Emergency ulcer surgery

Surgical Management of Upper Gastrointestinal Bleeding

The use of surgery in managing upper gastrointestinal (GI) bleeding has rapidly diminished secondary to advances in our understanding of the pathologies that underlie upper GI bleeding, pharmaceutical treatments for peptic ulcer disease, and endoscopic procedures used to gain hemostasis. A surgeon must work collaboratively with gastroenterologist and interventional radiologist to determine when, and what kind of, surgery is appropriate for the patient with upper GI bleeding.

Damage Control Surgery for Duodenal Ulcer Bleeding With Massive Hematoma and Perforation Due to Over-the-Scope Clip (OTSC)

Due to the advances in endoscopic technology, surgery for duodenal ulcer (DU) bleeding has decreased, although surgery is still necessary for more complicated cases. The concept of damage control surgery (DCS) has been established in the field of trauma, and a simple surgical approach may be preferable in serious cases such as uncontrolled DU bleeding. We present a successful case of bleeding with massive hematoma and perforation of the duodenum due to an over-the-scope clip that was treated by a less invasive surgical approach with consideration of the DCS.

Impact of Tailored-Enhanced Recovery After Surgery Versus Conventional Care in Patients of Gastro-Duodenal Perforation: A Pilot Randomized Control Trial

BACKGROUND

The enhanced recovery after surgery (ERAS) program established improved clinical outcomes in elective surgery; however, its role in emergencies is uncertain. This study was designed to assess the feasibility, safety, and efficacy of a tailored-ERAS (t-ERAS) protocol in patients undergoing modified Graham's patch closure for gastro-duodenal perforation.

METHODS

A single-centre, prospective, parallel-arm, open-label, randomized controlled trial was conducted from February 2021 to December 2021. Patients with gastroduodenal perforation undergoing modified Graham's patch were randomly assigned to either conventional care or the t-ERAS pathway. Patients with refractory septic shock, psychiatric or neurological disorders, pregnancy, multiple perforations, sealed-off perforations, and perforation sizes greater than 1.5 cm were excluded. The primary outcome was to compare the length of hospitalization (LOH). Functional recovery parameters and morbidity were compared in secondary outcomes.

RESULTS

Twenty-five patients each were included in conventional care and the t-ERAS group. In the t-ERAS group, LOH was significantly shorter (6.3 SD2.15 days versus 9.56 SD4.33 days, p = 0.001). Patients in the t-ERAS group had significantly early functional recovery (days) with time to first bowel sound (1.8 SD0.41; p 0.002), first flatus (2.52 SD0.65; p = 0.026), first stool (3.04 SD0.68; p < 0.001), first liquid diet (2.24 SD0.60; p = 0.002), and duration of ileus (2.64 SD0.86; p = 0.038). There was no significant difference in morbidity such as post-operative nausea and vomiting, SSI, or pulmonary complications between the two groups.

CONCLUSION

Tailored ERAS pathways are safe and effective in reducing the LOH and promoting early functional recovery in patients undergoing emergency closure of gastro-duodenal perforation.

Predicting in-hospital mortality risk for perforated peptic ulcer surgery: the PPUMS scoring system and the benefit of laparoscopic surgery: a population-based study

BACKGROUND

The major treatment for perforated peptic ulcers (PPU) is surgery. It remains unclear which patient may not get benefit from surgery due to comorbidity. This study aimed to generate a scoring system by predicting mortality for patients with PPU who received non-operative management (NOM) and surgical treatment.

METHOD

We extracted the admission data of adult (≥ 18 years) patients with PPU disease from the NHIRD database. We randomly divided patients into 80% model derivation and 20% validation cohorts. Multivariate analysis with a logistic regression model was applied to generate the scoring system, PPUMS. We then apply the scoring system to the validation group.

