis is the most common gastric motility disorder complicating long-standing diabetes. It can sometimes lead to mechanical obstruction as a result of formation of bezoars. Phytobezoars are the most common type of bezoar and are composed of indigestible food, vegetable fibre or seeds. Poor pyloric function and decreased acid formation predisposes phytobezoars formation in patients with diabetic gastroparesis. An 80-year-old patient with diabetes in our presentation developed gastric outlet obstruction due to impaction of phytobezoar over the pylorus.
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Affiliation(s)
- Om Prakash Dhakal
- Department of Medicine, Sikkim Manipal Institute of Medical Science, Gangtok, Sikkim, India
| | - Mona Dhakal
- Department of Medicine, Sikkim Manipal Institute of Medical Science, Gangtok, Sikkim, India
| | - Dhurba Bhandari
- Department of Microbiology, Sikkim Manipal Institute of Medical Sciences and Central Referral Hospital, Gangtok, Sikkim, India
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Abu Daya H, Eloubeidi M, Tamim H, Halawi H, Malli AH, Rockey DC, Barada K. Opposing effects of aspirin and anticoagulants on morbidity and mortality in patients with upper gastrointestinal bleeding. J Dig Dis 2014; 15:283-292. [PMID: 24593260 DOI: 10.1111/1751-2980.12140] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We aimed to determine the effect of antithrombotics on in-hospital mortality and morbidity in patients with peptic ulcer disease-related upper gastrointestinal bleeding (PUD-related UGIB). METHODS The study cohort was retrospectively selected from a tertiary center database of patients with PUD-related UGIB, defined as bleeding due to gastric or duodenal ulcers, or erosive duodenitis, gastritis or esophagitis. Outcomes were compared among patient groups based on their antithrombotic medications before admission. Patients on no antithrombotics served as controls. The composite adverse outcomes, in-hospital mortality, rebleeding and/or need for surgery were measured. Severe bleeding and in-hospital complications were also recorded. RESULTS Of 398 patients with PUD-related UGIB, 44.5% were on aspirin or anticoagulants only. The composite adverse outcome was most common in patients taking anticoagulants only (40.5%), intermediate in controls (23.1%) and least in those taking aspirin only (12.1%). On multivariate analysis, patients taking aspirin alone had a significantly lower risk of adverse outcome events (odds ratio [OR] 0.4, 95% CI 0.2-0.8) and a shorter length of hospital stay (regression coefficient = -3.4, 95% CI [-6.6, -0.6]). In contrast, taking anticoagulants was associated with a greater risk of adverse outcome events (OR 2.3, 95% CI 1.0-5.3), severe bleeding (OR 2.6, 95% CI 1.2-5.8) and in-hospital complications (OR 2.9, 95% CI 1.3-6.6). CONCLUSIONS Patients with PUB-related UGIB while taking aspirin had fewer adverse outcomes compared with those taking anticoagulants. Aspirin may have beneficial effects in this population.
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Affiliation(s)
- Hussein Abu Daya
- Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; Division of Gastroenterology and Hepatology, American University of Beirut Medical Center, Beirut, Lebanon
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Nikolaidis P, Hammond NA, Day K, Yaghmai V, Wood CG, Mosbach DS, Harmath CB, Taffel MT, Horowitz JM, Berggruen SM, Miller FH. Imaging Features of Benign and Malignant Ampullary and Periampullary Lesions. Radiographics 2014; 34:624-41. [DOI: 10.1148/rg.343125191] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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116
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Cavallaro LG, Monica F, Germanà B, Marin R, Sturniolo GC, Saia M. Time trends and outcome of gastrointestinal bleeding in the Veneto region: a retrospective population based study from 2001 to 2010. Dig Liver Dis 2014; 46:313-7. [PMID: 24365335 DOI: 10.1016/j.dld.2013.11.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 11/03/2013] [Accepted: 11/12/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Gastrointestinal bleeding is the most frequent emergency for gastroenterologists. Despite advances in management, an improvement in mortality is still not evident. AIM Determining time trends of gastrointestinal bleeding hospitalization and outcomes from 2001 to 2010 in the Veneto Region (Italy). PATIENTS AND METHODS Data of patients admitted with gastrointestinal bleeding from Veneto regional discharge records were retrospectively evaluated. Chi-squared and multivariate logistic regression model were used. RESULTS Overall, 44,343 patients (mean age 64.2 ± 8.6 years) with gastrointestinal bleeding were analysed: 23,450 (52.9%) had upper, 13,800 (31.1%) lower, and 7093 (16%) undefined gastrointestinal bleeding. Admission rate decreased from 108.0 per 100,000 in 2001 to 80.7 in 2010, mainly owing to a decrease in upper gastrointestinal bleeding (64.4 to 35.9 per 100,000, p<0.05). Reductions in hospital fatality rate (from 5.3% to 3%, p<0.05), length of hospital stay (from 9.3 to 8.7 days, p<0.05), and need for surgery (from 5.6% to 5%, p<0.05) were observed. Surgery (OR: 2.97, 95% CI: 2.59-3.41) and undefined gastrointestinal bleeding (OR: 2.89, 95% CI: 2.62-3.19) were found to be risk factors for mortality. CONCLUSIONS Patient admissions for gastrointestinal bleeding decreased significantly over the years, owing to a decrease in upper gastrointestinal bleeding. Improved outcomes could be related to regional dedicated clinical gastroenterological management.
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Affiliation(s)
| | - Fabio Monica
- Gastroenterology Unit, S. Bassiano Hospital, Bassano del Grappa (VI), Italy
| | | | - Renato Marin
- Gastroenterology Unit, Hospital of Dolo (VE), Italy
| | | | - Mario Saia
- Health Directorate, Veneto Region, Venezia, Italy
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117
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Rodrigues PA, Naresse LE, Minossi JG, Hasimoto CN. Alterations of the gastric stump and not resected stomach mucosa after truncal vagotomy in rats. Acta Cir Bras 2014; 29:99-103. [PMID: 24604313 DOI: 10.1590/s0102-86502014000200005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 01/21/2014] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To evaluate morphological changes of the gastric stump and not resected stomach mucosa after the completion of truncal vagotomy. METHODS Eighty male Wistar rats were divided into four groups: CT, TV, RY and RYTV. In CT group, abdominal viscera were manipulated and the abdominal cavity was closed, in TV vagal trunks were isolated and sectioned, in RY a partial Roux-en-Y gastrectomy was performed and in RYTV the vagal trunks were sectioned and a partial Roux-en-Y gastrectomy was performed. At the 54th week after surgery, the rats were euthanized. The findings were submitted to histological analyses. RESULTS None macroscopic or histological alterations in groups TV and CT was observed. Specimens from RY and RYTV groups did not show alterations in the gastric stump mucosa. At the jejunal side of the gastroenterostomy we found shallow ulcerative lesions always single, well-defined and with variable diameter 3 to 6 mm, six times in the RY group and none in the RYTV group (RY>RYTV, p=0.008). Neoplastic or preneoplastic lesions were not diagnosed in all groups. CONCLUSION Truncal vagotomy is a safe and non-carcinogenic method in not resected and partially resected stomach.
