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A Randomized Trial of Nonoperative Treatment for Perforated Peptic Ulcer
Abstract
To determine whether surgery could be avoided in some patients with perforated peptic ulcer, we conducted a prospective randomized trial comparing the outcome of nonoperative treatment with that of emergency surgery in patients with a clinical diagnosis of perforated peptic ulcer. Of the 83 patients entered in the study over a 13-month period, 40 were randomly assigned to conservative treatment, which consisted of resuscitation with intravenous fluids, institution of nasogastric suction, and intravenous administration of antibiotics (cefuroxime, ampicillin, and metronidazole) and ranitidine. Eleven of these patients (28 percent) had no clinical improvement after 12 hours and required an operation. Two of the 11 had a perforated gastric carcinoma, and 1 had a perforated sigmoid carcinoma. The other 43 patients were assigned to immediate laparotomy and repair of the perforation. One of these patients was found to have a perforated gastric carcinoma. The overall mortality rates in the two groups were similar (two deaths in each, 5 percent), and did not differ significantly in the morbidity (infection, cardiac failure, or renal failure) rates (40 percent in the surgical group and 50 percent in the nonsurgical group). The hospital stay was 35 percent longer in the group treated conservatively. Patients over 70 years old were less likely to respond to conservative treatment than younger patients (P less than 0.05). We conclude that in patients with perforated peptic ulcer, an initial period of nonoperative treatment with careful observation may be safely allowed except in patients over 70 years old, and that the use of such an observation period can obviate the need for emergency surgery in more than 70 percent of patients.
... trial, conducted by Croft et al. [8], comparing NOM and emergency surgery in patients with perforated peptic ulcer. Finally, the overall mortality rates (two deaths in each, 5%), and the morbidity rates (40% in the surgical group and 50% in the nonsurgical group) demonstrated no significantly difference. ...
... Several studies have reported that non-operative treatment may be successful. The reported success rate was 50%-70% [8,[10][11][12]. Although the reported mortality rates vary from 5% [8], 30%-40% [13,14], to more than 60% [15]. ...
... The reported success rate was 50%-70% [8,[10][11][12]. Although the reported mortality rates vary from 5% [8], 30%-40% [13,14], to more than 60% [15]. Age is reported to be a risk toward non-responder to NOM. ...
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.
... Some reports have shown that about 40-80% of PPU are self-resolving and tend to seal off with nonsurgical management spontaneously, and overall outcomes are comparable with surgical repair [61,[105][106][107]. The protocol for nonsurgical management includes a nasogastric tube, intravenous fluids, antibiotics, PPIs, and repeated clinical assessment [1]. ...
... Many authors exclude old patients from nonsurgical management. In a nationwide inpatient database study involving 14,918 patients with PPU, Konishi et al. reported 14,918 patients who underwent nonoperative treatment than prior studies, which only included a total of 107 patients [106][107][108][109][110]. Unlike previous studies, this study included more patients >65 years of age and divided their patients into three distinct groups-young (ages 18-64 years old), old (ages 65-74 years old), and old-old (ages ≥75 years old). ...
... Nonsurgical treatment is resource-intensive and requires active monitoring of the patient's clinical status, and a surgeon must be available ondemand if the patient deteriorates. Lastly, before nonsurgical management, absolute diagnostic certainty must be ensured as the wrong diagnosis could increase mortality risk [59,106,111]. We have summarized the principles of nonoperative management as six R's: radiologically undetected leak; repeated clinical examination; repeated blood investigations; respiratory and renal support; resources for monitoring; and readiness to operate [1]. ...
Perforated peptic ulcer (PPU) presents with a clinical triad of sudden severe epigastric pain, tachycardia, and abdominal rigidity. An erect chest X-ray is an important diagnostic test. Computerized tomography (CT) scan is indicated when PPU is suspected, but chest X-ray is normal. Compliance with sepsis bundle is an integral component of resuscitation. PPU is a surgical emergency, and source control warrants closure of perforation. Open and laparoscopic omental patch suture repair (OPR) techniques (Graham’s patch or Cellan-Jones repair) and falciformopexy are safe, feasible, and comparable. Laparoscopic OPR may expedite the post-operative recovery; however, it requires proficiency in intra-corporeal suturing. Non-operative management (NOM) and endoscopic clipping or stenting are reported to be safe in selected patients. The principles of NOM are six R’s: radiologically undetected leak; repeated clinical examination; repeated blood investigations; respiratory and renal support; resources for monitoring; and readiness to operate. Gastric resections are warranted in patients with suspected malignancy or a giant ulcer size. There is minimal data to suggest that gastric resection improves clinical outcomes in patients with a giant ulcer. Vagotomy can be considered obsolete. Proton pump inhibitors, smoking cessation, and Helicobacter pylori eradication are the cornerstone for preventing recurrence. Scoring systems can assist in predicting mortality.KeywordsLaparoscopyOmental patchPeptic ulcerPerforationScoring system
... Despite these changes in treatment approaches, perforations still carry a great risk for mortality, and patients need an individualized approach to treatment, with an early diagnosis and early treatment being important factors in the discussion [5,6]. Although surgery is not necessary in some situations [7,8], multiple authors have agreed that surgical treatment is necessary in situations such as ulcers increasing in size, failing to heal completely, perforations, and especially malignancies [9][10][11]. Interestingly, unlike duodenal ulcers, which have relatively insignificant rates of cancer, gastric ulcers are usually correlated with malignancies, which contribute to its increased morbidity and mortality [11,12]. ...
... A separate study found a 2.9% mortality in surgically treated patients with gastric ulcers, which was more in line with the findings of our study [28]. Interestingly, one randomized trial looking at perforated peptic ulcers found no differences in mortality between surgical and nonsurgical groups [7]. However, the same randomized trial also found that nonsurgical treatment failure was higher in patients over 70 years, meaning that surgery should be a serious consideration for elderly patients. ...
... This longer HLOS by itself may also increase the odds of mortality [6,25]. In contradiction, one study found that, when comparing surgical and nonsurgical groups for patients with perforated peptic ulcers, HLOS was significantly increased in the nonsurgical group [7]. The authors concluded that this was likely due to nonsurgical treatment failure that led to complications and increased HLOS. ...
Background:
Patients admitted emergently with a primary diagnosis of acute gastric ulcer have significant complications including morbidity and mortality. The objective of this study was to assess the risk factors of mortality including the role of surgery in gastric ulcers.
Methods:
Adult (18-64-year-old) and elderly (≥65-year-old) patients admitted emergently with hemorrhagic and/or perforated gastric ulcers, were analyzed using the National Inpatient Sample database, 2005-2014. Demographics, various clinical data, and associated comorbidities were collected. A stratified analysis was combined with a multivariable logistic regression model to assess predictors of mortality.
Results:
Our study analyzed a total of 15,538 patients, split independently into two age groups: 6338 adult patients and 9200 elderly patients. The mean age (SD) was 50.42 (10.65) in adult males vs. 51.10 (10.35) in adult females (p < 0.05). The mean age (SD) was 76.72 (7.50) in elderly males vs. 79.03 (7.80) in elderly females (p < 0.001). The percentage of total deceased adults was 1.9% and the percentage of total deceased elderly was 3.7%, a difference by a factor of 1.94. Out of 3283 adult patients who underwent surgery, 32.1% had perforated non-hemorrhagic ulcers vs. 1.8% in the non-surgical counterparts (p < 0.001). In the 4181 elderly surgical patients, 18.1% had perforated non-hemorrhagic ulcers vs. 1.2% in the non-surgical counterparts (p < 0.001). In adult patients managed surgically, 2.6% were deceased, while in elderly patients managed surgically, 5.5% were deceased. The mortality of non-surgical counterparts in both age groups were lower (p < 0.001). The multivariable logistic regression model for adult patients electing surgery found delayed surgery, frailty, and the presence of perforations to be the main risk factors for mortality. In the regression model for elderly surgical patients, delayed surgery, frailty, presence of perforations, the male sex, and age were the main risk factors for mortality. In contrast, the regression model for adult patients with no surgery found hospital length of stay to be the main risk factor for mortality, whereas invasive diagnostic procedures were protective. In elderly non-surgical patients, hospital length of stay, presence of perforations, age, and frailty were the main risk factors for mortality, while invasive diagnostic procedures were protective. The following comorbidities were associated with gastric ulcers: alcohol abuse, deficiency anemias, chronic blood loss, chronic heart failure, chronic pulmonary disease, hypertension, fluid/electrolyte disorders, uncomplicated diabetes, and renal failure.
Conclusions:
The odds of mortality in emergently admitted geriatric patients with acute gastric ulcer was two times that in adult patients. Surgery was a protective factor for patients admitted emergently with gastric perforated non-hemorrhagic ulcers.
... Nonoperative treatment should be considered in patients with uncomplicated PPU, which prevents surgery and its resultant morbidity. Studies have demonstrated that approximately 40%-80% of patients with PPU will heal spontaneously, and most patients with uncomplicated PPU can benefit from nonoperative management (NOM) [5,[9][10][11]. Prognostic factors that can enhance recovery, and reduce morbidity and mortality should be identified and investigated further. ...
... Several retrospective studies have reported that the NOM technique has a higher success rate in well-selected patients [13]. Moreover, surgical treatment did not show an advantage with regard to morbidity and mortality compared to NOM [5,9,10]. According to World Society of Emergency Surgery guidelines, patients with PPU were suggested to avoid endoscopic treatment such clipping, fibrin glue sealing, or stenting. ...
... In our study, approximately 81.6% (222/272) of patients received NOM, and the incidence of non-fatal complications was similar to that for those who converted to surgery. These data are in accordance with previous studies and indicate that NOM is a feasible approach [9,14]. However, NOM for PPU is still controversial and has not been widely adopted. ...
Background:
Nonoperative management (NOM) is a promising therapeutic modality for patients with perforated peptic ulcer (PPU). However, the risk factors for poor efficacy and adverse events of NOM are a concern.
Aim:
To investigate the factors predictive of poor efficacy and adverse events in patients with PPU treated by NOM.
