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Trends and Outcomes of Hospitalizations for Peptic Ulcer Disease in the United States, 1993 to 2006
Abstract
Despite progress in diagnosis and treatment, peptic ulcer disease (PUD) remains a common reason for hospitalization and operation. The purpose of this study was to quantify the time trends of hospitalizations and operations for PUD in the United States (US) since 1993.
The Healthcare Cost and Utilization Project Nationwide Inpatient Sample is a 20% stratified sample of all hospitalizations in the United States. It was used to study hospitalizations with PUD as the principal diagnosis during 1993 to 2006, including details on ulcer site, complications, procedures, and mortality. Statistical methods included the chi test and multivariate logistic regression.
The national estimate of hospitalizations for PUD decreased significantly from 222,601 in 1993 to 156,108 in 2006 (-29.9%), with a larger reduction in duodenal ulcers (95,552 in 1993 vs. 60,029 in 2006, -37.2%) than gastric ulcers (106,987 in 1993 vs. 86,064 in 2006, -19.6%). The inpatient mortality rate of PUD decreased from 3.8% to 2.7% during 1993 to 2006 (P < 0.001). Hemorrhage remained the most common complication (71.6% in 1993; 73.3% in 2006) but perforation had the highest mortality (15.1% in 1993; 10.6% in 2006). In comparison to 1993, patients hospitalized for PUD in 2006 more frequently had endoscopic treatment to control bleeding (12.9% vs. 22.2%, P < 0.001), similar use of surgical oversewing of ulcer (7.6% vs. 7.4%), less use of gastrectomy (4.4% vs. 2.1%, P < 0.001), and less use of vagotomy (5.7% vs. 1.7%, P < 0.001). In multivariate logistic regressions, the determinants of mortality were similar in 1993 and 2006.
Hospitalizations for PUD decreased in the United States from 1993 to 2006, suggesting a decrease in the prevalence and/or severity of ulcer complications over this recent time period. Despite increased patient age and comorbidities, there has been a significant decrease in PUD mortality, a significant increase in the use of therapeutic endoscopy for bleeding ulcer, and a significant decrease in the use of definitive surgery (vagotomy or resection) for ulcer complications.
... Despite a decrease in reported ulcer-related mortality, from 3.9% in 1993 to 2.7% in 2006, over 4000 estimated deaths are caused by PUD each year. [7] The antibiotics, PPIs, avoidance of NSAIDs, and advanced endoscopy techniques had contributed to reduction in the incidence of complications from PUD. The PUD requiring surgical intervention has decreased to approximately 11%. ...
... The PUD requiring surgical intervention has decreased to approximately 11%. [7] It is noteworthy to mention that complications from PUD include hemorrhage, obstruction, cancer, and perforation. The perforation has the highest mortality rate of any complication of ulcer disease, approaching 15%. ...
... The perforation has the highest mortality rate of any complication of ulcer disease, approaching 15%. [7] The Valentino syndrome occurs when fluid from perforated peptic ulcer collects in the right paracolic gutter and right lower quadrant leading to focal peritonitis and associated right lower quadrant pain. Initially, there would be diffuse or poorly localized pain over lower quadrants of the abdomen. ...
... According to many authors, the incidence of peptic ulcer of the stomach and duodenum is on average 5.1-5.7 per 1000 people [1, 2,3]. At the same time, the last decades have been characterized by a statistically significant increase in morbidity [4,5,6,7,8]. Quite often, the course of peptic ulcer of the stomach and duodenum is accompanied by such complications as penetration, perforation, bleeding, stenosis. ...
... These complications remain one of the most difficult problems in modern surgery. Uncomplicated peptic ulcer of the stomach and duodenum in practical medicine is amenable to conservative treatment under the action of anti-ulcer drugs [1, 2,3,8]. Complicated forms of peptic ulcer of the stomach and duodenum often require surgical intervention. ...
Objective: To enhance the immediate treatment outcomes of complicated peptic ulcers of the stomach and duodenum through the development and application of video-assisted organ-preserving surgeries. Materials and Methods: This study analyzed the treatment outcomes of 261 patients with complicated gastric and duodenal ulcers. The patients received the treatment in the surgical departments of Azerbaijan State Advanced Training Institute for Doctors named after A. Aliyev, Scientific Surgical Center named after M.A. Topchubashev, and Sabunchi Medical Center from 2015 to 2023. All patients with perforated and bleeding ulcers of the stomach and duodenum underwent clinical and instrumental examinations. The initial general condition of the patient was thoroughly assessed. Among the patients, there were 220 men (84.3%) and 41 women (15.7%), with ages ranging from 18 to 84 years. There were 75 (28.7%) patients complicated with bleeding of gastric and duodenal ulcer, and 186 (71.3%) patients with perforation. In the control group, traditional, "open" surgical interventions were performed in 164 (62.8%) patients, and minimally invasive endoscopic video-assisted operations were performed in 97 (37.2%) cases. Out of 186 patients, 124 (66.7%) underwent traditional suturing of a perforated gastroduodenal ulcer during laparotomy, while 62 (33.3%) underwent minimally invasive endosurgical interventions. In the control group, 12 (8.4%) patients underwent gastric resection, and 10 (5.4%) underwent vagotomy with pyloroplasty. The immediate results of radical operations for a perforated ulcer were characterized by a high percentage of early complications, with 5 (41.6%) cases. Results. Of the 186 patients operated on for perforated gastroduodenal ulcer, 12 individuals (6.5±2.9%) developed complications in the postoperative period: 9 (7.3%) in the comparison group, and 3 (4.8%) patients in the main group. We obtained a statistically significant shorter duration of a surgical intervention by 24.8 minutes and shorter hospital staying time due to a decrease in the duration of the postoperative period by 5.3 days, a lower number of postoperative complications by 2.5%, and a lower postoperative mortality by 2.4%. The duration of laparoscopic suturing of a perforated ulcer averaged 38.6 minutes. The duration of hospital staying averaged 6.9±1.2 days. The use of minimally invasive interventions for ulcerative duodenal bleeding was accompanied by a significant reduction in the rehabilitation period compared with that after traditional, "open" operations that amounted to 18.3+3.6 and 35.5±5.9 days, respectively. Postoperative mortality was 1.3% (1 patient in the control group died). Conclusion. The outcome of treatment depends on the age of patients, the timing of the onset of the disease, the severity of concomitant pathology, the severity and extent of peritonitis and the duration of ulcerative anamnesis.
... Approximately 4 million people are affected each year. [1] The global prevalence of PUD has decreased in recent years, [2,3] but the complications from peptic ulcers have not decreased. [3,4] The reduction in peptic ulcer disease is partly explained by helicobacter pylori eradication therapy. ...
... [1] The global prevalence of PUD has decreased in recent years, [2,3] but the complications from peptic ulcers have not decreased. [3,4] The reduction in peptic ulcer disease is partly explained by helicobacter pylori eradication therapy. However, the complications of peptic ulcer disease, especially bleeding and perforation, continue to occur suddenly. ...
Background:
The aim of our study was to investigate the prognostic role of platelet/albumin ratio in patients treated under emergency conditions for peptic ulcer perforation (PUP).
Methods:
A retrospective study involving emergency patients who were operated for PUP was carried out. The patients were divided into 2 groups: PUP patients who died after surgical treatment (PUP-M) and PUP patients who survived after surgical treatment (PUP-S). The laboratory values of the patients were compared statistically. A P value of <.05 was considered statistically significant.
Results:
This cohort study consisted of 171 patients treated between June 2013 and December 2019. The mean age of the patients was 46.3 ± 20.5 years; and 33 (19.3%) patients were women. The age (P ≤ .001), platelet/lymphocyte ratio (P = .02), lactic dehydrogenase to albumin ratio (P ≤ .001), and platelet/albumin ratio (PAR; P ≤ .001) values were high and lymphocyte count was low (P = .006) in the PUP-M group. A positive correlation was determined between length of stay in hospital and age (P ≤ .001), lactic dehydrogenase/albumin ratio (P ≤ .001), platelet count (P = .044), and PAR (P ≤ .001). A substantial negative correlation was determined between length of stay in hospital and albumin count (P ≤ .001).
Conclusions:
We determined a high preoperative PAR level in PUP patients who had undergone surgery as a negative prognostic parameter. PAR is a candidate biomarker for clinical practice.
... Возникновению дисбактериоза могут способствовать нервно-психическими перегрузки, нерегулярное и несбалансированное питание, курение, чрезмерное потребление алкоголя, загрязнение окружающей среды, гиподинамия и низкая санитарная культура населения [1]. ...
... 2 PPU constitutes about 10% of patients hospitalised for PUD in the United States of America (USA) and is responsible for 37% of deaths. 3 PUD was historically considered to be rare in Africa. 4 This is certainly no longer the case. ...
... Due to the development of proton pump inhibitor (PPI) treatment and Helicobacter pylori eradication therapy, elective surgery for peptic ulcers is rare. 1 However, complications caused by peptic ulcers require emergency surgery, with bleeding (73%), perforation (9%), and obstruction (3%) reported as the most common complications requiring emergency operations in the USA. 2 Of these, perforation accounts for approximately 10% of peptic ulcer complications, but is associated with the highest rate of mortality. 3 If a duodenal ulcer perforates, an emergency operation is needed. ...
Objective
To compare clinical and operative results between laparoscopic primary repair (LPR) alone and LPR with highly selective vagotomy (LPR-HSV) in patients with duodenal ulcer perforation.
Methods
Clinical data from patients who underwent either LPR or LPR-HSV by resecting both sides of the neurovascular bundle using an ultrasonic or bipolar electrosurgical device for duodenal ulcer perforations, between 2010 and 2020, were retrospectively collected. Between-group differences in continuous and categorical variables were statistically analysed.
Results
Data from 184 patients (mean age, 49.6 years), who underwent either LPR ( n = 132) or LPR-HSV ( n = 52) were included. The mean operation time was significantly longer in the LPR-HSV group (116.5 ± 39.8 min) than in the LPR group (91.2 ± 33.3 min). Hospital stay was significantly shorter in the LPR-HSV group (8.6 ± 2.6 days) versus the LPR group (11.3 ± 7.1 days). The mean postoperative day of starting soft fluid diet was also significantly shorter in the LPR-HSV group (4.5 ± 1.4 days) than in the LPR group (5.6 ± 4 days). No between-group difference in morbidity rate was observed. The learning curve of the HSV procedure showed a stable procedure time after 10 operations.
Conclusions
LPR with HSV may be a safe and feasible procedure for selective cases who are at high risk for ulcer recurrence.
... Gastroduodenal perforations are a common and highly critical emergency condition in visceral surgery, accounting for a significant proportion of surgical emergencies worldwide [1][2][3]. Peptic ulcers, in particular, significantly contribute to the incidence of gastroduodenal perforations, with studies reporting them as the leading cause in approximately 70-90% of cases. Moreover, gastroduodenal perforations can arise from various causes, including malignancies and iatrogenic interventions [4]. ...
