Helicobacter pylori infection in perforated peptic ulcer disease

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.

The Association Between Helicobacter Pylori and Perforated Gastroduodenal Ulcer

Background Although the role of Helicobacter pylori (H. pylori) is well known in peptic ulcer disease (PUD) etiology, its role in perforated peptic ulcer (PPU) is not well established. This study aimed to assess the role of H. pylori infection in patients with PPU and to compare it with its prevalence in patients with PUD. Methodology This prospective analytical study was conducted for two years. The study patients were classified into two groups: group I consisted of patients (n = 48) operated for PPU and group II were patients (n = 48) with PUD diagnosed by endoscopy. The study excluded patients with any previous anti-H. pylori treatment, gastric malignancy, conservative management of sealed PPU, and those with a diameter of perforation less than the diameter of endoscopic biopsy forceps. Blood samples were taken for H. pylori serology IgG (ELISA) test. The mucosal biopsy samples from both the groups were tested with a rapid urease test and modified Giemsa stain examination to detect H. pylori. Results The prevalence of H. pylori infection were significantly less in patients with PPU than with PUD: by rapid urease: 12.5% vs. 31.2%, p: 0.002; modified Giemsa stain: 10.4% vs. 31.2%, p: 0.012; and IgG serology: 50 % vs. 68.7%, p: 0.012, respectively. Alcohol and tobacco were significant risk factors (p: 0.002 vs. p: 0.002 respectively). However, nonsteroidal anti-inflammatory drugs (NSAIDs) use was not a significant risk factor for PPU (p: 0.083). Conclusion H. pylori infection was not significantly associated with PPU. Some other factors like alcohol intake and tobacco were also involved in perforation. We can conclude that H. pylori infection is not a risk factor for PPU.

High altitude area - A risk factor for gastric perforation? : A case series

INTRODUCTION

This is an original case series on soldiers evacuated from HAA(High Altitude Area) over last one year(Sept 2017-Aug 2018), of which 100% cases were found to have gastric antrum perforation. This is a deviation from the usual trend that is being noted in Indian subcontinent where duodenal perforations are commonest.

DISCUSSION

High altitude associated dyspepsia is a common phenomenon and some studies done in high altitude population have recorded high incidence of antral gastritis and mucosal atrophy on histo-pathological evaluation. This is also supported by high incidence of H. pylori infection. The presence of atrophic gastric mucosa associated with antral gastritis, when exposed to hypobaric hypoxemic conditions faced by soldiers posted to heights above 15,000 ft, may leads to increased intra-luminal pressure and ischemia which probably predisposes individuals for gastric antrum perforations.

CONCLUSION

This is a relatively untouched topic as we have not found studies onhigh altitude related gastric perforations and probably this is the first case series of its kind. The acknowledgement of this phenomenon may pave way for further studies for defining the role of high altitude in gastric perforations.

Perforated Peptic Ulcer Repair: Factors Predicting Conversion in Laparoscopy and Postoperative Septic Complications

OBJECTIVE

The surgical treatment for perforated peptic ulcers can be safely performed laparoscopically. The aim of the study was to define simple predictive factors for conversion and septic complications.

METHODS

This retrospective case-control study analyzed patients treated with either laparoscopic surgery or laparotomy for perforated peptic ulcers.

RESULTS

A total of 71 patients were analyzed. Laparoscopically operated patients had a shorter hospital stay (13.7 vs. 15.1 days). In an intention-to-treat analysis, patients with conversion to open surgery (analyzed as subgroup from laparoscopic approach group) showed no prolonged hospital stay (15.3 days) compared to patients with a primary open approach. Complication and mortality rates were not different between the groups. The statistical analysis identified four intraoperative risk factors for conversion: Mannheim peritonitis index (MPI) > 21 (p = 0.02), generalized peritonitis (p = 0.04), adhesions, and perforations located in a region other than the duodenal anterior wall. We found seven predictive factors for septic complications: age >70 (p = 0.02), cardiopulmonary disease (p = 0.04), ASA > 3 (p = 0.002), CRP > 100 (p = 0.005), duration of symptoms >24 h (p = 0.02), MPI > 21(p = 0.008), and generalized peritonitis (p = 0.02).

CONCLUSION

Our data suggest that a primary laparoscopic approach has no disadvantages. Factors necessitating conversions emerged during the procedure inhibiting a preoperative selection. Factors suggesting imminent septic complications can be assessed preoperatively. An assessment of the proposed parameters may help optimize the management of possible septic complications.

Laparoscopic versus Open Omental Patch Repair for Early Presentation of Perforated Peptic Ulcer: Matched Retrospective Cohort Study

Introduction. The aim of this study was to compare the outcomes between laparoscopic and open omental patch repair (LOPR versus OR) in patients with similar presentation of perforated peptic ulcer (PPU). The secondary aim was to evaluate the outcomes according to the severity of peritonitis. Methods. All patients who underwent omental patch repair at two university-affiliated institutes between January 2010 and December 2014 were reviewed. Matched cohort between LOPR and OR groups was achieved by only including patients that had ulcer perforation <2 cm in size and symptoms occurring <48 hours. Outcome measures were defined in accordance with length of stay (LOS), postoperative complications, and mortality. Results. 148 patients met the predefined inclusion criteria with LOPR performed in 40 patients. Outcome measures consistently support laparoscopic approach but only length of hospital stay (LOS) achieved statistical significance (LOPR 4 days versus OR 5 days, p < 0.01). In a subgroup analysis of patients with MPI score >21, LOPR is also shown to benefit, particularly resulting in significant shorter LOS (4 days versus 11 days, p < 0.01). Conclusion. LOPR offers improved short-term outcomes in patients who present within 48 hours and with perforation size <2 cm. LOPR also proved to be more beneficial in high MPI cases.

Use of nicorandil is Associated with Increased Risk for Gastrointestinal Ulceration and Perforation- A Nationally Representative Population-based study

Nicorandil is a vasodilatory drug used to relieve angina symptoms. Several healthcare products regulatory agencies have issued a warning associating the use of nicorandil and gastrointestinal (GI) ulceration. We aimed to evaluate the association between use of nicorandil and GI ulceration/perforation. A population-based cohort study involving 1 million randomly sampled participants in Taiwan’s National Health Insurance Research Database was carried out. We estimated the association between use of nicorandil and GI ulceration/perforation by a Cox proportional hazards regression model. A nicorandil-specific propensity score (PS) was also created for adjustment of 75 covariates and matching. 25.8% (183/710) of nicorandil-treated patients developed new GI ulcer events and 1.6% (20/1254) developed new GI perforation events in the three-year follow-up period, as compared to 9.3% (61,281/659,081) and 0.3% (2,488/770,537) in the general population comparator cohort. Patients treated with nicorandil were at significantly increased risk of GI ulcer (PS adjusted hazard ratio 1.43, 95% CI, 1.23 to 1.65, 6848 excess cases per 100,000 person years) or GI perforation (aHR 1.60, 95% CI 1.02–2.51, 315 excess cases per 100,000 person years) compared with the nicorandil unexposed population. Our finding may warn the clinicians to weigh the overall risk-benefit balance of nicorandil treatment in patients.

Laparoscopic versus open repair of perforated gastroduodenal ulcer: a National Surgical Quality Improvement Program analysis

BACKGROUND

Surgical repair of perforated gastroduodenal ulcers remains a common indication for emergent surgery. The aim of this study was to test the hypothesis that the laparoscopic approach (LA) would be associated with reduced length of stay compared to the open approach.