Methods:
This retrospective case-control study enrolled 272 patients who were diagnosed with PPU and initially managed nonoperatively from January 2014 to December 2018. Of these 272 patients, 50 converted to emergency surgery due to a lack of improvement (surgical group) and 222 patients were included in the NOM group. The clinical data of these patients were collected. Baseline patient characteristics and adverse outcomes were compared between the two groups. Logistic regression analysis and receiver operating characteristic curve analyses were conducted to investigate the factors predictive of poor efficacy of NOM and adverse outcomes in patients with PPU.
Results:
Adverse outcomes were observed in 71 patients (32.0%). Multivariate analyses revealed that low serum albumin level was an independent predictor for poor efficacy of NOM and adverse outcomes in patients with PPU.
Conclusion:
Low serum albumin level may be used as an indicator to help predict the poor efficacy of NOM and adverse outcomes, and can be used for risk stratification in patients with PPU.
... The asymptomatic patients are usually those who had typical symptoms of short duration with improvement by the time of hospital admission. Unlike gastric ulcer perforation, a large portion of duodenal ulcer perforation can be treated non-surgically (83). Pneumo-peritoneum has co-incidentally been discovered on erect chest or plain abdominal-x ray and, the computed tomography (CT) scan is used to investigate the pneumoperitoneum. ...
... Small trials showed similar results to operative intervention and mortality rates of 5% in each group. Morbidity of 40% in the Taylor's method group vs. 50% in the surgical repair group has been reported in some studies (83). The exception was patients older than 70 years of age which was a factor associated with higher risk of surgical intervention. ...
... The exception was patients older than 70 years of age which was a factor associated with higher risk of surgical intervention. The study concluded that patients with perforated peptic ulcer may be observed in the initial 24 h and managed non-operatively (83). Thirty percent for whom nonoperative treatment is initiated proceed to surgery, particularly if age is >70 (92). ...
Gastroduodenal perforation may be spontaneous or traumatic and the majority of
spontaneous perforation is due to peptic ulcer disease. Improved medical management
of peptic ulceration has reduced the incidence of perforation, but still remains a common
cause of peritonitis. The classic sub-diaphragmatic air on chest x-ray may be absent
and computed tomography scan is a more sensitive investigation in the stable patient.
The management of perforated peptic ulcer disease is still a subject of debate. The
majority of perforated peptic ulcers are caused by Helicobacter pylori, so definitive
surgery is not usually required. Perforated peptic ulcer is an indication for operation in
nearly all cases except when the patient is asymptomatic or unfit for surgery. However,
non-operative management has a significant incidence of intra-abdominal abscesses
and sepsis. Primary closure is achievable in traumatic perforation, but the management
follows the Advanced Trauma Life Support (ATLS) principles.
... reported the safety of conservative treatment [5]. Recently, the number of cases in which conservative treatment is selected based on certain criteria has been increasing. ...
... Traditionally, emergency surgery has been the gold standard treatment for upper gastrointestinal perforations caused by peptic ulcers. However, interest in conservative treatment has spread owing to the report of a randomized controlled trial conducted by Crofts et al. [5], and at present, there are more opportunities for conservative treatment to be performed after selecting suitable cases. ...
Background
Upper gastrointestinal perforation, primarily caused by peptic ulcers, remains a life-threatening condition associated with a high mortality rate. While surgical intervention has been the traditional first line of treatment, the establishment of various guidelines has prompted a shift in treatment strategies, particularly in cases of patients with mild symptoms of peritonitis who are aged < 70 years. The effectiveness of conservative treatment for upper gastrointestinal perforation in older patients remains unknown. Therefore, this study aimed to evaluate the effectiveness of conservative treatment by comparing it with that of surgical treatment in patients of the same age.
Methods
This retrospective study examined patients aged > 70 years with upper gastrointestinal perforation at Takeda General Hospital from April 2013 to March 2023. We focused on evaluating key factors such as duration of antibiotic use, blood transfusion requirements, fasting periods, length of hospital stay, discharge conditions, and mortality rates at 30- and 90-days post-treatment.
Results
The study included 31 patients (11 underwent conservative treatment and 20 underwent surgery). More patients had generalized peritonitis in the surgical group than in the conservative treatment group (p = 0.023). Regarding the course after intervention, the fasting period was slightly longer in the conservative treatment group than in the surgical group (p = 0.0064); however, no 30-day deaths were noted overall, with no significant difference in 90-day mortality between the two groups.
Conclusions
Conservative treatment for upper gastrointestinal perforation in older patients aged > 70 years, when appropriately selected, demonstrated outcomes equivalent to those of surgical intervention. Conservative treatment appears to be effective in cases of localized peritonitis, potentially avoiding unnecessary surgery. Further accumulation of case studies is desirable for establishment of clear criteria for conservative treatment indications in the older patients.
... Several studies have reported that conservative treatment may be successful. The reported success rate was 50-70% [4][5][6][7] . Although the reported mortality rates vary from 5% 4 , 30-40% 8,9 , to more than 60% 10 . ...
... Surgery may offer a limited survival bene t compared to nonoperative treatment for these patients. Nonoperative treatment, including antibiotics and/or percutaneous drainage, which may offer an approximately 70% success rate 4,5,7 , or hospice care, should be seriously considered in such situations. ...
The major treatment for perforated peptic ulcers (PPU) is surgery, and several scoring systems have been reported to predict morbidity and mortality after surgery. However, it remains unclear which patient should receive nonoperative management instead of surgery. This study aimed to generate a scoring system for surgeons to identify patients with PPU who may be too weak to undergo surgery and without any survival benefit. We extracted the admission data of adult (≥ 18 years) patients with PPU disease from the NHIRD database. They were randomly divided into an 80% model derivation cohort and a 20% validation cohort. Multivariate analysis with a logistic regression model was applied to generate the scoring system, PPUMS. The scoring system was then applied to the validation group. 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). In the derivation group, patients with PPUMS > 4 had a 45.9% in-hospital mortality rate and similar in-hospital mortality risk in the operation group [traditional laparotomy: odds ratio (OR) = 0.729, p = 0.320, laparoscopy: OR = 0.772, p = 0.697] and the non-operation group. In the validation group, patients with PPUMS > 4 points had a 36.9% mortality rate and similar mortality risk in the operation group (traditional laparotomy: OR = 0.353, p = 0.093, laparoscopy: no applicable) and non-operation group. PPUMS is a good predictor of mortality risk in patients with PPU and with various underlying diseases or comorbidities. Surgical management is suggested for patients with PPU with PPUMS ≤ 4 points because of lower mortality risk. However, in patients with PPUMS > 4 points, surgery may have limited benefit due to the high mortality rate compared to nonoperative treatment.
... 12 It has been estimated that about 40-80% of the perforations will seal spontaneously and overall morbidity and mortality are comparable. 3,[11][12][13] However, delaying the time point of operation beyond 12 h after the onset of clinical symptoms will worsen the outcome in PPU. 3,14 Also in patients >70 years of age conservative treatment is unsuccessful with a failure rate as high as 67%. ...
... 3,14 Also in patients >70 years of age conservative treatment is unsuccessful with a failure rate as high as 67%. 13,14 Shock at admission and conservative treatment were associated with a high mortality rate (64%). 11,14 In conclusion, one can say that non-operative treatment is limited to patients <70 years of age who are not eligible for surgical repair due to associated morbidity, with documented contrast studies showing that the perforation has sealed completely. ...
Background: Peptic ulcer disease is highly prevalent in general population managed mainly by medical treatment with H2 blockers, proton pump inhibitors and antibiotics with eradication of Helicobacter pylori, the complications have reduced, but perforation is still frequently occurring and is always a surgical emergency.Methods: It was a hospital based retrospective observational study from January 2015 to June 2017 and prospective observational study from July 2017 to June 2019. Study patients were diagnosed, managed and operated for perforated peptic ulcer at Sheri-i-Kashmir Institute of Medical Sciences, Soura, Kashmir, India. Data of 44 patients was collected using a standard proforma and their risk factors, operative procedure, post-operative progress and outcome was analysed.Results: In our study of 44 cases, patients between ages of 21-30 years (31.8) were commonly affected and there was male predominance (95.5%). Smoking, use of NSAIDS and improper treatment for peptic ulcer were major risk factors. 61.4% patients presented within 24 hours of presentation. Cellan Jones repair was performed in 60.4% patients. Complications were due to co-morbid illness, age and delayed presentation for treatment.Conclusions: Perforated peptic ulcer (PPU) is a frequent surgical emergency in our state, predominantly affecting young aged male, may be because of dietary habits (very spicy food), smoking, NSAIDS and other risk factors. Surgical intervention is always warranted. Simple closure with omental patch is standard procedure, followed by treatment for H. pylori eradication and was effective and majority of patients survived despite delayed preoperative admission.
... Although all eligible patients in this study were treated between 2005 and 2018, some patients were included before these guidelines were published, and the results of this study eventually confirmed the validity of these guidelines. Crofts et al. [25] reported that patients aged over 70 years were considered less likely to respond to conservative management than younger patients, and the Japanese guidelines recommend surgical treatment for such patients. It has also been reported that the age at which conservative therapy is indicated is < 70 years [10]. ...
... Approximately 50-70% of patients with PPU respond to conservative management without surgery [25,26]. The Japanese guidelines also estimate a treatment success rate of 83% (76-100%) for conservative management of PPU [10]. ...
Background
Gastroduodenal perforation is potentially life threatening and requires early diagnosis and treatment. Urgent endoscopy facilitates detecting bleeding sites and achieving hemostasis. However, there is no consensus on urgent endoscopy for gastroduodenal perforation in Japan.Methods
We evaluated the effectiveness and safety of urgent endoscopy for gastroduodenal perforation. We compared clinical characteristics between 140 patients who underwent urgent endoscopy (urgent endoscopy group) and 16 patients did not (no urgent endoscopy group) at Hiroshima City Asa Citizens Hospital between December 2005 and December 2018.ResultsEndoscopic diagnosis was possible in all urgent endoscopy group. In contrast, correct diagnosis of the perforation site was made on CT in 99 cases (63%). Furthermore, the proportion of cases with correct diagnosis of the perforation site by CT findings differed significantly between the urgent endoscopy group and the no urgent endoscopy group (66% vs. 38%, p < 0.05). No complications of urgent endoscopy were observed. Primary perforation site was gastric in 42 cases and duodenal in 114. In the 42 gastric perforation cases, 12 gastric perforation cases (29%) were managed conservatively, successfully in 9 (75%); 2 cases (17%) required delayed emergency surgery for worsening peritonitis. In the 114 duodenal perforation cases (duodenal ulcer in all cases), 52 cases (46%) were managed conservatively, successfully in 48 (92%); 3 cases (6%) required delayed emergency surgery for worsening peritonitis. A significantly higher proportion of gastric perforation cases than duodenal perforation cases required surgical treatment (76% vs. 57%, p < 0.05). Multivariate analysis revealed localized abdominal pain (no peritonism) (OR 0.25; 95% CI 0.08–0.75; p < 0.01) and perforation diameter ≤ 5 mm (OR 0.13; 95% CI 0.04–0.36; p < 0.01) as significant independent clinical factors for successful conservative management of duodenal ulcer perforation.Conclusions
Urgent endoscopy in gastroduodenal perforation enabled primary diagnosis and perforation site identification, and facilitated deciding the management strategy.