(1) Background: The aim of the present study was to identify risk factors associated with postoperative morbidity, suture/anastomotic insufficiency, re-surgery, and mortality in patients undergoing surgery for gastroduodenal perforation. (2) Methods: A retrospective analysis of 273 adult patients who received surgical treatment for gastroduodenal perforation from January 2006 to June 2021 at the University Hospital Erlangen was performed. The patient demographics and preoperative, intraoperative, and postoperative parameters were collected and compared among the different outcome groups (in-hospital morbidity, suture/anastomotic insufficiency, re-surgery, and 90-day mortality). (3) Results: In-hospital morbidity, suture/anastomotic insufficiency, need for re-surgery, and 90-day mortality occurred in 71%, 10%, 26%, and 25% of patients, respectively. The independent risk factors for morbidity were a significantly reduced general condition, a lower preoperative hemoglobin level, and a higher preoperative creatinine level. The independent risk factors for suture/anastomotic insufficiency could be identified as an intake of preoperative steroids and a perforation localization in the proximal stomach or duodenum. The four parameters were independent risk factors for the need for re-surgery: a significantly reduced general condition, a perforation localization in the proximal stomach, a higher preoperative creatinine level, and a higher preoperative CRP level. An age over 66 years and a higher preoperative CRP level were independent risk factors for 90-day mortality. (4) Conclusions: Our study could identify relevant risk factors for the postoperative outcome of patients undergoing surgical treatment for gastroduodenal perforation. Patients exhibiting the identified risk factors should receive heightened attention in the postoperative period and may potentially benefit from personalized and tailored therapy.
... The management of perforation is done by simple procedures such as open primary closure or modified Graham patch repair. Laparoscopic options are now being developed to reduce morbidity [6][7][8]. Though promising advancements have been made in the fields of surgery, anaesthesia, and medicine, the postoperative management of PPUD is based more on old traditional practices than evidence-based ones. ...
Background: The enhanced recovery after surgery (ERAS) program established improved clinical outcomes in elective surgery; however, its role in emergencies is uncertain. This study was designed to assess the feasibility, safety, and efficacy of a tailored-ERAS (t-ERAS) protocol in patients undergoing modified Graham’s patch closure for gastro-duodenal perforation.
Methods: A single-centre, prospective, parallel-arm, open-label, randomized controlled trial was conducted from February 2021 to December 2021. Patients with gastroduodenal perforation undergoing modified Graham's patch were randomly assigned to either conventional care or the t-ERAS pathway. Patients with refractory septic shock, psychiatric or neurological disorders, pregnancy, multiple perforations, sealed-off perforations, and perforation sizes greater than 1.5 cm were excluded. The primary outcome was to compare the length of hospitalization (LOH). Functional recovery parameters and morbidity were compared in secondary outcomes.
Results: Twenty-five patients each were included in conventional care and the t-ERAS group. In the t-ERAS group, LOH was significantly shorter (6.3 SD2.15 days versus 9.56 SD4.33 days, p = 0.001). Patients in the t-ERAS group had significantly early functional recovery (days) with time to first bowel sound (1.8 SD0.41; p 0.002), first flatus (2.52 SD0.65; p = 0.026), first stool (3.04 SD0.68; p < 0.001), first liquid diet (2.24 SD0.60; p = 0.002), and duration of ileus (2.64 SD0.86; p = 0.038). There was no significant difference in morbidity such as post-operative nausea and vomiting, SSI, or pulmonary complications between the two groups.
Conclusion: Tailored ERAS pathways are safe and effective in reducing the LOH and promoting early functional recovery in patients undergoing emergency closure of gastro-duodenal perforation.
... In the era of proton pump inhibitors and endoscopic treatment, the incidence of peptic ulcers has greatly decreased. However, the number of PPU cases has remained steady due to an increasing usage of nonsteroid anti-inflammatory drugs accompanied by an increasing patient age [1,2]. Additionally, the mortality rate of PPU has remained high at approximately 10% [3,22]. ...
Background
Perforated peptic ulcer (PPU) remains challenging surgically due to its high mortality, especially in older individuals. Computed tomography (CT)-measured skeletal muscle mass is a effective predictor of the surgical outcomes in older patients with abdominal emergencies. The purpose of this study is to assess whether a low CT-measured skeletal muscle mass can provide extra value in predicting PPU mortality.
Methods
This retrospective study enrolled older (aged ≥ 65 years) patients who underwent PPU surgery. Cross-sectional skeletal muscle areas and densities were measured by CT at L3 and patient-height adjusted to obtain the L3 skeletal muscle gauge (SMG). Thirty-day mortality was determined with univariate, multivariate and Kaplan–Meier analysis.
Results
From 2011 to 2016, 141 older patients were included; 54.8% had sarcopenia. They were further categorized into the PULP score ≤ 7 (n=64) or PULP score > 7 group (n=82). In the former, there was no significant difference in 30-day mortality between sarcopenic (2.9%) and nonsarcopenic patients (0%; p=1.000). However, in the PULP score > 7 group, sarcopenic patients had a significantly higher 30-day mortality (25.5% vs. 3.2%, p=0.009) and serious complication rate (37.3% vs. 12.9%, p=0.017) than nonsarcopenic patients. Multivariate analysis showed that sarcopenia was an independent risk factor for 30-day mortality in patients in the PULP score > 7 group (OR: 11.05, CI: 1.03-118.7).
Conclusion
CT scans can diagnose PPU and provide physiological measurements. Sarcopenia, defined as a low CT-measured SMG, provides extra value in predicting mortality in older PPU patients.
... In the United States, there has been a significant increase in inpatient mortality for NAFLD-cirrhosis by 32% between 2005-2015, despite a decrease in the inpatient mortality rates for patients with all other causes of liver cirrhosis [19]. However, there has been a significant decline in inpatient PUD mortality due to the increasing use of therapeutic endoscopic procedures for bleeding ulcers [20]. In our study, there was a rising trend of all-cause inpatient mortality for NAFLD hospitalizations with PUD (Table 2). ...
Background:
Peptic ulcer disease (PUD) is frequently seen in patients with liver cirrhosis. However, current literature lacks data on PUD in non-alcoholic fatty liver disease (NAFLD) hospitalizations.
Aim:
To identify trends and clinical outcomes of PUD in NAFLD hospitalizations in the United States.
Methods:
The National Inpatient Sample was utilized to identify all adult (≥ 18 years old) NAFLD hospitalizations with PUD in the United States from 2009-2019. Hospitalization trends and outcomes were highlighted. Furthermore, a control group of adult PUD hospitalizations without NAFLD was also identified for a comparative analysis to assess the influence of NAFLD on PUD.
Results:
The total number of NAFLD hospitalizations with PUD increased from 3745 in 2009 to 3805 in 2019. We noted an increase in the mean age for the study population from 56 years in 2009 to 63 years in 2019 (P < 0.001). Racial differences were also prevalent as NAFLD hospitalizations with PUD increased for Whites and Hispanics, while a decline was observed for Blacks and Asians. The all-cause inpatient mortality for NAFLD hospitalizations with PUD increased from 2% in 2009 to 5% in 2019 (P < 0.001). However, rates of Helicobacter pylori (H. pylori) infection and upper endoscopy decreased from 5% in 2009 to 1% in 2019 (P < 0.001) and from 60% in 2009 to 19% in 2019 (P < 0.001), respectively. Interestingly, despite a significantly higher comorbidity burden, we observed lower inpatient mortality (2% vs 3%, P = 0.0004), mean length of stay (LOS) (11.6 vs 12.1 d, P < 0.001), and mean total healthcare cost (THC) ($178598 vs $184727, P < 0.001) for NAFLD hospitalizations with PUD compared to non-NAFLD PUD hospitalizations. Perforation of the gastrointestinal tract, coagulopathy, alcohol abuse, malnutrition, and fluid and electrolyte disorders were identified to be independent predictors of inpatient mortality for NAFLD hospitalizations with PUD.
Conclusion:
Inpatient mortality for NAFLD hospitalizations with PUD increased for the study period. However, there was a significant decline in the rates of H. pylori infection and upper endoscopy for NAFLD hospitalizations with PUD. After a comparative analysis, NAFLD hospitalizations with PUD had lower inpatient mortality, mean LOS, and mean THC compared to the non-NAFLD cohort.
... Bleeding is the most frequent complication (73%), followed by perforation (9%) and gastric outlet obstruction (3%). [6] Despite the decrease in hospitalizations for bleeding, the rate of perforation and obstruction remains steady. The exact rate of the penetration, however, remains unknown. ...
Introduction: The penetration into adjacent organs is a classical complication of peptic ulcer despite being less frequent than the other complications. The current work presents a rare case of gastric ulcer penetrating the duodenojejunal flexure and discusses the diagnostic difficulties, pitfalls, and current treatment strategy.
Case report: A 63-years-old woman was admitted complaining of intermittent black stools defecations, and a weight of 44 kg. The referral gastroscopy revealed a 10 cm ulcer on the posterior wall of the stomach. The histology demonstrated severe gastritis with atypical cells. The hemoglobin level was 88g/l. The patient was scheduled for elective resection for suspected gastric cancer. The intraoperative finding was completely different – there was an ulcer approximately 4-5 cm in diameter infiltrating the transverse mesocolon and duodenojejunal flexure. The case was considered T4 cancer and we decided against elective gastrectomy. The postoperative CT showed an ulcer penetrating the duodenojejunal flexure. The second gastroscopy found an ulcer with a size of 3-4 cm. The multiple biopsies showed exacerbated chronic peptic ulcer with H. pylori infection, which was treated with proton pump inhibitors and antibiotics. The follow-up gastroscopy four months later demonstrated shrinkage of the ulcer to 15 mm with complete epithelization. One year later she gained 23 kg and was free of complaints.
Conclusion: Penetration and fistulization to the duodenojejunal flexure are uncommon but possible complications of peptic ulcer disease. They are not an absolute indication for surgery. Decision-making should take into account the clinical presentation, patient age, and comorbidity.
... 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. Além disso, permanece um número significativo de pacientes que foram submetidos à cirurgia antes do desenvolvimento das terapias médicas padrão atuais que continuam a ter problemas relacionados à operação original 1,2 . Devido à diminuição na taxa de hospitalização por úlcera péptica, os cirurgiões em treinamento agora têm menos exposição ao manejo geral da úlcera péptica, incluindo complicações, bem como alguns dos procedimentos tecnicamente mais exigentes para o tratamento da úlcera péptica, como vagotomia altamente seletiva (vagotomia de células parietais) 2 . ...
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.
... Perforation is one of the detrimental complications of peptic ulcers with increased mortality. [6][7][8] The eponym Valentino's syndrome is referred to when the digestive fluid from peptic ulcer perforation seeps and settles down in the right iliac fossa causing inflammation and giving rise to symptoms and signs similar to acute appendicitis. The majority (60%) of peptic ulcers are anterior and perforation occurs into the peritoneal cavity. ...
Due to the rarity of the condition, Valentino’s syndrome is an underrated differential diagnosis for acute appendicitis. We describe a patient with Valentino’s syndrome in whom preoperative and intraoperative diagnoses were challenging due to misleading clinical, investigative, and morphological findings. A 31-year-old woman who was on methylprednisolone for sensory radiculopathy presented to the emergency department with acute right lower quadrant pain. The clinical diagnosis of acute appendicitis was supported by the elevated inflammatory markers and ultrasonographic findings. An appendicectomy and an ovarian cystectomy were performed due to the findings of mild appendicitis and right ovarian endometrioma, respectively. Postoperatively, she developed peritonitis with a purulent bile-stained discharge from the surgical site and per vagina. Contrast-enhanced computed tomography of the abdomen showed a retroperitoneal collection at the second lumbar vertebral level extending along the right paracolic gutter to the pelvis and intraperitoneal fluid collections in right lower quadrant and pelvis. An emergency exploratory laparotomy confirmed a perforation at the posterior aspect of the duodenum which was repaired with an omental patch. Unfortunately, relaparotomy and end ileostomy were required due to colonic perforation with the eroded drain tube. She made an uneventful recovery with intensive care and underwent ileostomy reversal after 12 weeks. We emphasize the clues to have a high degree of suspicion during preoperative and intraoperative evaluation to recognize this lethal mimicker of acute appendicitis.