RESULT

The PPUMS score ranged from 0 to 8 points, composite with age (< 45: 0 points, 45-65: 1 point, 65-80: 2 points, > 80: 3 points), and five comorbidities (congestive heart failure, severe liver disease, renal disease, history of malignancy, and obesity: 1 point each). The areas under ROC curve were 0.785 and 0.787 in the derivation and validation groups. The in-hospital mortality rates in the derivation group were 0.6% (0 points), 3.4% (1 point), 9.0% (2 points), 19.0% (3 points), 30.2% (4 points), and 45.9% when PPUMS > 4 point. Patients with PPUMS > 4 had a similar in-hospital mortality risk between the surgery group [laparotomy: odds ratio (OR) = 0.729, p = 0.320, laparoscopy: OR = 0.772, p = 0.697] and the non-surgery group. We identified similar results in the validation group.

CONCLUSION

PPUMS scoring system effectively predicts in-hospital mortality for perforated peptic ulcer patients. It factors in age and specific comorbidities is highly predictive and well-calibrated with a reliable AUC of 0.785-0.787. Surgery, no matter laparotomy or laparoscope, significantly reduced mortality for scores <  = 4. However, patients with a score > 4 did not show this difference, calling for tailored approaches to treatment based on risk assessment. Further prospective validation is suggested.

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.

Tratamiento laparoscópico de úlcera duodenal perforada mediante parche de Graham en un paciente pediátrico

Introducción. La úlcera duodenal perforada es una entidad de etiología no clara que rara vez ocurre en la población pediátrica. Generalmente se diagnostica de manera intraoperatoria y el tratamiento ideal incluye el uso del parche de epiplón o de ser necesario, la resección quirúrgica. Caso clínico. Se presenta un paciente de 12 años con abdomen agudo y diagnóstico tomográfico prequirúrgico de úlcera duodenal perforada, tratado por vía laparoscópica con drenaje de peritonitis y parche de Graham. La evolución y el seguimiento posterior fueron adecuados. Discusión. La úlcera duodenal perforada es una entidad multifactorial, en la que se ha implicado el Helicobacter pylori. El diagnóstico preoperatorio es un reto y el tratamiento debe ser quirúrgico. Conclusiones. Cuando se logra establecer el diagnóstico preoperatorio, se puede realizar un abordaje laparoscópico y el uso del parche de Graham cuando las úlceras son menores de dos centímetros.

Risk Factors of Mortality in Patients Hospitalized With Chronic Duodenal Ulcers

Background

We aimed to identify risk factors of mortality in patients hospitalized with duodenal ulcers (DUs).

Methods

A National Inpatient Sample–based retrospective cohort study from 2005 to 2014 was conducted on patients undergoing emergency admission for chronic DUs. Demographics, clinical data, and outcomes were collected. Multivariable logistic regression model was applied to find the risk factors of mortality.

Results

70 641 patients were included in this study, of which 30 525 (43%) were non-elderly (< 65 years) and 40 116 (57%) were elderly (65+ years) patients. 72% of non-elderly and 57% of elderly patients were males. Mortality rate of men vs women was similar in non-elderly group (1.9% vs 2%, respectively), whereas it significantly differed in elderly patients (4.5% vs 5.3%, respectively, P<.0001). Time to operation was 1.15 (1.83) days in survived vs 1.55 (3.86) days in deceased non-elderly patients ( P < .001). Time to operation was .85 (1.73) days in survived vs 1.79 (7.28) days in deceased elderly patients ( P < .001). In patients with operation, age, delayed operation, frailty, and presence of perforation were the main risk factors of mortality in both elderly and non-elderly patients. Invasive diagnostic procedure was shown as a protective factor in elderly patients. In the final model for patients with no operation, age, hospital length of stay, and frailty were the main risk factors of mortality in both elderly and non-elderly patients. Invasive diagnostic procedure was revealed as a protective factor in all patients as well.

Conclusion

Early operation in patients with DU requiring surgical intervention is essential to improve the outcomes.

A Retrospective Database Study of Gastrointestinal Events and Medical Costs Associated with Nonsteroidal Anti-Inflammatory Drugs in Japanese Patients of Working Age with Osteoarthritis and Chronic Low Back Pain

CONTEXT

The real-world burden of gastrointestinal (GI) events associated with the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in Japanese patients with osteoarthritis (OA) and/or chronic low back pain (CLBP) remains unreported.