... In 1989, Croft was the first to compare two different methods for treating ulcer perforations. He performed a randomized study comparing conservative treatment and surgical closure with surprisingly good results in both groups [24]. However, in both these studies, the diagnoses of ulcer perforation in non-operated patients were not verified. ...
... Our study indicates that the diagnosis of a perforated ulcer cannot be established without either gastroscopy or laparoscopy. Croft concluded, in his study, that conservative treatment might not be a good option in elderly patients, who might be less prone to spontaneous ulcer sealing [24]. In our current study and in our previous case series [18], age did not seem to influence the clinical outcome of stent treatment, where the ulcer seals when the leak is covered. ...
Background
Perforated peptic ulcer is a life-threatening condition. Traditional treatment is surgery. Esophageal perforations and anastomotic leakages can be treated with endoscopically placed covered stents and drainage. We have treated selected patients with a perforated duodenal ulcer with a partially covered stent. The aim of this study was to compare surgery with stent treatment for perforated duodenal ulcers in a multicenter randomized controlled trial.
Methods
All patients presenting at the ER with abdominal pain, clinical signs of an upper G-I perforation, and free air on CT were approached for inclusion and randomized between surgical closure and stent treatment. Age, ASA score, operation time, complications, and hospital stay were recorded. Laparoscopy was performed in all patients to establish diagnosis. Surgical closure was performed using open or laparoscopic techniques. For stent treatment, a per-operative gastroscopy was performed and a partially covered stent was placed through the scope. Abdominal lavage was performed in all patients, and a drain was placed. All patients received antibiotics and intravenous PPI. Stents were endoscopically removed after 2–3 weeks. Complications were recorded and classified according to Clavien-Dindo (C-D).
Results
43 patients were included, 28 had a verified perforated duodenal ulcer, 15 were randomized to surgery, and 13 to stent. Median age was 77.5 years (23–91) with no difference between groups. ASA score was unevenly distributed between the groups (p = 0.069). Operation time was significantly shorter in the stent group, 68 min (48–107) versus 92 min (68–154) (p = 0.001). Stents were removed after a median of 21 days (11–37 days) without complications. Six patients in the surgical group had a complication and seven patients in the stent group (C-D 2–5) (n.s.).
Conclusions
Stent treatment together with laparoscopic lavage and drainage offers a safe alternative to traditional surgical closure in perforated duodenal ulcer. A larger sample size would be necessary to show non-inferiority regarding stent treatment.
... [6,7] In the literature, it is stated that the patients who are under 70 years of age, who are admitted to hospital within 24 hours after the onset of the symptoms, who have localized peritonitis findings and non-extensive fluid in the abdomen by imaging methods and whose peritoneal irritation symptoms are limited in the upper quadrants, can be followed-up conservatively. [8,9] The success rate of the conservative approach using this method was reported as 72% by Crofts et al. [8] In our study, all of the patients were admitted to the hospital at an early stage. Five cases were under 70 years of age. ...
... [6,7] In the literature, it is stated that the patients who are under 70 years of age, who are admitted to hospital within 24 hours after the onset of the symptoms, who have localized peritonitis findings and non-extensive fluid in the abdomen by imaging methods and whose peritoneal irritation symptoms are limited in the upper quadrants, can be followed-up conservatively. [8,9] The success rate of the conservative approach using this method was reported as 72% by Crofts et al. [8] In our study, all of the patients were admitted to the hospital at an early stage. Five cases were under 70 years of age. ...
Open or laparoscopic Graham's omentopexy is frequently used in the treatment of peptic ulcer perforation (PUP). The technical difficulty of applying the omental plug, especially in patients with previous omentum resection, has led to the use of falciform ligament for the PUP, and some studies have reported that PUP may even be a more advantageous technique than omentopexy. Here, in this study, we aimed to compare the retrospective results of patients who underwent falciformopexy or omentopexy for PUP.
METHODS:
Between 1999 and 2018, 303 patients who were followed-up and treated for PUP were included in this study. Patients who had malignancy, gastric resection, definitive ulcer surgery, laparoscopic surgery and nonoperative treatment were excluded from this study. In the remaining patients, either open ometopexy or falciformopexy were applied based on the surgeon's choice. These two techniques were compared for intraoperative and postoperative outcomes.
RESULTS:
Falciformopexy (n=46) and omentopexy (n=243) groups had similar demographics, but ASA scores were lower in the falciformopexy group. For ulcer size and localization, duration of operation, no difference was found between the groups. There was no significant difference between the groups concerning general postoperative morbidity and mortality. However, atelectasis was more frequently observed in the omentopexy group, whereas the pexia failure was more frequent in the falciformopexy group (2.6% and 8.7%, p=0.04).
CONCLUSION:
Falciformopexy is an alternative technique that can be used in situations where it is not possible to use the omentum. Falciformopexy is not superior to omentopexy for the repair of the PUP.
... Therefore, many doctors oppose conservative approaches in upper gastrointestinal system perforations, addressing their ineffectiveness in controlling intra-abdominal sepsis. [6] In a study reviewing 80 perforations, increased mortality was observed in patients diagnosed with perforation more than 24 hours after ERCP and experiencing delayed surgical intervention. [7] In the delayed surgery group, all deaths were attributed to sepsis or multiorgan failure. ...
Background:
While numerous studies have proposed algorithms for the management of Stapfer Type 2 ERCP perforations, there is limited research on surgical treatment options specifically for this patient group. Our aim is not to propose a new algorithm for these patients but to describe our surgical approach and contribute to the literature with our surgical procedure applied in Stapfer Type 2 ERCP perforation cases.
Methods:
Between 2016 and 2023, a total of 12 patients with Stapfer Type 2 ERCP perforations underwent surgery at our hospital. Duodenal diverticulization is a commonly used method in complex duodenal perforation cases. We performed a procedure that involves the removal of the external biliary pathway, hepaticojejunostomy, and a wide Braun anastomosis in addition to the duodenal diverticulization procedure, which we have termed "modified duodenal diverticulization."
Results:
Eleven out of the 12 patients were discharged successfully without any complications. One patient, who had a late diagnosis, underwent surgery 5 days after ERCP. This patient had ongoing sepsis before the operation, which continued postoperatively and eventually led to multiple organ failure and death.
Conclusion:
There are limited alternatives for the surgical treatment of Type 2 ERCP perforations, and the widely preferred triple ostomy method may not address the underlying pathology necessitating ERCP. The modified duodenal diverticulization method, offering a definitive treatment, can be considered a surgical option for Type 2 ERCP perforations.
... 12 In preparation for surgery, patients with a perforated viscus should receive fluid resuscitation and broad-spectrum intravenous antibiotics with good coverage for Gram-negative organisms. 13 Intravenous proton-pump inhibitor therapy is also suggested for patients with perforated peptic ulcer. 14 Barium esophagram is indicated for the evaluation of dysphagia (eg, patients with suspected hiatal hernia, achalasia, esophageal webs). ...
... Chung et al. reported that about 40%-80% of PPU will spontaneously seal with conservative management known as the "Taylor method," consisting of nasogastric suction, intravenous drip, antibiotics, and repeated clinical assessment only, and the overall morbidity and mortality were comparable [13,21,22]. Our patient was also managed conservatively for a sealed perforated peptic ulcer and showed complete recovery. ...
Hypercalcemia is a common electrolyte abnormality with different causes. Hypercalcemia is most often associated with malignancy and primary hyperparathyroidism and malignancy together account for most cases. Primary hyperparathyroidism manifests as hypercalcemia owing to the overproduction of parathyroid hormone. In most cases, primary hyperparathyroidism manifests due to a solitary parathyroid adenoma. Based on calcium levels, hypercalcemia can be classified as mild, moderate, and severe. Hypercalcemia typically presents with non-specific clinical features. Here, we present the case of a 38-year-old male patient who presented to the emergency department (ED) with acute abdominal pain and a tender abdomen with absent bowel sounds. He had chest radiography and blood tests initially. Chest radiography showed left-sided pneumoperitoneum, and the patient was suspected to have a perforated peptic ulcer due to hypercalcemia secondary to a parathyroid adenoma during the second wave of the coronavirus disease 2019 (COVID-19) pandemic. The findings were confirmed by a computerized tomography scan of the abdomen, and the patient was treated with intravenous fluids for hypercalcemia and was managed conservatively for a sealed perforated peptic ulcer following discussion in the multi-disciplinary team meeting (MDT). The COVID-19 pandemic led to a long waiting list and delays in the timely management of patients requiring elective surgical intervention, such as parathyroidectomy. The patient made a complete recovery and had parathyroidectomy of the inferior right lobe two months later.
... H. pylori eradikasyonu için kullanılan üçlü tedavi ve omeprazolün rekürrensi azalttığı bilinmektedir. [17] Yapılan çalışmalarda PÜP'ün %40-80 oranında konservatif tedaviyle kapandığı saptanmıştır. [2,18,19] Klinik olarak stabil olan ve takiplerinde klinik düzelme saptanan kapalı perforasyonu bulunan hastalarda konservatif tedavi etkili bir seçenek olarak görülmektedir. ...
... As úlceras gástricas tipo IV estão localizadas ao longo da curvatura menor, perto de 1 a 2 cm da junção gastroesofágica. Pacientes com úlcera gástrica tipo IV apresentam hipoacidez e apresentam disfagia e refluxo gastroesofágico 10,11 . ...
