Perforated gastric ulcer

Perforated gastric ulcer after unhealthy decisions in a patient with an intragastric balloon, a hangover you will regret

BACKGROUND

Perforated gastric ulcers are life-threatening surgical emergencies that need early diagnosis and treatment to overcome severe complications. With the rise of obesity in recent years, intragastric balloons have arisen as a "safe" strategy; however, in medicine, no treatment is risk-free. Nausea, pain, vomiting, and more severe complications like perforation, ulceration, and death can occur.

CASE PRESENTATION

We present the case of a 28-year-old man with obesity; treatment with an intragastric balloon was initiated with good results at the beginning of his treatment. However, he neglected his treatment over time and made unhealthy choices, leading to a severe complication. However, thanks to prompt surgical treatment, he made a full recovery.

COMPLICATIONS

Gastric perforation following an intragastric balloon is a severe and potentially life-threatening complication that an experienced multidisciplinary team must treat promptly and, more importantly, prevent.

Risk Factors for Mortality in Emergently Admitted Patients with Acute Gastric Ulcer: An Analysis of 15,538 Patients in National Inpatient Sample, 2005-2014

Background: Patients admitted emergently with a primary diagnosis of acute gastric ulcer have significant complications including morbidity and mortality. The objective of this study was to assess the risk factors of mortality including the role of surgery in gastric ulcers. Methods: Adult (18−64-year-old) and elderly (≥65-year-old) patients admitted emergently with hemorrhagic and/or perforated gastric ulcers, were analyzed using the National Inpatient Sample database, 2005−2014. Demographics, various clinical data, and associated comorbidities were collected. A stratified analysis was combined with a multivariable logistic regression model to assess predictors of mortality. Results: Our study analyzed a total of 15,538 patients, split independently into two age groups: 6338 adult patients and 9200 elderly patients. The mean age (SD) was 50.42 (10.65) in adult males vs. 51.10 (10.35) in adult females (p < 0.05). The mean age (SD) was 76.72 (7.50) in elderly males vs. 79.03 (7.80) in elderly females (p < 0.001). The percentage of total deceased adults was 1.9% and the percentage of total deceased elderly was 3.7%, a difference by a factor of 1.94. Out of 3283 adult patients who underwent surgery, 32.1% had perforated non-hemorrhagic ulcers vs. 1.8% in the non-surgical counterparts (p < 0.001). In the 4181 elderly surgical patients, 18.1% had perforated non-hemorrhagic ulcers vs. 1.2% in the non-surgical counterparts (p < 0.001). In adult patients managed surgically, 2.6% were deceased, while in elderly patients managed surgically, 5.5% were deceased. The mortality of non-surgical counterparts in both age groups were lower (p < 0.001). The multivariable logistic regression model for adult patients electing surgery found delayed surgery, frailty, and the presence of perforations to be the main risk factors for mortality. In the regression model for elderly surgical patients, delayed surgery, frailty, presence of perforations, the male sex, and age were the main risk factors for mortality. In contrast, the regression model for adult patients with no surgery found hospital length of stay to be the main risk factor for mortality, whereas invasive diagnostic procedures were protective. In elderly non-surgical patients, hospital length of stay, presence of perforations, age, and frailty were the main risk factors for mortality, while invasive diagnostic procedures were protective. The following comorbidities were associated with gastric ulcers: alcohol abuse, deficiency anemias, chronic blood loss, chronic heart failure, chronic pulmonary disease, hypertension, fluid/electrolyte disorders, uncomplicated diabetes, and renal failure. Conclusions: The odds of mortality in emergently admitted geriatric patients with acute gastric ulcer was two times that in adult patients. Surgery was a protective factor for patients admitted emergently with gastric perforated non-hemorrhagic ulcers.