... Peptic ulcer disease (PUD) including duodenal ulcer (DU) can cause critical outcomes when hemorrhage and perforation occur [10,11]. Generally, non-steroidal antiinflammatory drugs and Helicobacter pylori are the two major risk factors for PUD [12]. ...
Background:
The rupture of a hepatic artery pseudoaneurysm (HAP) is a rare but lethal complication after living donor liver transplantation (LDLT) and often manifests as acute gastrointestinal bleeding.
Case presentation:
This report describes three patients who experienced HAP after LDLT. These patients initially presented with active bleeding of a duodenal ulcer (DU) in the duodenal bulb, followed by diagnosis of the ruptured HAP by angiography. None of the patients had evidence of an active intra-abdominal infection or bile leakage preceding the rupture of HAP. All patients were initially treated by transcatheter arterial coil embolization (TAE). In all cases, TAE was successful for hemostasis but resulted in complete obstruction of the arterial inflow to the graft. Arterial revascularization by surgical reconstruction using the autologous arterial graft in one case and re-LDLT in another one was successfully performed. The other one succumbed to sepsis caused by later liver abscesses.
Conclusion:
This is the first detailed case series of massive DU bleeding as a warning signal of ruptured HAP after LDLT. HAP should be included in the differential diagnosis when an LDLT recipient presents with gastrointestinal bleeding.
... 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. Além disso, permanece um número significativo de pacientes que foram submetidos à cirurgia antes do desenvolvimento das terapias médicas padrão atuais que continuam a ter problemas relacionados à operação original 1,2 . Devido à diminuição na taxa de hospitalização por úlcera péptica, os cirurgiões em treinamento agora têm menos exposição ao manejo geral da úlcera péptica, incluindo complicações, bem como alguns dos procedimentos tecnicamente mais exigentes para o tratamento da úlcera péptica, como vagotomia altamente seletiva (vagotomia de células parietais) 2 . ...
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.
... Perforation is a common complication of PUD, with an average 2-14% of peptic ulcers resulting in perforation [3], most commonly occurring in females over the age of 60 and NSAID, alcohol or tobacco users. While bleeding is the most frequent complication of PUD, perforation carries a higher rate of surgical intervention and is the most lethal complication, associated with a 30-days mortality risk ranging from 3-40%, with advanced age, higher American Society of Anesthesiologists (ASA) classification, elevated body mass index (BMI), and perforation diameter being nonmodifiable risk factors associated with increased mortality [5][6][7][8]. The only modifiable risk factor associated with mortality is time to operation, whereby a delay of more than three hours is associated with a doubling of mortality risk [1]. ...
Introduction
Minimally invasive or open Graham Patch repair remains the gold standard approach for management of perforated peptic ulcers (PPU). Herein, we report outcomes of laparoscopic technique and compare it with open approach at a community hospital.
Methods
Retrospective observational study conducted comparing laparoscopic modified Cellan-Jones repair (mCJR) versus the standard open repair of PPU. Patients aged 18–90 years during 2016–2021 were offered either a minimally invasive or open approach depending on surgeon laparoscopic capability, and were compared in terms of demographics, co-morbidities, intra-operative details, and short-term outcomes.
Results
A total of 49 patients were included (46.9% males, mean age 52.9 years, mean BMI 25.0, ASA ≥ III 75.5%, 75.5% smokers, 26.5% current NSAIDs use, and 71.4% alcohol drinkers). Duodenum was the most common perforation site (57.1%), and majority of ulcers were 1–2 cm (72.9%). Laparoscopic approach was performed in 16 consecutive patients (32.7%) by a single surgeon, with no conversions. Preoperative characteristics were similar for both groups. Compared to open approach, laparoscopic group were taken to operation immediately (< 4 h) (87.5% vs. 15.2%, p < 0.001), had lower estimated blood loss (11.8 ml vs. 73.8 ml, p = 0.063), and longer operative time (117.1 min vs. 85.6 min, p = 0.010). Postoperatively, nasogastric tube was removed earlier in laparoscopic group (POD1-2, 87.5% vs. 24.2%, p = 0.001), with earlier resumption of diet (POD1-2, 62.6% vs. 9.1%, p = 0.002), less narcotic usage (< 3 days, 58.3% vs. 6.1%, p < 0.001), earlier return of bowel function (POD1-2, 43.8% vs. 9.1%, p = 0.003) and shorter length of stay (LOS) (3.7 days vs. 16.1 days, p < 0.001). Both in-house mortality and morbidity rates were lower in the laparoscopic group, but not statistically significant [(0% vs. 6.1%, p = 0.347) and (12.5% vs. 39.4%, p = 0.500), respectively].
Conclusion
Laparoscopic mCJR is a feasible method for repair of PPU, and it is associated with shorter LOS, and less narcotics usage in comparison to the open repair approach.
Graphical abstract
... Approximately six million people in the United States having peptic ulcer disease(PUD) with an annual direct cost estimate (1) of around 3.1billions .HELICOBACTER PYLORI infection and no steroidal anti inflammatory drugs (NSAIDS) use are the two main causes followed by Alcohol intake.with improvements in understanding the pathogenesis of PUD and treatment with antibiotics and proton pump inhibitors(PPIs),avoidance of NSAIDs and advanced endoscopy techniques,the incidence of complications from PUD requiring surgical intervention (2) has reduced to approximately 11.2% .While this rare event of ulcer perforation is associated with high mortality at 10.6% and emergency surgeon has to be aware of it.Acute appendicitis usually present with right iliac fossa pain and some may present in few atypical ways like, diffuse abdominal pain(generalised peritonitis).There are wide range of medical disorders that present mimicking acute appendicitis includes tuboovarian abscess,colorectal cancer,sigmoid diverticulitis,acute ileocecal enterocolitis (typhlitis),gastric or duodenal perforated ulcer(Valentino's syndrome)cecal tumors etc.,Valentino syndrome is a rare differential diagnosis to appendicitis and is presentation as pain in RIF can occur due to perforation of a duodenal ulcer (3,4,5,6) through the retroperitoneum . It was first reported in Italian actor RUDOLPH VALENTINO who presented with right iliac fossa pain got operated for appendicitis and later patient go deteriorated on post operative day 2 and died later his post-mortem report reveals having perforated peptic ulcer. ...
Valentino syndrome is a rare presentation of perforated peptic ulcer in retroperitoneum,which can present as right iliac fossa pain mimicking acute appendicitis(AA).The purpose of this report is to emphasise on rare presentation of right iliac fossa (RIF)tenderness In a suspected case of acute appendicitis,later diagnosed it to be Valentino’s syndrome.We reported a case of 22 years old male patient presented to emergency with complaints of pain in the right groin with fever.The diagnosis was inconclusive after routine investigations and clinical examination later proceeded with contrast enhanced computed tomography which reveals air pockets around right kidney and retro pneumoperitoneum and free fluid in the Morrisons pouch.An exploratory laparotomy revealed a perforation of peptic ulcer in the second part of duodenum which was closed by grahams omental patch repair.post operatively antibiotics were prescribed and the patient was discharged without any complications.A differential diagnosis of Valentino syndrome for perforated duodenal ulcer must be considered,while examining a case of pain in the RIF.The final diagnosis may be intraoperative,however,contrast enhanced computed tomography scans remains gold standard ones.valentino’s syndrome occurs when gastric and duodenal fluids collect in the right paracolic gutter causing focal peritonitis and RLQ pain.
... The more frequent complication of peptic ulcer disease (PUD) is the bleeding (hemorrhage), followed by perforation and obstruction [13]. Some differences in the frequency among various complications can be found in the geographic distribution, due to amount of NSAIDs and ASA use, diffusion of H. pylori infection, lifestyles of the community. ...
... The more frequent complication of peptic ulcer disease (PUD) is the bleeding (hemorrhage), followed by perforation and obstruction [13]. Some differences in the frequency among various complications can be found in the geographic distribution, due to amount of NSAIDs and ASA use, diffusion of H. pylori infection, lifestyles of the community. ...
... The impact of JRS on HUI3 domains was modeled using data from a cohort of patients treated at the Vancouver General Hospital [37]. Each side effect of medical treatment (except dyspepsia) and JRS were associated with a specified risk of death based on data from the literature [5,35,36,[43][44][45][46][47]. ...
Objectives
The purpose of this study was to compare three strategies for reducing population health burden of osteoarthritis (OA): improved pharmacological treatment of OA-related pain, improved access to joint replacement surgery, and prevention of OA by reducing obesity and overweight.
Methods
We applied a validated computer microsimulation model of OA in Canada. The model simulated a Canadian-representative open population aged 20 years and older. Variables in the model included demographics, body mass index, OA diagnosis, OA treatment, mortality, and health-related quality of life. Model parameters were derived from analyses of national surveys, population-based administrative data, a hospital-based cohort study, and the literature. We compared 8 what-if intervention scenarios in terms of disability-adjusted life years (DALYs) relative to base-case, over a wide range of time horizons.
Results
Reductions in DALYs depended on the type of intervention, magnitude of the intervention, and the time horizon. Medical interventions (a targeted increase in the use of painkillers) tended to produce effects quickly and were, therefore, most effective over a short time horizon (a decade). Surgical interventions (increased access to joint replacement) were most effective over a medium time horizon (two decades or longer). Preventive interventions required a substantial change in BMI to generate a significant impact, but produced more reduction in DALYs than treatment strategies over a very long time horizon (several decades).
Conclusions
In this population-based modeling study we assessed the potential impact of three different burden reduction strategies in OA. Data generated by our model may help inform the implementation of strategies to reduce the burden of OA in Canada and elsewhere.
... Complications of PUD vary in frequency geographically; in the United States, hemorrhage (73 %) is the most common complication of PUD, followed by perforation (9 %), and obstruction (3 %) [4] . The mortality rate from complications of PUD is over 10 times that of acute appendicitis or acute cholecystitis. ...
The plant Dialium guineense (DAG) has been claimed by local users, to be effective in the treatment of peptic ulcers, especially, when taken as an aqueous decoction. The present study assessed the antiulcer activity of the plant, as well as explored the possible mechanisms of action of the herbal drug, aside identifying some of the various phytoconstituents, which could be responsible for its antiulcer activity. Different ulcerogens (ethanol 99.9 %, indomethacin 50 mg/kg, cysteamine 400 mg/kg, glacial acetic acid) and the pylorus ligation-induced ulcers were used to induce acute and chronic ulcers, with doses of 100, 300 and 750 mg/kg DAG and the standard drugs relative to each model, while assessing drug activity through ulcer scoring and comparing it with both the negative and positive controls. The extract, which has an LD50 of 1584.89 mg/kg when administered intraperitoneally, recorded a significant (p<0.05) antiulcer effect in all the models used in the study. Similarly, in the pylorus-ligated group, DAG compared effectively with atropine (1 mg/kg) and ranitidine (100 mg/kg), the standard antagonists of the secretagogues- carbachol and histamine employed in the study. The herbal drug produced a significant reduction in gastric juice volume, as well as in the free and the total acidity. The results suggest that DAG possesses a significant antiulcer property through cytoprotective and antisecretory actions, and it could be projected that the presence of secondary metabolites such as tannins, saponins and flavonoids could be responsible for its ulcer protective and healing property. The study therefore validates the folkloric use of DAG in the treatment of peptic ulcer.