O tratamento cirúrgico da úlcera péptica é reservado para úlcera péptica refratária ao tratamento clínico e/ou endoscópico, para suspeita de malignidade dentro de uma úlcera ou para o tratamento de complicações da úlcera péptica. Os pacientes com úlcera duodenal e indicação de cirurgia eletiva, sugere-se a vagotomia em vez de outro procedimento de redução de ácido. A vagotomia reduz o risco de ulceração recorrente, minimizando as complicações pós-operatórias e as sequelas a longo prazo. Para pacientes com úlcera duodenal hemorrágica que receberam tratamento médico adequado, sugere-se realizar uma vagotomia troncular e piloroplastia após o controle do sangramento, em vez de outro procedimento. O manejo do leito da úlcera sozinho para controlar o sangramento é apropriado em pacientes hemodinamicamente instáveis, pacientes com comorbidades significativas que limitam a expectativa de vida e pacientes com infecção por Helicobacter pylori não tratada. A compreensão do manejo cirúrgico continua sendo importante, uma vez que a cirurgia é a base do tratamento de emergência dessas complicações com risco de vida e para doenças refratárias ao tratamento médico.
... As úlceras gástricas tipo IV estão localizadas ao longo da curvatura menor, perto de 1 a 2 cm da junção gastroesofágica. Pacientes com úlcera gástrica tipo IV apresentam hipoacidez e apresentam disfagia e refluxo gastroesofágico 10,11 . ...
O tratamento cirúrgico da úlcera péptica é reservado para úlcera péptica refratária ao tratamento clínico e/ou endoscópico, para suspeita de malignidade dentro de uma úlcera ou para o tratamento de complicações da úlcera péptica. Os pacientes com úlcera duodenal e indicação de cirurgia eletiva, sugere-se a vagotomia em vez de outro procedimento de redução de ácido. A vagotomia reduz o risco de ulceração recorrente, minimizando as complicações pós-operatórias e as sequelas a longo prazo. Para pacientes com úlcera duodenal hemorrágica que receberam tratamento médico adequado, sugere-se realizar uma vagotomia troncular e piloroplastia após o controle do sangramento, em vez de outro procedimento. O manejo do leito da úlcera sozinho para controlar o sangramento é apropriado em pacientes hemodinamicamente instáveis, pacientes com comorbidades significativas que limitam a expectativa de vida e pacientes com infecção por Helicobacter pylori não tratada. A compreensão do manejo cirúrgico continua sendo importante, uma vez que a cirurgia é a base do tratamento de emergência dessas complicações com risco de vida e para doenças refratárias ao tratamento médico.
... The viability of nonoperative care for PPU was not demonstrated until the results of the first randomised controlled trial were published in 1989. According to Crofts et al. [4], nonoperative therapy using comparable methods can effectively treat approximately 72% of cases with comparable morbidity and mortality as compared to the immediate surgical group. Perforated peptic ulcer is currently treated medically and surgically, both of which have benefits and drawbacks of their own. ...
Perforated peptic ulcer (PPU) treatment guidelines are still up for discussion. Due to the morbidity and mortality linked to each, the use of both operative and non-operative management, including conservative and endoscopic treatment, is still debatable. A standardized protocol has been used to write a best evidence topic. The discussion focused on whether operative management for PPU is preferable to non-operational management or vice versa.
MEDLINE, the Cochrane Library, Scopus, and the Web of Science were the databases used to conduct an electronic search of the pertinent literature.
We found 56 articles, out of these only 5 studies were found to be appropriate to answer the question. The outcome assessed was failure of management. The best evidence showed that both operative and non-operative management can be used with similar outcomes depending on the patient selection for each category.
... The advantages of conservative management include avoi dance of surgery, risks of general anaesthesia and postoperative compli cations. On the other hand, disadvantages include misdiagnosis and higher mortality rate if conser vative management fails (19). In clinical practice, the non-operative management strategy is resource-intensive and requires a commitment of active regular clinical examination along with round the clock availability of a surgeon, and if there is clinical deterioration, emergency surgery is warranted. ...
Peptic ulcers are caused by acid peptic damage to the mucosal layer in the gastro-duodenal area of the gut, which results in mucosal erosion that exposes the underlying tissues to the digestive action of gastro-duodenal secretions. This pathology was traditionally related to a hypersecretory acid environment, dietary factors and stress. There are other causes of ulcers such as Helicobacter pylori infection, excessive use of NSAIDs, and smoke and alcohol abuse. Perforation and bleeding are two major complications of the disease. A typical symptom of perforated peptic ulcers (PPU) is a sudden onset of abdominal pain or acute deterioration of the ongoing abdominal pain. Perforated peptic ulcer can be diagnosed by a simple X-ray and CT scan of the abdomen. Laboratory tests are also run to rule out differential diagnosis. Although there are several choices for surgical intervention, minimally invasive techniques have been taking over as a frequent option in feasible cases. Techniques like laparoscopy have been surfacing because of their advantages. But the efficiency of minimally invasive techniques compared to conventional approach is yet to be defined. Hence, the present review of the literature aims to describe and delineate the current perspective on PPU management by minimally invasive and low risk techniques.
... In contrast, evidence from conservative treatment in patients with perforated peptic ulcers shows a success rate for non-operative therapy of 50% -70% 11,12 . Recent case reports 13,14 and patient series report similar findings: Rossetti et al. performed a retrospective analysis 7 akin to the one presented by us, reporting on seven patients with contained perforation of the duodenum. ...
Surgical therapy of duodenal perforation into the retroperitoneum entails high morbidity. Conservative treatment and endoscopic negative pressure therapy have been suggested as promising therapeutic alternatives. We aimed to retrospectively assess outcomes of patients treated for duodenal perforation to the retroperitoneum at our department. A retrospective analysis of all patients that were treated for duodenal perforation to the retroperitoneum at our institution between 2010 and 2021 was conducted. Different therapeutic approaches with associated complications within 30 days, length of in-hospital stay, number of readmissions and necessity of parenteral nutrition were assessed. We included thirteen patients in our final analysis. Six patients underwent surgery, five patients were treated conservatively and two patients received interventional treatment by endoscopic negative pressure therapy. Length of stay was shorter in patients treated conservatively. One patient following conservative and surgical treatment each was readmitted to hospital within 30 days after initial therapy whereas no readmissions after interventional treatment occurred. There was no failure of therapy in patients treated without surgery whereas four (66.7%) of six patients required revision surgery following primary surgical therapy. Conservative and interventional treatment were associated with fewer complications than surgical therapy which involves high morbidity. Conservative and interventional treatment using endoscopic negative pressure therapy in selected patients might constitute appropriate therapeutic alternatives for duodenal perforations to the retroperitoneum.
... Those who are in favour argue that operation, anesthesia in associated morbidity, reduction in postoperative intraabdominal adhesion induced by surgery which makes future elective definitive surgery for PUD or other indications difficult but hospital stay is shorter where as those who are not in favour, argue that there is prolonged hospital stay, higher mortality rate if conservative fails, lack of benefit of laparoscopy as diagnostic tool in cases of patient with misdiagnosis and missing of gastric cancer. (35,37,38) So in cases in whom conservative treatment is chosen UGI endoscopy should be performed to rule out gastric cancer. In the present series we have not managed any case conservatively. ...
Background: Perforated peptic ulcer (PPU) is a common life-threatening surgical emergency. The discovery of H. pylori (1985) changed the concept of the management of peptic ulcer. Nowadays reduction in gastric acid production with proton pump inhibitors along with eradication of H. pylori is recommended. Objective: to analysis the surgical outcome for management of perforated peptic ulcer in Al-gomhuri Hospital during 2017-2020. Methods: Clinically suspected cases of PPU were confirmed by radiological and laboratory investigation. These patients were subjected to exploratory laparotomy with Graham’s omental patch repair after adequate fluid resuscitation with optimal hemodynamic status with peritoneal drainage Postoperatively these patients kept in SICU and closely monitored. Data were collected, tabulated and analyzed. Results: 62 cases enrolled; Male patients were predominant than female in a ratio of 60:2. Age ranges from 20 to >60 years. Majority of the patients belongs to the age group 30-40 years of age. The morbidity and mortality rates were (20%) and (3.2%) respectively. Conclusions: Adequate fluid resuscitation with optimal hemodynamic status and optimal kidney function is the key to decrease morbidity and mortality rates. Simple closure with omental patch followed by H. pylori eradication is effective with an excellent outcome in most of survivor despite late presentation. Definitive surgery for ulcer recurrence is no more done except in special situations.
... The total incidence of PPU has decreased since anti-acid drugs, such as H2 blockers or proton pump inhibitors (PPIs), have been used and since H. pylori eradication became standard [4,5]. Some studies have suggested that selected PPU patients can be treated by conservative therapy [6,7]. However, PPU is basically a surgical disease with serious morbidity and mortality that shows 30-day mortality up to 20% and 90-day mortality up to 30% [8][9][10][11][12]. ...
Background:
Perforated peptic ulcer (PPU) is a disease whose incidence is decreasing. However, PPU still requires emergency surgery. The aim of this study was to review the clinical characteristics of patients who received primary repair for PPU and identify the predisposing factors associated with severe complications.
Method:
From January 2011 to December 2020, a total of 75 patients underwent primary repair for PPU in our hospital. We reviewed the patients' data, including general characteristics and perioperative complications. Surgical complications were evaluated using the Clavien-Dindo Classification (CDC) system, with which we classified patients into the mild complication (CDC 0-III, n = 61) and severe complication (CDC IV-V, n = 14) groups.
Result:
Fifty patients had gastric perforation, and twenty-five patients had duodenal perforation. Among surgical complications, leakage or fistula were the most common (5/75, 6.7%), followed by wound problems (4/75, 5.3%). Of the medical complications, infection (9/75, 12%) and pulmonary disorder (7/75, 9.3%) were common. Eight patients died within thirty days after surgery (8/75, 10.7%). Liver cirrhosis was the most significant predisposing factor for severe complications (HR = 44.392, p = 0.003).
Conclusion:
PPU is still a surgically important disease that has significant mortality, above 10%. Liver cirrhosis is the most important underlying disease associated with severe complications.