METHODS

Patients with acute, perforated gastroduodenal ulcer were identified in the National Surgical Quality Improvement Program database, of whom 50 had the LA. One-to-one case/control matching on the basis of age, American Society of Anesthesiologists class, gender, and cardiac disease was evaluated for outcome analysis.

RESULTS

After matching, the 2 groups had similar characteristics. The rates of wound complications, organ space infections, prolonged ventilation, postoperative sepsis, return to the operating room, and mortality tended to be lower for the LA, although not significantly. Length of hospital stay was, however, significantly shorter for the LA by an average of 5.4 days.

CONCLUSIONS

The LA appears to be safe in mild to moderately ill patients with perforated peptic ulcer disease and is associated with reduced use of hospital resources.

Standard triple versus levofloxacin based regimen for eradication of Helicobacter pylori

AIM

To compare the eradication rates for Helicobacter pylori (H. pylori) and ulcer recurrence of standard triple therapy (STT) and levofloxacin based therapy (LBT).

METHODS

Seventy-four patients with perforated duodenal ulcer treated with simple closure and found to be H. pylori infected on 3 mo follow up were randomized to receive either the STT group comprising of amoxicillin 1 g bid, clarithromycin 500 mg bid and omeprazole 20 mg bid or the LBT group comprising of amoxicillin 1 g bid, levofloxacin 500 mg bid and omeprazole 20 mg bid for 10 d each. The H. pylori eradication rates, side effects, compliance and the recurrence of ulcer were assessed in the two groups at 3 mo follow up.

RESULTS

Thirty-four patients in the STT group and 32 patients in the levofloxacin group presented at 3 mo follow up. H. pylori eradication rates were similar with STT and the LBT groups on intention-to-treat (ITT) analysis (69% vs 80%, P = 0.425) and (79% vs 87%, P = 0.513) by per-protocol (PP) analysis respectively. Ulcer recurrence in the STT and LBT groups on ITT analysis was (20% vs 14%, P = 0.551) and (9% vs 6%, P = 1.00) by PP analysis. Compliance and side effects were also comparable between the groups. A complete course of STT costs Indian Rupees (INR) 1060.00, while LBT costs only INR 360.00.

CONCLUSION

H. pylori eradication rates and the rate of ulcer recurrence were similar between the STT and LBT. The LBT is a more economical option compared to STT.

Standard triple versus levofloxacin based regimen for eradication of Helicobacter pylori

AIM

To compare the eradication rates for Helicobacter pylori (H. pylori) and ulcer recurrence of standard triple therapy (STT) and levofloxacin based therapy (LBT).

METHODS

Seventy-four patients with perforated duodenal ulcer treated with simple closure and found to be H. pylori infected on 3 mo follow up were randomized to receive either the STT group comprising of amoxicillin 1 g bid, clarithromycin 500 mg bid and omeprazole 20 mg bid or the LBT group comprising of amoxicillin 1 g bid, levofloxacin 500 mg bid and omeprazole 20 mg bid for 10 d each. The H. pylori eradication rates, side effects, compliance and the recurrence of ulcer were assessed in the two groups at 3 mo follow up.

RESULTS

Thirty-four patients in the STT group and 32 patients in the levofloxacin group presented at 3 mo follow up. H. pylori eradication rates were similar with STT and the LBT groups on intention-to-treat (ITT) analysis (69% vs 80%, P = 0.425) and (79% vs 87%, P = 0.513) by per-protocol (PP) analysis respectively. Ulcer recurrence in the STT and LBT groups on ITT analysis was (20% vs 14%, P = 0.551) and (9% vs 6%, P = 1.00) by PP analysis. Compliance and side effects were also comparable between the groups. A complete course of STT costs Indian Rupees (INR) 1060.00, while LBT costs only INR 360.00.

CONCLUSION

H. pylori eradication rates and the rate of ulcer recurrence were similar between the STT and LBT. The LBT is a more economical option compared to STT.

Is Helicobacter pylori Infection the Primary Cause of Duodenal Ulceration or a Secondary Factor? A Review of the Evidence

Helicobacter pylori (H. pylori) has a role in the multifactorial etiology of peptic ulcer disease. A link between H. pylori infection and duodenal ulcer disease is now established. Other contributing factors and their interaction with the organism may initiate the ulcerative process. The fact that eradication of H. pylori infection leads to a long-term cure in the majority of duodenal ulcer patients and the fact that the prevalence of infection is higher in ulcer patients than in the normal population are cogent arguments in favor of it being the primary cause of the ulceration. Against this concept there are issues that need explanation such as the reason why only a minority of infected persons develop duodenal ulceration when infection with H. pylori is widespread. There is evidence that H. pylori infection has been prevalent for several centuries, yet duodenal ulceration became common at the beginning of the twentieth century. The prevalence of duodenal ulceration is not higher in countries with a high prevalence of H. pylori infection. This paper debate puts forth the point of view of two groups of workers in this field whether H. pylori infection is the primary cause of duodenal ulcer disease or a secondary factor.

Análise epidemiológica e emprego do teste rápido da urease em pacientes com úlcera péptica perfurada

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.

Systematic review and meta-analysis: Helicobacter pylori eradication therapy after simple closure of perforated duodenal ulcer

BACKGROUND

The most common complications of peptic ulcer are bleeding and perforation. In many regions, definitive acid reduction surgery has given way to simple closure and Helicobacter pylori eradication.

AIM

To perform a systematic review and meta-analysis to ask whether this change in practice is in fact justified.

MATERIALS AND METHODS

A search on the Cochrane Controlled Trials Register, Medline, and Embase was made for controlled trials of duodenal ulcer perforation patients using simple closure method plus postoperative H. pylori eradication therapy versus simple closure plus antisecretory non-eradication therapy. The long-term results for prevention of ulcer recurrence were compared.

RESULTS

The pooled incidence of 1-year ulcer recurrence in H. pylori eradication group was 5.2% [95% confidence interval (CI) of 0.7 and 9.7], which is significantly lower than that of the control group (35.2%) with 95% CI of 0.25 and 0.45. The pooled relative risk was 0.15 with 95% CI of 0.06 and 0.37.

CONCLUSIONS

Helicobacter pylori eradication after simple closure of duodenal ulcer perforation gives better result than the operation plus antisecretory non-eradication therapy for prevention of ulcer recurrence. All duodenal ulcer perforation patients should be tested for H. pylori infection, and eradication therapy is required in all infected patients.

Gastric tube perforation after esophagectomy for esophageal cancer

We searched for cases of perforation of the gastric tube after esophagectomy for esophageal cancer by reviewing the literature. Only 13 cases were found in the English literature, and serious complications were seen in all cases, especially in cases of posterior mediastinal reconstruction. However, in the Japanese literature serious complications were also frequently seen in retrosternal reconstruction. Gastric tubes are at a higher risk of developing an ulcer than the normal stomach, including an ulcer due to Helicobacter pylori infection, insufficient blood supply, gastric stasis, and bile juice regurgitation. H. pylori eradication and acid-suppressive medications are important preventive therapies for ordinary gastric ulcers, but for gastric tube ulcers the effects of such treatments are still controversial. We tried to determine the most appropriate treatment to avoid serious complications in the gastric tubes, but we could not confirm an optimal route because each had advantages and disadvantages. However, at least in cases with severe atrophic gastritis due to H. pylori infection or a history of frequent peptic ulcer treatment, the antesternal route is clearly the best. Many cases of gastric tube ulcers involve no pain, and vagotomy may be one of the reasons for this absence of pain. Therefore, periodic endoscopic examination may be necessary to rule out the presence of an ulcer.