Outcomes of omental patch repair in large or giant perforated peptic ulcer are comparable to gastrectomy

PURPOSE

Perforated peptic ulcer (PPU) complicates 2 to 10% of patients with peptic ulcer disease and has mortality risk of up to 20%. Omental patch repair is the mainstay of surgical management and gastric resectional procedures are advocated for a large/giant ulcer or suspected malignancy. Emergency gastrectomy is associated with increased morbidity and mortality. The aim of this study is to compare the outcomes of omental patch repair with gastrectomy in patients with large PPU (≥ 20 mm).

METHODS

A retrospective review of all PPU patients who underwent surgery from January 2008 to December 2014 was done. Patients with PPU < 20 mm were excluded. Patient demographics and perioperative data were recorded. Length of hospital stay, post-operative complications, need for intensive care unit admission and all-cause mortality are reported.

RESULTS

110 patients with a median age of 69.1 (range 28-90) years had PPU ≥ 20 mm. 42 (38.2%) patients presented within 24 h from the onset of abdominal pain. The median American Society of Anaesthesiology score was 3 (range 1-4). 52 patients had omental patch repair and 58 patients had gastrectomy. The overall incidence of intra-abdominal collection, post-operative leakage, re-operation and all-cause mortality was 16.4%, 11.8%, 6.4% and 19.1%, respectively. No difference in post-operative outcomes between the two groups was detected: intra-abdominal collection (p = 0.793), post-operative leakage (p = 0.813), re-operation (p = 0.809) and all-cause mortality (p = 0.736).

CONCLUSION

Omental patch repair confers similar perioperative outcomes as compared to gastrectomy in patients with large PPU.

A pilot study to evaluate the effectiveness and safety of urgent endoscopy for gastroduodenal perforation

BACKGROUND

Gastroduodenal perforation is potentially life threatening and requires early diagnosis and treatment. Urgent endoscopy facilitates detecting bleeding sites and achieving hemostasis. However, there is no consensus on urgent endoscopy for gastroduodenal perforation in Japan.

METHODS

We evaluated the effectiveness and safety of urgent endoscopy for gastroduodenal perforation. We compared clinical characteristics between 140 patients who underwent urgent endoscopy (urgent endoscopy group) and 16 patients did not (no urgent endoscopy group) at Hiroshima City Asa Citizens Hospital between December 2005 and December 2018.

RESULTS

Endoscopic diagnosis was possible in all urgent endoscopy group. In contrast, correct diagnosis of the perforation site was made on CT in 99 cases (63%). Furthermore, the proportion of cases with correct diagnosis of the perforation site by CT findings differed significantly between the urgent endoscopy group and the no urgent endoscopy group (66% vs. 38%, p < 0.05). No complications of urgent endoscopy were observed. Primary perforation site was gastric in 42 cases and duodenal in 114. In the 42 gastric perforation cases, 12 gastric perforation cases (29%) were managed conservatively, successfully in 9 (75%); 2 cases (17%) required delayed emergency surgery for worsening peritonitis. In the 114 duodenal perforation cases (duodenal ulcer in all cases), 52 cases (46%) were managed conservatively, successfully in 48 (92%); 3 cases (6%) required delayed emergency surgery for worsening peritonitis. A significantly higher proportion of gastric perforation cases than duodenal perforation cases required surgical treatment (76% vs. 57%, p < 0.05). Multivariate analysis revealed localized abdominal pain (no peritonism) (OR 0.25; 95% CI 0.08-0.75; p < 0.01) and perforation diameter ≤ 5 mm (OR 0.13; 95% CI 0.04-0.36; p < 0.01) as significant independent clinical factors for successful conservative management of duodenal ulcer perforation.

CONCLUSIONS

Urgent endoscopy in gastroduodenal perforation enabled primary diagnosis and perforation site identification, and facilitated deciding the management strategy.