OBJECTIVE

To assess the incidence and economic burden of NSAID-induced GI events by using data from large-scale real-world databases.

METHODS

We used the Japanese Medical Data Center database to retrospectively evaluate anonymized claims data of medical insurance beneficiaries employed by middle- to large-size Japanese companies who were prescribed NSAIDs for OA and/or CLBP between 2009 and 2018.

RESULTS

Overall, 180,371 patients were included in the analysis, of whom 32.9% had OA, 53.8% had CLBP, and 13.4% had both OA and CLBP. NSAIDs were administered as first-line analgesics to 161,152 (89.3%) of the patients in the sample, in oral form to 90.3% and as topical patches to 80.4%. A total of 65.1% used combined oral/topical patches. Of the 21.0% of patients consistently using NSAIDs (percentage of days supplied ≥70%), 54.5% received patches. A total of 51.5% patients used NSAIDs for >1 to ≤6 months. The incidence of GI events was 9.97 per 10,000 person-years (95% confidence interval: 8.92-11.03). The risk of developing GI events was high in elderly patients and patients with comorbidities and remained similar for patients receiving oral vs. topical NSAIDs. Longer treatment duration and consistent NSAID use increased the risk of GI events. The cost (median [interquartile range]) of medications (n = 327) was US$ 80.70 ($14.10, $201.40), that of hospitalization (n = 33) was US$ 2,035.50 ($1,517.80, $2,431.90), and that of endoscopic surgery (n = 52) was US$ 418.20 ($418.20, $418.20).

CONCLUSION

NSAID-associated GI toxicity imposes a significant health and economic burden on patients with OA and/or CLBP, irrespective of whether oral or topical NSAIDs are used.

Iatrogenic injury of duodenum: malady of a therapeutic misadventure

Endoscopic procedures are the front-runner of the management of bleeding duodenal ulcer. Rarely, surgical intervention is sought for acute bleeding, not amenable to endoscopic procedures. Oversewing of the gastroduodenal artery at ulcer crater by transduodenal approach is the most acceptable and recommended method of treatment. We describe a case of an intraoperative duodenal injury that occurred during an attempt to oversew the gastroduodenal artery after a duodenotomy, leading to an unsatisfactory and meagre duodenal stump. This case will highlight the intraoperative turmoil, postoperative complications and management of a series of anticipated but unfortunate events that have rendered us wiser in terms of surgical management of a bleeding duodenal ulcer.

Novel approach for peptic ulcer perforation surgery

A case of peritonitis following the repair of perforated peptic ulcer using omental flap. The revision surgery was performed using pedicled falciform ligament flap, and no postoperative and one‐month follow‐up complications were reported. In cases of perforated peptic ulcer that cannot be treated with omentopexy, use of a falciform ligament.

Factors Associated with Recurrent Ulcers in Patients with Gastric Surgery after More Than 15 Years: A Cross-Sectional Single-Center Study

Aim

We aimed to establish the independent predictive factors (from Helicobacter pylori infection, biliary reflux, histologic features of the gastric mucosa, drugs, comorbidities, and social habits) for gastric stump ulcer occurrence more than 15 years after surgery.

Methods

76 patients with previous gastric surgery were included: 21 patients with gastric ulcer (marginal ulcer or ulcer of the rest of the gastric remnant-study group) and 55 controls (nonulcer group).

Results

Helicobacter pylori infection tended to be higher in the control group than in the ulcer group (14.5% vs. 4.8%, p = 0.43), without statistical significance. Alcohol consumption had a significant positive association with ulcer (p = 0.008), while smoking (p = 0.064), low-dose aspirin (p = 0.063), and biliary reflux (p = 0.106) had a tendency toward statistical signification for positive association. On univariate analysis, smoking (p = 0.048, OR = 3.15, 95% CI: 1.01-9.93) and low-dose aspirin consumption (p = 0.067, OR = 2.63, 95% CI: 0.95-7.68) were significantly associated with ulcer. According to the multivariable regression model, alcohol consumption (OR = 6.68, 95% CI: 1.29-41.14) and biliary reflux (OR = 6.12, 95% CI: 1.36-38.26) remained significantly associated with increased odds of stump ulcer.