Perforated peptic ulcer: different ethnic, climatic and fasting risk factors for morbidity in Al-ain medical district, United Arab Emirates

AIM

To evaluate risk factors, morbidity and mortality rates of perforated peptic ulcer (PPU) and to investigate factors affecting postoperative complications of PPU.

BACKGROUND

The incidence of PPU has remained constant, simple closure with omental patch repair being the mainstay of treatment.

PATIENTS AND METHODS

One hundred and nineteen patients admitted to Al-Ain Hospital with PPU between January 2000 and March 2004 was studied retrospectively; two with deficient data were excluded from the analysis. Logistic regression was used to define factors affecting postoperative complications.

RESULTS

The mean age of patients was 35.3 years (range, 20-65). 45.7% of patients were Bangladeshi, and 85.3% originated from the Indian subcontinent. One patient, subsequently found to have a perforated gastric cancer, died. In 116 patients, 26 complications were recorded in 20 patients (17.2%). Common risk factors for perforation were smoking, history of peptic ulcer disease (PUD) and use of non-steroidal anti-inflammatory drugs (NSAIDs). A significantly increased risk of perforation was evident during the daytime fasting month of Ramadan. An increase in the acute physiology and chronic health evaluation (APACHE) II score (p = 0.047) and a reduced white blood cell count (0.04) were highly significant for the prediction of postoperative complications.

CONCLUSION

Patients with dyspeptic symptoms and a history of previous PUD should be considered for prophylactic treatment to prevent ulcer recurrence during prolonged daytime fasting in Ramadan, especially during the winter time.

Refractory peptic ulcer disease

Refractory PUD is a diagnostic and therapeutic challenge. Optimal management of severe or refractory PUD requires a multidisciplinary team approach, using primary care providers, gastroenterologists, and general surgeons. Medical management has become the cornerstone of therapy. Identification and eradication of H pylori infection combined with acid reduction regimens can heal ulceration and also prevent recurrence. Severe, intractable or recurrent PUD and associated complications mandates a careful and methodical evaluation and management strategy to determine the potential etiologies and necessary treatment (medical or surgical) required.

Decreasing incidence of peptic ulcer complications after the introduction of the proton pump inhibitors, a study of the Swedish population from 1974-2002

Background

Despite a decreasing incidence of peptic ulcer disease, most previous studies report a stabile incidence of ulcer complications. We wanted to investigate the incidence of peptic ulcer complications in Sweden before and after the introduction of the proton pump inhibitors (PPI) in 1988 and compare these data to the sales of non-steroid anti-inflammatory drugs (NSAID) and acetylsalicylic acid (ASA).

Methods

All cases of gastric and duodenal ulcer complications diagnosed in Sweden from 1974 to 2002 were identified using the National hospital discharge register. Information on sales of ASA/NSAID was obtained from the National prescription survey.

Results

When comparing the time-periods before and after 1988 we found a significantly lower incidence of peptic ulcer complications during the later period for both sexes (p < 0.001). Incidence rates varied from 1.5 to 7.8/100000 inhabitants/year regarding perforated peptic ulcers and from 5.2 to 40.2 regarding peptic ulcer bleeding. The number of sold daily dosages of prescribed NSAID/ASA tripled from 1975 to 2002. The number of prescribed sales to women was higher than to males. Sales of low-dose ASA also increased. The total volume of NSAID and ASA, i.e. over the counter sale and sold on prescription, increased by 28% during the same period.

Conclusion

When comparing the periods before and after the introduction of the proton pump inhibitors we found a significant decrease in the incidence of peptic ulcer complications in the Swedish population after 1988 when PPI were introduced on the market. The cause of this decrease is most likely multifactorial, including smoking habits, NSAID consumption, prevalence of Helicobacter pylori and the introduction of PPI. Sales of prescribed NSAID/ASA increased, especially in middle-aged and elderly women. This fact seems to have had little effect on the incidence of peptic ulcer complications.

Perforated peptic ulcer: how to improve outcome?

Despite the introduction of histamine H2-receptor antagonists, proton-pump inhibitors and the discovery of Helicobacter pylori, both the incidence of emergency surgery for perforated peptic ulcer and the mortality rate for patients undergoing surgery for peptic ulcer perforation have increased. This increase has occurred despite improvements in perioperative treatment and monitoring. To improve the outcome of these patients, it is necessary to investigate the reasons behind this high mortality rate. In this review we evaluate the existing evidence in order to identify significant risk factors with an emphasis on risks that are preventable. A systematic review including randomized studies was carried out. There are a limited number of studies of patients with peptic ulcer perforation. Most of these studies are of low evident status. Only a few randomized, controlled trials have been published. The mortality rate and the extent of postoperative complications are fairly high but the reasons for this have not been thoroughly explained, even though a number of risk factors have been identified. Some of these risk factors can be explained by the septic state of the patient on admission. In order to improve the outcome of patients with peptic ulcer perforation, sepsis needs to be factored into the existing knowledge and treatment.

Effect of Helicobacter pylori eradication on ulcer recurrence after simple closure of perforated duodenal ulcer

BACKGROUND

This study was conducted to elucidate the prevalence of Helicobacter pylori in patients with a perforated duodenal ulcer and to determine whether eradication of H. pylori prevent ulcer recurrence following simple repair of the perforation.

PATIENTS AND METHOD

Eighty-three patients with perforated duodenal ulcer (68 males); mean age was 47.8 years+/-7.2. Antral mucosal biopsies (to determine the status of HP by rapid urease test, culture and histological examination/staining) were obtained during laparotomy by passing a biopsy forceps through the perforation site. H. pylori positive patients who had undergone patch repair were randomized into the eradication group who received amoxicillin, metranidazole plus omperazole and the control group was given omeprazole alone. Follow-up endoscopy and antral biopsies were performed at 8 weeks, 16 weeks and 1 year to show ulcer healing and determine H. pylori state.

RESULTS

Of 77 patients in the study, 65 patients (84.8%) had H. pylori. These patients were randomly divided into the triple therapy group (34 patients) and the control group (31 patients). Eradication of H. pylori was significantly higher in the triple therapy group than the control group and initial ulcer healing was significantly better in the eradication group. After 1 year, ulcer recurrence was (6.1%) in the eradication group vs. (29.6%) in the control group (P=0.001).

CONCLUSION

H. pylori was present in a high proportion of patients with duodenal ulcer perforation. Eradication of H. pylori after simple closure of a perforated duodenal ulcer reduced the incidence of recurrent ulcer.

Surgical management of complicated ulcer disease

The advent of excellent acid-suppressing medications and the not-so-recent realization of the importance of Helicobacter pylori have markedly altered the physician's management of ulcer-related problems. Although the investigation of acid-peptic disorders helped to launch the modern understanding of abdominal surgery, the majority of operative interventions are now aimed at managing emergent problems that arise from ulcers. There are a waning number of surgeons with extensive experience in the operations that will be described in this report. The global management of patients who suffer from ulcer-related problems will require close cooperation among and between specialties, as well as clear understanding of our respective capabilities and limitations.

Persistence of Helicobacter pylori infection in patients with peptic ulcer perforation

OBJECTIVE

In patients with perforated peptic ulcer (PPU) the convergence between the high eradication rate of Helicobacter pylori infection and low rates of ulcer relapse after treatment has been associated with reinfection by non-virulent strains. The objective of this study was to evaluate the persistence of infection by virulent H. pylori strains and ulcer recurrence in 33 patients with PPU one year after surgery and antimicrobial treatment.