Perforated peptic ulcer - an update

Peptic ulcer disease (PUD) affects 4 million people worldwide annually. The incidence of PUD has been estimated at around 1.5% to 3%. Perforated peptic ulcer (PPU) is a serious complication of PUD and patients with PPU often present with acute abdomen that carries high risk for morbidity and mortality. The lifetime prevalence of perforation in patients with PUD is about 5%. PPU carries a mortality ranging from 1.3% to 20%. Thirty-day mortality rate reaching 20% and 90-d mortality rate of up to 30% have been reported. In this review we have summarized the current evidence on PPU to update readers. This literature review includes the most updated information such as common causes, clinical features, diagnostic methods, non-operative and operative management, post-operative complications and different scoring systems of PPU. With the advancement of medical technology, PUD can now be treated with medications instead of elective surgery. The classic triad of sudden onset of abdominal pain, tachycardia and abdominal rigidity is the hallmark of PPU. Erect chest radiograph may miss 15% of cases with air under the diaphragm in patients with bowel perforation. Early diagnosis, prompt resuscitation and urgent surgical intervention are essential to improve outcomes. Exploratory laparotomy and omental patch repair remains the gold standard. Laparoscopic surgery should be considered when expertise is available. Gastrectomy is recommended in patients with large or malignant ulcer.

Treatment for perforated gastric ulcer: a multi-institutional retrospective review

BACKGROUND

The optimal treatment for patients with perforated gastric ulcer (PGU) remains controversial. This study therefore investigated the treatment status for this disease in clinical practice.

METHODS

We retrospectively reviewed 183 patients with PGU from 1998 to 2007 across 15 institutions, and analyzed patient characteristics and short- and long-term outcomes according to treatments received.

RESULTS

Of the 183 patients, 57 who were treated conservatively had less abdominal tenderness, lower levels of serum C-reactive protein, and shorter time to presentation than the 126 patients who underwent emergency surgery. There was no significant difference in baseline characteristics between the 41 successful patients and 16 failed patients in the conservative treatment group; however, the latter had a longer average hospital stay. Eighty-three of the emergency surgery patients who underwent gastrectomy had longer surgical times, greater blood loss, and shorter time to resumption of diet than the 57 patients undergoing stomach-preserving surgery; however, there was no significant difference in postoperative complications and hospital stay between these groups. Of 91 patients who received stomach-preserving treatment, only three had treatment failure in the long-term follow-up period.

CONCLUSION

Strictly selected patients should be initially considered for conservative treatment. The short-term outcomes of stomach-preserving surgery are comparable to gastrectomy; however, further evaluation of the long-term outcomes of stomach-preserving treatment is required.

Early Outcome Following Emergency Gastrectomy

Introduction: Emergency gastrectomy has been shown to be associated with poor morbidity and mortality rates. The aims of this study were to review the outcomes of emergency gastrectomy in our institution and to determine any factors that were associated with worse perioperative outcomes. Materials and Methods: A retrospective review of all patients who underwent emergency gastrectomy for various indications from October 2003 to April 2009 was performed. All the complications were graded according to the classification proposed by Clavien and group. Results: Eighty-five patients, median age 70 (range, 27 to 90 years), underwent emergency gastrectomy. The indications for the surgery included perforation, bleeding and obstruction in 45 (52.9%), 32 (37.6%) and 8 (9.4%) patients, respectively. The majority of the patients (n = 46, 54.1%) had an American Society of Anesthesiologists (ASA) score of 3. Partial or subtotal, and total gastrectomy were performed in 75 (88.2%) and 10 (11.8%) patients, respectively. Malignancy was the underlying pathology in 33 (38.8%) patients. The perioperative mortality rate was 21.2% (n = 18) with another 27 (31.8%) patients having severe complications. Twelve (14.1%) patients had a duodenal stump leak. The independent factors predicting worse perioperative complications included high ASA score and in perforation cases. Other factors such as malignancy, age and extent of surgery were not significantly related. The presence of a duodenal stump leak was the only independent factor predicting mortality. Conclusion: Emergency gastrectomy is associated with dismal morbidity and mortality rates. Patients with high ASA scores and perforations fared worse, and duodenal stump leak increases the risk of mortality. Key words: Emergency, Gastrectomy, Surgery, Treatment outcome

Preoperative prognostic factors for mortality in peptic ulcer perforation: a systematic review

OBJECTIVE

Mortality and morbidity following perforated peptic ulcer (PPU) is substantial and probably related to the development of sepsis. During the last three decades a large number of preoperative prognostic factors in patients with PPU have been examined. The aim of this systematic review was to summarize available evidence on these prognostic factors.