... The spectrum of etiology of perforation is different between developing and developed countries. 2 The Western literature suggests that foreign body, ischemia, radiotherapy, diverticula, and Crohn's disease are the main causes of perforation, which are more commonly seen in elderly patients. In contrast to this, infection is the most common cause for perforations in developing countries. ...
Background: Gastrointestinal perforation is one of the common surgical emergencies in developing countries. The diagnosis is mainly clinical and is aided by radiological investigations. This study was designed to highlight the spectrum of hollow viscus perforation peritonitis in terms of etiology, clinical presentations, site of perforation, surgical treatment, postoperative complications, and mortality.Methods: The study was a hospital‑based observational study and included 462 patients of perforation peritonitis (diffuse or localized) who were studied retrospectively in terms of cause, site of perforation, surgical treatment, complications, and mortality. Only those patients who underwent exploratory laparotomy for management of perforation peritonitis were included.Results: Overall stomach was the most common site of perforation (33%). Ileum (26%) was the second common site of perforation. Duodenal perforations were seen in 88 (19%) cases whereas appendicular perforations were seen in 46 (10%) cases. Colonic perforations were least common. Acid peptic disease was the most common etiology of stomach perforations. Enteric fever (63%) was the most common etiology of jejuno-ileal perforation. Other causes include tuberculosis (23%), trauma (8%), malignancy (3%) and idiopathic in rest. Males were six times more commonly affected than females. Peak incidence was noted in the 2nd and 3rd decades of life.Conclusions: Spectrum of perforation peritonitis cases in developing world is different from developed countries The Western literature suggests that foreign body, ischemia, radiotherapy, diverticula, and Crohn’s disease are the main causes of perforations. In contrast to this, infection is the most common cause for perforations in developing countries.
... Among the complications of PUD, bleeding is most common (73%), followed by perforation (9%). 1 Most perforations involve the anterior wall of the duodenum (60). 2 Penetration is pathologically similar to perforation, except that the ulcer erodes into another organ such as the liver or the pancreas instead of the peritoneal cavity. 3 An extensive literature search was performed on PubMed, Google Scholar, Embase, and MEDLINE to look for similar cases. ...
Peptic ulcer disease (PUD) has a significant health burden. Penetration is a rare complication of PUD, where an ulcer erodes into another organ. To the best of our knowledge, we present the fourth case in the literature where a gastric ulcer has penetrated the pancreas. A 67-year-old man with a history of PUD presented to the emergency department for epigastric pain. Endoscopy revealed a large gastric ulcer at the incisura with magnetic resonance imaging demonstrating gastropancreatic fistula. Our case emphasizes on the importance of timely identification and treatment strategies for gastropancreatic fistula, the rarest complications of PUD.
... Administrative data sources, such as the US National Inpatient Sample [28] and Health Insurance Claims Registry in Korea [29] report low mortality rates (around 3%). For the USA, such low mortality in administrative datasets contrasts with rates in other reports (mortality of 15%) from the same country [30]. In prospective, nationwide data collection, such as the Danish Clinical Register of Emergency Surgery, mortality is reported to be as high as 28% Thus, in addition to geographical variation ( Figure-1), method of data capture must be considered carefully when mortality rates are compared [31]. ...
... Emergency surgery for complication required in 7% of hospitalized peptic ulcer disease patients. 2 Factors such as >24 hours of history, concomitant disease, shock, post operated wound infections, all are associated with increase in mortality and morbidity. 3 Open repair with G patch omentopexy (Graham-Steel) remains the Conventional method of management since years. ...
Background: Perforation is a common complication of peptic ulcer disease and presents as Perforation peritonitis. It has the highest number of mortality among all complications (≈15%). In spite of modern progress in the management, it is still a life-threatening catastrophe. Emergency surgery for complicated cases required in 7% of hospitalized peptic ulcer disease patients. Factors such as >24 hours of history, concomitant disease, shock, post operated wound infections, all are associated with increase in mortality and morbidity.Methods: A Prospective, observational, single hospital base study done during the period from 2016 to 2020 in the Department of Surgery, Gandhi medical college Bhopal. Sample size was taken 63Results: 52 out 63 cases presented with perforation peritonitis included under study period, 11 cases were excluded due to death and absconding of cases. In rest 52 cases, 15 of them went through laparoscopic repair, 28.85% of the cases were shifted directly to ORG.Conclusions: Laparoscopic repair of peptic ulcer perforation is feasible if patient presents early to the hospital. All perforation peritonitis should give fair chance to repair laparoscopically if patient’s general condition and anesthetic permits. This is a good alternative for conventional open surgery with less post-operative pain, early return to normal activities, less hospital stays and few postoperative wound infections. Thus it can significantly decrease the economic burden.
... Although the incidence of peptic ulcer disease has been decreasing in recent decades due to eradication therapy for Helicobacter pylori and improvements in pharmacological therapies including H2 blockers and proton pump inhibitors, the incidence of PPU has largely remained unchanged (2,3). PPU is the most important contributor to inpatient mortality in peptic ulcer disease due to accompanying peritonitis (4,5). Surgery, which remains the standard of care for patients with PPU, has been simplified by primary repair of the perforation site and placement of a free omental patch (6,7). ...
Background:
Perforated peptic ulcer (PPU) is a fatal complication of peptic ulcer disease, which requires emergency surgery. Laparoscopic repair is the widely accepted and effective method for the treatment of PPU. The aim of this study was to evaluate the safety and efficacy of duet laparoscopic repair of PPU with knotless barbed sutures.
Methods:
From January 2013 to May 2019, 40 patients with PPU underwent laparoscopic primary repair and omentopexy at the Dankook University Hospital. The operative outcomes and complications of patients undergoing surgery using continuous suturing with absorbable knotless barbed sutures (group A, n=15) were compared with those undergoing surgery with conventional interrupted sutures (group B, n=25).
Results:
The mean operative time was significantly shorter in group A than group B (84.4±39.8 vs. 104.2±49.4 min, P<0.001). There were no differences in other operative outcomes or postoperative complications (group A vs. group B, 20.0% vs. 24.0%, respectively; P=0.249) between the two groups. The mean operation time spent for laparoscopic sutures and omentopexy was 22.7 minutes.
Conclusions:
The findings of the current study, albeit performed retrospectively at a single institution, suggested that duet laparoscopic repair of PPU with knotless barbed sutures might be considered as an alternative option, especially in hospitals lacking manpower.
... Gastrointestinal (GI) ulcer disease, defined as a clearly demarcated ulcer between the esophagus to ileocecal valve, is relatively uncommon in the pediatric population with an annual incidence of approximately 5.4 per 10 0,0 0 0 [1] . A study by Wang et al. found that pediatric hospitalizations for GI ulcer disease decreased by 30 percent from 1993 to 2006 [2] . Concomitantly, surgical repair of gastrointestinal (GI) ulcer disease is becoming less prevalent due to increased early detection of ulcers in the population, introduction of acid suppression treatment, and detection and eradication of Helicobacter pylori infections [3 , 4] . ...
Background
: There is a lack of contemporary data about pediatric gastrointestinal ulcer disease. We hypothesized that ulcers found in immunosuppressed children were more likely to require surgical intervention.
Methods
: All children <21 years (n=129) diagnosed with ulcers at a quaternary hospital from 1990 to 2019 were retrospectively reviewed. Clinical findings and pertinent information were collected.
Results
: Of 129 cases, 19 (14.7%) were immunosuppressed. Eight were post-transplant; four were diagnosed with post-transplant lymphoproliferative disease (PTLD). Eight were associated with cancer. Three were both. Three of 19 immunosuppressed and 28/110 immunocompetent patients were taking acid suppression therapy. Nine immunosuppressed patients required surgical intervention, including all PTLD cases, compared to 14 immunocompetent (47.3% vs 16.4%, p<0.01). Five patients had duodenal perforation, two had multiple small bowel perforations, and two had uncontrolled bleeding. Of 9/19 immunosuppressed patients, surgical complications included bleeding (n=7), sepsis (n=2), ostomy reoperation/readmissions (n=2), and death within 30 days (n=2). Two/eighteen immunocompetent patients had bleeding complications.
Conclusion
: Surgical treatment for ulcers remains relevant for pediatric patients. Immunosuppressed patients have more complications, longer hospital stays, and are more likely to need surgical intervention. Efforts should be made for ulcer prophylaxis with a low threshold to investigate epigastric pain in these complex patients.
The elderly population is rapidly increasing around the world, and the number of the patients requiring an operation is outpacing and expanding. The role of minimally invasive surgery (MIS) has been growing in all surgical specialties. This new technology changes the surgical practices and enables the surgeon to perform complex procedures with small incisions and great outcomes for the patient. This trend continues and brings great benefit for surgeons and patients. The MIS techniques utilized for general surgery are not only for laparoscopic surgery, but also they expand to robotic surgery as well. We will discuss the innovations of MIS in various emergent general surgery settings for the elderly population.
Background
Peptic ulcer disease (PUD) is common worldwide. Its incidence and prevalence have been declining in recent years in developed countries, and a similar trend has been observed in many parts of Africa including Nigeria.
Aim
This study aimed to provide an endoscopic update on PUD in the Northern Savannah of Nigeria and compare with past reports from the region and recent reports from Nigeria, Africa, and the rest of the world.
Methods
Upper gastrointestinal endoscopy records of consecutive patients diagnosed with PUD between January 2014 and September 2022 at an endoscopy unit of a tertiary institution in North-West Nigeria were retrieved and demographic data, types of peptic ulcer, and their characteristics were extracted and analyzed.
Results
Over a 9-year period, 171/1958 (8.7%) patients were diagnosed with PUD: mean age 48.8 years (range 14–85), 68.4% male, and 70% >40 years. 59.6% were gastric ulcers (GU), 31.6% duodenal ulcers (DU), and 8.8% were both. The mean age of patients with GU was slightly higher than those with DU (49.9 years vs. 46.6 years, P = 0.29); patients aged <40 years were significantly more likely to be diagnosed with DU than GU (54.7% vs. 33.9%, P = 0.016) while those >40 years significantly more GU than DU (74.6% vs. 54.7%, P = 0.016). There were no significant gender differences between GU and DU.
Conclusion
The prevalence and pattern of PUD in Northern Savannah of Nigeria have changed – patients were predominantly male and older, and GU predominated.
Our study to evaluate the aetiological and clinical spectrum of gastric outlet obstruction (GOO) in North-west India showed malignant cause (54.9%) was more common than benign (45.1%). Common causes of malignancy were gall bladder (37.5%), gastric (31.8%) and pancreatic carcinoma (19.6%); commonest benign causes were opioid abuse (29%), peptic ulcer disease (21.6%), ingestion of corrosives (20.2%) and chronic pancreatitis (12.3%).
Earlier the treatment for peptic ulcer was surgery such as truncal vagotomy and drainage procedure. Recurrence after surgery and complications were common. It was because of our lack of knowledge about helicobacter pylori bacteria we used to blame factors such as lifestyle, other than infections causing peptic ulcer. It was due to two genius Australian doctors who identified the bacteria and the scenario was changed. Surgery for peptic ulcer gradually diminished dramatically after the development of H2 receptor antagonists and proton pump inhibitors. The surgery for complications of peptic ulcer such as perforations remain same but elective surgery for peptic ulcer drastically reduced. There was a time when after failed medical treatment for peptic ulcer patients were advised surgery or remain on cold milk and bread. These researches in medicine have alleviated human suffering from peptic ulcer disease. Patients of deep penetrating peptic ulcer used to weep with pain and treating clinicians also used to get frustrated for not getting ways to make patients painfree.