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Affiliation(s)
- Paulo Antônio Rodrigues
- PhD, Assistant Professor, Departament of Surgery & Orthopedics, Faculty of Medicine, Sao Paulo State University (UNESP), Botucatu-SP, Brazil
| | - Luiz Eduardo Naresse
- PhD, Associate Professor, Departament of Surgery & Orthopedics, Faculty of Medicine, UNESP, Botucatu-SP, Brazil
| | - José Guilherme Minossi
- PhD, Assistant Professor, Departament of Surgery & Orthopedics, Faculty of Medicine, UNESP, Botucatu-SP, Brazil
| | - Claudia Nishida Hasimoto
- Fellow Master degree, Postgraduate Program in General Basis of Surgery, Faculty of Medicine, UNESP, Botucatu-SP, Brazil
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118
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Malmi H, Kautiainen H, Virta LJ, Färkkilä N, Koskenpato J, Färkkilä MA. Incidence and complications of peptic ulcer disease requiring hospitalisation have markedly decreased in Finland. Aliment Pharmacol Ther 2014; 39:496-506. [PMID: 24461085 DOI: 10.1111/apt.12620] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2013] [Revised: 04/08/2013] [Accepted: 12/24/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND The characteristics of peptic ulcer disease (PUD) are changing. AIM To evaluate time trends in the incidence of PUD and its complications in hospitalised patients at the beginning of the 21st century, drug therapies in out-patient care as a risk factor for recurrent PUD, and medication used by PUD patients compared with the background population. METHODS In this retrospective epidemiologic cohort study, data from the years 2000-2008 came from The Hospital District of Helsinki and Uusimaa, and the Finnish Care Register. All hospitalised adult patients with PUD in the capital region of Finland were included. The data were linked with nationwide Prescription Register of the Finnish Social Insurance Institution allowing detailed individual medicine purchase data. RESULTS A total of 9951 peptic ulcers were detected among 8146 individual patients during the study period. The mean annual incidence of all peptic ulcers decreased from 121/100,000 (95% CI: 117-125) in 2000-2002, to 79 (95% CI: 76-82) in 2006-2008 [Incidence rate ratio = 0.62 (95% CI: 0.58-0.64), P < 0.001 after age and sex adjustment]. Decrease in incidence was seen in all age groups and in both sexes. The overall rate of severe complications of PUD was reduced. One-year cumulative incidence of recurrent ulcers was 13%. Use of several drugs was associated with increased risk for recurrence. The purchases of various drugs were more common among PUD patients compared with background population. CONCLUSIONS Both the incidence and complication rates have markedly decreased during the study period. Recurrent peptic ulcer disease was associated with polypharmacy.
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Affiliation(s)
- H Malmi
- Department of Gastrointestinal Surgery, Helsinki University Central Hospital, Helsinki, Finland
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119
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Leontiadis GI, Nyrén O. Epidemiology of Helicobacter PyloriInfection, Peptic Ulcer Disease and Gastric Cancer. GI EPIDEMIOLOGY 2014:135-157. [DOI: 10.1002/9781118727072.ch14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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120
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What is the best predictor of mortality in perforated peptic ulcer disease? A population-based, multivariable regression analysis including three clinical scoring systems. J Gastrointest Surg 2014; 18:1261-8. [PMID: 24610235 PMCID: PMC4057623 DOI: 10.1007/s11605-014-2485-5] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 02/11/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Mortality rates in perforated peptic ulcer (PPU) have remained unchanged. The aim of this study was to compare known clinical factors and three scoring systems (American Society of Anesthesiologists (ASA), Boey and peptic ulcer perforation (PULP)) in the ability to predict mortality in PPU. MATERIAL AND METHODS This is a consecutive, observational cohort study of patients surgically treated for perforated peptic ulcer over a decade (January 2001 through December 2010). Primary outcome was 30-day mortality. RESULTS A total of 172 patients were included, of whom 28 (16 %) died within 30 days. Among the factors associated with mortality, the PULP score had an odds ratio (OR) of 18.6 and the ASA score had an OR of 11.6, both with an area under the curve (AUC) of 0.79. The Boey score had an OR of 5.0 and an AUC of 0.75. Hypoalbuminaemia alone (≤37 g/l) achieved an OR of 8.7 and an AUC of 0.78. In multivariable regression, mortality was best predicted by a combination of increasing age, presence of active cancer and delay from admission to surgery of >24 h, together with hypoalbuminaemia, hyperbilirubinaemia and increased creatinine values, for a model AUC of 0.89. CONCLUSION Six clinical factors predicted 30-day mortality better than available risk scores. Hypoalbuminaemia was the strongest single predictor of mortality and may be included for improved risk estimation.
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121
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Søreide K, Thorsen K, Søreide JA. Strategies to improve the outcome of emergency surgery for perforated peptic ulcer. Br J Surg 2013; 101:e51-64. [PMID: 24338777 DOI: 10.1002/bjs.9368] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Perforated peptic ulcer (PPU) is a common surgical emergency that carries high mortality and morbidity rates. Globally, one-quarter of a million people die from peptic ulcer disease each year. Strategies to improve outcomes are needed. METHODS PubMed was searched for evidence related to the surgical treatment of patients with PPU. The clinical registries of trials were examined for other available or ongoing studies. Randomized clinical trials (RCTs), systematic reviews and meta-analyses were preferred. RESULTS Deaths from peptic ulcer disease eclipse those of several other common emergencies. The reported incidence of PPU is 3.8-14 per 100,000 and the mortality rate is 10-25 per cent. The possibility of non-operative management has been assessed in one small RCT of 83 patients, with success in 29 (73 per cent) of 40, and only in patients aged less than 70 years. Adherence to a perioperative sepsis protocol decreased mortality in a cohort study, with a relative risk (RR) reduction of 0.63 (95 per cent confidence interval (c.i.) 0.41 to 0.97). Based on meta-analysis of three RCTs (315 patients), laparoscopic and open surgery for PPU are equivalent, but patient selection remains a challenge. Eradication of Helicobacter pylori after surgical repair of PPI reduces both the short-term (RR 2.97, 95 per cent c.i. 1.06 to 8.29) and 1-year (RR 1.49, 1.10 to 2.03) risk of ulcer recurrence. CONCLUSION Mortality and morbidity from PPU can be reduced by adherence to perioperative strategies.
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Affiliation(s)
- K Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, and Department of Clinical Medicine, University of Bergen, Bergen, Norway
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122
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Lu Y, Loffroy R, Lau JYW, Barkun A. Multidisciplinary management strategies for acute non-variceal upper gastrointestinal bleeding. Br J Surg 2013; 101:e34-50. [PMID: 24277160 DOI: 10.1002/bjs.9351] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2013] [Indexed: 01/12/2023]
Abstract
BACKGROUND The modern management of acute non-variceal upper gastrointestinal bleeding is centred on endoscopy, with recourse to interventional radiology and surgery in refractory cases. The appropriate use of intervention to optimize outcomes is reviewed. METHODS A literature search was undertaken of PubMed and the Cochrane Central Register of Controlled Trials between January 1990 and April 2013 using validated search terms (with restrictions) relevant to upper gastrointestinal bleeding. RESULTS Appropriate and adequate resuscitation, and risk stratification using validated scores should be initiated at diagnosis. Coagulopathy should be corrected along with blood transfusions, aiming for an international normalized ratio of less than 2·5 to proceed with possible endoscopic haemostasis and a haemoglobin level of 70 g/l (excluding patients with severe bleeding or ischaemia). Prokinetics and proton pump inhibitors (PPIs) can be administered while awaiting endoscopy, although they do not affect rebleeding, surgery or mortality rates. Endoscopic haemostasis using thermal or mechanical therapies alone or in combination with injection should be used in all patients with high-risk stigmata (Forrest I-IIb) within 24 h of presentation (possibly within 12 h if there is severe bleeding), followed by a 72-h intravenous infusion of PPI that has been shown to decrease further rebleeding, surgery and mortality. A second attempt at endoscopic haemostasis is generally made in patients with rebleeding. Uncontrolled bleeding should be treated with targeted or empirical transcatheter arterial embolization. Surgical intervention is required in the event of failure of endoscopic and radiological measures. Secondary PPI prophylaxis when indicated and Helicobacter pylori eradication are necessary to decrease recurrent bleeding, keeping in mind the increased false-negative testing rates in the setting of acute bleeding. CONCLUSION An evidence-based approach with multidisciplinary collaboration is required to optimize outcomes of patients presenting with acute non-variceal upper gastrointestinal bleeding.