... All patients that experienced gastric perforation in our study were surgically managed with partial gastrectomy in order to remove the ischemic tissue. Even though conservative management of perforated gastric ulcers has been demonstrated to be feasible [29], almost all cases of gastric perforation after CRS reported in the literature have been surgically treated [17,21,22,24]. Moreover, patients with a perforated gastric ulcer still have the omentum which can cover the gastric defect in case of conservative management, whereas patients undergoing CRS have a devascularized greater gastric curvature due to the omentectomy. ...
Background
Gastric perforation after cytoreductive surgery (CRS) is an infrequent complication. There is lack of evidence regarding the risk factors for this postoperative complication. The aim of this study was to assess the prevalence of postoperative gastric perforation in patients undergoing CRS for peritoneal carcinomatosis (PC) and to evaluate risk factors predisposing to this complication.
Methods
We designed a unicentric retrospective study to identify all patients who underwent an open upfront or interval CRS after a primary diagnosis of PC of different origins between March 2007 and December 2018 at a French Comprehensive Cancer Center. The main outcome was the occurrence of postoperative gastric perforation.
Results
Five hundred thirty-three patients underwent a CRS for PC during the study period and 13 (2.4%) presented a postoperative gastric perforation with a mortality rate of 23% (3/13). Neoadjuvant chemotherapy was administered in 283 (53.1%) patients and 99 (18.6%) received hyperthermic intraperitoneal chemotherapy (HIPEC). In the univariate analysis, body mass index (BMI), peritoneal cancer index, splenectomy, distal pancreatectomy, and histology were significantly associated with postoperative gastric perforation. After multivariate analysis, BMI (OR [95%CI] = 1.13 [1.05–1.22], p = 0.002) and splenectomy (OR [95%CI] = 26.65 [1.39–509.67], p = 0.029) remained significantly related to the primary outcome.
Conclusions
Gastric perforation after CRS is a rare event with a high rate of mortality. While splenectomy and increased BMI are risk factors associated with this complication, HIPEC does not seem to be related. Gastric perforation is probably an ischemic complication due to a multifactorial process. Preventive measures such as preservation of the gastroepiploic arcade and prophylactic suture of the greater gastric curvature require further assessment.
... do not have generalized peritonitis or continued duodenal leak) and (2) the unfit patients [23][24][25]. Non-operative management has been largely abandoned even in high risk cases because the conversion to operative treatment is required in up to a third and the high incidence of intra-abdominal abscesses and sepsis [26,27]. Operative management is encouraged by the current advances in anaesthetic approach [28]. ...
Gastric perforations may be spontaneous or traumatic and most of the spontaneous perforation is due to peptic ulcer disease. Improved medical management of peptic ulceration has reduced the incidence of perforation, but still remains a common cause of peritonitis. The management of perforated peptic ulcer disease is still a subject of debate. The majority of perforated peptic ulcers are caused by Helicobacter pylori, so apart from simple closure, definitive surgery is not usually required. Perforated peptic ulcer is an indication for operation in nearly all cases except when the patient is unfit for surgery. However, with the current advances in anaesthetic approach and with the high incidence of intra-abdominal abscesses and sepsis, non-operative management has largely been abandoned.
... He stayed at the hospital 61 days after surgery with CD Grade . The WSES and JSGE guidelines both recommend performing surgery as soon as possible, especially in patients older than 70 years old and instances where hospital admission was delayed [11,12,15,16]. Buck et al. have shown that elderly patients may experience higher mortality. ...
Background The perforation of upper gastrointestinal tract, primarily caused by peptic ulcer or cancer, is afflicted by a notoriously high mortality rate. The selection of appropriate risk assessments and therapeutic alternatives becomes important when addressing the risk for morbidity and mortality. We aimed to evaluate the optimal treatment and the post-treatment complications for this condition.
Methods We retrospectively analyzed 50 patients with intraperitoneal free air due to perforated stomach or duodenum who were consecutively treated at a single institution between 2010 and 2019.
Results All patients received initial inpatient treatment that was categorized as either surgery (n = 43, 86%) or non-surgery (n = 7, 14%). The non-surgically cured patients were significantly younger and had no or localized peritonitis, no ascites, lower C-reactive protein (CRP) levels, and shorter hospital stay than the surgery patients. Of seven non-surgery patients, two patients were converted to surgery for worsening symptoms. One of them, who was elderly and had a longer perforation-to-treatment time, stayed at the hospital more than 2 months after surgery with CD Grade Ⅱ. Evaluation of postoperative complications using the Clavien-Dindo classification showed that the patients with Grade Ⅱ–Ⅴ (n=21) were significantly older and had higher heart rates, poorer physical status, and longer perforation-to-surgery than those with Grade 0–Ⅰ (n=24). Preoperative CRP, prothrombin time, and lactate were significantly higher, and hemoglobin was significantly lower in the patients with Grade Ⅱ–Ⅴ. They had significantly longer operation times and found acute renal failure more frequently. Postoperative findings showed a significantly more prolonged period of antibiotic administration, fasting, and hospital stay. The postoperative blood examinations of them showed that minor changes were observed in WBC and neutrophil, and neutrophil and CRP were significantly higher after surgery. The multivariable analyses identified elevated lactate as an independent risk factor for postoperative complications. The postoperative outcomes in patients with perforated gastric cancer depended on the stage and whether a curative resection could be performed.
Conclusions Consideration should be given to the indications of non-surgery in elderly patients as well as the delay of treatment and postoperative outcomes of patients with elevated lactate preoperatively.
... The antibiotic regime should cover enteric gram-negative rods, anaerobes and oral flora. Although perforated ulcers may seal without operation in some patients, such an approach is associated with high morbidity and mortality, especially in elderly, high-risk patients like those in this case review [20]. Operative management of perforated DU also comprises appropriate resuscitation, intravenous hydration, analgesia and broadspectrum antibiotics. ...
Background: Despite advances in the medical management of peptic ulcer disease, duodenal ulcer (DU) perforation remains a common surgical emergency. Most DU perforations are small and can be managed with omental patch repair. However, occasionally the surgeon may encounter a giant perforation not amenable to this. Giant DU perforations are defined as > 2cm. They are associated with high leak rates and mortality. Prognosis in elderly patients are particularly poor because of advanced age and comorbidities. Furthermore, there are no specific recommendations for their management despite a variety of repair techniques being described. Here, we aim to describe a novel technique used to treat such patients, especially those of advanced age, in our institution and to review the current literature. Case presentation: Four patients with giant DU perforation underwent emergency laparotomy and repair with our duodenojejunostomy technique at our hospital. Post-operatively, patients were monitored clinically and radiologically and discharged when well and tolerating diet. The mean age of the patients was 67 years with an equal gender distribution. The average Charlson Comorbidity Index (CCI) score was 3 (moderately severe). All presented with peritonitis and two had concomitant bleeding. There were two anterior and two posterior ulcers. One was a revision repair after a leak post laparoscopic omental patch repair for the initial perforation. In all cases, the duodenojejunostomy repair technique was used. Post-operative recovery was uneventful for all except one who developed pneumonia. In particular; there were no anastomotic leaks, intra-abdominal collections, gastric outlet obstructions or mortalities. Conclusion: Giant DU perforation remains a challenge to the general surgeon, particularly so in elderly patients with multiple comorbids. A review of the current literature suggests a myriad of surgical techniques but no perfect solution. Some suggested techniques include omental patch with pyloric exclusion, controlled tube duodenostomy, jejunal pedicled graft or serosal patch, gastric disconnection and partial gastrectomy. Here, we propose that isolated duodenojejunostomy can be a quick, safe and novel solution that ensures definitive repair of giant ulcer perforation in a single setting in the high-risk patient.
... The rationale of NOM is that, in the case of small perforations, the ulcer seals by omental adhesions and can then heal and the peritonitis does not need operation [36]. In 1989 Croft et al. conducted a prospective randomized trial [37] comparing emergency surgery and NOM in patients with a clinical diagnosis of perforated peptic ulcer: 83 patients were entered in the study over a period of 13 months and were randomly assigned to one the two study groups. In the NOM group, 11 patients (28 percent) had no clinical Improvement after 12 h and required an operation. ...
Background:
Peptic ulcer disease is common with a lifetime prevalence in the general population of 5-10% and an incidence of 0.1-0.3% per year. Despite a sharp reduction in incidence and rates of hospital admission and mortality over the past 30 years, complications are still encountered in 10-20% of these patients. Peptic ulcer disease remains a significant healthcare problem, which can consume considerable financial resources. Management may involve various subspecialties including surgeons, gastroenterologists, and radiologists. Successful management of patients with complicated peptic ulcer (CPU) involves prompt recognition, resuscitation when required, appropriate antibiotic therapy, and timely surgical/radiological treatment.
Methods:
The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the board of the WSES to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the 5th WSES Congress, and for each statement, a consensus among the WSES panel of experts was reached.
Conclusions:
The population considered in these guidelines is adult patients with suspected complicated peptic ulcer disease. These guidelines present evidence-based international consensus statements on the management of complicated peptic ulcer from a collaboration of a panel of experts and are intended to improve the knowledge and the awareness of physicians around the world on this specific topic. We divided our work into the two main topics, bleeding and perforated peptic ulcer, and structured it into six main topics that cover the entire management process of patients with complicated peptic ulcer, from diagnosis at ED arrival to post-discharge antimicrobial therapy, to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.
Introduction
Perforated peptic ulcers are a life-threatening complication associated with high morbidity and mortality. Several treatment approaches are available. The aim of this network meta-analysis (NMA) is to compare surgical and alternative approaches for the treatment of perforated peptic ulcers regarding mortality and other patient-relevant outcomes.
Methods and analysis
A systematic literature search of PubMed/MEDLINE, Cochrane Library, Embase, CINAHL, ClinicalTrials.gov trial registry and ICTRP will be conducted with predefined search terms.To address the question of the most effective treatment approach, an NMA will be performed for each of the outcomes mentioned above. A closed network of interventions is expected. The standardised mean difference with its 95% CI will be used as the effect measure for the continuous outcomes, and the ORs with 95% CI will be calculated for the binary outcomes.
Ethics and dissemination
In accordance with the nature of the data used in this meta-analysis, which involves aggregate information from previously published studies ethical approval is deemed unnecessary. Results will be disseminated directly to decision-makers (eg, surgeons, gastroenterologists) through publication in peer-reviewed journals and presentation at conferences.
PROSPERO registration number
CRD42023482932.