MATERIAL AND METHODS

MEDLINE (January 1966 to June 2009), EMBASE (January 1980 to June 2009), and the Cochrane Library (Issue 3, 2009) were screened for studies reporting preoperative prognostic factors for mortality in patients with PPU. The methodological quality of the included studies was assessed. Summary relative risks with 95% confidence intervals for the identified prognostic factors were calculated and presented as Forest plots.

RESULTS

Fifty prognostic studies with 37 prognostic factors comprising a total of 29,782 patients were included in the review. The overall methodological quality was acceptable, yet only two-thirds of the studies provided confounder adjusted estimates. The studies provided strong evidence for an association of older age, comorbidity, and use of NSAIDs or steroids with mortality. Shock upon admission, preoperative metabolic acidosis, tachycardia, acute renal failure, low serum albumin level, high American Society of Anaesthesiologists score, and preoperative delay >24 h were associated with poor prognosis.

CONCLUSIONS

In patients with PPU, a number of negative prognostic factors can be identified prior to surgery, and many of these seem to be related to presence of the sepsis syndrome.

Risk factors related to operative mortality and morbidity in patients undergoing emergency gastrectomy

BACKGROUND

Emergency gastric resection for complicated peptic ulcer and gastric cancer is a major challenge for general surgeons. This study aimed to evaluate the results of emergency gastrectomy and to examine the factors that predict the operative outcome.

METHODS

A total of 82 consecutive patients who underwent emergency gastrectomy were studied. The following variables were assessed: pathology, mortality rate, morbidity, reasons for reoperation and factors related to the outcome.

RESULTS

There were 64 men and 18 women with a median age of 62 (range 30-90) years. The indications were bleeding and perforated gastric or duodenal ulcers in 45 and 20 patients respectively, and bleeding and perforated gastric tumours in seven and ten patients respectively. The overall mortality rate was 17 per cent (n = 14). The complication rate was 63 per cent and 11 patients (13 per cent) required reoperation. By multivariate analysis, age greater than 65 years and blood haemoglobin level less than 10 g/dl on admission were predictive of complications after emergency gastrectomy. Postoperative pulmonary and cardiac complications and hypotension on admission were independent risk factors associated with operative death.

CONCLUSION

Age more than 65 years, haemoglobin level less than 10 g/dl and hypotension on admission were associated with a poor outcome after emergency gastrectomy. The operative result was not affected by the underlying gastric pathology.

Effect of a pneumoperitoneum on the extent and severity of peritonitis induced by gastric ulcer perforation in the rat

Laparoscopic surgical repair of perforated gastroduodenal ulcer is technically feasible. To study the effect of a pneumoperitoneum on the extent and severity of peritonitis this animal study was devised. In rats gastric ulceration was induced by instillation of ethanol (50%, 2 ml) and followed by gastrotomy to simulate perforation. Animals were randomly allocated to pneumoperitoneum (PP) and control groups. In PP groups CO2 was insufflated intraperitoneally 6, 9, 12, and 24 h after gastrotomy. In controls the abdomen was only punctured. Animals were sacrificed 5 h after the end of PP or abdominal puncture. Blood cultures and intraabdominal swabs were assessed. A peritonitis severity score (PSS) based on histologies from peritoneum, liver, left kidney, spleen, and first jejunal loop was estimated. Six and 9 h after gastrotomy no significant differences between the PP and control groups were observed; 12 h after gastrotomy cultures of blood samples and abdominal swabs were positive in 67% and 75% in the PP group compared to 42% (P < 0.05), and 42% (P < 0.05) in controls. The mean PSS was 20.8 (standard deviation [SD] 2.2) in the PP group compared to 11.3 (1.5) (P < 0.01) in controls; 24 h after gastrotomy cultures of blood samples and abdominal swabs were positive in 83% and 100% in the PP group compared to 42% (P < 0.05) and 50% (P < 0.01) in controls. The mean PSS was 22.1 (1.5) in the PP group compared to 11.8 (2.4) (P < 0.01) in the controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Adverse effects of delayed treatment for perforated peptic ulcer