Background and aims
Endoscopic submucosal dissection (ESD) for anastomotic lesions is technically challenging due to severe fibrosis, deformity, staples, and limited space for procedure. We aimed to characterize the clinicopathological characteristics, feasibility, and effectiveness of ESD for anastomotic lesions of the upper gastrointestinal tract.
Methods
We retrospectively investigated 43 patients with lesions involving the anastomoses of the upper GI tract who underwent ESD from April 2007 to February 2021. We collected clinicopathological characteristics, procedure‑related parameters and outcomes, and follow‑up data and analyzed the impact of anastomotic involvement.
Results
The median duration from previous upper GI surgery was 60 months and the median procedure duration was 30 min. The rate of en bloc resection and en bloc with R0 resection was 90.7% and 81.4%, respectively. Two patients (4.7%) experienced major adverse events, including delayed bleeding and febrile episode. During a median follow-up of 80 months, 3 patients had local recurrence and 4 patients had metastases. The 5-year disease-free survival (DFS) and overall survival (OS) rates were 89.6% and 95.1%, respectively. Compared with the unilaterally involving group, the straddling anastomosis group had significantly longer procedure duration, larger specimen, lower rates of en bloc resection and en bloc with R0 resection, and shorter DFS and OS (all P < 0.05). However, rates of adverse events did not differ significantly between the two groups.
Conclusions
The short‑ and long-term outcomes of ESD for upper GI anastomotic lesions were favorable. Although with technically challenging, ESD could be performed safely and effectively for anastomotic lesions.
A 69-year-old male presented with a sudden onset of whole abdominal severe pain worsening in the last 12 hours. Two days before, he felt moderate pain in the abdominal right lower quadrant (RLQ). He had also 2 times of hematemesis and melena. Abdominal examination showed mild distension, generalized tenderness, guarding, and rebound tenderness. Left lateral decubitus radiograph showed pneumoperitoneum. Lower abdominal ultrasonography led to appendicitis suspicion. In the explorative laparotomy procedure, the appendix was concluded to be in normal condition. However, a 3×3 cm type I perforated gastric ulcer was found intraoperatively. Cellan-Jones technique was performed for this perforation. Thereafter, an incidental appendectomy was conducted. The patient was finally discharged from ICU on the fifth day with a stable condition. Explorative laparotomy followed with required pathology repair of the peritonitis underlying causes should be immediately performed, especially for a geriatric patient who is at high risk to develop sepsis. If a Valentino’s Syndrome is suspected, incidental appendectomy might be beneficial to prevent future appendicitis and eliminate future conflicting diagnosis confusion involving appendicitis.
The most common indications for gastric operation are morbid obesity, neoplasm, gastrostomy tube placement, and ulcer disease. This chapter discusses important concepts relevant to the choice of operation for these common indications and the management of postoperative complications.KeywordsGastric surgeryGastrectomyBbariatric surgeryMorbid obesitySleeve gastrectomyRoux-en-Y gastric bypassGastric cancerPeptic ulcerGastric ulcer
Pyloroplasty is now primarily used in patients undergoing emergency surgery for massive hemorrhage from duodenal ulcer when other methods of control have failed. A truncal vagotomy may be added if the patient has been noncompliant with medical therapy (see Chaps. 25 and 26). This chapter describes several techniques for pyloroplasty and considerations for suture ligation of the gastroduodenal artery. Indications, preoperative preparation, pitfalls, surgical strategy and technique, and complications are all discussed.KeywordsPyloroplastyduodenal ulcerupper gastrointestinal bleedgastroduodenal arteryHeineke-MikuliczFinney
Background:
Peptic ulcer disease (PUD), once primary a surgical problem, is now medically managed in the majority of patients. The surgical treatment of PUD is now strictly reserved for life-threatening complications. Free perforation, refractory bleeding and gastric outlet obstruction, although rare in the age of medical management of PUD, are several of the indications for surgical intervention. The acute care surgeon caring for patients with PUD should be facile in techniques required for bleeding control, bypass of peptic strictures, and vagotomy with resection and reconstruction. This video procedures and techniques paper demonstrates these infrequently encountered, but critical operations.Content (Video Description)A combination of anatomic representations and videos of step-by-step instructions on perfused cadavers will demonstrate the key steps in the following critical operations. Graham patch repair of perforated peptic ulcer is demonstrated in both open and laparoscopic fashion. The choice to perform open versus laparoscopic repair is based on individual surgeon comfort. Oversewing of a bleeding duodenal ulcer via duodenotomy and ligation of the gastroduodenal artery is infrequent in the age of advanced endoscopy and interventional radiology techniques, yet this once familiar procedure can be lifesaving. Repair of giant duodenal or gastric ulcers can present a challenging operative dilemma on how to best repair or exclude the defect. Vagotomy and antrectomy, perhaps the least common of all the aforementioned surgical interventions, may require more complex reconstruction than other techniques making it challenging for inexperienced surgeons. A brief demonstration on reconstruction options will be shown and includes Roux-en-Y gastrojejunostomy.
Conclusions:
Surgical management of PUD is reserved today for life-threatening complications for which the acute care surgeon must be prepared. This presentation provides demonstration of key surgical principles in management of bleeding and free perforation as well as gastric resection, vagotomy and reconstruction.
Level of evidence:
Not applicable.
Acute gastrointestinal (GI) bleeding is a common surgical emergency requiring hospital admission and associated with high morbidity and mortality. Appropriate decision-making is essential to make a prompt diagnosis, accurate risk assessment, and proper resuscitation of patients with gastrointestinal bleeding. Despite multiple randomized trials and meta-analyses, there is still controversy on various management issues like appropriate risk stratification, the timing of endoscopy, choosing an appropriate endoscopic, and radiological intervention in these groups of patients. As the usage of nonsteroidal anti-inflammatory drugs, antiplatelet, and antithrombotic agents is common in patients with gastrointestinal bleeding, the physician is challenged with proper management of these drugs. The present review summarizes the current strategies for risk stratification, localization of bleeding source, endoscopic and radiological intervention in patients with acute nonvariceal upper GI, middle GI, and lower GI bleeding.
Helicobacter pylori is a widespread bacterial infection found in more than half the world's population. It is associated with several gastric disorders such as peptic ulcer disease, gastric cancer, MALT lymphoma, and dyspepsia. The bacterium plays a role in a multitude of disorders outside the stomach including gastro-esophageal reflux disease, Barrett's esophagus, esophageal adenocarcinoma, eosinophilic esophagitis, Celiac disease, inflammatory bowel disease, nonalcoholic fatty liver disease, and iron deficiency anemia. The understanding of its role in extragastric digestive disorders is evolving, with studies showing both positive and negative associations. We will provide herein a review of the role and impact of H. pylori on human physiology, pathophysiology, and a spectrum of diverse digestive disorders.
Les bases de données hospitalières nationales sont de plus en plus utilisées pour étudier des résultats chirurgicaux en vie réelle. Néanmoins, les données collectées dans ces bases reflètent l'activité de routine des hôpitaux et ne répondent pas à une question spécifique de recherche. Certaines données peuvent être manquantes ou de qualité insuffisante pour contrôler divers facteurs confondants ce qui peut conduire à une interprétation erronée des résultats. L'objectif de ce travail était d'explorer différentes méthodes permettant de mieux contrôler de potentiels facteurs confondants mesurés ou non, lors de l'étude de résultats chirurgicaux dans les grandes bases de données hospitalières nationales. Dans un premier temps, nous avons réalisé une revue de la littérature afin de décrire la qualité méthodologique des études analysant la mortalité chirurgicale dans les bases de données hospitalières nationales et d'identifier des pistes d'amélioration pour mieux contrôler ces facteurs confondants. Dans un second temps, nous avons proposé trois travaux dans lesquels nous avons cherché à contrôler des facteurs confondants à diverses étapes de réalisation d'une étude incluant son schéma méthodologique, les stratégies de sélection de sa population, l'analyse statistique et les analyses de sensibilité. Nous avons en particulier étudié le lien entre le volume d'activité et le résultat chirurgical dans les hôpitaux et la comparaison directe d'efficacité entre différentes procédures. Ainsi, le large périmètre dans le temps et l'espace des bases hospitalières nationales permet d'envisager différentes méthodes pour contrôler de potentiels facteurs confondants
Abdominal pain is a common and challenging problem in the geriatric population, characterized by severe pain that requires an urgent and specific diagnosis. A rapidly worsening prognosis is possible in absence of prompt intervention. The most common causes of acute abdomen in the older age group are acute cholecystitis, acute appendicitis, perforated peptic ulcer disease, acute pancreatitis, intestinal obstruction, ischemic bowel disease, diverticulitis, obstructed hernias and aortic aneurysm rupture. Symptoms and physical findings often differ from that of the younger patient and are unreliable in older people, contributing to an estimated 40% misdiagnosis rate. Misleadingly benign examination, inordinate delays of initial assessment, diagnosis and treatment, along with coexisting disease, contribute to significantly increased mortality. Upright chest X-ray initially to exclude free intraperitoneal air, followed by CT, have the highest yield. Older adults have acceptable survival rates after major abdominal surgery, but tolerate complications poorly. While aggressive resuscitation, high level of suspicion for severe pathology and prompt surgical intervention tailored to the physiologic status are crucial, early diagnosis is the most modifiable risk factor for improving outcome.
Background:
Perforated peptic ulcer is a morbid emergency general surgery condition. Best practices for postoperative care remain undefined. Surgical dogma preaches practices such as peritoneal drain placement, prolonged nil per os, and routine postoperative enteral contrast imaging despite a lack of evidence. We aimed to evaluate the role of postoperative enteral contrast imaging in postoperative perforated peptic ulcer care. Our primary objective was to assess effects of routine postoperative enteral contrast imaging on early detection of clinically significant leaks.
Methods:
We conducted a multicenter retrospective cohort study of patients who underwent repair of perforated peptic ulcer between July 2016 and June 2018. We compared outcomes between those who underwent routine postoperative enteral contrast imaging and those who did not.
Results:
Our analysis included 95 patients who underwent primary/omental patch repair. The mean age was 60 years, and 54% were male. Thirteen (14%) had a leak. Eighty percent of patients had a drain placed. Nine patients had leaks diagnosed based on bilious drain output without routine postoperative enteral contrast imaging. Use of routine postoperative enteral contrast imaging varied significantly between institutions (30%-87%). Two late leaks after initial normal postoperative enteral contrast imaging were confirmed by imaging after a clinical change triggered the second study. Two patients had contained leaks identified by routine postoperative enteral contrast imaging but remained clinically well. Duration of hospital stay was longer in those who received routine postoperative enteral contrast imaging (12 vs 6 days, median; P = .000).
Conclusion:
Routine postoperative enteral contrast imaging after perforated peptic ulcer repair likely does not improve the detection of clinically significant leaks and is associated with increased duration of hospital stay.
Introduction
Infection control in patients with perforated peptic ulcers (PPU) commonly includes empiric antifungals (AF). We investigated the variation in the use of empiric AF and explored the association between their use and the subsequent development of organ space infection (OSI).
Methods
This was a secondary analysis of a multicenter, case–control study of patients treated for PPU at nine institutions between 2011 and 2018. Microbiology and utilization of empiric AF, defined as AF administered within 24 hours from the index surgery, were recorded. Patients who received empiric AF were compared with those who did not. The primary outcome was OSI and secondary outcome was OSI with growth of Candida spp. A logistic regression was used to adjust for differences between the two cohorts.