Gastroduodenal perforation has a spectrum of presentations and can be due to varying aetiologies: spontaneous, traumatic, neoplastic or due to peptic ulcer disease. Evolution in the medical management of peptic ulceration disease has reduced the incidence of perforation, however, internationally it still has a relatively high incidence. It may be diagnosed by the presence of subphrenic air on an erect chest radiograph, and increasingly is diagnosed on computed tomography. The management of perforated peptic ulcer disease is still a subject of debate.
Helicobacter pylori (H. Pylori) is the main risk factor for peptic ulcer, gastric associated lymphoid tissue and gastric adenocarcinoma. Several studies have revealed H. Pylori association in 70-75% cases of dyspepsia. H. Pylori is found in 80-100% of duodenal ulcers and 60-75% of gastric ulcers. With this background, a study was conducted to document prevalence of H. pylori in dyspepsia patients in a tertiary care hospital. Material and Methods: A cross sectional study was conducted in a tertiary care hospital in Khammam from January 2020 to December 2020 on 100 purposively selected dyspepsia patients attending Medicine Outpatient department (OPD). Presence of H. Pylori was confirmed after histopathology and microbiological investigations of the endoscopy biopsy sample. Data was entered in Microsoft excel and analysed using Open Epi software. Descriptive statistics and chi square test was applied. Three fourth (75%) of the study participants were males. The mean age of the study participants was 39.25±10.87 years. All the patients presented with upper abdominal pain (100%) followed by nausea/vomiting (94%). Endoscopic findings revealed that three fifth (60%) of the patients had ulcer dyspepsia and two fifth (40%) of them had non ulcer dyspepsia. About 68% of the patients were infected with H. Pylori. A significant association was found between H. Pylori and duodenal ulcers (p 0.001). The overall prevalence of H. Pylori infection in patients of dyspepsia was 68%. The prevalence of H. Pylori was higher in ulcer dyspepsia patients. There was a significant association between H. Pylori and duodenal ulcers (p 0.001).
Objective:
To understand how multimorbidity impacts operative versus non-operative management of Emergency General Surgery conditions.
Background:
Emergency General Surgery (EGS) is a heterogenous field, encompassing operative and non-operative treatment options. Decision-making is particularly complex for older patients with multimorbidity.
Methods:
Using an instrumental variable approach with near-far matching, this national, retrospective observational cohort study of Medicare beneficiaries examines the conditional effects of multimorbidity, defined using Qualifying Comorbidity Sets, on operative versus non-operative management of EGS conditions.
Results:
Of 507,667 patients with EGS conditions, 155,493 (30.6%) received an operation. Overall, 278,836 (54.9%) were multimorbid. After adjustment, multimorbidity significantly increased the risk of in-hospital mortality associated with operative management for general abdominal patients (+9.8%; P=0.002) and upper gastrointestinal patients (+19.9%, P<0.001) and the risk of 30-day mortality (+27.7%, P<0.001) and nonroutine discharge (+21.8%, P=0.007) associated with operative management for upper gastrointestinal patients. Regardless of multimorbidity status, operative management was associated with higher risk of in-hospital mortality among colorectal patients (multimorbid: + 12%, P<0.001; non-multimorbid: +4%, P=0.003), higher risk of nonroutine discharge among colorectal (multimorbid: +42.3%, P<0.001; non-multimorbid: +55.1%, P<0.001) and intestinal obstruction patients (multimorbid: +14.6%, P=0.001; non-multimorbid: +14.8%, P=0.001), and lower risk of nonroutine discharge (multimorbid: -11.5%, P<0.001; non-multimorbid: -11.9%, P<0.001) and 30-day readmissions (multimorbid: -8.2%, P=0.002; non-multimorbid: -9.7%, P<0.001) among hepatobiliary patients.
Conclusions:
The effects of multimorbidity on operative versus non-operative management varied by EGS condition category. Physicians and patients should have honest conversations about expected risks and benefits of treatment options, and future investigation should aim to understand optimal management of multimorbid EGS patients.
As the global geriatric population continues to grow, an increasing proportion of people reporting to emergency departments are elderly. The work-up of these patients uses more time and resources than that of younger patients, and is complicated by the fact that acute disease often presents more subtly, without the outward manifestations typically seen in younger patients. This volume focuses on the unique pathophysiology of the elderly, presenting guidelines for resuscitation, evaluation and management. The first section discusses general principles including demographics, pharmacology and pain management. The following sections cover high-risk chief presenting complaints and review geriatric emergencies. Finally, topics of particular relevance in the geriatric population are discussed, including functional assessment, end-of-life care, financial considerations and abuse. This book provides a comprehensive, practical framework for community and academic emergency medicine practitioners, as well as emergency department administrators striving to improve delivery of care to this vulnerable, growing population.
Perforated peptic ulcer (PPU) is a life-threatening emergency associated with peptic ulcer disease (PUD). PPU patients often present with an acute abdomen with high risk of morbidity and mortality. Mortality rates up to 30% have been reported. In this chapter, we focus on the epidemiology, clinical features, diagnostic methods, risk scores, nonoperative and operative management, and postoperative care.KeywordsPerforated peptic ulcerDuodenal ulcerGastric ulcerPeptic ulcer diseaseLaparoscopySurgery
Objective:
To determine the effect of operative versus nonoperative management of emergency general surgery conditions on short-term and long-term outcomes.
Background:
Many emergency general surgery conditions can be managed either operatively or nonoperatively, but high-quality evidence to guide management decisions is scarce.
Methods:
We included 507,677 Medicare patients treated for an emergency general surgery condition between July 1, 2015, and June 30, 2018. Operative management was compared with nonoperative management using a preference-based instrumental variable analysis and near-far matching to minimize selection bias and unmeasured confounding. Outcomes were mortality, complications, and readmissions.
Results:
For hepatopancreaticobiliary conditions, operative management was associated with lower risk of mortality at 30 days [-2.6% (95% confidence interval: -4.0, -1.3)], 90 days [-4.7% (-6.50, -2.8)], and 180 days [-6.4% (-8.5, -4.2)]. Among 56,582 intestinal obstruction patients, operative management was associated with a higher risk of inpatient mortality [2.8% (0.7, 4.9)] but no significant difference thereafter. For upper gastrointestinal conditions, operative management was associated with a 9.7% higher risk of in-hospital mortality (6.4, 13.1), which increased over time. There was a 6.9% higher risk of inpatient mortality (3.6, 10.2) with operative management for colorectal conditions, which increased over time. For general abdominal conditions, operative management was associated with 12.2% increased risk of inpatient mortality (8.7, 15.8). This effect was attenuated at 30 days [8.5% (3.8, 13.2)] and nonsignificant thereafter.
Conclusions:
The effect of operative emergency general surgery management varied across conditions and over time. For colorectal and upper gastrointestinal conditions, outcomes are superior with nonoperative management, whereas surgery is favored for patients with hepatopancreaticobiliary conditions. For obstructions and general abdominal conditions, results were equivalent overall. These findings may support patients, clinicians, and families making these challenging decisions.
Background
Peptic ulcer perforation is a common surgical emergency and a major cause of death especially in elderly patients, despite the fact of the presence of effective drug treatments and an increased understanding of its etiology. Giant duodenal perforations, in particular, pose a significant challenge and there is scarce data regarding their optimal management. Laparoscopic surgery is advocated in the surgical treatment of perforated duodenal ulcer disease, in experienced hands.
Methods
Herein we present an 84-year-old man with past medical history of type II diabetes mellitus and hypertension who was admitted to our Department due to epigastric pain and diffuse peritonitis. CT scan revealed the presence of a significant amount of free air and fluid in the upper abdomen secondary to a duodenal perforation.
Results
The patient was taken immediately to the theater for an urgent laparoscopy. Methylene blue via the NG tube better defined the extent of the duodenal perforation which was not amenable to a primary repair. Consequently, a decision was made for a laparoscopic pancreas-sparing, ampulla preserving gastroduodenectomy with intracorporeal Billroth II gastrojejunal anastomosis. The postoperative period was uneventful and the patient was discharged on the 13th postoperative day. Histopathology revealed a large benign duodenal ulcer.
Conclusions
Although the incidence of peptic ulcer disease is decreasing, it appears that the incidence of complications is rising. Laparoscopic approach, especially when performed by laparoscopic surgery experts, could be a treatment option for difficult duodenal ulcer perforations with less pain, shorter hospital stay and reduced morbidity.
Background: Peptic ulcer perforation is a complication of peptic ulcer disease frequently encountered in the emergency departments. Although there are many treatment options ranging from nonoperative treatment to wide resections, surgery is the first treatment option in peptic ulcer perforations. In this article, we aimed to present the feasibility of nonoperative treatment in appropriate and selected cases. Materials and Methods: The data of the patients who were not operated but provided with medical treatment in our clinic between January 2016 and July 2018 were evaluated retrospectively. Results: Three of the patients were male, one of them was female, and the mean age was 58 years (range, 35-79). On physical examination, there were no signs of acute abdomen, only tenderness was observed in the right upper quadrant and epigastric region. Standing direct abdominal radiography revealed free air under the diaphragm in three patients. The diagnosis was made with tomographic findings in one patient. No contrast agent extravasation was observed in any patient. The patients were examined intermittently by a specialist surgeon, oral intake was permitted on the 4th day of hospitalization, and they were discharged on the 7th day on average. Conclusion: Peptic ulcer perforation is a condition, which is still common and requires emergency surgery in case of acute abdomen development. Although the time elapsed after perforation is a factor affecting mortality and morbidity, nonoperative treatment is a method that can be successfully applied under strict physical examination and laboratory follow-up in appropriate and selected patients without diffuse peritonitis and extravasation on CT with water-soluble contrast agent.
Peptic ulcer disease and complications of peptic ulcer disease are common in the geriatric population. We discuss the main causes of ulcer disease, their diagnosis, treatment, complications, and prevention. This chapter deals with the pathophysiology, diagnosis, manifestations, and therapy of peptic ulcers with special emphasis on the diagnosis and management of ulcers and ulcer disease related to Helicobacter pylori, nonsteroidal anti-inflammatory drug use, and stress ulcers. We provide detailed advice regarding the mechanistic and therapeutic role of acid suppression medication for the treatment of peptic ulcer disease and prevention of related complications, in particular proton pump inhibitors and H. pylori diagnosis and therapy. There is also an in depth discussion of ulcer complications of obstruction, perforation, and upper gastrointestinal bleeding, with a comprehensive overview of the risk factors and medical and endoscopic treatment options for the most common ulcer complication of hemorrhage. The chapter provides readers with both a historical and current perspective on peptic ulcer disease to help guide therapy and clinical decision-making.