OBJECTIVE

The authors assessed the consequences of delayed treatment for ulcer perforation with regard to short-term and long-term survival, complication rates, and length of hospital stay.

SUMMARY BACKGROUND DATA

Important adverse effects of delayed treatment have not been studied previously. Conflicting results have been given with regard to short-term survival.

METHODS

One thousand two hundred ninety-two patients operated on for perforated peptic ulcer in the Bergen area between 1935 and 1990 were studied. The effect of delay on postoperative lethality and complications adjusted for age, sex, ulcer site, and year of perforation was analyzed by stepwise logistic regression. The effect of delay on duration of hospital stay adjusted for potential confounding factors was analyzed by Cox proportional hazards regression. Observed survival was estimated by the Kaplan-Meier method, and expected survival was calculated from population mortality data.

RESULTS

Adverse effects increased markedly when delay exceeded 12 hours. Delay of more than 24 hours increased lethality sevenfold to eightfold, complication rate to threefold, and length of hospital stay to twofold, compared with delay of 6 hours or less. The reduced long-term survival for patients treated more than 12 hours after perforation could be attributed entirely to high postoperative mortality.

CONCLUSIONS

Delayed treatment after peptic ulcer perforation reduced survival, increased complication rates, and caused prolonged hospital stay. To improve outcome after ulcer perforation, an effort should be made to keep delay at less 12 hours, particularly in elderly patients.

Surgical treatment of peptic ulcer disease

Elective surgery for peptic ulcer disease has diminished significantly over the past 15 years. However, emergency surgery has not shown a decline. Some series have even reported an increase in hospitalizations and operations for hemorrhage. The appropriate surgical procedure for peptic ulcer disease must be tailored to the specific needs of the individual patient. During emergency operations for hemorrhage from duodenal ulcer, we recommend suture ligature of the bleeding vessel and vagotomy-pyloroplasty for high-risk patients, or vagotomy-antrectomy for the lower-risk patient. Bleeding gastric ulcers should be resected, if possible. For massive hemorrhage from stress ulceration requiring surgery, near-total or total gastrectomy should be performed. Perforated duodenal ulcers are best managed by closure and a definitive ulcer operation, such as vagotomy-pyloroplasty. Perforated gastric ulcers are best excised but may be simply closed if conditions do not favor resection. In these situations, biopsy should be performed. We recommend truncal vagotomy-antrectomy for patients presenting with obstruction. Vagotomy (truncal or proximal gastric) with drainage is an acceptable alternative in this situation. For patients with intractable ulcer disease or for those who are noncompliant, proximal gastric vagotomy is the preferred operation. However, other operations may need to be considered, depending on the specific situation. Recurrent ulceration needs appropriate work-up to determine the possible cause. Although patients with ulcer recurrence initially may be placed on medical treatment, about 50% will require reoperation. The most effective procedure for peptic ulcer disease is truncal vagotomy-antrectomy, which has a recurrence rate of less than 1%. The procedure with the least morbidity and the fewest undesirable side effects is proximal gastric vagotomy. Ulcer recurrence after proximal gastric vagotomy or truncal vagotomy-pyloroplasty is in the range of 10% to 15%.