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Affiliation(s)
- Y Lu
- Division of Gastroenterology and
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123
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Enhanced postoperative recovery pathways in emergency surgery: a randomised controlled clinical trial. Am J Surg 2013; 207:807-14. [PMID: 24119887 DOI: 10.1016/j.amjsurg.2013.07.025] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 07/12/2013] [Accepted: 07/18/2013] [Indexed: 12/15/2022]
Abstract
BACKGROUND Enhanced recovery pathways are now widely used in elective surgical procedures. The feasibility of enhanced postoperative recovery pathways in emergency surgery for perforated peptic ulcer disease was investigated in this randomized controlled clinical trial. METHODS Patients with perforated peptic ulcer disease who underwent laparoscopic repair were randomized into 2 groups. Group 1 patients were managed with standard postoperative care and group 2 patients with enhanced postoperative recovery pathways. The primary endpoints were the length of hospital stay and morbidity and mortality. RESULTS Forty-seven patients were included in the study. There were 26 patients in group 1 and 21 in group 2. There were no significant differences in the morbidity and mortality rates, whereas the length of hospital stay was significantly shorter in group 2. CONCLUSIONS The application of enhanced postoperative recovery pathways in selected patients with perforated peptic ulcer disease who undergo laparoscopic Graham patch repair seems feasible.
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Smith JW, Mathis T, Benns MV, Franklin GA, Harbrecht BG, Larson G. Socioeconomic disparities in the operative management of peptic ulcer disease. Surgery 2013; 154:672-8; discussion 678-9. [PMID: 23978592 DOI: 10.1016/j.surg.2013.06.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 06/25/2013] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Over the last 60 years, there has been a nationwide decrease in the number of operations performed for peptic ulcer disease (PUD). In contrast, the experience at our university-based safety net hospital (SNH) was that ulcer operations are still performed frequently. We hypothesized that differences in frequency of PUD operation may occur in hospitals that serve different patient populations. The purpose of this study was to evaluate our experience with PUD and compare it with national trends. METHODS We received institutional review board approval and performed this retrospective study of patients undergoing operation for PUD between January 2008 and December 2011. Patient records at 2 hospitals (a private community hospital and a university SNH) with similar admission numbers and geographic catchment were examined for PUD risk factors, Helicobacter pylori status, insurance/income status, type of operation, and surgical outcomes. A case-matched control group of medically treated patients were identified after primary diagnosis of PUD by endoscopy at the SNH. Univariate and multivariate analyses were performed. RESULTS The total number of operations for PUD performed at the SNH was greater than those performed at the private hospital from 2008 to 2011 (142 vs 24; P < .001). The private hospital followed national trends over the same time period with a decrease in operations for PUD of approximately 93% between 1967 and 2008 (115 to 8 operations per year nationally and 119 to 6 at the private hospital). In contrast with the national and local private hospital experience, the number of operations for PUD at SNH increased from 27 per year in 1985 to 36 per year in 2008. Additionally, 43% of patients at the SNH had no insurance, and 61% resided in the poorest quartile of zip codes compared with the 3% uninsured patient rate at the private hospital for a similar group of patients. At both hospitals, most operations were emergent (range, 83-92%) and treated with omental patch (45%), gastric wedge resection (15%), vagotomy and antrectomy (19%), or vagotomy and pyloroplasty (14%). At the SNH, the H pylori infection rate was less (48% vs 83%; P < .001) and nonsteroidal anti-inflammatory drug (NSAID) use was greater (76% vs 63%; P < .01) in the 142 surgical patients compared with the 320 medical controls. Adjusted risk ratios demonstrated insurance status, NSAID use, and lower socioeconomic class were all equally predictive of operative ulcer disease when compared with medical controls. CONCLUSION Our study provides 2 observations. First, patients of lower socioeconomic standing may have increased rates of complicated PUD owing to multiple medical factors and other factors related to healthcare. Second, surgical care for PUD retains a clinically important role within this patient population.
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Affiliation(s)
- Jason W Smith
- Hiram C. Polk Department of Surgery, University of Louisville School of Medicine, Louisville, KY.
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125
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Mortality and readmission rates after hospitalization for upper and lower gastrointestinal events in Quebec, Canada. J Clin Gastroenterol 2013; 47:586-92. [PMID: 23426460 DOI: 10.1097/mcg.0b013e318282a1d7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
GOALS We determined yearly rates of upper and lower gastrointestinal (GI) hospitalizations in Quebec, Canada and compared the 1-year readmission and mortality risks among those discharged from lower versus upper GI hospitalizations. BACKGROUND The burden of serious upper and lower GI events is substantial. STUDY Demographic, medical, pharmaceutical, and hospital records were used in a retrospective cohort study to assess risks of mortality and hospital readmission for upper and lower GI events among patients 50 years and older during 1998 to 2006. RESULTS Among included 39,771 GI hospitalizations, 5238 were from 1998 to 1999, and 5050 from 2005 to 2006. Rates of upper GI hospitalizations decreased in the study period, whereas that of lower GI events did not change. The risk of in-hospital mortality was higher in patients with small bowel versus upper GI events [odds ratio 2.11; 95% confidence interval (CI), 1.81-2.47] and lower in patients with colon/rectal events 0.30 (0.25-0.36). One-year mortality risk after discharge was lower in patients with lower versus upper GI events (small bowel hazard ratio 0.81; 95% CI, 0.70-0.93; and colon/rectal: 0.77; 95% CI, 0.71-0.83). Compared to upper GI events, the risk of hospital readmission was higher in those with small bowel 1.53 (1.19-1.97) and similar in those with colon/rectal events 1.12 (0.96-1.31). CONCLUSIONS The risk of upper GI events may be decreasing, but remains over 3 times as high as that of lower GI events and among those admitted for GI events, about 80% of in-hospital mortality occurred in those with upper GI problems. Although GI events in the small bowel are less frequent than those in upper or lower GI tract, they are the most severe and are associated with higher risks of mortality and hospital readmissions.
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126
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Abstract
Acute upper gastrointestinal bleeding is a common medical emergency worldwide, a major cause of which are bleeding peptic ulcers. Endoscopic treatment and acid suppression with proton-pump inhibitors are cornerstones in the management of the disease, and both treatments have been shown to reduce mortality. The role of emergency surgery continues to diminish. In specialised centres, radiological intervention is increasingly used in patients with severe and recurrent bleeding who do not respond to endoscopic treatment. Despite these advances, mortality from the disorder has remained at around 10%. The disease often occurs in elderly patients with frequent comorbidities who use antiplatelet agents, non-steroidal anti-inflammatory drugs, and anticoagulants. The management of such patients, especially those at high cardiothrombotic risk who are on anticoagulants, is a challenge for clinicians. We summarise the published scientific literature about the management of patients with bleeding peptic ulcers, identify directions for future clinical research, and suggest how mortality can be reduced.
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Affiliation(s)
- James Y W Lau
- Institute of Digestive Diseases, The Chinese University of Hong Kong, Hong Kong, China.