Conclusion

Biliary reflux and alcohol consumption, but not Helicobacter pylori infection or gastrotoxic drug, seem to be the most important predictors for ulcer recurrence in patients with gastric surgery for peptic ulcer after more than 15 years.

Laparoscopy is an available alternative to open surgery in the treatment of perforated peptic ulcers: a retrospective multicenter study

Background

Perforated peptic ulcers (PPU) remain one of the most frequent causes of death. Their incidence are largely unchanged accounting for 2–4% of peptic ulcers and remain the second most frequent abdominal cause of perforation and of indication for gastric emergency surgery. The minimally invasive approach has been proposed to treat PPU however some concerns on the offered advantages remain.

Methods

Data on 184 consecutive patients undergoing surgery for PPU were collected. Likewise, perioperative data including shock at admission and interval between admission and surgery to evaluate the Boey’s score.

It was recorded the laparoscopic or open treatments, the type of surgical procedure, the length of the operation, the intensive care needed, and the length of hospital stay.

Post-operative morbidity and mortality relation with patient’s age, surgical technique and Boey’s score were evaluated.

Results

The relationship between laparoscopic or open treatment and the Boey’s score was statistically significant (p = 0.000) being the open technique used for the low-mid group in 41.1% and high score group in 100% and laparoscopy in 58.6% and 0%, respectively. Postoperative complications occurred in 9.7% of patients which were related to the patients’ Boey’s score, 4.7% in the low-mid score group and 21.4% in the high risk score group (p = 0.000). In contrast morbidity was not related to the chosen technique being 12.8% in open technique and 5.3% in laparoscopic one (p = 0.092, p > 0.05).

30-day post-operative mortality was 3.8% and occurred in the 0.8% of low-mid Boey’s score group and in the 10.7% of the high Boey’s score group (p = 0.001). In respect to the surgical technique it occurred in 6.4% of open procedures and in any case in the Lap one (p = 0.043). Finally, there was a statistically significant difference in morbidity and mortality between patients < 70 and > 70 years old (p = 0.000; p = 0.002).

Conclusions

Laparoscopy tends to be an alternative method to open surgery in the treatment of perforated peptic ulcer. Morbidity and mortality were essentially related to Boey’s score. In our series laparoscopy was not used in high risk Boey’s score patients and it will be interesting to evaluate its usefulness in high risk patients in large randomized controlled trials.

Transcatheter Arterial Embolization for Bleeding Peptic Ulcers: A Multicenter Study

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Non-perforated peptic ulcer disease: multidetector CT findings, complications, and differential diagnosis

Abstract

Despite availability of effective therapies, peptic ulcer disease (PUD) remains a major global disease, resulting from a combination of persistent Helicobacter pylori infection and widespread use of nonsteroidal anti-inflammatory drugs. Albeit endoscopy definitely represents the mainstay diagnostic technique, patients presenting to emergency departments with unexplained abdominal pain generally undergo multidetector CT as an initial investigation. Although superficial ulcers generally remain inconspicuous, careful multiplanar CT interpretation may allow to detect deep ulcers, secondary mural and extraluminal signs of peptic gastroduodenitis, thereby allowing timely endoscopic verification and appropriate treatment. This pictorial essay aims to provide radiologists with an increased familiarity with CT diagnosis of non-perforated PUD, with emphasis on differential diagnosis. Following an overview of current disease epidemiology and complications, it explains the appropriate CT acquisition and interpretation techniques, and reviews with several examples the cross-sectional findings of uncomplicated PUD. Afterwards, the CT features of PUD complications such as ulcer haemorrhage, gastric outlet obstruction, biliary and pancreatic fistulisation are presented.