MATERIAL AND METHODS

The histological evaluation and molecular detection of H. pylori cagA and ureA genes, vacA allelic types and the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analyses of the glmM gene products from antral mucosa specimens were performed initially, 2-5 months and 1 year after therapy.

RESULTS

The density of H. pylori colonization was temporarily decreased (p<0.05) 2-5 months after therapy. After one year, complete eradication was achieved in only 7 patients (23%) at histological examination and recurrent ulcers were found in 3/33 (9%) patients. The vacA s1a allelic type of cagA-positive strains persisted in 19/33 (58%) PPU patients with identical PCR-RFLP fingerprints in 8/9 (89%) of the patients.

CONCLUSIONS

In PPU patients with a low eradication rate of H. pylori infection after surgical and antimicrobial treatment, the frequent recrudescence of the infection is mostly caused by the persisting virulent strains of the cagA and vacA s1a subtypes. In the 1-year follow-up period the recurrent ulceration can be postponed just by the lowered colonization density of H. pylori after eradicative therapy.

Helicobacter pylori eradication prevents recurrence after simple closure of perforated duodenal ulcer

BACKGROUND AND AIM

Evidence remains inconclusive as to whether eradication of Helicobacter pylori prevents ulcer relapse after simple closure of a perforated duodenal ulcer. This study was conducted to determine the effect of H. pylori eradication using a quadruple drug regimen along with a probiotic on ulcer recurrence after perforation closure.

METHODS

A total of 93 patients who had presented with perforated duodenal ulcer and had a simple closure of a duodenal perforation comprised the study group. Three months postoperatively, patients who were found to be positive for H. pylori infection (n = 60) were administered quadruple therapy consisting of omeprazole, clarithromycin, amoxicillin and colloidal bismuth subcitrate for 10 days along with the probiotic Lactobacillus sporogenes for 14 days. Diagnosis of H. pylori was carried out by urease test and histology. Patients were followed for 18 months. Recurrence of ulcer was analyzed for correlation with H. pylori status.

RESULTS

Of 60 patients who received H. pylori eradication therapy, 53 were available for subsequent follow up. H. pylori eradication was achieved in 43/53 (81.1%) patients. The ulcer recurrence in the eradicated group was 18.6% (8/43) compared to 70% (7/10) in the noneradicated group (P = 0.003).

CONCLUSION

Eradication of H. pylori significantly reduces the relapse of duodenal ulcer after simple closure of perforation. Anti H. pylori therapy must be recommended for all H. pylori positive patients after simple closure of a perforated duodenal ulcer.

Endoscopic therapy of benign pyloric stenosis and gastric outlet obstruction

PURPOSE OF REVIEW

To examine the short and long-term success rates of balloon dilation of pyloric stenosis.

RECENT FINDINGS

Several large studies have demonstrated high rates of success for the relief of symptoms from pyloric stenosis using through-the-scope balloons. These dilating balloons readily increase the diameter of the stenotic pylorus on average from 6 to 16 mm. Patients who require more than two dilations are at high risk of endoscopic failure and the need for surgical intervention. Rapid re-stenosis rates are observed in patients with malignant pyloric obstruction. Since many patients with benign pyloric stenosis have underlying ulcer disease, helicobacter infection is a relatively common finding. Eradication of this infection at the time of balloon dilation will ensure higher long-term success rates.

SUMMARY

In summary, benign pyloric stenosis can be readily treated with endoscopic balloon dilation and should be the first-line therapy.

Surgical management of perforated peptic ulcer disease

BACKGROUND

Surgery for perforated peptic ulcer disease is one of the most common emergency procedures carried out in the western world. The role of postoperative empiric Helicobacter Pylori eradication therapy is controversial.

METHODS

The clinical, operative and postoperative surveillance details of 84 consecutive patients who underwent surgery for perforated peptic ulcer were reviewed.

RESULTS

All patients underwent omentopexy +/- simple closure followed by proton pump therapy. Patients were followed-up for an average of 44 +/- 19 months. Females were older than male patients (59 +/- 20 vs. 46 + 17 years; p<0.05), presented with symptoms of a longer duration (17.9 +/- 16 vs. 8.9 +/- 9 hours; p=0.045) and had a higher mortality rate (18% vs 3%; p<0.05). Seventy-nine per cent of patients received postoperative empiric Helicobacter Pylori eradication therapy.

CONCLUSIONS

Surgery for perforated peptic ulcer is associated with a significant perioperative mortality rate. Elderly female patients are particularly at risk.

Management strategies, early results, benefits, and risk factors of laparoscopic repair of perforated peptic ulcer

The primary goal of this study was to describe epidemiology and management strategies of the perforated duodenal ulcer, as well as the most common methods of laparoscopic perforated duodenal ulcer repair. The secondary goal was to demonstrate the value of prospective and retrospective studies regarding the early results of surgery and the risk factors. The tertiary goal was to emphasize the benefits of this operation, and the fourth goal was to clarify the possible risk factors associated with laparoscopic repair of the duodenal ulcer. The Medline/Pubmed database was used. Review was done after evaluation of 96 retrieved full-text articles. Thirteen prospective and twelve retrospective studies were selected, grouped, and summarized. The spectrum of the retrospective studies' results are as follows: median overall morbidity rate 10.5 %, median conversion rate 7%, median hospital stay 7 days, and median postoperative mortality rate 0%. The following is the spectrum of results of the prospective studies: median overall morbidity rate was slightly less (6%); the median conversion rate was higher (15%); the median hospital stay was shorter (5 days) and the postoperative mortality was higher (3%). The risk factors identified were the same. Shock, delayed presentation (> 24 hours), confounding medical condition, age > 70 years, poor laparoscopic expertise, ASA III-IV, and Boey score should be considered preoperative laparoscopic repair risk factors. Each of these factors independently should qualify as a criterion for open repair due to higher intraoperative risks as well as postoperative morbidity. Inadequate ulcer localization, large perforation size (defined by some as > 6 mm diameter, and by others as > 10 mm), and ulcers with friable edges are also considered as conversion risk factors.

Perforated peptic ulcer treated by simple closure and Helicobacter pylori eradication

Simple closure followed by Helicobacter pylori (Hp) eradication has become the most used procedure in perforated ulcer treatment. However, its efficacy and safety are still to be determined. To assess recurrence and re-perforation rates, and as a secondary objective, to analyze Hp infection rates in perforated ulcer patients and controls, we conducted a prospective study. Ninety-two consecutive patients (ages: 19-96 years) were operated on between 1996 and 2002, and treated by simple closure followed by Hp eradication and NSAID avoidance. The data were prospectively collected in a database. Hp infection was diagnosed in 68 patients (73.9%). Thirty-four patients (37%) consumed nonsteroidal anti-inflammatory drugs (NSAIDs), and 23 (25%) had both Hp infection and NSAID antecedents. The perforation was gastric in 4 cases and pre-pyloric, pyloric or duodenal in 88. There were postoperative complications in 24 patients (26%) and 4 patients died (4.3%). Hp eradication was shown in 46 patients. There was clinical ulcer recurrence in 4 (4.3%); in 3 of them recurrence manifested as re-perforation, all in gastric locations. Overall relapse and re-perforation 1-year crude rates were 6.1% and 4.1%, respectively. Crude rates for non-gastric ulcer recurrence were 0 at 1 year and 2.6% at 2 years and for non-gastric ulcer re-perforation rates were 0 at 1 and 2 years. This therapeutic strategy is associated with a low rate of recurrence and no re-perforations in case of duodenal, pyloric, or pre-pyloric perforated ulcers, but it is not acceptable for perforated gastric ulcers.