The expansion of the elderly population led to an increased number of older adults presenting to emergency departments following trauma; the outcome of injuries in geriatric patients is worsened by a weaker mechanism of compensation, ongoing chronic medical conditions, and increased risk for complications due to a greater number of comorbidities and physiological changes.
Peptic ulcer is a very common disease in the population, especially in the elderly, with an incidence of 5–10%. It is estimated that 2–10% of patients with peptic ulcer undergo ulcer perforation, which is one of the most common complications. The control of risk factors over time, associated with the improvement of diagnostic criteria and the improvement of surgical techniques, has made the outcome of this pathology much better. The aim of this chapter was to focus on the consequences and diagnostic-therapeutic management of peptic ulcer perforation in the frail elderly patient. The purpose was to identify in the literature which clinical and diagnostic criteria may be used in order to identify the patients who can obtain the best outcome through surgical treatment for peptic ulcer perforation.
Background:
Gastroduodenal ulcer perforation is a common abdominal emergency that may be curable without surgical repair in non-elderly patients with localized and stable symptoms. However, the outcomes of nonoperative approaches have rarely been described.
Methods:
Using a Japanese national inpatient database, we identified 14,918 patients with gastroduodenal ulcer perforation who were hospitalized and received nonoperative treatment from July 2010 to March 2017. We categorized these patients into three groups according to age: 18 to 64 years (young group, n=8407), 65 to 74 years (old group, n=2616), and ≥75 years (old-old group, n=3895). We investigated the characteristics, treatments, and outcomes in each group.
Results:
Most of the patients were men (71%), and the median patient age was 62 years (interquartile range, 47-75 years). The old and old-old groups had more comorbidities than the young group. Whereas most patients were administered proton pump inhibitors and various antibiotics (96% and 90%, respectively), only 58% of patients underwent gastric tube placement. Surgical repair >3 days after admission was performed in 7.1% of all patients (6.3% vs. 7.9% vs. 5.5%, P<0.001). The old and old-old groups showed higher mortality (1.4% vs. 8.3% vs. 18%, P<0.001) and morbidity (6.6% vs. 15% vs. 17%, P<0.001) than the young group. The median length of stay was almost 2 weeks (13 vs. 17 vs. 20 days, P<0.001).
Discussion:
Unlike previous studies, many patients aged >65 years received nonoperative treatment in this nationwide cohort. Our findings provide useful information for clinicians and patients hospitalized for gastric ulcer perforation.
PurposeThe perforation of the upper gastrointestinal tract is still associated with a high risk of complications and mortality. We aimed to evaluate the optimal treatment and post-treatment complications for this condition.Methods
This was a retrospective, single-center study conducted between 2010 and 2019. We analyzed 50 patients with intraperitoneal free air caused by peptic ulcer (44 cases) or cancer (six cases).ResultsAll patients initially received either conservative therapy (n = 7) or surgery (n = 43). The nonsurgically cured patients were significantly younger and had mild peritonitis and also had a shorter hospital stay. Two patients were converted to surgery due to worsening symptoms, and one of them was elderly and had a long perforation-to-treatment time. Regarding postoperative complications, patients with Grade II–V (n = 21) were significantly older and had a poorer physical status, longer perforation-to-surgery time, and higher preoperative CRP and lactate than those with Grade 0–I (n = 24). Multivariable analyses identified elevated preoperative lactate as an independent risk factor for postoperative complications. The patients with noncurative surgery for perforated advanced gastric cancer all died within 1 year after surgery.Conclusions
Consideration should be given to the nonsurgical indications in elderly and delayed treatment patients and the postoperative outcomes of patients with preoperatively elevated lactate levels.
Gastrointestinal complications in critically ill patients during the COVID-19 pandemic pose a diagnostic and treatment dilemma. We present a case of a 74-year-old male who was brought to our emergency department with worsening shortness of breath, fever, and dry cough and was found to have COVID-19 pneumonia. Early in his hospital course, he was admitted to the intensive care unit, and was found to have significant abdominal distension with large amounts of simple fluid on bedside ultrasound. Bedside paracentesis returned succus and enteric feeds, and a methylene blue test confirmed a likely gastrointestinal perforation. The patients’ family refused surgical intervention and the patient underwent bedside drainage. This case represents several critical dilemmas clinicians faced during the recent surge of the COVID-19 pandemic.
Gastrointestinal ulcers and perforations can occur as a complication of nonsteroidal anti‐inflammatory drugs (NSAID). Emerging endoscopic technologies can be utilized to successfully intervene perforations that fail surgical intervention. We report a case of perforated duodenal ulcer that failed surgical intervention and, however, was successfully closed with over‐the‐scope clip (OTSC) closure with concomitant placement of fully covered stent. Gastrointestinal ulcers and perforations can occur as a complication of nonsteroidal anti‐inflammatory drugs (NSAID). Emerging endoscopic technologies can be utilized to successfully intervene perforations that fail surgical intervention. We report a case of perforated duodenal ulcer that failed surgical intervention and, however, was successfully closed with over‐the‐scope clip (OTSC) closure with concomitant placement of fully covered stent.
A consecutive series of 25 patients with chronic duodenal ulcer has been treated by highly selective vagotomy without a drainage procedure. The vagal fibres passing to the distal 5–7 cm. of the stomach—the nerves of Latarjet—were left intact, as were the hepatic and coeliac branches of the vagus. The object was to denervate only the parietal cell mass, while preserving normal gastric emptying and normal inhibition of gastric secretion from the antrum and duodenum. This operation should cure the ulcer as effectively as vagotomy with drainage does, and at lower cost in terms of side-effects such as dumping and diarrhoea.
The insulin test was negative in each case, suggesting that vagal denervation of the parietal cell mass was complete. Evidence provided by mucosal biopsies taken at operation does not fully support this view, however. Pentagastrin-stimulated acid output was reduced by 70 per cent, and pepsin output by 51 per cent, 3 months after operation. The volume of resting juice was halved and spontaneous acid output was reduced by 97 per cent at this time. Thus, highly selective vagotomy is as effective as truncal or bilateral selective vagotomy with drainage in reducing gastric acid output in the early months after operation.
There have been no deaths. With 2 exceptions, the patients appear to be doing well clinically and few complain of side-effects, but the period of follow-up is only from 3 to 11 months.
These results are encouraging. They suggest that a highly selective vagotomy, denervating the parietal cell mass but leaving the antrum innervated, may be all that is required to cure most patients who have a chronic duodenal ulcer.
Of 50 patients with a perforated duodenal ulcer treated with simple suture closure, 36 (72%) had symptoms before the perforation for a mean period of 9.9 years. 24 of the 36 (66.6%) acquired further symptoms or complications at 1--48 months (mean 11 months) after the operation, whereas only 2 of the 14 patients (14%) who were symptom-free preoperatively had further complications. At follow-up 48% of the patients were still free of symptoms. Simple suture closure with a "wait and see" policy remains the treatment of choice, and a prospective clinical study to evaluate definitive emergency surgery for duodenal ulcer has been cancelled.
Twenty-one patients with acute perforated duodenal ulcer were managed by proximal gastric vagotomy without drainage and simple closure of the perforation reinforced with an omental patch. There was no operative mortality. No recurrent duodenal ulcers have developed. All patients have achieved a good to excellent clinical result from their operation. Dumping, diarrhea, and reflux gastritis have not developed. Follow-up studies extend to three and one-half years. Proximal gastric vagotomy with simple closure is safe, effective management for the patient with an acute perforated duodenal ulcer. This operation is a satisfactory compromise between simple closure alone which does not protect against recurrent ulcer and definitive ulcer operations which may subject patients who would not have further ulcer symptoms to the unnecessary risk of increased mortality, morbidity, and postgastrectomy disorders.
In the period 1959--1971 a simple operative closure was the initial management of 112 patients with acute perforation of duodenal ulcers. At follow-up 6--18 years after perforation the relevance of the length of ulcer history prior to perforation in deciding upon 'definitive' emergency operation is evaluated. Using such a selection criterion, the rate of misinterpretation at the time of perforation is close on 50%, and half of these patients would be subjected to an apparently unnecessary operation. Furthermore, about 80% of the patients for whom simple closure was not sufficient treatment developed ulcer dyspepsia within the first year after the perforation. Therefore, simple suture of a duodenal perforation with careful clinical follow-up for at least 1 year is recommended.
Selective treatment of duodenal ulcer with perforation has been based on several premises: 1) The natural history of the ulcer following closure of a perforation is generally favorable with an acute and unfavorable with a chronic ulcer. 2) An upper gastrointestinal series with water soluble contrast media can reliably document a spontaneously sealed perforation. 3) With a spontaneous seal, nonsurgical therapy is an acceptable option and is preferable for an acute ulcer or a chronic ulcer with poor surgical risk. 4) The treatment of choice for an unsealed perforation of an acute ulcer is simple surgical closure. 5) The treatment of choice of perforation of a chronic ulcer with acceptable surgical risk is an ulcer definitive operation. Sixty cases of perforation of duodenal ulcer have been treated. Nonsurgical therapy was employed without complication in eight cases with radiologically documented spontaneous seal. Truncal vagotomy and pyloroplasty in 36 cases and truncal vagotomy and antrectomy in two cases were each without mortality. Four fatalities occurred among 13 cases of closure and omental patch, each a case with severe associated disease. The mortality was 6.7% among the 60 cases; 2.4% for chronic ulcer and 16% for acute ulcer.
Retrospective analysis of twenty-eight patients with perforated gastric ulcers and 141 patients with perforated duodenal ulcer showed that delay in surgery increased operative mortality. Gastrectomy is advocated for gastric ulcers, and definitive ulcer surgery, not plication, for duodenal ulcers.
A prospective controlled study in 60 patients undergoing simple closure of perforated duodenal ulcer demonstrated a significant (P less than 0.05) benefit following postoperative cimetidine treatment, in terms of avoiding subsequent dyspeptic symptoms and complications of peptic ulcer disease. Thus cimetidine is recommended in the follow-up management of perforated duodenal ulcers.