Teaching points

• Gastric and duodenal peptic ulcers are increasingly caused by nonsteroidal anti-inflammatory drugs

• Multiplanar CT interpretation allows detecting deep ulcers and secondary signs of gastroduodenitis

• CT diagnosis of uncomplicated peptic disease relies on direct and indirect signs

• Currently the commonest complication, haemorrhage may be treated with transarterial embolisation

• Other uncommon complications include gastric outlet obstruction and biliopancreatic fistulisation

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

Background

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

Patients and Method

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

Results

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

Conclusion

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

The Development of Diabetes after Subtotal Gastrectomy with Billroth II Anastomosis for Peptic Ulcer Disease

PURPOSE

A duodenal bypass after a Roux-en-Y gastric bypass operation for obesity can ameliorate the development of diabetes mellitus (DM). We attempted to determine the subsequent risk of developing DM after subtotal gastrectomy with Billroth II anastomosis (SGBIIA) for peptic ulcer disease (PUD).

METHODS

We identified 662 patients undergoing SGBIIA for PUD between 2000 and 2011 from the Longitudinal Health Insurance Database as the study cohort, and we randomly selected 2647 controls from the peptic ulcer population not undergoing SGBIIA and were frequency-matched by age, sex, and index year for the control cohort. All patient cases in both cohorts were followed until the end of 2011 to measure the incidence of DM. We analyzed DM risk by using a Cox proportional hazards regression model.

RESULTS

The patients who underwent SGBIIA demonstrated a lower cumulative incidence of DM compared with the control cohort (log-rank test, P < .001 and 6.73 vs 12.6 per 1000 person-y). The difference in the DM risk between patients with and without SGBIIA increased gradually with the follow-up duration. Age and sex did not affect the subsequent risk of developing DM, according to the multivariable Cox regression model. Nevertheless, the SGBIIA cohort exhibited a lower DM risk after we adjusted for the comorbidities of hypertension, hyperlipidemia, and coronary artery disease (adjusted hazard ratio (aHR): 0.56, 95% confidence interval (CI): 0.40-0.78). The incidence rate ratio (IRR) of DM in the SGBIIA cohort was lower than that in the control cohort for all age groups (age ≤ 49 y, IRR: 0.40, 95% CI: 0.16-0.99; age 50-64 y, IRR: 0.54, 95% CI: 0.31-0.96; age ≧ 65 y, IRR: 0.57, 95% CI: 0.36-0.91). Moreover, the IRR of DM was significantly lower in the SGBIIA cohort with comorbidities (IRR: 0.50, 95% CI: 0.31-0.78) compared with those without a comorbidity (IRR: 0.65, 95% CI: 0.40-1.04).

CONCLUSION

The findings of this population-based cohort study revealed that SGBIIA was associated with a reduced risk of DM development, and the inverse association was greater in the presence of a comorbidity.

Subtotal Gastrectomy With Billroth II Anastomosis Is Associated With a Low Risk of Ischemic Stroke in Peptic Ulcer Disease Patients: A Nationwide Population-Based Study

Duodenal diversion can ameliorate lipid and glucose metabolism. We assessed the risk of stroke after subtotal gastrectomy with Billroth II anastomosis (SGBIIA) in peptic ulcer disease (PUD). We identified 6425 patients who received SGBIIA for PUD between 1998 and 2010 from the Taiwan National Health Insurance Research Database as the study cohort; we frequency-matched them with 25,602 randomly selected controls from the PUD population who did not receive SGBIIA according to age, sex, index year, and comorbidities including hypertension, diabetes mellitus, hyperlipidemia, coronary artery disease, congestive heart failure, chronic kidney disease, chronic obstructive pulmonary disease (COPD), and obesity. All patients were followed until the end of 2011 to determine the incidence of stroke. The incidence of stroke was lower in patients in the SGBIIA cohort than in those in the non-SGBIIA cohort (18.9 vs 22.9 per 1000 person-years, adjusted hazard ratio [aHR] 0.80, 95% confidence interval [CI] 0.72-0.89, P < 0.001). The risk of ischemic stroke (aHR 0.77, 95% CI 0.69-0.86, P < 0.001), rather than hemorrhagic stroke (aHR 1.00, 95% CI 0.78-1.28), was lower for the SGBIIA cohort than for the non-SGBIIA cohort according to the multivariable Cox proportional hazard regression analysis. The relative risk of ischemic stroke after SGBIIA was lower in men (aHR 0.77, 95% CI 0.69-0.86) than in women (aHR 0.80, 95% CI 0.65-0.99) and in patients aged ≥65 years (aHR 0.72, 95% CI 0.63-0.81) than in those of other age groups (≤49 years, aHR 0.82, 95% CI 0.48-1.39; 50-64 years, aHR 1.01, 95% CI 0.79-1.28). The relative risk of ischemic stroke after SGBIIA was also reduced in patients with comorbidities (aHR 0.84, 5% CI 0.75-0.95) rather than in those without comorbidities (aHR 0.81, 95% CI 0.59-1.12). SGBIIA is associated with a low risk of ischemic stroke for PUD patients, and its protective effect is prominent in men, patients aged ≥65 years, and those with comorbidities.