Surgical Management of Ulcer Disease

Surgical management of patients who have acid peptic ulcers requires a firm understanding of the technical options and an even firmer grasp of the anatomic, physiologic, and pathophysiologic relationships of the organs involved. This is a constellation of problems in which the surgeon needs to be far more than a technician. The wealth of information discovered on this subject, from the clinical observations of William Beaumont to the discovery of complex cellular biology and hormonal signaling, is enough to occupy the study of several careers. Although patients who have acid peptic disorders have largely become the primary responsibility of physicians and specialists other than surgeons, when significant complications occur in these patients, it is the surgeon who is called upon to intervene.

Laparoscopic treatment of gastroduodenal perforations: comparison with conventional surgery

BACKGROUND

Laparoscopic techniques have been proposed as an alternative to open surgery for the treatment of peptic ulcer perforation. This study compared the outcome of laparoscopic and open approaches for the repair of gastroduodenal perforations.

METHODS

A retrospective review was conducted with 134 consecutive patients treated for gastroduodenal perforations. These patients included 122 with perforated duodenal ulcers, 10 with perforated gastric ulcers, and 2 with iatrogenic duodenal perforations. Whereas 68 patients were treated laparoscopically, 66 patients underwent conventional (open) surgery.

RESULTS

Laparoscopic repair was successful in 65 cases (96 %). The mean operating time was shorter with the laparoscopic technique (68 vs 59 min), but the difference was not significant. The duration of postoperative nasogastric aspiration and time to resumed oral intake were shorter in the laparoscopic group (2.6 vs 4.1 days and 4.4 vs. 5.2 days, respectively; p = 0.043). The postoperative analgetic requirements, and overall complications rate were significantly lower after laparoscopic surgery (p = 0.03 and p = 0.004, respectively). There was no statistically significant difference in hospital stay (5.1 vs 6.1 days) or mortality rate between the two procedures.

CONCLUSION

Laparoscopic repair of gastroduodenal perforations is a safe alternative treatment offering certain significant short-term advantages.

[Non operative treatment for perforated peptic ulcer: results of a prospective study]

BACKGROUND

The conservative management of perforated peptic ulcer has not gained widespread acceptance despite introduction of proton-pomp inhibitors because surgical procedures can achieve immediate closure by eventually using a laparoscopic approach. The aim of this prospective study was to evaluate the results of Taylor's method and to identify predictive factors of failure of medical treatment in patients presenting with perforated peptic ulcer.

METHOD

Between 1990 and 2000, 82 consecutive patients, with diagnosis of perforated peptic ulcer were prospectively included in this study. They were initially treated with non-operative procedure (nasogastric suction and intravenous administration of H2-blockers or proton-pomp inhibitors). No clinical improvement after 24 hours required a surgical treatment. Predictive factors of failure of non-operative treatment were tested in univariate or multivariate analysis.

RESULTS

Clinical improvement was obtained with non-operative treatment in 54% of the patients (44/82). The overall mortality rate was 1%. In univariate analysis, significant predictive factors of failure of non-operative treatment were: size of pneumoperitoneum, heart beat >94 bpm, abdominal meteorism, pain at digital rectal exam, and age >59 years. In multivariate analysis, the significant factors were the size of pneumoperitoneum, heart beat, and abdominal meteorism. The association of these criteria: size of pneumoperitoneum >size of the first lumbar vertebra, heart beat >94 bpm, pain at digital rectal exam and age > 59 years , led to surgical treatment in all cases.

CONCLUSION

These results suggest that more than 50% of patients with perforated peptic ulcer respond to conservative treatment without surgery and that the association of few criteria (size of pneumoperitoneum, heart beat, pain at digital rectal exam and age) require emergency surgery.

Laparoscopic repair of perforated peptic ulcer: a meta-analysis

BACKGROUND

Laparoscopic repair of perforated peptic ulcer has been gaining popularity in recent years, but few data exist to support the superiority of the laparoscopic approach over open repair. The objective of the current study was to compare the safety and efficacy of open and laparoscopic repair of perforated peptic ulcer in an evidence-based approach using meta-analytical techniques.

METHODS

A search of electronic databases, including MEDLINE and EMBASE, was conducted to identify relevant articles published between January 1990 and December 2002. Only studies in the English language comparing the outcomes of laparoscopic and open repair of perforated peptic ulcer were recruited. All reports were critically appraised with respect to their methodology and outcome. Data from all included studies were extracted using standardized data extraction forms developed a priori. Both qualitative and quantitative statistical analyses were performed. The effect size of outcome parameters was estimated by odds ratio where feasible and appropriate.

RESULTS

A total of 13 publications comprising 658 patients met the inclusion criteria. The overall success rate of laparoscopic repair was 84.7% (n = 249). Postoperative pain was lower after laparoscopic repair than after open repair, supported by a significant reduction in postoperative analgesic requirement after laparoscopic repair. Meta-analyses demonstrated a significant reduction in the wound infection rate after laparoscopic repair, as compared with open repair, but a significantly higher reoperation rate was observed after laparoscopic repair.

CONCLUSIONS

Evidence suggests that laparoscopic repair of perforated peptic ulcer confers superior short-term benefits in terms of postoperative pain and wound morbidity. This approach is as safe and effective as open repair. Laparoscopic Graham-Steele patch repair of perforated duodenal or justapyloric ulcer is beneficial for patients without Boey's risk factors.

Endoscope-Assisted Laparoscopic Repair of Perforated Peptic Ulcers

Laparoscopic repairs for perforated peptic ulcer (PPU) are likely to fail in patients with shock, gastric outlet obstruction, or large perforations. This prospective study was performed to evaluate a revised approach of laparoscopic repair with endoscopic assistance to treat these patients. Between April 2001 and February 2002, 30 consecutive patients with PPU were enrolled in this study. The mean age was 43.1 ± 12.2 years. Male to female ratio was 27:2. One patient was excluded from laparoscopic repair due to a gastric outlet obstruction. The other 29 patients were managed according to a protocol of preoperative upper endoscopy and laparoscopic intracorporeal suture repair with an omental patch. The average operative time was 58.1 ± 13.5 minutes (range, 36–96 min). The average diameter of perforation was 4.2 ± 2.0 mm (range, 1–12 mm). The average time to resume oral fluids was 3.2 ± 0.8 days (range, 2–8 days). The average hospital stay was 4.7 ± 1.1 days (range, 3–10 days). There was no leakage or mortality. Most patients did not receive parenteral analgesics postoperatively. We conclude that endoscope-assisted laparoscopic repair for PPU is safe and effective. This revised technique allows surgeons to exclude patients who are likely to fail the laparoscopic repair.

Surgical complications of selected gastrointestinal emergencies: pitfalls in management of the acute abdomen

Complaints referable to the abdomen are common emergency department presentations. Many of these conditions prove to be benign and self-limited, whereas others are potentially catastrophic. Because serious and benign intra-abdominal conditions share many relatively nonspecific symptoms, it is often difficult to identify patients who have life-threatening problems early in the course of their disease. Apart from relieving the patient's symptoms, the emergency physician's primary role is to detect and stabilize life-threatening conditions in a rapid and cost-effective manner.