Results
A total of 554 patients underwent a surgical procedure for PPU and had available timing of AF administration. The median age was 57 years and 61% were male. Laparoscopy was used in 24% and omental patch was the most common procedure performed (78%). Overall, 239 (43%) received empiric AF. There was a large variation in the use of empiric AF among participating centers, ranging from 25% to 68%. The overall incidence of OSI was 14% (77/554) and was similar for patients who did or did not receive empiric AF. The adjusted OR for development of OSI for patients who received empiric AF was 1.04 (95% CI 0.64 to 1.70), adjusted p=0.86. The overall incidence of OSI with growth of Candida spp was 5% and was similar for both groups (adjusted OR 1.29, 95% CI 0.59 to 2.84, adjusted p=0.53).
Conclusion
For patients undergoing surgery for PPU, the use of empiric AF did not yield any significant clinical advantage in preventing OSI, even those due to Candida spp. Use of empiric AF in this setting is unnecessary.
Study type
Original article, case series.
Level of evidence
III.
Background
Perforated peptic ulcer (PPU) is a surgical emergency needing swift operative resolution. While laparoscopic and open approaches are viable options, it remains unclear whether laparoscopic repair has significantly improved outcomes. We use a national surgical database to compare perioperative and 30-d postoperative (30POP) outcomes.
Materials and methods
The 2016-2018 ACS-NSQIP database was used to create the patient cohort, using ICD-10 and CPT codes. An unmatched analysis identified factors that likely contributed to the laparoscopic versus open treatment allocation. Propensity score matching (PSM) was used to identify outcomes that were not explained by underlying differences in the patient cohorts.
Results
A total of 3475 patients were included: 3135 in open group (OG), 340 (~10%) in laparoscopic group (LG). After PSM to control for comorbidities and illness severity that differed between groups on univariate analysis, 288 patients remained in each group. Analysis of the matched cohorts revealed no statistically significant difference in mortality (5.9% OG versus 3.8% LG, P = 0.245). The LG had significantly longer operative times (92 versus 79 min, P = 0.003), shorter hospital stays (8.2 versus 9.4 d, P = 0.044) and higher probability of being discharged home (81% versus 73%, P = 0.017). 30POP outcomes were largely equivalent, except that OG had higher risk for bleeding (14.6% versus 8%, P = 0.012) and pneumonia (8.7% versus 4.5%, P = 0.044).
Conclusions
While laparoscopic repairs take longer, they lead to shorter hospital stays and higher likelihood of discharge home. Further study to identify patients that are candidates for this technique is warranted.
Background
Several trauma studies have shown that a “flat” inferior vena cava (IVC) is associated with poor clinical outcomes, including hypovolemic shock, major bleeding, transfusions and mortality. These studies utilize IVC measurements on computed tomography (CT) scans, and rarely include emergency general surgery patients. We examine the association between IVC flatness and clinical outcomes in a series of patients with perforated viscus.
Materials and methods
Medical records at an academic hospital were reviewed of adults with perforated viscus. Patients who underwent laparotomy or laparoscopy were included if they underwent CT within 12 h prior to incision time. Perforated appendicitis was excluded. A ratio was calculated of the transverse to anterior-posterior diameter of the IVC at 3 locations, then averaged. Clinical outcomes were analyzed by the average IVC ratio.
Results
A total of 83 patients were included. Using binomial regression, the average IVC ratio significantly correlated with ICU admission (OR 3.6, 95% CI 1.2 to 11) and acute kidney injury (OR 2.3, 95% CI 1.0 to 5.3), but not postoperative shock (OR 1.2, 95% CI 0.56 to 2.6).
Conclusions
A flat IVC on CT prior to an operation for perforated viscus was associated with worse outcomes, including increased rate of ICU admission and acute kidney injury. More outcomes research is needed to assess the potential role of IVC assessment in preoperative resuscitation.
Background
Despite a strong link between Helicobacter Pylori infection and peptic ulcer disease (PUD), rates of testing for H. Pylori in hospitalized patients with PUD remain largely unexplored. We aimed to determine H. Pylori testing practices at our institution among inpatients with PUD, and to implement a protocol to improve testing rates.
Materials and Methods
In this quality improvement initiative, baseline H. Pylori testing practices were determined by analysis of historical data on 100 subsequent inpatients with PUD from January 2016 to June 2017 at a tertiary care hospital undergoing esophagogastroduodenoscopy (EGD). Subsequently, a division‐wide testing protocol was implemented, and data were analyzed from 43 consecutive inpatients with PUD from October 2019‐March 2020 to determine the protocol's effects.
Results
The analysis of baseline testing practices showed a 57% testing rate for H. Pylori. Gastric biopsies were less likely to be performed during EGDs done outside the endoscopy unit (5.9% vs 32.7%, P = 0.001), outside of usual business hours (6.7% vs 24.3%, P = 0.04), and in cases where endoscopic therapy was administered (6% vs 32%, P = 0.02). After implementation of the new division‐wide testing protocol, testing rates increased to 93% (P < 0.001).
Conclusions
Low baseline inpatient testing for H. Pylori represents a missed opportunity to test a substantial number of high‐risk patients with PUD. Implementation of a conceptually simple protocol aimed at increasing rates of gastric biopsy significantly improved testing rates in a prospective follow‐up. Widespread standardization of H. Pylori testing for inpatients with PUD may improve important patient outcomes related to complicated PUD.
Mortality for perforated peptic ulcer (PPU) surgery ranges from 2-22% with morbidity ranging from 15-45%. Traditionally, these had been repaired with vagotomy and antrectomy or pyloroplasty with smaller perforations repaired with an omentoplasty. Laparoscopic repair has become increasingly prevalent and demonstrated to have shorter length of stay (LOS) and fewer complications. We are evaluating the surgical repair of PPU with omentoplasty to determine trends of utilization and surgical outcomes. We conducted a 13-year (2005-2017) retrospective review, utilizing the National Surgical Quality Improvement Program database. A total of 6873 patients had open or laparoscopic repair of a PPU, with 2285 patients identified as utilizing omentoplasty. Five hundred eighty-eight omentoplasty patients were further identified as having a laparoscopic technique. We compared patient demographics, comorbidities, and perioperative morbidity and mortality for surgical patients between 2005-2011 and 2012-2017. We trended the perioperative outcomes across the study intervals. Parametric and nonparametric tests were used to evaluate outcomes. Between 2005 and between 2017, laparoscopic surgical repair with omentoplasty has increased from 3.8% to 34.6%. Overall mortality for open operations declined during this interval (12.7%-9.3%) while it remained unchanged for laparoscopic operations (4.6%-4.2%), there was not a significant difference between the laparoscopic and open 30-day mortality. Both open surgery and laparoscopic surgery are being used on an increasingly healthy cohort (increased functional status decreased predicted perioperative morbidity). Relative to the 2005-2011, the laparoscopic surgery 2012-2017 cohort had increases in both serious and overall morbidity, although this was not statistically significant. Compared to the 2005-2011, the 2012-2017 open surgery cohort had increasing serious morbidity (OR 2.03) and overall morbidity (OR 1.91). There was a trend of decreasing LOS and increased return to the operating room for patients with laparoscopic surgery. Laparoscopic Graham patch repair of peptic ulcers significantly increased, although open repair still constitutes the majority of the cases. Despite Graham patch repair being utilized on a healthier patient population, morbidity and mortality for laparoscopic repair have remained unchanged. Postoperative morbidity and mortality for open surgery have increased. This indicates that laparoscopic repair is more commonly utilized for low- or medium risk patients, leaving an increasingly sick patient population selected to open repair.
The mortality associated with acute bleeding from a peptic ulcer remains high (5 to 10%), and the condition accounts for more than 400,000 hospital admissions per year in the United States. This review summarizes the approach to patient triage and risk stratification, the goals of early endoscopy, the options for medical therapy, and the role of surgery and interventional radiology.
Suppressing acid secretion is thought o reduce the risk of ulcers associated with regular use of nonsteroidal antiinflammatory drugs (NSAIDs), but the best means of accomplishing this is uncertain.
We studied 541 patients who required continuous treatment with NSAIDs and who had ulcers or more than 10 erosions in either the stomach or duodenum. Patients were randomly assigned to double-blind treatment with omeprazole, 20 mg or 40 mg orally per day, or ranitidine, 150 mg orally twice a day, for four or eight weeks, depending on when treatment was successful (defined as the resolution of ulcer and the presence of fewer than five erosions in the stomach, and fewer than five erosions in the duodenum, and not more than mild dyspepsia). We randomly assigned 432 patients in whom treatment was successful to maintenance treatment with either 20 mg of omeprazole per day or 150 mg of ranitidine twice a day for six months.
At eight weeks, treatment was successful in 80 percent (140 of 174) of the patients in the group given 20 mg of omeprazole per day, 79 percent (148 of 187) of those given 40 mg of omeprazole per day, and 63 percent (110 of 174) of those given ranitidine (P<0.001 for the comparison with 20 mg of omeprazole and P=0.001 for the comparison with 40 mg of omeprazole). The rates of healing of all types of lesions were higher with omeprazole than with ranitidine. During maintenance therapy, the estimated proportion of patients in remission at the end of six months was 72 percent in the omeprazole group and 59 percent in the ranitidine group. The rates of adverse events were similar between groups during both phases. Both medications were well tolerated.
In patients with regular use of NSAIDs, omeprazole healed and prevented ulcers more effectively than did ranitidine.
After endoscopic treatment of bleeding peptic ulcers, bleeding recurs in 15 to 20 percent of patients.
We assessed whether the use of a high dose of a proton-pump inhibitor would reduce the frequency of recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. Patients with actively bleeding ulcers or ulcers with nonbleeding visible vessels were treated with an epinephrine injection followed by thermocoagulation. After hemostasis had been achieved, they were randomly assigned in a double-blind fashion to receive omeprazole (given as a bolus intravenous injection of 80 mg followed by an infusion of 8 mg per hour for 72 hours) or placebo. After the infusion, all patients were given 20 mg of omeprazole orally per day for eight weeks. The primary end point was recurrent bleeding within 30 days after endoscopy.
We enrolled 240 patients, 120 in each group. Bleeding recurred within 30 days in 8 patients (6.7 percent) in the omeprazole group, as compared with 27 (22.5 percent) in the placebo group (hazard ratio, 3.9; 95 percent confidence interval, 1.7 to 9.0). Most episodes of recurrent bleeding occurred during the first three days, which made up the infusion period (5 in the omeprazole group and 24 in the placebo group, P<0.001). Three patients in the omeprazole group and nine in the placebo group underwent surgery (P=0.14). Five patients (4.2 percent) in the omeprazole group and 12 (10 percent) in the placebo group died within 30 days after endoscopy (P=0.13).
After endoscopic treatment of bleeding peptic ulcers, a high-dose infusion of omeprazole substantially reduces the risk of recurrent bleeding.
Given the advancements in medical treatment of peptic ulcer disease such as Helicobacter pylori eradication and proton-pump inhibitors, we sought to assess their impact on the need for surgical intervention. Patients who underwent peptic ulcer surgery between 1981 and 1998 were evaluated in a retrospective chart review from a tertiary-care hospital (n = 222). The number of operations performed for peptic ulcers decreased annually (24 vs 11.3). Seventy-seven per cent of all cases were done urgently; most were performed for acute perforated ulcers. The overall 30-day mortality rate was 13 per cent, which remained unchanged over the past two decades. The highest mortality rate (82%) was in the transplanted population (n = 11). Our institutional experience demonstrates that despite the lower volume of patients requiring operative management a greater percentage of these patients are presenting with urgent need for surgery. Also despite the aggressive endoscopic management of acutely bleeding ulcers there was no change in the percentage of patients taken to the operating room for uncontrollable hemorrhage. Improvements in medical management of peptic ulcer disease have decreased the surgical volume; nevertheless we show a rising proportion of urgent operations performed annually, and mortality remains high.
