Gastric, Duodenal, and Small Bowel Emergencies

Gastric and small bowel emergencies are often seen in the emergency department and require rapid assessment and intervention as patients can deteriorate quickly. Some of the more frequently seen gastric emergencies include gastric volvulus and peptic ulcer disease, which can present with ischemia, strangulation, perforation, or severe bleeding. Swift diagnosis is crucial to ensuring the proper management whether that is endoscopic or with surgical exploration. Perforated peptic ulcers that are not contained will require surgical intervention, whereas bleeding ulcers can often be controlled with endoscopic interventions.

Outcomes of Laparoscopic vs Open Repair of Perforated Peptic Ulcers: An ACS-NSQIP Study

BACKGROUND

Perforated peptic ulcer (PPU) is a surgical emergency needing swift operative resolution. While laparoscopic and open approaches are viable options, it remains unclear whether laparoscopic repair has significantly improved outcomes. We use a national surgical database to compare perioperative and 30-d postoperative (30POP) outcomes.

MATERIALS AND METHODS

The 2016-2018 ACS-NSQIP database was used to create the patient cohort, using ICD-10 and CPT codes. An unmatched analysis identified factors that likely contributed to the laparoscopic versus open treatment allocation. Propensity score matching (PSM) was used to identify outcomes that were not explained by underlying differences in the patient cohorts.

RESULTS

A total of 3475 patients were included: 3135 in open group (OG), 340 (~10%) in laparoscopic group (LG). After PSM to control for comorbidities and illness severity that differed between groups on univariate analysis, 288 patients remained in each group. Analysis of the matched cohorts revealed no statistically significant difference in mortality (5.9% OG versus 3.8% LG, P = 0.245). The LG had significantly longer operative times (92 versus 79 min, P = 0.003), shorter hospital stays (8.2 versus 9.4 d, P = 0.044) and higher probability of being discharged home (81% versus 73%, P = 0.017). 30POP outcomes were largely equivalent, except that OG had higher risk for bleeding (14.6% versus 8%, P = 0.012) and pneumonia (8.7% versus 4.5%, P = 0.044).

CONCLUSIONS

While laparoscopic repairs take longer, they lead to shorter hospital stays and higher likelihood of discharge home. Further study to identify patients that are candidates for this technique is warranted.

The case series of peritonitis due to perforated peptic ulcer: How does conservative management play role?

INTRODUCTION

Surgical intervention is a conventional treatment for perforated peptic ulcer patients. This study aims to determine whether and how conservative non-operative management plays role in patients with pneumoperitoneum-peritonitis due to perforated peptic ulcers.

METHODS

A 9-year retrospective study was conducted in patients, who visit one surgeon service, with peritonitis due to perforated peptic ulcer and received non-operation conservative treatment. The treatment consists of nasogastric suction, intravenous fluid (IV) resuscitation, IV antibiotic and IV omeprazole. Outcomes and clinical course of conservative treatment in the selected group were reviewed. Factors associated with those outcomes and clinical course were analyzed.

RESULTS

There were 38 patients in this case series. Of which, 36 patients (94.7%) showed improvement after 24 h of conservative treatment and discharged without operation. Two patients underwent laparotomy in the 3^rd day of admission due to severe abdominal pain and progression of abdominal sign. There was no mortality in this case series. The conservative series had shorter hospital stay and lesser complication but prolong fever. Three factors indicated good outcomes in this series were found i.e. 1) free air in abdominal x-ray was not broader than the 1^st lumbar vertebral column height, 2) no free fluid seen in intra-peritoneal cavity by bedside ultrasound, 3) resuscitate fluid in the first 24 h was not more than 5 ml/kg/h.

CONCLUSION

In this case series, conservative non-surgical management showed good results for patients with peptic ulcers perforation. It could be used as an effective alternative modality when carefully patient selection and closely observed.