Eradication of Helicobacter pylori improves the healing rate and reduces the relapse rate of nonbleeding ulcers in patients with bleeding peptic ulcer

OBJECTIVE

A causal relationship between Helicobacter pylori (H. pylori) and peptic ulcer complications remains obscure. The aim of this study was to determine the importance of H. pylori and other risk factors for healing rate, ulcer recurrence, and rebleeding in patients with bleeding peptic ulcer.

METHOD

A total of 223 patients with H. pylori positive bleeding peptic ulcer were randomly allocated to three treatment groups: 1) quadruple therapy (QT) (88 patients); 2) dual therapy (DT) (88 patients); and 3) omeprazole and placebo therapy (OPl) (47 patients). Endoscopic assessment was performed initially and at 8 and 52 wk. Ulcer healing and eradication rates were assessed; endpoints were ulcer relapse and ulcer rebleeding during 52 wk.

RESULTS

Results after 8 and 52 wk were available for 211 and 179 patients, respectively. Eradication rate was 100% (95% CI = 96-100%) in the QT, 84% (95% CI = 74-91%) in the DT, and 4% (95% CI = 1-15%) in the OPl group. Ulcer healing rate was 95% (95% CI = 91-98%) in H. pylori negative and 8% (95% CI = 70-91%) in H. pylori positive patients. Ulcer relapses occurred in 2% (95% CI = 0.5-6%) of H. pylori negative and in 38% (95% CI = 24-54%) of H. pylori positive patients, and rebleeding occurred in five patients (three H. pylori positive and two negative).

CONCLUSIONS

Eradication of H. pylori infection enhances healing of bleeding peptic ulcers after endoscopic therapy. H. pylori infection is an important independent risk factor for relapsing of nonbleeding ulcers in patients with bleeding peptic ulcer.

Helicobacter pylori infection and perforated peptic ulcer prevalence of the infection and role of antimicrobial treatment

Although the role of Helicobacter pylori infection on noncomplicated peptic ulcer disease has been definitively established, the precise relationship between the organism and complicated ulcer has hardly been studied. The mean prevalence of H. pylori infection in patients with perforated peptic ulcer is of only about 65-70%, which contrasts with the almost 90-100% figure reported in noncomplicated ulcer disease. However, H. pylori infection rates in various studies range markedly from 0% to 100%, suggesting that differences in variables as number and type of diagnostic methods used to diagnose H. pylori infection, or frequency of nonsteroidal anti-inflammatory drug intake, may be responsible for the low prevalence reported in some studies. Recurrent ulcer disease after peptic ulcer perforation mainly occurs in patients with H. pylori infection, which suggests that the microorganism plays an important role in this complication. All patients with perforated peptic ulcer should be treated by simple closure of the perforation and with therapy aimed at healing of the ulcer and eradicating the H. pylori infection, as disappearance of the organism prevents, or at least decreases, ulcer recurrence and ulcer perforation in patients with H. pylori-associated perforated ulcers after simple closure. Therefore, H. pylori eradicating treatment should be started during the immediate postoperative period. The patients with intractable recurrent symptoms of peptic ulcer despite adequate medical treatment, but without H. pylori infection (e.g. a patient using nonsteroidal anti-inflammatory drugs), is probably the only remaining indication for elective definitive surgical treatment of peptic ulcer disease.

[Surgical treatment of perforated gastric ulcer]

INTRODUCTION

Peptic ulcer perforation is a complication of ulcer disease which requires urgent surgical treatment. The aim of this paper was to point out our experience in surgical treatment of perforated peptic ulcer.

MATERIAL AND METHODS

This retrospective study analyzes results of surgical treatment in 365 patients with perforated peptic ulcer during the period January 1996 to December 2000.

RESULTS

During the last 5-year period 365 patients were treated following peptic ulcer perforation. The average age was 43.53 +/- 8.26, with the span from 18 to 86. The most frequent surgical procedures in treatment of peptic ulcer perforation were: simple closure with biopsy (55.88%), excision of the ulcer with a pyloroplasty and vagotomy (35.29%) as nonresection surgical procedures and stomach resection after Billroth II (8.83%). The postoperative mortality was 4.41%.

CONCLUSIONS

The methods of choice in surgical treatment of gastric ulcer perforation are nonresection surgical procedures with drug therapy and eradication of Helicobacter pylori, if present.

Epidemiology of duodenal ulcer perforation: a study on hospital admissions in Norfolk, United Kingdom

BACKGROUND

Studies on the incidence of perforated duodenal ulcer are limited and in the United Kingdom, data are largely based on findings observed over two decades ago. To provide updated epidemiological data on duodenal ulcer perforation, the incidence of the disease in Norfolk, United Kingdom was determined.

METHODOLOGY

Medical records of patients with duodenal ulcer perforation were reviewed to confirm the diagnosis and obtain information on possible risk factors, namely, Helicobacter pylori infection, smoking and intake of non-steroidal anti-inflammatory drugs. The patients were admitted between 1 January 1996 and 31 December 1998, and were residents of Norfolk, United Kingdom.

RESULTS

Sixty-eight cases of duodenal ulcer perforation were identified, 36 (52.9%) were males and 32 (47.1%) were females. The age-standardised incidence rate was 3.77 per 100,000 population per year (95% confidence interval 3.72-3.83). The mean age upon admission for all cases was 72.3 years (standard deviation: 17.8). The mean age for males was 67.7 years (standard deviation: 19.4) and for females 77.6 years (standard deviation: 15.7), which differed significantly (difference in means: 9.9, 95% confidence interval 1.5-18.3). There were 29 deaths (42.7%), of which 19 were females. After adjustment for covariates, the odds ratio of mortality in women was 4.57 (95% confidence interval 1.28-16.29). There were 25 (36.8%) smokers and 22 (32.4%) patients were non-steroidal anti-inflammatory drug users. Helicobacter pylori infection was assessed in only 14 (20.6%) patients; 2 were positive, 3 were negative, and in the rest the results were unrecorded.

CONCLUSIONS

The incidence rates were lower compared to previous studies in the United Kingdom conducted in the 1960's and 1980's, which could reflect either improved health care or decreasing exposure to known risk factors. Furthermore, the difference in age distribution of incident cases between males and females may explain the higher mortality in females.

Effect of Helicobacter pylori eradication on the ulcer recurrence rate after simple closure of perforated duodenal ulcer: retrospective and prospective randomized controlled studies

BACKGROUND

The possible advantage of eradication of Helicobacter pylori in patients with perforated duodenal ulcer is unknown. This study was planned to assess the prevalence of H. pylori after simple closure of a perforated duodenal ulcer and to study the effect of H. pylori eradication on ulcer persistence and recurrence.

METHODS

Some 202 patients were followed prospectively for 2 years after simple closure of a perforated duodenal ulcer (prospective group). A second group of 60 patients was reviewed 5 years or more after perforation closure (retrospective group). The prevalence of H. pylori in patients with perforated duodenal ulcer was compared with that in controls. Patients in the prospective group were randomized to receive either ranitidine alone or quadruple therapy (ranitidine, colloidal bismuth subcitrate, metronidazole and tetracycline) after operation. The incidence of H. pylori infection after the two treatments and the association with residual or recurrent ulcer were studied. In the retrospective group long-term ulcer recurrence was correlated with H. pylori status.

RESULTS

The prevalence of H. pylori in patients with perforated duodenal ulcer was not significantly different from that in controls. At every interval of follow-up in the prospective group and in the retrospective group the H. pylori infection rate was significantly higher in patients who had recurrent or residual ulcers.

CONCLUSION

Eradication of H. pylori after simple closure of a perforated duodenal ulcer should reduce the incidence of residual and recurrent ulcers.