A practical scoring system to predict mortality in patients with perforated peptic ulcer

Introduction

The mortality rate of perforated peptic ulcer is still high particularly for aged patients and all the existing scoring systems to predict mortality are complicated or based on history taking which is not always reliable for elderly patients. This study’s aim was to develop an easy and applicable scoring system to predict mortality based on hospital admission data.

Methods

Total 227 patients operated for perforated peptic ulcer in two centers were included. All data that may be potential predictors with respect to hospital mortality were retrospectively analyzed.

Results

The mortality and morbidity rates were 10.1% and 24.2%, respectively. Multivariated analysis pointed out three parameters corresponding 1 point for each which were age >65 years, albumin ≤1,5 g/dl and BUN >45 mg/dl. Its prediction rate was high with 0,931 (95% CI, 0,890 to 0,961) value of AUC. The hospital mortality rates for none, one, two and three positive results were zero, 7.1%, 34.4% and 88.9%, respectively.

Conclusion

Because the new system consists only age and routinely measured two simple laboratory tests (albumin and BUN), its application is easy and prediction power is satisfactory. Verification of this new scoring system is required by large scale multicenter studies.

Upper-gastrointestinal bleeding secondary to peptic ulcer disease: Incidence and outcomes

AIM: To evaluate the incidence, surgery, mortality, and readmission of upper gastrointestinal bleeding (UGIB) secondary to peptic ulcer disease (PUD).

METHODS: Administrative databases identified all hospitalizations for UGIB secondary to PUD in Alberta, Canada from 2004 to 2010 (n = 7079) using the International Classification of Diseases Codes (ICD-10). A subset of the data was validated using endoscopy reports. Positive predictive value and sensitivity with 95% confidence intervals (CI) were calculated. Incidence of UGIB secondary to PUD was calculated. Logistic regression was used to evaluate surgery, in-hospital mortality, and 30-d readmission to hospital with recurrent UGIB secondary to PUD. Co-variants accounted for in our logistic regression model included: age, sex, area of residence (i.e., urban vs rural), number of Charlson comorbidities, presence of perforated PUD, undergoing upper endoscopy, year of admission, and interventional radiological attempt at controlling bleeding. A subgroup analysis (n = 6356) compared outcomes of patients with gastric ulcers to those with duodenal ulcers. Adjusted estimates are presented as odds ratios (OR) with 95%CI.

RESULTS: The positive predictive value and sensitivity of ICD-10 coding for UGIB secondary to PUD were 85.2% (95%CI: 80.2%-90.2%) and 77.1% (95%CI: 69.1%-85.2%), respectively. The annual incidence between 2004 and 2010 ranged from 35.4 to 41.2 per 100000. Overall risk of surgery, in-hospital mortality, and 30-d readmission to hospital for UGIB secondary to PUD were 4.3%, 8.5%, and 4.7%, respectively. Interventional radiology to control bleeding was performed in 0.6% of patients and 76% of these patients avoided surgical intervention. Thirty-day readmission significantly increased from 3.1% in 2004 to 5.2% in 2010 (OR = 1.07; 95%CI: 1.01-1.14). Rural residents (OR rural vs urban: 2.35; 95%CI: 1.83-3.01) and older individuals (OR ≥ 65 vs < 65: 1.57; 95%CI: 1.21-2.04) were at higher odds of being readmitted to hospital. Patients with duodenal ulcers had higher odds of dying (OR = 1.27; 95%CI: 1.05-1.53), requiring surgery (OR = 1.73; 95%CI: 1.34-2.23), and being readmitted to hospital (OR = 1.54; 95%CI: 1.19-1.99) when compared to gastric ulcers.