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127
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Mapel D, Roberts M, Overhiser A, Mason A. The epidemiology, diagnosis, and cost of dyspepsia and Helicobacter pylori gastritis: a case-control analysis in the Southwestern United States. Helicobacter 2013; 18:54-65. [PMID: 23067108 PMCID: PMC3607406 DOI: 10.1111/j.1523-5378.2012.00988.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Dyspepsia is among the most common complaints evaluated by gastroenterologists, but there are few studies examining its current epidemiology, evaluation, and costs. We examined these issues in a large managed care system in the Southwestern United States. METHODS We conducted a retrospective case-control analysis of adults with incident dyspepsia or a Helicobacter pylori-related condition in years 2006 through 2010 using utilization data. Medical record abstraction of 400 cases was conducted to obtain additional clinical information. RESULTS A total of 6989 cases met all inclusion and exclusion criteria. Women had a substantially higher risk of dyspepsia than men (14 per 1000 per year vs 10 per 1000; p < .001), and the incidence of dyspepsia increased with age such that persons in their seventh decade had almost twice the risk of those aged 18-29. Hispanic persons had a significantly higher risk of dyspepsia and positive H. pylori testing. Dyspepsia cases had a higher prevalence of other chronic comorbidities than their matched controls. Dyspepsia patients had healthcare costs 54% higher than controls even before the diagnosis was made, and costs in the initial diagnostic period were $483 greater per person, but subsequent costs were not greatly affected. Among those aged 55 and younger, the "test and treat" approach was used in 53% and another 18% had an initial esophagogastroduodenoscopy, as compared to 47 and 27%, respectively, among those over the age of 55. CONCLUSIONS Women and older adults have a higher incidence of dyspepsia than previously appreciated, and Hispanics in this region also have a higher risk. Current guidelines for dyspepsia evaluation are only loosely followed.
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Affiliation(s)
| | | | | | - Andrew Mason
- Southwest Gastroenterology AssociatesAlbuquerque, NM, USA
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128
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Why do mortality rates for nonvariceal upper gastrointestinal bleeding differ around the world? A systematic review of cohort studies. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2012; 26:537-43. [PMID: 22891179 DOI: 10.1155/2012/862905] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Discrepancies exist in reported mortality rates of nonvariceal upper gastrointestinal bleeding (NVUGIB). OBJECTIVE To perform a systematic review assessing possible reasons for these disparate findings and to more reliably compare them. METHODS The MEDLINE, EMBASE and ISI Web of Knowledge databases were searched for studies reporting mortality rates in NVUGIB involving adults and published in English. To ensure robust and contemporary estimates, studies spanning 1996 to January 2011 that included more than 1000 patients were selected. RESULTS Eighteen of 3077 studies were selected. Ten studies used administrative databases and the remaining eight used registries. The mortality rates reported in these studies ranged from 1.1% in Japan to 11% in Denmark. There were variations in reported mortality rates among countries and also within countries. Reasons for these disparities included a spectrum of quality in reporting as well as heterogeneous definitions of case ascertainment, differing patient populations with regard to severity of presentation and associated comorbidities, varying durations of follow-up and different health care system-related practices. CONCLUSIONS Wide differences in reported NVUGIB mortality rates are attributable to differences in adopted methodologies and populations studied. More uniform standards in reporting are needed; only then can true observed variations enable a better understanding of causes of death and pave the way to improved patient outcomes.
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129
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Wong CS, Chia CF, Lee HC, Wei PL, Ma HP, Tsai SH, Wu CH, Tam KW. Eradication of Helicobacter pylori for prevention of ulcer recurrence after simple closure of perforated peptic ulcer: a meta-analysis of randomized controlled trials. J Surg Res 2012; 182:219-26. [PMID: 23158404 DOI: 10.1016/j.jss.2012.10.046] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2012] [Revised: 10/10/2012] [Accepted: 10/23/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Eradication of Helicobacter pylori has become part of the standard therapy for peptic ulcer. However, the role of H pylori eradication in perforation of peptic ulcers remains controversial. It is unclear whether eradication of the bacterium confers prolonged ulcer remission after simple repair of perforated peptic ulcer. METHODS A systematic review and meta-analysis of randomized controlled trials was performed to evaluate the effects of H pylori eradication on prevention of ulcer recurrence after simple closure of perforated peptic ulcers. The primary outcome to evaluate these effects was the incidence of postoperative ulcers; the secondary outcome was the rate of H pylori elimination. RESULTS The meta-analysis included five randomized controlled trials and 401 patients. A high prevalence of H pylori infection occurred in patients with perforated peptic ulcers. Eradication of H pylori significantly reduced the incidence of ulcer recurrence at 8 wk (risk ratio 2.97; 95% confidence interval: 1.06-8.29) and 1 y (risk ratio 1.49; 95% confidence interval: 1.10-2.03) postoperation. The rate of H pylori eradication was significantly higher in the treatment group than in the nontreatment group. CONCLUSIONS Eradication therapy should be provided to patients with H pylori infection after simple closure of perforated gastroduodenal ulcers.
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Affiliation(s)
- Chung-Shun Wong
- Department of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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130
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Kim JJ, Kim N, Park HK, Jo HJ, Shin CM, Lee SH, Park YS, Hwang JH, Kim JW, Jeong SH, Lee DH, Kim JM, Lee JH, Jung HC, Song IS. [Clinical characteristics of patients diagnosed as peptic ulcer disease in the third referral center in 2007]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2012; 59:338-46. [PMID: 22617527 DOI: 10.4166/kjg.2012.59.5.338] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND/AIMS In spite of the improvement of medical treatment for the peptic ulcer disease (PUD), PUD is still one of the common upper gastrointestinal diseases. The purpose of this study was to evaluate the risk factors and general characteristics of Korean patients diagnosed as PUD at a single third referral center. METHODS A total of 310 patients, diagnosed as PUD through endoscopy during one year of 2007 at Seoul National University Bundang Hospital were, retrospectively, evaluated regarding age, gender, Helicobacter pylori (H. pylori) positivity, clinical manifestations, comorbidities and medications. In addition, PUD was analyzed in the aspect of ulcer location, type of visit, gastrointestinal bleeding, and age. RESULTS The mean age was 61.5 years old (48.1% over 65) and 208 (66.7%) patients were men. The rate of H. pylori infection was 47.8%, and any ulcerogenic medication history such as antiplatelet agents and NSAIDs was found to be 21.0% (65 patients). The rate of idiopathic peptic ulcer without evidence of H. pylori and NSAIDs was found to be 40.6% (126 patients). Among 310 PUD patients, bleeding symptoms such as melena, hematemesis and hematochezia occurred in 110 patients (35.5%). CONCLUSIONS PUD was more prevalent in the elderly patients and frequently associated with bleeding. Substantial proportion of PUD patients had neither H. pylori infection nor history of ulcerogenic medications, suggesting of increasing prevalence of idiopathic PUD.
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Affiliation(s)
- Jin Joo Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, 82 Gumiro 173-gil, Bundang-gu, Seongnam 463-707, Korea
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131
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Bae S, Shim KN, Kim N, Kang JM, Kim DS, Kim KM, Cho YK, Jung SW. Incidence and short-term mortality from perforated peptic ulcer in Korea: a population-based study. J Epidemiol 2012; 22:508-16. [PMID: 22955110 PMCID: PMC3798562 DOI: 10.2188/jea.je20120056] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background Perforated peptic ulcer (PPU) is associated with serious health and economic outcomes. However, few studies have estimated the incidence and health outcomes of PPU using a nationally representative sample in Asia. We estimated age- and sex-specific incidence and short-term mortality from PPU among Koreans and investigated the risk factors for mortality associated with PPU development. Methods A retrospective population-based study was conducted from 2006 through 2007 using the Korean National Health Insurance claims database. A diagnostic algorithm was derived and validated to identify PPU patients, and PPU incidence rates and 30-day mortality rates were determined. Results From 2006 through 2007, the PPU incidence rate per 100 000 population was 4.4; incidence among men (7.53) was approximately 6 times that among women (1.24). Incidence significantly increased with advanced age, especially among women older than 50 years. Among 4258 PPU patients, 135 (3.15%) died within 30 days of the PPU event. The 30-day mortality rate increased with advanced age and reached almost 20% for patients older than 80 years. The 30-day mortality rate was 10% for women and 2% for men. Older age, being female, and higher comorbidity were independently associated with 30-day mortality rate among PPU patients in Korea. Conclusions Special attention should be paid to elderly women with high comorbidity who develop PPU.