Operations for peptic ulcer disease: paradigm lost

Over the past several decades, the pharmacologic and endoscopic treatment of peptic ulcer disease (PUD) has dramatically improved. To determine the effects of these and other changes on the operative management of PUD, we reviewed our surgical experience with gastroduodenal ulcers over the past 20 years. A computerized surgical database was used to analyze the frequencies of all operations for PUD performed in two training hospitals during four consecutive 5-year intervals beginning in 1980. Operative rates for both intractable and complicated PUD were compared with those for other general surgical procedures and operations for gastric malignancy. In the first 5-year period (1980 to 1984), a yearly average of 70 upper gastrointestinal operations were performed. This experience included 36 operations for intractability, 15 for hemorrhage, 12 for perforation, and seven for obstruction. During the same time span, 13 resections were performed annually for gastric malignancy. By the most recent 5-year interval (1994 to 1999), the total number of upper gastrointestinal operations had declined by 80% (14 cases), although the number of operations for gastric cancer had changed only slightly. Operations decreased most markedly for patients with intractability, but the prevalence of operations for bleeding, obstruction, and perforation was also decreased. We conclude that improved pharmacologic and endoscopic approaches have progressively curtailed the use of operative therapy for PUD. Elective surgery is now rarely indicated, and emergency operations are much less common. This changed paradigm poses new challenges for training and suggests different approaches for practice.

Peptic ulcer and Helicobacter pylori

Although there has been an explosion of data not only since the discovery of H. pylori in 1982, but also since the first comprehensive review of H. pylori in the Gastroenterology Clinics in 1993, much remains to be learned. In 1993, there were many skeptics doubting the importance of H. pylori in ulcer disease. Although this skepticism has dissipated, many ulcer patients infected with H. pylori still do not receive appropriate therapy. This situation possibly relates to the safety, efficacy, and simplicity of prescribing acid-suppressive therapy in contrast to the confusion regarding anti-H. pylori treatment regimens. Among the many continuing unanswered questions regarding the role of H. pylori and PUD are the still enigmatic nature of host, environmental, and H. pylori-related factors that determine outcome. Why do only some infected individuals (and why do more men than women) develop PUD, and what determines whether gastric ulcers or duodenal ulcers develop? What is the explanation for the seasonal variation in ulcer disease? Although PUD is an infectious disease, are other environmental factors critical for the manifestation of ulcers in association with infection? What factors govern the outcome of the combination of H. pylori infection and NSAID use? Has attention been too focused first on the pathophysiology of acid secretion and now on H. pylori? In curing H. pylori in association with PUD, are clinicians going to displace disease northward, substituting erosions, inflammation, and neoplasia (and associated symptoms) in the esophagus and gastroesophageal junction for an ulcer crater (and its associated symptoms) in the duodenum or stomach? The epidemiology of PUD is changing--in more recent reports of ulcer patients, H. pylori and NSAID use are less prevalent than in earlier reports. These questions and comments should not be misinterpreted as advocating a lack of aggressiveness in diagnosis and treatment of H. pylori in the setting of PUD, however. Nevertheless, the pendulum is swinging.

[Laparoscopic treatment of perforated duodenal ulcers. Results of a retrospective multicentric study. French Society of Laparoscopic Surgery]

STUDY AIM

The aim of this multicentric retrospective study was to report procedures, mortality and morbidity rate in a series of patients operated on for perforated duodenal ulcer with a laparoscopic approach.

PATIENTS AND METHODS

Four-hundred and nineteen patients from 18 centers were included. The duration of the study was ten years (1990 to 1999). There were 299 men and 120 women aged from 19 to 98 years (mean: 48 years). The ASA scores were as follows: I (48.7%), II (31.3%), III (17.5%), IV (2.5%). The mean duration between the onset of perforation and the time of operation was 13.4 hours (range: 1-70). The surgical procedures were suture (76.7%), epiploplasty (9.9%), only irrigation of the abdominal cavity (2.7%).

RESULTS

Conversion into laparotomy was performed in 10.6% of the patients. Mean operative time was 85 minutes. The morbidity and mortality rates were 13.4 and 1.4% respectively. Seventeen patients were reoperated because of fistula (n = 5), intra-abdominal abscess (n = 5), small bowel obstruction (n = 4), bleeding ulcer (n = 1), iatrogenic perforation of the gallbladder (n = 1) and small bowel (n = 1). Mean hospital stay was 8.5 days. All patients were discharged with a medical treatment of the peptic ulcer disease and in most of the cases, with antibiotics for Helicobacter pylori eradication. Six patients out of 96 with a medical history of chronic peptic ulcer underwent a vagotomy.

CONCLUSION

Laparoscopic repair of perforated duodenal ulcer is a safe option providing low rates of morbidity, reoperation and mortality, and can be considered the treatment of choice.

Gastric outlet obstruction resulting from peptic ulcer disease requiring surgical intervention is infrequently associated with Helicobacter pylori infection

BACKGROUND

Gastric outlet obstruction (GOO) secondary to peptic ulcer disease requiring therapeutic intervention remains a common problem. The incidence of Helicobacter pylori infection in this cohort has not been well defined. Pneumatic dilatation (PD) has been proposed as first-line therapy before surgical intervention. If H pylori infection in patients with GOO is infrequent, PD may not offer permanent control without the need for longterm antacid therapy.

STUDY DESIGN

The purpose of this study was to examine the incidence of H pylori infection and surgical outcomes in patients undergoing resection for GOO. The records of all patients having resection (vagotomy and antrectomy) for benign disease from 1993 to 1998 for GOO at the University of Tennessee affiliated hospitals were reviewed retrospectively. Smoking history, NSAID use, weight loss, previous ulcer treatment, previous treatment for H pylori, and previous attempts at PD were among the factors examined. H pylori infection was documented by Steiner stain from either preoperative biopsy or, in most patients, final surgical specimens. Surgical complications and patient satisfaction were ascertained from inpatient records, postoperative clinical notes, and, where possible, followup telephone surveys.

RESULTS

Twenty-four patients underwent surgical resection during the study period. There were 16 men and 8 women, with a mean age of 61 years (range 40 to 87 years). Weight loss was documented in 58% and averaged 27 lb. Five of 24 patients had previous attempts at PD, 3 of whom were H pylori negative. All five had further weight loss after these failed attempts. Of the 24 patients reviewed, only 8 (33%) were H pylori positive. There were no procedure-related deaths. Longterm clinical followup was possible in 16 of 24 patients, and all but one demonstrated dramatic clinical improvement by Visick score.

CONCLUSIONS

We conclude the following: 1) In this cohort, H pylori infection was present in a minority; 2) previous attempts at PD were unsuccessful, which may be related to the H pylori-negative status of the patients; 3) mortality related to the operation was zero; and 4) patient satisfaction was positive by the Visick scale. Patients with H pylori-negative GOO resulting from peptic ulcer disease should be strongly considered for an early, definitive, acid-reducing surgical procedure.

Effect of Helicobacter pylori eradication on peptic ulcer disease complicated with outlet obstruction

BACKGROUND

At present, the prevalence of Helicobacter pylori (H. pylori) in complicated peptic ulcer and the effect of H. pylori eradication on complicated peptic ulcer have not been fully established. In this study, we report the prevalence of H. pylori in peptic ulcer patients complicated with gastric outlet obstruction, effectiveness of oral eradication therapy on these patients, and their long-term follow up.