CONCLUSION: UGIB secondary to PUD, particularly duodenal ulcers, was associated with significant morbidity and mortality. Early readmissions increased over time and occurred more commonly in rural areas.

Vagotomy/drainage is superior to local oversew in patients who require emergency surgery for bleeding peptic ulcers

OBJECTIVE

To compare early postoperative outcomes of patients undergoing different types of emergency procedures for bleeding or perforated gastroduodenal ulcers.

BACKGROUND

Although definitive acid-reducing procedures are being used less frequently during emergency ulcer surgery, there is little published data to support this change in practice.

METHODS

A retrospective analysis of data for patients from the 2005-2011 American College of Surgeons National Surgical Quality Improvement Program database who underwent emergency operation for bleeding or perforated peptic ulcer disease was performed to determine the association between surgical approach (local procedure alone, vagotomy/drainage, or vagotomy/gastric resection) and 30-day postoperative outcomes. Multivariable regression analysis was used to adjust for a number of patient-related factors.

RESULTS

A total of 3611 patients undergoing emergency ulcer surgery (775 for bleeding, 2374 for perforation) were included for data analysis. Compared with patients undergoing local procedures alone, vagotomy/gastric resection was associated with significantly greater postoperative morbidity when performed for either ulcer perforation or bleeding. For patients with perforated ulcers, vagotomy/drainage produced similar outcomes as local procedures but required a significantly greater length of postoperative hospitalization. Conversely, vagotomy/drainage was associated with a significantly lower postoperative mortality rate than local ulcer oversew when performed for bleeding ulcers.

CONCLUSIONS

Simple repair is the procedure of choice for patients requiring emergency surgery for perforated peptic ulcer disease. For patients requiring emergency operation for intractable ulcer bleeding, vagotomy/drainage is associated with lower postoperative mortality than with simple ulcer oversew.

Strategies to improve the outcome of emergency surgery for perforated peptic ulcer

BACKGROUND

Perforated peptic ulcer (PPU) is a common surgical emergency that carries high mortality and morbidity rates. Globally, one-quarter of a million people die from peptic ulcer disease each year. Strategies to improve outcomes are needed.

METHODS

PubMed was searched for evidence related to the surgical treatment of patients with PPU. The clinical registries of trials were examined for other available or ongoing studies. Randomized clinical trials (RCTs), systematic reviews and meta-analyses were preferred.

RESULTS

Deaths from peptic ulcer disease eclipse those of several other common emergencies. The reported incidence of PPU is 3.8-14 per 100,000 and the mortality rate is 10-25 per cent. The possibility of non-operative management has been assessed in one small RCT of 83 patients, with success in 29 (73 per cent) of 40, and only in patients aged less than 70 years. Adherence to a perioperative sepsis protocol decreased mortality in a cohort study, with a relative risk (RR) reduction of 0.63 (95 per cent confidence interval (c.i.) 0.41 to 0.97). Based on meta-analysis of three RCTs (315 patients), laparoscopic and open surgery for PPU are equivalent, but patient selection remains a challenge. Eradication of Helicobacter pylori after surgical repair of PPI reduces both the short-term (RR 2.97, 95 per cent c.i. 1.06 to 8.29) and 1-year (RR 1.49, 1.10 to 2.03) risk of ulcer recurrence.

CONCLUSION

Mortality and morbidity from PPU can be reduced by adherence to perioperative strategies.

Damage control surgery for abdominal emergencies

BACKGROUND

Damage control surgery is a management sequence initiated to reduce the risk of death in severely injured patients presenting with physiological derangement. Damage control principles have emerged as an approach in non-trauma abdominal emergencies in order to reduce mortality compared with primary definitive surgery.