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Affiliation(s)
- Seungjin Bae
- Health Insurance Review and Assessment Service, Research and Development Center, Seoul, South Korea
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132
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Vashist YK, Yekebas EF, Gebauer F, Tachezy M, Bachmann K, König A, Kutup A, Izbicki JR. Management of the difficult duodenal stump in penetrating duodenal ulcer disease: a comparative analysis of duodenojejunostomy with "classical" stump closure (Nissen-Bsteh). Langenbecks Arch Surg 2012; 397:1243-9. [PMID: 22903877 DOI: 10.1007/s00423-012-0990-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Accepted: 07/31/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Duodenal stump insufficiency after surgery for penetrating gastroduodenal ulcer is associated with substantial mortality. "Classical" technique of closing a difficult duodenal stump (Nissen-Bsteh) has, up to now, not been compared with duodenojejunostomy (DJ) in larger patient sets. This also refers to the potential benefit of a gastric and biliary diversion under such conditions. The aim of the present study was to compare classical duodenal closure (CC) with DJ and to evaluate the impact of gastric and biliary diversion on postoperative outcome after surgery for penetrating, high-risk duodenal ulcer in a matched control study. METHODS Out of 321 patients, treated for penetrating duodenal ulcer disease, the perioperative outcome of 62 DJ patients was compared with 62 patients undergoing CC matched for age, gender, biliary diversion, and the operating surgeon collective. A total of 70 patients, equally distributed between DJ and CC subsets, received temporary biliary diversion. RESULTS Overall perioperative mortality was 10.5%. However, DJ significantly reduced the mortality rate (4.8%) associated with penetrating duodenal ulcer compared to CC (16.1%, P < 0.04). The overall morbidity in DJ patients nearly equalled that in the CC group (P = 0.4). Differences in the prevalence of duodenal leakage rate between DJ (14.5%) and CC (29%) patients were of borderline significance (P = 0.05). Temporary biliary diversion was identified as a prognostic factor for closure consistency with lower duodenal leakage rates in both DJ (odds ratio 0.05, 95% confidence interval 0.005-0.42) and CC patients (odds ratio 0.2, 95% confidence interval 0.05-0.6). In contrast, gastric diversion performed in a subset of 35 DJ patients had no protective effect. CONCLUSION Duodenojejunostomy combined with temporary biliary diversion substantially improves perioperative outcome in management of penetrating duodenal ulcer.
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Affiliation(s)
- Yogesh K Vashist
- Department of Surgery, University Hospital Hamburg-Eppendorf, Martinistrasse52, 20246, Hamburg, Germany
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Vera-Arzave C, Antonio LC, Arrieta J, Cruz-Hernández G, Velázquez-Méndez AM, Reyes-Ramírez A, Sánchez-Mendoza ME. Gastroprotection of suaveolol, isolated from Hyptis suaveolens, against ethanol-induced gastric lesions in Wistar rats: role of prostaglandins, nitric oxide and sulfhydryls. Molecules 2012; 17:8917-27. [PMID: 22836211 PMCID: PMC6268582 DOI: 10.3390/molecules17088917] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Revised: 07/20/2012] [Accepted: 07/23/2012] [Indexed: 11/16/2022] Open
Abstract
Hyptis suaveolens is a medicinal plant that is, according to traditional medicine, considered useful in the treatment of gastric ulcers. Although its gastroprotective activity was reported, the active compounds have not been identified. Therefore, the aim of the present study was to identify at least one active compound potentially responsible for the gastroprotective activity of H. suaveolens by using a bioassay guided study with an ethanol-induced gastric ulcer experimental model in rats. The results show that the hexane extract had protective activity (close to 70% when using doses between 10 and 100 mg/kg), and that the compound suaveolol, isolated from this extract, was one of the active gastroprotective agents. This is the first report about the gastroprotective activity of suaveolol. Rats treated with this compound at 3, 10, 30 and 100 mg/kg showed 12.6, 21.3, 39.6 and 70.2% gastroprotection respectively. The effect elicited by suaveolol (at 100 mg/kg) was attenuated by pretreatment with either NG-nitro-L-arginine methyl ester (70 mg/kg, i.p.), a nitric oxide (NO) synthase inhibitor, indomethacin (10 mg/kg, s.c.), a blocker of prostaglandin synthesis, or N-ethylmaleimide (10 mg/kg, s.c.), a blocker of sulfhydryl groups. This suggests that the gastroprotective mechanism of action of this compound involves NO, prostaglandins and sulfhydryl groups.
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Affiliation(s)
- Carlos Vera-Arzave
- Superior Medicine School, National Polytechnic Institute, Plan de San Luis y Díaz Mirón, Colonia Santo Tomás, Delegación Miguel Hidalgo, Mexico City, 11340, Mexico; (C.V.-A.); (J.A.); (G.C.-H.)
| | - Leticia Cruz Antonio
- Zaragoza Faculty of Higher Studies, Batalla del 5 de Mayo Esquina Fuerte de Loreto, Ejército de Oriente, Mexico City, 09230, Mexico; (L.C.A.); (A.R.-R.)
| | - Jesús Arrieta
- Superior Medicine School, National Polytechnic Institute, Plan de San Luis y Díaz Mirón, Colonia Santo Tomás, Delegación Miguel Hidalgo, Mexico City, 11340, Mexico; (C.V.-A.); (J.A.); (G.C.-H.)
| | - Gerardo Cruz-Hernández
- Superior Medicine School, National Polytechnic Institute, Plan de San Luis y Díaz Mirón, Colonia Santo Tomás, Delegación Miguel Hidalgo, Mexico City, 11340, Mexico; (C.V.-A.); (J.A.); (G.C.-H.)
| | - Antonio Magdiel Velázquez-Méndez
- Technological University of the Jungle, Entronque Toniná Carretera Ocosingo-Altamirano, Ocosingo, State of Chiapas, 29950, Mexico;
| | - Adelfo Reyes-Ramírez
- Zaragoza Faculty of Higher Studies, Batalla del 5 de Mayo Esquina Fuerte de Loreto, Ejército de Oriente, Mexico City, 09230, Mexico; (L.C.A.); (A.R.-R.)
| | - María Elena Sánchez-Mendoza
- Superior Medicine School, National Polytechnic Institute, Plan de San Luis y Díaz Mirón, Colonia Santo Tomás, Delegación Miguel Hidalgo, Mexico City, 11340, Mexico; (C.V.-A.); (J.A.); (G.C.-H.)
- Author to whom correspondence should be addressed; ; Tel.: +55-5729-6300 (ext. 62827); Fax: +55-5622-5329
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Al Moutaery M, Al Rayes H, Al Swailam R, Elfaki I, Khan HA, Alhomida AS, Arshaduddin M, Tariq M. 2,3-Dimercaptopropanol, a thiol chelator, alleviates gastroduodenal ulcers in rats. Fundam Clin Pharmacol 2012; 26:402-409. [PMID: 21477207 DOI: 10.1111/j.1472-8206.2011.00941.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Earlier studies have implicated reactive oxygen species and transitional metals in the pathogenesis of gastric lesions. In this study, we have evaluated the effect of 2,3-dimercaptopropanol (DMP), a thiol compound and metal chelator, on chemically induced gastroduodenal ulcers in rats. Acid secretion studies were undertaken using pylorus-ligated rats pretreated with DMP (3-100 mg/kg, i.p.). The effect of orally administered DMP on cysteamine-induced duodenal ulcers and ethanol-induced gastric ulcers was also tested. The level of nonprotein sulfhydryls (NP-SH) and gastric wall mucus was measured in the glandular stomach of rats treated with ethanol. None of the dose of DMP affected the volume or acidity of gastric secretion. Low doses of DMP (3 and 10 mg/kg) significantly reduced cysteamine-induced duodenal ulcers, whereas the high doses (30 and 100 mg/kg) were ineffective in this model. All the doses of DMP significantly and dose dependently attenuated ethanol-induced gastric lesions. The adverse effects of ethanol on gastric wall mucus and NP-SH were significantly and dose dependently reversed by DMP. In conclusion, the protective effects of DMP appear to be independent of gastric acid secretion and may be associated with counteracting the oxidative stress by replenishing glutathione and reducing the pool of transition metals.