PATIENTS AND METHODS

Ten consecutive patients presenting with clinically and endoscopically significant obstructed peptic ulcers were included in this study. During each endoscopy, seven gastric biopsy specimens were obtained and analyzed for H. pylori colonization.

RESULTS

The antral mucosal biopsy specimens were positive for H. pylori in nine patients. H. pylori infection was eradicated and complete ulcer healing was observed in all patients. The mean follow-up period was 14 (7-24) months. One patient had duodenal perforation and underwent surgical intervention following medical treatment, despite the eradication of H. pylori. Ulcer recurrence was noted in two (22.2%) of nine patients, and in one of them the recurrent ulcer was complicated with obstruction (11. 1%). The mean time to ulcer recurrence was 17 months (range, 10-24 months). The biopsies and CLOtests were H. pylori negative at the time of ulcer or erosion recurrence in two patients.

CONCLUSION

We suggest that H. pylori eradication may improve the resolution in obstructive ulcer cases with colonization.

Eradication of Helicobacter pylori prevents recurrence of ulcer after simple closure of duodenal ulcer perforation: randomized controlled trial

OBJECTIVE

In this randomized trial, the authors sought to determine whether eradication of Helicobacter pylori could reduce the risk of ulcer recurrence after simple closure of perforated duodenal ulcer.

BACKGROUND DATA

Immediate acid-reduction surgery has been strongly advocated for perforated duodenal ulcers because of the high incidence of ulcer relapse after simple patch repair. Although H. pylori eradication is now the standard treatment of uncomplicated and bleeding peptic ulcers, its role in perforation remains controversial. Recently a high prevalence of H. pylori infection has been reported in patients with perforations of duodenal ulcer. It is unclear whether eradication of the bacterium confers prolonged ulcer remission after simple repair and hence obviates the need for an immediate definitive operation.

METHODS

Of 129 patients with perforated duodenal ulcers, 104 (81%) were shown to be infected by H. pylori. Ninety-nine H. pylori-positive patients were randomized to receive either a course of quadruple anti-helicobacter therapy or a 4-week course of omeprazole alone. Follow-up endoscopy was performed 8 weeks, 16 weeks (if the ulcer did not heal at 8 weeks), and 1 year after hospital discharge for surveillance of ulcer healing and determination of H. pylori status. The endpoints were initial ulcer healing and ulcer relapse rate after 1 year.

RESULTS

Fifty-one patients were assigned to the anti-Helicobacter therapy and 48 to omeprazole alone. Nine patients did not undergo the first follow-up endoscopy. Of the 90 patients who did undergo follow-up endoscopy, 43 of the 44 patients in the anti-Helicobacter group and 8 of the 46 in the omeprazole alone group had H. pylori eradicated; initial ulcer healing rates were similar in the two groups (82% vs. 87%). After 1 year, ulcer relapse was significantly less common in patients treated with anti-Helicobacter therapy than in those who received omeprazole alone (4.8% vs. 38.1%).

CONCLUSIONS

Eradication of H. pylori prevents ulcer recurrence in patients with H. pylori-associated perforated duodenal ulcers. Immediate acid-reduction surgery in the presence of generalized peritonitis is unnecessary.

Laparoscopic closure of perforated duodenal ulcer

BACKGROUND

Medical treatment of peptic ulcer is highly successful, and the eradication of Helicobacter pylori (H. pylori) reduces ulcer recurrence. However, the incidence of perforated duodenal ulcer and its associated mortality have not been reduced by modern methods of therapy. Laparoscopic simple closure and omental plug by suturing, fibrin glue, and stapler have been successful.

METHODS

Over a 1-year period (1996-97), 21 patients with perforated duodenal ulcer were operated on in our hospital by laparoscopic simple closure and omental patch. The mean age was 36.4 +/- 11.8 years (range, 18-61). Twenty patients were male (93.7%). The mean duration of pain was 9.1 +/- 11.7 hs (range, 2-48). Three patients had a previous history of duodenal ulcer (14.3%), and another three (14.3%) patients had a history of nonsteroidal antiinflammatory drug (NSAID) intake. Erect chest radiograph showed that 19 patients had air under the diaphragm (90.5%). Sixteen patients (76.2%) had frank pus in the abdomen, and five patients had a minimal peritoneal reaction (23.8%).

RESULTS

The mean operative time was 71.6 +/- 24.6 mins (range, 40-120), and the mean hospital stay was 5.2 +/- 1.6 days (range, 3-9). The mean time to resume oral fluids was 3.1 +/- 0.8 days (range, 2-4). Only one patient was reoperated due to leakage identified by gastrographin swallow.

CONCLUSIONS

This procedure is safe and efficient; however, further study of its long-term effectiveness and comparability to existing therapy is still needed.

Management of Helicobacter pylori infection: gastroenterological and surgical perspectives

Diagnosis and treatment of Helicobacter pylori is a crucial point in the management of the different gastroduodenal disorders. Management involves the general practitioner and different specialists such as internists, gastroenterologists and surgeons. Among the most frequent H. pylori-related gastroduodenal disorders of medical interest are some diseases such as dyspepsia and gastroesophageal reflux, where the role of the bacterium is not well defined and therefore the importance H. pylori eradication is still controversial. On the contrary, the relationship of H. pylori and gastric and duodenal peptic ulcer is widely and definitively proven, and there are no doubts regarding the importance of curing the bacterium in these disorders. However, the surgical aspect of peptic ulcer, in particular the relevance and management of its complications, has not been widely investigated so far. In fact, the prevalence of H. pylori in perforated, bleeding and stenotic peptic ulcers seem to be lower that in non-complicated peptic ulcer, and whenever H. pylori eradication virtually prevents the re-bleeding of peptic ulcer in all cases, the effect of curing the bacterium in perforated and stenotic ulcers is still largely unknown. The management of H. pylori infection after gastric surgery is also still controversial. Most studies suggest that H. pylori can persist after gastric surgery whenever its incidence is much lower than that before operation. However it seems most unlikely that the infection plays a major role in the development of ulcer recurrence after gastric surgery or in the induction of gastric carcinoma. In any case, there are no convincing data that its cure may prevent the occurrence of gastric carcinoma following gastrectomy procedures.

Helicobacter pylori status and endoscopy follow-up of patients having a history of perforated duodenal ulcer

BACKGROUND

The aim of this study was to determine whether the recurrence of symptoms or ulcer disease in patients with a history of perforated duodenal ulcer is related to Helicobacter pylori infection.

METHODS

One hundred sixty-three consecutive patients with history of perforated duodenal ulcer unrelated to nonsteroidal anti-inflammatory drugs underwent upper endoscopy. Any recurrent symptoms or complications were documented. Regardless of the endoscopic findings, three antral biopsy specimens were taken for histologic examination and a rapid urease test.

RESULTS

There was a preponderance of men (male/female = 5.3:1). The mean age was 55.9 years. Sixty-seven (41.1%) patients gave a history of recurrent epigastric pain, seven of whom also had a history of bleeding ulcer. Upper endoscopy was performed at a mean of 74.5 +/- 7.1 months after operation. Positive endoscopic findings were noted in 68 (41.7%) patients; H. pylori was found in the biopsy specimens from 77 (47.2%) patients. Recurrent duodenal ulcer was found in 29 (17.8%) patients and was significantly related to male gender, recurrent epigastric pain, bleeding ulcer, longer interval from previous operation, and positive H. pylori status. Positive H. pylori status and male gender were independent factors associated with recurrent duodenal ulcer.

CONCLUSIONS

Recurrent ulcer disease in patients with a history of perforated duodenal ulcer is related to H. pylori infection.