A prospective randomized trial of simple closure versus closure and proximal gastric vagotomy was conducted in 50 consecutive patients with perforated duodenal ulcer. There was one postoperative death in each group and no difference in postoperative morbidity. After a median follow-up of 54 months (24-96) the cumulative recurrence rate after simple suture was 52 per cent against 16 per cent after proximal gastric vagotomy and closure (P less than 0.01). The recurrence rate after proximal gastric vagotomy for perforated duodenal ulcer was comparable to the recurrence rate seen after the electively performed operation.
To assess the results of proximal gastric vagotomy (PGV) in the definitive treatment of perforated duodenal ulcers, a prospective study was carried out comparing PGV in association with omental patch suture (PGV + S) with the simple omental patch suture procedure (S). The PGV + S series consisted of 38 consecutive patients with perforated duodenal ulcer and the S series consisted of 38 survivors of a similar series of 41 consecutive patients. Surgical mortality was zero in the PGV + S series. The patients were followed up for 1 to 7 years. No cases of dumping or diarrhoea were observed. Thirty-three patients in the PGV + S series (87 per cent) were classified as Visick grade I and only two (5 per cent) as Visick grade IV. In contrast, 11 patients (29 per cent) were Visick grade I and 22 (58 per cent) were Visick grade IV in the S series. Recurrent ulcer was detected endoscopically in 58 per cent of the patients who had been treated with simple suture and in only 5 per cent after suture plus PGV. PGV is a safe operation with a negligible morbidity rate and with a significant rate of effective control of ulcer disease. Depending on the general condition of the patient and on the surgeon's skill, it appears preferable to treat not only the acute perforation but also the ulcer disease by PGV.
The good results of highly selective vagotomy (H.S.V.) in the elective surgical treatment of uncomplicated duodenal ulcer led to its use in the treatment of 30 patients who were suffering from complications of peptic ulcer, over a period of 21 months. In the emergency situation it is vital to select for H.S.V. patients who are fit enough to withstand a 1–2-hour operation.
Five out of a total of 9 patients with perforated duodenal ulcer were deemed to be suitable for H.S.V. In contrast, H.S.V. was used in the treatment of all 10 patients with haemorrhage (5 patients with duodenal ulcer and 5 with gastric ulcer), because definitive treatment for the ulcer is essential after haemorrhage has been arrested by direct suture.
Pyloric stenosis was diagnosed in 15 of 75 patients who came to elective surgery for duodenal ulcer. The diagnosis was made on clinical and radiological grounds and was confirmed at operation. Seven of the 15 patients had concomitant gastric ulceration. All 15 patients were treated by H.S.V. without a drainage procedure. The stenosis was simply dilated digitally. Seven patients who were followed up for at least a year underwent barium-meal examination, which showed that gastric emptying was normal in each case and that there was no sign of recurrent ulceration.
There was no operative mortality. None of the patients with haemorrhage bled again after operation. Only 1 of the 30 patients developed gastric retention, which was transient. Of the 14 patients who were reviewed more than 1 year after H.S.V., 11 had a perfect clinical result, 2 were very good, and 1 was ‘fair’ (Visick grade 3). The long-term prognosis should be the same as that of patients who have undergone elective H.S.V.
Granted a modicum of case selection, H.S.V. is a safe operation in the treatment of emergencies such as haemorrhage or perforation. In pyloric stenosis H.S.V. preserves and makes use of the stomach's compensatory mechanisms of hypertrophy and hyperperistalsis, whereas both gastrectomy and vagotomy with drainage destroy them. Vagotomy of the entire stomach makes necessary the addition of a drainage procedure. Vagotomy with drainage impairs the ability of the antrum to ‘mill’ food and to propel chyme onwards, and destroys or by-passes the pyloric sphincter. These surgical insults to normal gastric physiology harm the patient by producing dumping, diarrhoea, bilious vomiting, steatorrhoea, and gross elevation of serum gastrin. The main conclusion of this paper is that such harm can be avoided, because it is shown that even patients with pyloric stenosis can be treated by H.S.V. without a drainage procedure. The routine use of complete gastric vagotomy with a drainage procedure in the elective surgical treatment of duodenal ulcer is no longer justified.
A review of 346 patients with acute perforated duodenal ulcer treated at the Yale-New Haven Medical Center during the last forty-four years is presented. An analysis of the long-term results of operative therapy indicates that suture plication remains the treatment of choice except in male patients forty to sixty-four years old with a history of chronic ulcer disease prior to perforation. Subsequent definitive surgery to control recurrent symptoms was required in 65 per cent of the patients in this group after plication. The risk of a definitive procedure being required subsequent to plication in all other patients was only 18 per cent.
Of 168 consecutive patients presenting with a perforated duodenal, pyloric or prepyloric ulcer, 123 patients were judged fit or suitable for parietal cell vagotomy (PCV). It was, however, only added to simple closure in 67 patients with a previous history of dyspepsia prone to develop recurrent ulceration, whereas 56 patients with no previous symptoms and an established low risk of recurrence were managed by simple closure only. In the comparable groups, postoperative morbidity did not differ, entailing mortality rates of 4.5% and 5.3% following PCV or simple closure only. An overall clinical grading of 106 patients (91%) followed up (median 4 years, range 1-10 years) revealed equally good results. In patients with previous dyspepsia and an established high recurrence rate if managed by simple closure only, a satisfactory reduction of the recurrence rate was found when PCV was added to suture closure (cumulative recurrence rate 20.7 +/- SD 69 compared to 29% +/- SD 9.4 following simple closure in patients with no previous dyspeptic symptoms). It is concluded that in patients with a perforating duodenal ulcer deemed fit or suitable for PCV, assessed by good clinical judgement, PCV does not carry an added risk and provides a fairly good protection against recurrent ulceration.
Nine cases of perforation whilst patients received cimetidine therapy were identified and followed prospectively. There was a high correlation with the other major complications of duodenal ulceration: pyloric stenosis and haemorrhage. Initially, three of the nine patients had simple suture of the perforation, but eventually all required truncal vagotomy and a drainage procedure. The follow-up ranges from 6 months to 2.5 years and the results in the surviving patients are good. The preoperative identification of this group, being established medical failures with the high probability of requiring necessary definitive surgery, will aid the surgical management of this condition.
Operative risk factors for patients with perforated duodenal ulcers were examined prospectively in 213 operated patients. Nine hospital deaths (4.2%) resulted from respiratory failure, sepsis, and bleeding. Forty-five complications developed in 27 patients (12.7%). Concurrent medical illness, preoperative shock, and longstanding perforations (more than 48 hours) were significant features that increased mortality. Old age, gross peritoneal soiling, and the length of the ulcer history did not affect mortality in the absence of risk factors. No death attributable to either sepsis or abscess formation occurred when surgery was performed within two days of perforation. Bacterial contamination may not signify clinical peritonitis during this period. We conclude that simple closure of perforated ulcers is a more prudent choice when any risk factor is present, but that definitive surgery in good-risk patients merits further evaluations.
A clinical trial cannot be adequately interpreted without information about the methods used in the design of the study and the analysis of the results. To determine the frequency of reporting what we consider 11 important aspects of design and analysis, we surveyed all 67 clinical trials published in the New England Journal of Medicine, the Lancet, and the British Medical Journal from July through December 1979 and in the Journal of the American Medical Association from July 1979 through June 1980. Of all 11 items in the 67 trials published in all four journals, 56 per cent were clearly reported, 10 per cent were ambiguously mentioned, and 34 per cent were not reported at all. At least 80 per cent of the 67 trials reported information about statistical analyses, statistical methods used, and random allocation of subjects, yet only 19 per cent reported the method of randomization. Loss to follow-up was discussed in 79 per cent of the articles, treatment complications in 64 per cent, and admission of subjects before allocation in 57 per cent, but eligibility criteria for admission to the trial appeared in only 37 per cent. Although information about whether patients were blind to treatment was given in 55 per cent, information about whether there was blind assessment of outcome was reported in only 30 per cent. The statistical power of the trial to detect treatment effects was discussed in only 12 per cent of the articles. The clinical trials published in The New England Journal of Medicine reported 71 per cent of the 11 items, those in the Journal of the American Medical Association 63 per cent, those in the British Medical Journal 52 per cent, and those in the Lancet 46 per cent. These rates are significantly different (P less than 0.001). We recommend that editors improve the reporting of clinical trials by giving authors a list of the important items to be reported.
One hundred and nine patients with perforated duodenal ulcer were treated by operation between 1973 and 1980. The operations performed included simple closure in 37 patients, vagotomy and drainage or gastric resection in 12 patients, and proximal gastric vagotomy without drainage and with omental patch of the perforation in 60 patients. Patients who were treated by proximal gastric vagotomy have been observed for 1-8 yr and form the basis of this study. There was no operative mortality. One patient with a postoperative infection required secondary drainage and a second patient with intestinal obstruction required lysis of adhesions. There were no other important complications. Persistent mild dumping occurred in 1 patient. Diarrhea was not a complication for any patient. One patient developed a recurrent ulcer and underwent truncal vagotomy and pyloroplasty. All patients except the patient with a recurrent ulcer had a Visick grading or I or II. Proximal gastric vagotomy, omental patch of the ulcer, and no drainage procedure is the ideal operation for patients who are candidates for definitive treatment of a perforated duodenal ulcer.
A prospective, randomized, double-blind trial was conducted in 101 patients to evaluate the safety and benefits of immediate definitive surgery for perforated duodenal ulcers. These patients, who were judged by predefined criteria to be medically fit and to have perforations in chronic ulcers, were randomized to undergo simple closure (35 patients), truncal vagotomy and drainage (VD) (32 patients), or proximal gastric vagotomy with closure (PGV) (34 patients). Patients were followed with endoscopic assessment for up to 39 months. There was no mortality and only a few minor postoperative complications. At 39 months follow-up, the cumulative rates of recurrence were 63.3%, 11.8% and 3.8% after closure, VD, and PGV, respectively (p less than 0.001). With the exception of the one recurrence after PGV, all relapses were symptomatic, and eight of these 18 required reoperation. Relapse rates and Visick scores between VD and PGV were significantly different. Both safe as well as effective, immediate, nonresective, definitive operation is indicated for good-risk patients who have perforations in chronic duodenal ulcers.