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Affiliation(s)
- Meshal Al Moutaery
- Prince Sultan Cardiac Center, Armed Forces Hospital, Riyadh, Saudi Arabia
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Kuwabara K, Matsuda S, Fushimi K, Ishikawa KB, Horiguchi H, Fujimori K. Community-based evaluation of laparoscopic versus open simple closure of perforated peptic ulcers. World J Surg 2012; 35:2485-92. [PMID: 21915743 DOI: 10.1007/s00268-011-1252-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Several studies have advocated laparoscopic simple closure (LSC) as the treatment of choice for perforated peptic ulcer disease (PUD). However, there has been no comprehensive community-based evaluation of the advantages of using LSC over open simple closure (OSC). Using an administrative database, we evaluated LSC versus OSC for patients with perforated ulcers. METHODS From 6,334 patients with perforated ulcers, we identified 2,909 simple closure cases between 2006 and 2010. Study variables were demographics, mortality, co-morbidities, complications, ulcer location, surgical timing, blood transfusion, postoperative ventilation, operating room (OR) time, time to resumption of oral food intake, length of stay (LOS), and total charges. After matching patient baseline variables between OSC and LSC, we performed multivariate analyses to assess the impacts of LSC on mortality, complications, and ventilation administration. RESULTS A total of 2,073 OSC cases and 836 LSC cases were identified in 670 hospitals. Younger age, duodenal ulcer, and pre-existing PUD were indicators for selection of LSC. Matching analysis indicated a correlation between LSC and lower mortality, less frequent postoperative and overall blood transfusion, shorter LOS, earlier return to oral intake, and longer OR time. There was no difference between OSC and LSC in complication rate or mortality. Longer OR time was correlated with a higher complication rate and the need for ventilation, the latter of which was independently associated with an increase in mortality. CONCLUSIONS Because longer OR time was associated with more frequent complications and ventilation, surgeons should obtain the skills and strategies necessary to accomplish LSC without extending OR time improperly.
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Affiliation(s)
- Kazuaki Kuwabara
- Department of Health Care Administration and Management, Kyushu University, Graduate School of Medical Sciences, 3-1-1 Maidashi Higashi-ku, Fukuoka, 812-8582, Japan.
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Schöttker B, Adamu MA, Weck MN, Brenner H. Helicobacter pylori infection is strongly associated with gastric and duodenal ulcers in a large prospective study. Clin Gastroenterol Hepatol 2012; 10:487-93.e1. [PMID: 22230167 DOI: 10.1016/j.cgh.2011.12.036] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Revised: 12/15/2011] [Accepted: 12/20/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Infection with Helicobacter pylori (H pylori) is a risk factor for peptic ulcer disease (PUD), but there are limited longitudinal data on the associations between infection and incident gastric or duodenal ulcers. METHODS Information on potential risk factors, lifetime history of PUD, and serologic measurements of H pylori infection were obtained from a German cohort of 9953 adults, 50 to 74 years old at baseline (2000-2002). The incidence of ulcers was determined by questionnaires sent to study participants and general practitioners 2 and 5 years later, and was validated by medical records. RESULTS A lifetime history of PUD was reported by 1030 participants, and during the follow-up period 48 had a first gastric and 22 had a first duodenal ulcer. Infection with H pylori strains that express cytotoxin-associated gene A (cagA) was significantly associated with a lifetime history of PUD (odds ratio, 1.75; 95% confidence interval [CI], 1.50-2.04). Based on longitudinal analyses with physician-validated end points, the adjusted hazard ratios for incident gastric and duodenal ulcer disease were 2.9 (95% CI, 1.5-5.5) and 18.4 (95% CI, 4.2-79.9), respectively, among patients infected with cagA-positive strains of H pylori. CONCLUSIONS In cross-sectional analysis, infection with cagA-positive strains of H pylori was associated with a 1.75-fold increased risk of peptic ulcer disease. Longitudinal analyses revealed an 18.4- and 2.9-fold increased risk for duodenal ulcer and gastric ulcer, respectively. The proportion of PUD that is attributable to H pylori infection might be larger than previously believed.
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Affiliation(s)
- Ben Schöttker
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany.
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Casali JJ, Franzon O, Kruel NF, Neves BD. Análise epidemiológica e emprego do teste rápido da urease em pacientes com úlcera péptica perfurada. Rev Col Bras Cir 2012. [DOI: 10.1590/s0100-69912012000200003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Analisar o perfil epidemiológico de pacientes com úlcera péptica gastroduodenal perfurada e verificar se a presença do H. pylori nas secreções peritoneais e intraluminais desses pacientes pode ser avaliada pelo teste rápido da urease. MÉTODOS: Realizou-se estudo prospectivo, transversal, descritivo, com dados de pacientes atendidos em um hospital de abrangência regional, em portadores de úlcera péptica perfurada. Coletou-se, no transoperatório, amostras de líquido peritoneal (na proximidade da perfuração) e da secreção intraluminal, sendo encaminhadas para cultura e teste rápido de urease. RESULTADOS: Quatorze pacientes foram analisados. A média etária foi 41,06 anos, todos homens, brancos (71,4%), tabagistas (57,2%), IMC < 30 (85,7%), com história prévia de dispepsia (78,6%). Sorologia para H. pylori foi positiva em 84,6% dos casos. O teste rápido da urease foi positivo em 78,6% das amostras do tubo digestivo e em 42,8% das amostras da cavidade peritoneal; 41,6% foram positivos em ambos os locais, 50% somente na cavidade digestiva e 8,4% exclusivamente na cavidade peritoneal. Dos 11 pacientes com sorologia positiva para H. pylori 100% apresentaram positividade em pelo menos um dos sítios pesquisados. CONCLUSÃO: Verificou-se que a incidência foi menor que a esperada. Há associação significativa entre a infecção pelo H. pylori e a ocorrência de perfuração. A presença deste patógeno pode ser avaliada tanto pela sorologia quanto pela realização do teste rápido da urease do fluido coletado na cavidade peritoneal e na luz gástrica/duodenal.
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Silva AAR, Bezerra MM, Chaves HV, Pereira KMA, Aguiar JA, Pinto VPT, Abbet C, Simões-Pires CA, Franco ES, Henriques AT, Hostettmann K, Maia MBS. Protective effect of Chresta martii extract against indomethacin-induced gastric lesions in mice. J Nat Med 2012; 67:143-51. [PMID: 22450730 DOI: 10.1007/s11418-012-0663-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Accepted: 03/12/2012] [Indexed: 10/28/2022]
Abstract
Chresta martii (Asteraceae) is a plant found in the Xingó region (semi-arid area) in Northeastearn Brazil, and is recognized by the local population as a traditional herb used to treat gastric diseases. This is the first report of the chemical composition, acute toxicity, and gastroprotective effect in mice of the hydroalcoholic extract (HAE) from the aerial parts (leaves and flowers) of Chresta martii. Animals received HAE doses from 10 to 2000 mg/kg, i.p. or 50 to 3000 mg/kg, p.o.) and were observed over 48 h for toxicity signs and mortality; sub-chronic toxicity was evaluated through 14 days treatment with once-daily HAE doses (400 mg/kg, p.o.). The gastroprotective effect of HAE was demonstrated on the indomethacin-induced gastric ulcer model after the administration of extracts. Data comparison of ulcer index averages between saline and HAE (100 or 400 mg/kg, p.o.) groups showed significant (P < 0.01) inhibition (71.73 and 76.72 %, respectively) of indomethacin-induced gastric lesions. Histological analyses showed significant (P < 0.05) inhibition of leukocyte migration in HAE-treated groups. A fingerprint of the HAE obtained by HPLC/UV/MS analysis showed major peaks characteristic of sesquiterpene lactones. Compound 1 was isolated and elucidated as a new natural product. Its capacity to prevent leukocyte chemotaxis was demonstrated in vitro, corroborating the pharmacological effects observed for C. martii HAE.