From the Canadian Registry of patients with Upper Gastrointestinal Bleeding and Endoscopy (RUGBE), we determined clinical outcomes and explored the roles of endoscopic and pharmacologic therapies in a contemporary real-life setting.
Analysis of randomly selected patients endoscoped for nonvariceal upper gastrointestinal bleeding at 18 community and tertiary care institutions between 1999 and 2002. Covariates and outcomes were defined a priori and 30-day follow-up obtained. Logistic regression models identified predictors of outcomes.
One thousand eight-hundred and sixty-nine patients were included (66 +/- 17 yr, 38% female, 2.5 +/- 1.6 comorbid conditions, hemoglobin, 96 +/- 27 g/L, 54% received a mean of 2.9 +/- 1.7 units of blood). Endoscopy was performed within 24 h in 76%, with ulcers (55%) most commonly noted. High-risk endoscopic stigmata and endoscopic therapy were reported in 37%. Rebleeding, surgery, and mortality rates were 14.1%, 6.5%, and 5.4%, respectively. Decreased rebleeding was significantly and independently associated with PPI use (85% of patients, mean daily dose 56 +/- 53 mg) in all patients regardless of endoscopic stigmata, (odds ratio (OR):0.53, 95% confidence interval, 95% CI:0.37-0.77) and endoscopic hemostasis in patients with high-risk stigmata (OR:0.39, 95% CI:0.25-0.61). PPI use (OR:0.18, 95% CI:0.04-0.80) and endoscopic therapy (OR:0.31, 95% CI:0.11-0.91) were also each independently associated with decreased mortality in patients with high-risk stigmata.
These results appear to confirm the protective role of endoscopic therapy in patients with high-risk stigmata, and suggest that acute use of PPIs may be associated with a reduction of rebleeding in all patients, and lower mortality in patients with high-risk stigmata. Independent prospective validation of these observational findings is now required.
Levels of staffing and access to diagnostics at weekends are recognised to be significantly lower than on weekdays. It is unclear if subsequent inpatient mortality and readmission rates for acute medical admissions are increased for weekend admissions compared to those on a weekday. A large Canadian study demonstrated increased weekend mortality but does the Edinburgh healthcare model support these findings? This study analysed all hospital admissions in 2001 to the Royal Infirmary of Edinburgh for six predetermined diagnoses (total 3,244): chronic obstructive pulmonary disease, cerebrovascular accidents, pulmonary embolism, pneumonia, collapse and upper gastrointestinal bleed. We compared hospital mortality rates, readmission rates and hospital length of stay for weekend admissions as compared to those on a weekday. Weekend admission was not associated with significantly higher in-hospital mortality, readmission rates or increased length of stay compared to the weekday equivalent for any of the six conditions. The implementation of an acute medical admissions unit in the Royal Infirmary of Edinburgh, with consistent staffing levels and 24-hour access to diagnostics for the early phase of critical illness, may have helped address the discrepancy in care suggested by previous studies.
For much of the twentieth century, surgery was frequently the solution for peptic ulcer disease. Our understanding of the pathophysiology of ulcers paralleled the development of potent pharmaceutical therapy. As the surgical world developed parietal cell vagotomy which would minimize the complications of surgery, patients failing medical therapy became rare. Emergent surgery for complicated peptic ulcers has not declined however. The development of proton pump inhibitors and the full understanding of the impact of H pylori has led to a trend towards minimalism in surgical therapy for complicated peptic ulcer disease. In addition to the changes in patient care, these developments have had an impact on the training of surgeons. This article outlines these trends and developments.
Keywords: Perspectives, Peptic ulcer disease, Gastritis
Citation: Lipof T, Shapiro D, Kozol RA. Surgical perspectives in peptic ulcer disease and gastritis. World J Gastroenterol 2006; 12(20): 3248-3252
In conclusion, the understanding of the pathophysiology of peptic ulcer and the development of powerful pharmaceuticals has had a great impact on the practice of surgery in this disorder. The discovery of and treatment for H pylori in peptic ulcer disease has affected surgical approaches. Complications of peptic ulcer disease have not gone away although they are being treated non-surgically with increasing frequency. When surgery is required for complicated peptic ulcer disease most surgeons now favor a minimalist approach with closure of perforations or simple over sewing bleeding vessels but without a definitive anti-ulcer operation. When the next generation of surgical residents finish their training will ulcer surgery even exist, or will it simply be a historical topic in surgical textbooks Will case numbers drop to the point where we won’t have surgeons who are trained in performing these operations or will endo-luminal approaches eliminate the need for these operations Surgery for unremitting hemorrhage from gastritis has disappeared. Considering the advances made in the twentieth century is there reason not to think that with future advances anti-ulcer surgery will go the same route
A neutral gastric pH is critical for the stability of clots over bleeding arteries. We investigated the effect of preemptive infusion of omeprazole before endoscopy on the need for endoscopic therapy.
Consecutive patients admitted with upper gastrointestinal bleeding underwent stabilization and were then randomly assigned to receive either omeprazole or placebo (each as an 80-mg intravenous bolus followed by an 8-mg infusion per hour) before endoscopy the next morning.
Over a 17-month period, 638 patients were enrolled and randomly assigned to omeprazole or placebo (319 in each group). The need for endoscopic treatment was lower in the omeprazole group than in the placebo group (60 of the 314 patients included in the analysis [19.1%] vs. 90 of 317 patients [28.4%], P=0.007). There were no significant differences between the omeprazole group and the placebo group in the mean amount of blood transfused (1.54 and 1.88 units, respectively; P=0.12) or the number of patients who had recurrent bleeding (11 and 8, P=0.49), who underwent emergency surgery (3 and 4, P=1.00), or who died within 30 days (8 and 7, P=0.78). The hospital stay was less than 3 days in 60.5% of patients in the omeprazole group, as compared with 49.2% in the placebo group (P=0.005). On endoscopy, fewer patients in the omeprazole group had actively bleeding ulcers (12 of 187, vs. 28 of 190 in the placebo group; P=0.01) and more omeprazole-treated patients had ulcers with clean bases (120 vs. 90, P=0.001).
Infusion of high-dose omeprazole before endoscopy accelerated the resolution of signs of bleeding in ulcers and reduced the need for endoscopic therapy. (ClinicalTrials.gov number, NCT00164866 [ClinicalTrials.gov] .).
Objective. - To integrate the realization that peptic ulcer most commonly reflects infection with Helicobacter pylori or use of aspirin and other nonsteroidal antiinflammatory drugs (NSAIDs) into a disease management approach. Participants. - Guidelines were outlined by the author and presented for review to the American College of Gastroenterology (ACG) Practice Parameters Committee, selected by the president of the ACG, and a panel of experts in peptic ulcer, selected by the committee. Evidence and Consensus Process. - These guidelines were formulated following extensive review of the literature obtained by a MEDLINE search and presented for detailed review and revision to unpublicized committee meetings on three occasions and to experts by mail. These recommendations are an official statement of the ACG and have been approved by the American Gastroenterological Association and the American Society for Gastroenterological Endoscopy. Firm recommendations are discriminated from reasonable suppositions pending definitive data. Conclusions. - Since cure of H pylori infection decreases recurrence rates and facilitates healing, antibiotic therapy is indicated for all H pylori-infected ulcer patients. No optimal, simple antibiotic regimen has yet emerged. Simultaneous conventional ulcer therapy is recommended to facilitate symptom relief and healing. For refractory ulcers, only maximal acid inhibition offers advantage over continued conventional therapy; cure of H pylori infection is likely to facilitate healing of refractory ulcers. Only with complicated or refractory ulcers should conventional maintenance therapy be continued, at least until successful H pylori eradication is confirmed. A search for NSAID use is indicated for all ulcer patients. For NSAID-associated ulcers these drugs should be discontinued if possible and H pylori, if present, should be cured.
Background:
In the last 4 decades, the prevalence rates of peptic ulcer disease and our understanding of its pathophysiological features underwent major changes.
Objective:
To analyze how these trends affected physician visits and treatment of ulcer disease.
Methods:
The National Diseases and Therapeutic Index of IMS America Ltd, Plymouth Meeting, Pa, was used as the data source. Survey data were obtained from a representative sample of US physicians 4 times per year during a 48-hour period and extrapolated to a national level. Physician visits for gastric, duodenal, and all peptic ulcers were expressed as rates per 100 000 living US population.
Results:
Between 1958 and 1995, physician visits for duodenal ulcer showed a marked decline, while those for gastric ulcer remained largely unchanged. In 1995, 4 million patients visited a physician because of peptic ulcer, corresponding to a rate of 1500 per 100 000 US population. The predominant therapy changed from anticholinergics, tranquilizers, and antacids between 1958 and 1977 to histamine2 receptor antagonist from 1978 until 1988, which subsequently became replaced in part by sucralfate and proton pump inhibitors. In 1995, about 75% of ulcers were still treated primarily with antisecretory medications, and only 5% received antibiotic therapy.
Conclusions:
Peptic ulcer is still common, although duodenal ulcer rates continue to decrease. The historical trends of treatment regimens show a steady change between various medications. No therapeutic class dominated ulcer therapy for more than 20 years. This trend is likely to continue, particularly, in light of the small fraction currently treated by antibiotics to eradicate Helicobacter pylori.Arch Intern Med. 1997;157:1489-1494
Administrative databases are increasingly used for studying outcomes of medical care. Valid inferences from such data require the ability to account for disease severity and comorbid conditions. We adapted a clinical comorbidity index, designed for use with medical records, for research relying on International Classification of Diseases (ICD-9-CM) diagnosis and procedure codes. The association of this adapted index with health outcomes and resource use was then examined with a sample of Medicare beneficiaries who underwent lumbar spine surgery in 1985 ( n = 27,111). The index was associated in the expected direction with postoperative complications, mortality, blood transfusion, discharge to nursing home, length of hospital stay,and hospital charges. These associations were observed whether the index incorporated data from multiple hospitalizations over a year's time, or just from the index surgical admission. They also persisted after controlling for patient age. We conclude that the adapted comorbidity index will be useful in studies of disease outcome and resource use employing administrative databases.