METHODS

A PubMed/MEDLINE literature review was conducted of data available over the past decade (up to August 2013) to gain information on current understanding of damage control surgery for abdominal surgical emergencies. Future directions for research are discussed.

RESULTS

Damage control surgery facilitates a strategy for life-saving intervention for critically ill patients by abbreviated laparotomy with subsequent reoperation for delayed definitive repair after physiological resuscitation. The six-phase strategy (including damage control resuscitation in phase 0) is similar to that for severely injured patients, although non-trauma indications include shock from uncontrolled haemorrhage or sepsis. Minimal evidence exists to validate the benefit of damage control surgery in general surgical abdominal emergencies. The collective published experience over the past decade is limited to 16 studies including a total of 455 (range 3-99) patients, of which the majority are retrospective case series. However, the concept has widespread acceptance by emergency surgeons, and appears a logical extension from pathophysiological principles in trauma to haemorrhage and sepsis. The benefits of this strategy depend on careful patient selection. Damage control surgery has been performed for a wide range of indications, but most frequently for uncontrolled bleeding during elective surgery, haemorrhage from complicated gastroduodenal ulcer disease, generalized peritonitis, acute mesenteric ischaemia and other sources of intra-abdominal sepsis.

CONCLUSION

Damage control surgery is employed in a wide range of abdominal emergencies and is an increasingly recognized life-saving tactic in emergency surgery performed on physiologically deranged patients.

Enhanced postoperative recovery pathways in emergency surgery: a randomised controlled clinical trial

BACKGROUND

Enhanced recovery pathways are now widely used in elective surgical procedures. The feasibility of enhanced postoperative recovery pathways in emergency surgery for perforated peptic ulcer disease was investigated in this randomized controlled clinical trial.

METHODS

Patients with perforated peptic ulcer disease who underwent laparoscopic repair were randomized into 2 groups. Group 1 patients were managed with standard postoperative care and group 2 patients with enhanced postoperative recovery pathways. The primary endpoints were the length of hospital stay and morbidity and mortality.

RESULTS

Forty-seven patients were included in the study. There were 26 patients in group 1 and 21 in group 2. There were no significant differences in the morbidity and mortality rates, whereas the length of hospital stay was significantly shorter in group 2.

CONCLUSIONS

The application of enhanced postoperative recovery pathways in selected patients with perforated peptic ulcer disease who undergo laparoscopic Graham patch repair seems feasible.

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.

The management of perforated gastric ulcers

INTRODUCTION

Perforated gastric ulcers are potentially complicated surgical emergencies and appropriate early management is essential in order to avoid subsequent problems including unnecessary gastrectomy. The aim of this study was to examine the management and outcome of patients with gastric ulcer perforation undergoing emergency laparotomy for peritonitis.

METHODS

Patients undergoing laparotomy at the Royal Infirmary of Edinburgh for perforated gastric ulcers were identified from the prospectively maintained Lothian Surgical Audit (LSA) database over the five-year period 2007-2011. Additional data were obtained by review of electronic records and review of case notes.

RESULTS

Forty-four patients (25 male, 19 female) were identified. Procedures performed were: 41 omental patch repairs (91%), 2 simple closures (4.5%) and 2 distal gastrectomies (4.5%; both for large perforations). Four perforated gastric tumours were identified (8.8%), 2 of which were suspected intra-operatively and confirmed histologically, 1 had unexpected positive histology and 1 had negative intra-operative histology, but follow-up endoscopy confirmed the presence of carcinoma (1 positive biopsy in 21 follow-up endoscopies); all 4 were managed without initial resection. Median length of stay was 10 days (range 4-68). Overall 7 patients died in hospital (15.9%) and there were 21 morbidities (54.5%). Registrars performed the majority of the procedures (16 alone, 21 supervised) with no significant difference in post-operative morbidity (P = 0.098) or mortality (P = 0.855), compared to consultants.

CONCLUSION

Almost all perforated gastric ulcers can be effectively managed by laparotomy and omental patch repair. Initial biopsy and follow-up endoscopy with repeat biopsy is essential to avoid missing an underlying malignancy.