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Affiliation(s)
- A A R Silva
- Federal University of Ceará Brazil, Avenida Comandante Maurocélio Rocha Pontes, Sobral, Brazil.
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Abstract
The usefulness of the minilaparotomy approach for perforated duodenal ulcer repair was retrospectively evaluated in 37 patients (26 men; mean age, 56.5 years). Simple closure with an omental patch by minilaparotomy (skin incision, < or = 7 cm) was successful in 86.5% of the cases, with an operative mortality of 2.7%. Compared with the results in historic control patients who underwent conventional open surgery (n = 27), a shorter operative time (P < 0.01), lower frequency of analgesic use (P = 0.03), earlier passage of flatus (P < 0.01), and shorter hospital stay (P = 0.04) were obtained in the patients undergoing minilapartomoy. The postoperative morbidity was identical between the two groups (16.2% versus 33.3%, P = 0.40). On multivariate analysis, a large amount of intraabdominal fluid was the only significant risk factor for extension of the minilaparotomy wound (P = 0.012). The minilaparotomy approach appears to be a feasible, safe, and less invasive approach compared with the conventional open approach and could be a useful alternative to the laparoscopic approach in selected patients with perforated duodenal ulcer.
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Bonin EA, Moran E, Gostout CJ, McConico AL, Zielinski M, Bingener J. Natural orifice transluminal endoscopic surgery for patients with perforated peptic ulcer. Surg Endosc 2011; 26:1534-8. [PMID: 22179453 DOI: 10.1007/s00464-011-2063-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Accepted: 11/09/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Perforation accounts for 70% of deaths attributed to peptic ulcers. Laparoscopic repair is effective but infrequently used. Our aim was to assess how many patients with perforated peptic ulcer could be candidates for a transluminal endoscopic omental patch closure. METHODS This retrospective study reviewed patients with perforated peptic ulcer from 2005 to 2010. Demographics, ulcer characteristics, operative procedure, and outcomes were recorded. Candidates for endoscopic transluminal repair were defined as those having undergone omental patch closure of an ulcer of appropriate size and no contraindications to laparoscopy or endoscopy. RESULTS In the retrospective review, a total of 104 patients were identified; 62% female, mean age = 68 years, mean ASA of 3, and 63% medication-related ulcers. Fifty-nine (63%) had an omental patch (80% open), and 35 (37%) had other procedures. Ten patients had nonoperative management. Thirty-day mortality was 14% and 1 year mortality was 35%. Forty-nine patients (52%) were considered potential candidates for transluminal repair. CONCLUSION Sixty-three percent of our patients sustained a medication-related perforation with 1 year mortality of 35%. The majority of patients were treated using open omental patch repair. Transluminal endoscopic repair may provide an additional situation for a minimally invasive approach for a number of these patients.
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Affiliation(s)
- Eduardo A Bonin
- Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Abstract
The rate of elective surgery for peptic ulcer disease has been declining steadily over the past 3 decades. During this same period, the rate of emergency ulcer surgery rose by 44%. This means that the gastrointestinal surgeon is likely to be called on to manage the emergent complications of peptic ulcer disease without substantial experience in elective peptic ulcer disease surgery. The goal of this review is to familiarize surgeons with our evolving understanding of the pathogenesis, epidemiology, presentation, and management of peptic ulcer disease in the emergency setting, with a focus on peptic ulcer disease-associated bleeding and perforation.
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Affiliation(s)
- Constance W Lee
- Department of Surgery, University of Florida College of Medicine, 1600 Southwest Archer Road, PO Box 100109, Gainesville, FL 32610-0109, USA
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Kuwabara K, Matsuda S, Fushimi K, Ishikawa KB, Horiguchi H, Fujimori K. Reappraising the surgical approach on the perforated gastroduodenal ulcer: should gastric resection be abandoned? J Clin Med Res 2011; 3:213-22. [PMID: 22383908 PMCID: PMC3279482 DOI: 10.4021/jocmr608w] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2011] [Indexed: 12/12/2022] Open
Abstract
Background Advancements in medical care for peptic ulcer disease (PUD) have reduced the need for invasive surgical procedures such as gastric resection (GR). Community-based PUD studies from a large sampling of PUD patients designed to analyze hospital resource use and outcomes after different surgical procedures have been rare. We aimed to exhaustively reappraise the risk factors and patient demographics that affect PUD patient recoveries after GR compared to those after simple closure (SC). Methods We used a Japanese administrative database for 6 consecutive months each year between 2006 and 2010. The database included a total of 68,432 PUD patients; we analyzed 6,334 perforation cases and 3,148 cases of patients who underwent GR or SC. Study variables were demographics, comorbidities, characteristics of PUD, and operative day. Study outcomes that were analyzed included mortality, postoperative complications, ventilation administration, postoperative blood transfusions, length of stay, total charges, operating room (OR) time, and the postoperative fasting period (defined as the day of surgery to the day oral food intake was resumed.) To reduce selection bias in study procedures and to control the variation in hospital practice, a propensity score (PS) matching cohort analysis and a mixed linear regression model were used to assess the effects of GR on the outcomes. Results In 699 hospitals, 322 GRs and 2,826 SCs were observed. Younger age, duodenal ulcers, preexisting anemia and an operative day no more than 24hours were significant associated with the choice of SCs. No significant differences were observed in study outcomes after either GR or SC; more postoperative blood transfusions and longer OR times but shorter postoperative fasting periods were observed after GR. Longer OR times, ventilation and postoperative blood transfusion were significantly associated with mortality. Not GR but longer OR times use of ventilation and complications were the most significant indicators of increased resource use. Conclusions There were no major significant differences in GR when compared to SC with regards to patient recoveries. Surgeons should obtain the skills and establish strategies to optimize either type of surgical procedure including minimizing OR time and establishing the best perioperative critical care. Keywords Peptic ulcer perforation; Simple closure; Gastric resection; Outcome; Resource use
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Affiliation(s)
- Kazuaki Kuwabara
- Kyushu University, Graduate School of Medical Sciences, Department of Health Care Administration and Management, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
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Changes in the localization of perforated peptic ulcer and its relation to gender and age of the patients throughout the last 45 years. World J Surg 2011; 35:811-6. [PMID: 21267567 PMCID: PMC3047674 DOI: 10.1007/s00268-010-0917-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background Throughout recent decades there has been noticeable change in the incidence of peptic ulcer disease and its complications. The aim of the present study was to determine the character of changes over the last 45 years in the localization of perforation, in patient age, and in patient gender. Methods A group of 881 patients admitted to the Second Department of General Surgery in Krakow, Poland, from 1962 to 2006 were included in the study and constituted the material for the analysis. The study was divided into three time periods (1962–1976, 1977–1991, and 1992–2006) to allow statistical analysis of trends. Results The general incidence of perforations of peptic ulcer did not show changes; however, the percentage of women with perforated duodenal ulcer markedly increased. Patients with perforated stomach ulcer—regardless of gender—and females suffering from perforated duodenal ulcer were, on the average, about 10 years older than males with perforated duodenal ulcers. The mean age of male and female patients with perforated duodenal ulcer over the last 45 years showed an insignificant upward trend. Conclusions (1) The percentage of women with perforated duodenal ulcer continuously and statistically significantly rose. (2) Men with perforated duodenal ulcer were significantly younger than other patients. (3) The mean ages of male and female patients with perforated duodenal ulcer over the last 45 years showed an insignificant upward trend.
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Fukami N, Anderson MA, Khan K, Harrison ME, Appalaneni V, Ben-Menachem T, Decker GA, Fanelli RD, Fisher L, Ikenberry SO, Jain R, Jue TL, Krinsky ML, Maple JT, Sharaf RN, Dominitz JA. The role of endoscopy in gastroduodenal obstruction and gastroparesis. Gastrointest Endosc 2011; 74:13-21. [PMID: 21704805 DOI: 10.1016/j.gie.2010.12.003] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2010] [Accepted: 12/03/2010] [Indexed: 02/08/2023]
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Lopez N, Kobayashi L, Coimbra R. A Comprehensive review of abdominal infections. World J Emerg Surg 2011; 6:7. [PMID: 21345232 PMCID: PMC3049134 DOI: 10.1186/1749-7922-6-7] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Accepted: 02/23/2011] [Indexed: 12/11/2022] Open
Affiliation(s)
- Nicole Lopez
- Assistant Professor of Surgery, University of California, San Diego, 200 W, Arbor Dr, #8896, San Diego, CA 92103-8896, USA.
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Trends in diagnosis and surgical management of patients with perforated peptic ulcer. J Gastrointest Surg 2011; 15:1329-35. [PMID: 21567292 PMCID: PMC3145078 DOI: 10.1007/s11605-011-1482-1] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Accepted: 02/27/2011] [Indexed: 02/07/2023]
Abstract
INTRODUCTION While the laparoscopic treatment of perforated peptic ulcers (PPU) has been shown to be feasible and safe, its implementation into routine clinical practice has been slow. Only a few studies have evaluated its overall utility. The aim of this study was to investigate changes in surgical management of PPU and associated outcomes. MATERIAL AND METHODS The study was a retrospective, single institution, population-based review of all patients undergoing surgery for PPU between 2003 and 2009. Patient demographics, diagnostic evaluation, management, and outcomes were evaluated. RESULTS Included were 114 patients with a median age of 67 years (range, 20-100). Women comprised 59% and were older (p < 0.001), had more comorbidities (p = 0.002), and had a higher Boey risk score (p = 0.036) compared to men. Perforation location was gastric/pyloric in 72% and duodenal in 28% of patients. Pneumoperitoneum was diagnosed by plain abdominal x-ray in 30 of 41 patients (75%) and by abdominal computerized tomography (CT) in 76 of 77 patients (98%; p < 0.001).Laparoscopic treatment was initiated in 48 patients (42%) and completed in 36 patients (75% of attempted cases). Laparoscopic treatment rate increased from 7% to 46% during the study period (p = 0.02). Median operation time was shorter in patients treated via laparotomy (70 min) compared to laparoscopy (82 min) and those converted from laparoscopy to laparotomy (105 min; p = 0.017). Postoperative complications occurred in 56 patients (49%). Overall 30-day postoperative mortality was 16%. No statistically significant differences were found in morbidity and mortality between open versus laparoscopic repair. CONCLUSION This study demonstrates an increased use of CT as the primary diagnostic tool for PPU and of laparoscopic repair in its surgical treatment. These changes in management are not associated with altered outcomes.
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Kim JJ, Kim N, Lee BH, Kang JM, Seo P, Lim MK, Kwon JH, Song BJ, Lee JW, Lee SH, Park YS, Hwang JH, Kim JW, Jeong SH, Lee DH, Jung HC, Song IS. [Risk factors for development and recurrence of peptic ulcer disease]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2010; 56:220-8. [PMID: 20962557 DOI: 10.4166/kjg.2010.56.4.220] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND/AIMS Peptic ulcer disease (PUD) is one of the common gastrointestinal diseases, and its medical management has been developed so much that the incidence of its serious complications, such as bleeding and perforation, are declining significantly. Its prevalence in Korea is not definitely decreased, probably due to increasing proportion of elderly patients and their rising usage of non-steroidal anti-inflammatory drugs (NSAIDs) and aspirin. This study was conducted to identify the risk factors for development and recurrence of peptic ulcer disease in Korea. METHODS From 2003 to 2008, upper gastrointestinal endoscopy and detailed personal questionnaires were performed for patients who visited Department of Gastroenterology at Seoul National University Bundang Hospital. In total, 475 PUD patients and 335 non-ulcer dyspepsia patients were included. The results of questionnaires and repeated upper gastrointestinal endoscopy at initial diagnosis time and follow-up periods were analyzed. RESULTS Multivariable analysis showed that male, H. pylori infection, NSAIDs use and smoking were risk factors for the development of PUD. The use of proton pump inhibitors (PPIs) and H2 receptor antagonists has significantly reduced the risk of PUD in patients who had taken NSAIDs and/or aspirin. H. pylori infection was found as the only risk factor for the recurrence of PUD. CONCLUSIONS For the old patients who are taking drugs, such as NSAIDs and aspirin, concomitant use of PPIs or H2 receptor antagonists should be considered to protect from the development of PUD. H. pylori eradication has been confirmed again to be essential for the treatment of PUD patients infected with H. pylori.
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Affiliation(s)
- Jin Joo Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Smith BR, Wilson SE. Impact of Nonresective Operations for Complicated Peptic Ulcer Disease in a High-Risk Population. Am Surg 2010. [DOI: 10.1177/000313481007601028] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Over the past two decades, surgery for complicated peptic ulcer disease has evolved to a “less-is-more” approach due predominately to improved medical therapy. This study sought to determine whether a nonresective operative strategy has been an effective and prudent approach. A 20-year retrospective evaluation was conducted to compare outcomes of patients from the first decade (1990-1999) with those from the more recent decade (2000-2009). In all, 50 patients underwent surgery for complications of peptic ulcer disease, 36 in the early period and 14 in the later period, with 94 per cent being urgent or emergent. Acid-reducing procedures (vagotomy) decreased significantly from 29 to 7 over the two periods ( P = 0.04), as did gastric resections from 23 to 3 ( P = 0.01). The prevalence of H. pylori and use of NSAIDs both increased from 28 per cent to 36 per cent and 31 per cent to 43 per cent, respectively. Postoperative mortality remained unchanged, 22 per cent vs 7 per cent ( P = 0.41) over the two periods. Resections and definitive acid-reducing procedures continue to decline with no increase in adverse outcomes. This more moderate operative approach to complicated peptic ulcer surgery is appropriate given the trend towards lower mortality and improved medical treatment. In our high-risk veteran population, overall perioperative mortality, length of stay, and reoperations have been reduced.
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Affiliation(s)
- Brian R. Smith
- Departments of Surgery, University of California Irvine Medical Center, and VA Long Beach Healthcare System, Long Beach, California
| | - Samuel Eric Wilson
- Departments of Surgery, University of California Irvine Medical Center, and VA Long Beach Healthcare System, Long Beach, California
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Abstract
PURPOSE OF REVIEW To review recent literature (2009-2010) on acute nonvariceal upper gastrointestinal hemorrhage. RECENT FINDINGS There is a decreasing trend in the incidence and hospitalization for acute nonvariceal upper gastrointestinal hemorrhage worldwide, with significant improvement in rebleeding and mortality. One study showed that Glasgow-Blatchford score was superior to Rockall score in predicting the need of intervention or death. None of those categorized as low risk required any intervention. Another database research from United States demonstrated that those managed as outpatients upon clinician decision had 6.3% mortality. Recent meta-analysis demonstrated that epinephrine injection should be used in combination with one other modality for hemostasis in bleeding ulcers, whereas thermal, sclerosant, clips and thrombin/fibrin glue appeared to be effective alone. Despite meta-analysis showing that second look endoscopy with thermal therapy reduced rebleeding, international consensus from experts recommended proton pump inhibitor infusion as the preferred strategy to prevent ulcer rebleeding. SUMMARY Epidemiological studies worldwide confirmed reduction in the incidence and improvement in clinical outcomes for acute nonvariceal upper gastrointestinal bleeding. Patients categorized as low risk may be managed as outpatients. Endoscopic therapy remained the mainstay of ulcer hemostasis and high dose proton pump inhibitor infusion should be employed to prevent rebleeding.
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