Context
Since publication in 1994 of guidelines for management of peptic ulcer
disease (PUD), trends in physician practice and outcomes related to guideline
application have not been evaluated.Objectives
To describe changes in process of care that occurred in a quality improvement
program for patients hospitalized with PUD and to evaluate associations between
in-hospital treatment of PUD and 1-year rehospitalization for PUD and mortality
in a subset of these patients.Design, Setting, and Patients
Cohort study of 4292 sequential Medicare beneficiaries hospitalized
at acute care hospitals with a principal diagnosis of PUD in 5 states (Colorado,
Georgia, Connecticut, Oklahoma, and Virginia) in 1995 (baseline) and 1997
(remeasurement); outcomes were evaluated for 752 patients in Colorado.Main Outcome Measures
Changes in rates of screening for Helicobacter pylori infection, treatment for H pylori infection,
screening for nonsteroidal anti-inflammatory drug (NSAID) use, counseling
about NSAID use; outcomes included rehospitalization for PUD and all-cause
mortality within 1 year of discharge in Colorado.Results
Screening for H pylori infection increased
significantly (12%-19% increase; P<.001) in each
of the 5 states. Treatment of H pylori infection
increased in each state and was significantly increased for the entire group
of hospitalizations examined (8% increase overall; P
= .001). Despite increased screening, detection of H pylori infection was less frequent than expected in every state, (13%-24%)
and did not increase in any state. Screening for and counseling about NSAIDs
did not significantly increase overall or in any state. In the Colorado cohort,
the proportion of patients rehospitalized was unchanged in 1995 (8.9%) and
1997 (6.8%), and 124 patients (16%) in the combined 1995 and 1997 cohorts
died within 1 year. Treatment for H pylori was not
associated with a reduction in rehospitalization within 1 year (adjusted odds
ratio [OR], 1.24; 95% confidence interval [CI], 0.65-2.36) or with a reduction
in mortality (adjusted OR, 1.08; 95% CI, 0.68-1.71). Counseling about NSAID
use was associated with a decrease in risk of 1-year rehospitalization for
PUD (adjusted OR, 0.47; 95% CI, 0.22-0.99) and risk of all-cause mortality
(adjusted OR, 0.44; 95% CI, 0.26-0.75).Conclusions
This quality improvement program for elderly patients with PUD resulted
in increased screening for H pylori and increased
treatment of H pylori infection but no change in
counseling about NSAID use. However, with the low prevalence of H pylori detected, treatment of H pylori infection
was not associated with a reduction in repeat hospitalization for PUD or subsequent
mortality, whereas counseling about the risks of using NSAIDs was associated
with a reduction in the risk of both outcomes.
Figures in this Article
Peptic ulcer disease (PUD) is one of the most common disorders affecting
the gastrointestinal system, with a lifetime cumulative prevalence of 10%1 and a peak prevalence between ages 65 and 74 years.2 The costs of PUD, including the indirect costs of
lost work time and productivity, are estimated to be at least $8 billion per
year in the United States.3 In 1998, approximately
1.5% of all Medicare hospital costs were spent treating the consequences of
PUD.4
Infection with Helicobacter pylori is considered
to be the cause of 95% to 100% of duodenal ulcers and 70% to 90% of gastric
ulcers, and among persons without H pylori infection,
nonsteroidal anti-inflammatory drug (NSAID) use is assumed to be the major
cause.2,5 In the elderly, use
of NSAIDs is a contributing factor for up to 50% of ulcers and is associated
with increased rates of ulcer-related complications, such as perforation,
bleeding, and death.6- 9
In 1994, a National Institutes of Health (NIH) Consensus Development
Conference published recommendations for the management of PUD that reflect
the new understanding of the role of H pylori infection.5 The panel advised that all patients should be screened
for H pylori and that infection should be eradicated
whenever detected. The panel also recommended that all patients should be
evaluated for use of NSAIDs and that use of these drugs should be eliminated
whenever possible. Practice guidelines were subsequently published incorporating
these recommendations and also endorsing empirical treatment of H pylori infection in patients with duodenal ulcers because of the
strong association of infection with ulcers in this location.10
Although the efficacy of each intervention in the PUD guidelines has
been demonstrated in randomized controlled trials, the effectiveness of guideline
implementation to change clinically relevant health outcomes11- 12
in an unselected patient population has not been measured. Recommendations
to eradicate H pylori in PUD are based on randomized,
controlled clinical trials13- 17
that used endoscopic end points and, in many cases, excluded patients of advanced
age13,16- 17 or with
comorbidities15- 16 or NSAID use.14- 16 Recommendations to
eliminate NSAID use are based on extensive experience with these drugs in
patients with PUD, particularly in the elderly.2,8,18- 19
The 1994 NIH recommendations prompted quality improvement projects (QIPs)
within the Health Care Quality Improvement Program for Medicare beneficiaries
led by the Health Care Financing Administration (HCFA; now the Centers for
Medicare and Medicaid Services). Health Care Quality Improvement Program projects
are intended to improve practice by encouraging compliance with national guidelines.20
For this report, we obtained information from a peptic ulcer disease
QIP performed by 5 state peer review organizations: Colorado Foundation for
Medical Care, Connecticut Peer Review Organization, Georgia Medical Care Foundation,
Oklahoma Foundation for Medical Quality, and Virginia Health Quality Center.
The specific objectives of the QIP were to measure and improve the practice
of testing for and treating H pylori and to measure
and improve the practice of screening for and counseling about the risks of
NSAID use. Practice was measured in hospital cases from 1995 (baseline) and
in 1997 (remeasurement). Improvement was planned through data feedback vs
a focused continuing medical education program tested by a randomized controlled
trial (the results of this intervention evaluation will be published elsewhere).
The assessment of baseline practice patterns from 1995 has been previously
published.21
The patient population in this QIP is unselected, is older and sicker
than populations used in clinical trials,13- 17
and represents patients with PUD who consume the most resources, have the
highest rate of poor outcomes,2 and presumably
have the most to gain from effective treatment.
The purposes of this study were (1) to describe changes in management
of PUD in a cohort of Medicare patients during a multistate QIP and (2) to
explore associations between PUD management and rehospitalization for PUD
and all-cause mortality at 1 year after discharge for the index hospitalization
in the Colorado cohort.
Objective.
—To integrate the realization that peptic ulcer most commonly reflects infection with Helicobacter pylori or use of aspirin and other nonsteroidal antiinflammatory drugs (NSAIDs) into a disease management approach.
Participants.
—Guidelines were outlined by the author and presented for review to the American College of Gastroenterology (ACG) Practice Parameters Committee, selected by the president of the ACG, and a panel of experts in peptic ulcer, selected by the committee.
Evidence and Consensus Process.
—These guidelines were formulated following extensive review of the literature obtained by a MEDLINE search and presented for detailed review and revision to unpublicized committee meetings on three occasions and to experts by mail. These recommendations are an official statement of the ACG and have been approved by the American Gastroenterological Association and the American Society for Gastroenterological Endoscopy. Firm recommendations are discriminated from reasonable suppositions pending definitive data.
Conclusions.
—Since cure of H pyloriinfection decreases recurrence rates and facilitates healing, antibiotic therapy is indicated for all H pylori—infected ulcer patients. No optimal, simple antibiotic regimen has yet emerged. Simultaneous conventional ulcer therapy is recommended to facilitate symptom relief and healing. For refractory ulcers, only maximal acid inhibition offers advantage over continued conventional therapy; cure of H pylori infection is likely to facilitate healing of refractory ulcers. Only with complicated or refractory ulcers should conventional maintenance therapy be continued, at least until successful H pylori eradication is confirmed. A search for NSAID use is indicated for all ulcer patients. For NSAIDassociated ulcers these drugs should be discontinued if possible and H pylori, if present, should be cured.(JAMA. 1996;275:622-629)
In the last 4 decades, the prevalence rates of peptic ulcer disease and our understanding of its pathophysiological features underwent major changes.
To analyze how these trends affected physician visits and treatment of ulcer disease.
The National Diseases and Therapeutic Index of IMS America Ltd, Plymouth Meeting, Pa, was used as the data source. Survey data were obtained from a representative sample of US physicians 4 times per year during a 48-hour period and extrapolated to a national level. Physician visits for gastric, duodenal, and all peptic ulcers were expressed as rates per 100,000 living US population.
Between 1958 and 1995, physician visits for duodenal ulcer showed a marked decline, while those for gastric ulcer remained largely unchanged. In 1995, 4 million patients visited a physician because of peptic ulcer, corresponding to a rate of 1500 per 100,000 US population. The predominant therapy changed from anticholinergics, tranquilizers, and antacids between 1958 and 1977 to histamine2 receptor antagonist from 1978 until 1988, which subsequently became replaced in part by sucralfate and proton pump inhibitors. In 1995, about 75% of ulcers were still treated primarily with antisecretory medications, and only 5% received antibiotic therapy.
Peptic ulcer is still common, although duodenal ulcer rates continue to decrease. The historical trends of treatment regimens show a steady change between various medications. No therapeutic class dominated ulcer therapy for more than 20 years. This trend is likely to continue, particularly, in light of the small fraction currently treated by antibiotics to eradicate Helicobacter pylori.
After endoscopic treatment to control bleeding of peptic ulcers, bleeding recurs in 15 to 20 percent of patients. In a prospective, randomized study, we compared endoscopic retreatment with surgery after initial endoscopy. Over a 40-month period, 1169 of 3473 adults who were admitted to our hospital with bleeding peptic ulcers underwent endoscopy to reestablish hemostasis. Of 100 patients with recurrent bleeding, 7 patients with cancer and 1 patient with cardiac arrest were excluded from the study; 48 patients were randomly assigned to undergo immediate endoscopic retreatment and 44 were assigned to undergo surgery. The type of operation used was left to the surgeon. Bleeding was considered to have recurred in the event of any one of the following: vomiting of fresh blood, hypotension and melena, or a requirement for more than four units of blood in the 72-hour period after endoscopic treatment.
Of the 48 patients who were assigned to endoscopic retreatment, 35 had long-term control of bleeding. Thirteen underwent salvage surgery, 11 because retreatment failed and 2 because of perforations resulting from thermocoagulation. Five patients in the endoscopy group died within 30 days, as compared with eight patients in the surgery group (P=0.37). Seven patients in the endoscopy group (including 6 who underwent salvage surgery) had complications, as compared with 16 in the surgery group (P=0.03). The duration of hospitalization, the need for hospitalization in the intensive care unit and the resultant duration of that stay, and the number of blood transfusions were similar in the two groups. In multivariate analysis, hypotension at randomization (P=0.01) and an ulcer size of at least 2 cm (P=0.03) were independent factors predictive of the failure of endoscopic retreatment.
In patients with peptic ulcers and recurrent bleeding after initial endoscopic control of bleeding, endoscopic retreatment reduces the need for surgery without increasing the risk of death and is associated with fewer complications than is surgery.
Medical management of giant peptic ulcers has traditionally been associated with significant morbidity and mortality rates, dictating the need for surgical intervention.
To determine if recent advances in therapy has reduced the number of patients who require surgical procedures, we reviewed the medical records of all patients with peptic ulcers of 2 cm or more at our institution from January 1991 to August 1996.
We identified 75 patients with giant ulcers who were followed for a mean duration of 36 months. Sixty-three patients (84%) were managed without operation with a good outcome, documented by healing on repeat esophagogastroduodenoscopy and/or resolution of symptoms. Medical management included treatment of Helicobacter pylori infection, stopping nonsteroidal anti-inflammatory drugs, and potent acid suppression. Endoscopic intervention to control bleeding was successful in 7 patients (9%), and 2 patients (3%) were treated successfully with angiographic embolization. Only 12 patients (16%) required surgical intervention: 6 as the result of bleeding, 2 as the result of perforation, 1 as the result of obstruction, and 3 with intractable disease.
In this series of patients with giant peptic ulcers, most patients (84%) were managed without surgical treatment. Our data suggest that improvements in medical therapy have obviated the need for eventual surgical intervention in most patients with giant ulcers.
The level of staffing in hospitals is often lower on weekends than on weekdays, despite a presumably consistent day-to-day burden of disease. It is uncertain whether in-hospital mortality rates among patients with serious conditions differ according to whether they are admitted on a weekend or on a weekday.
We analyzed all acute care admissions from emergency departments in Ontario, Canada, between 1988 and 1997 (a total of 3,789,917 admissions). We compared in-hospital mortality among patients admitted on a weekend with that among patients admitted on a weekday for three prespecified diseases: ruptured abdominal aortic aneurysm (5454 admissions), acute epiglottitis (1139), and pulmonary embolism (11,686) and for three control diseases: myocardial infarction (160,220), intracerebral hemorrhage (10,987), and acute hip fracture (59,670), as well as for the 100 conditions that were the most common causes of death (accounting for 1,820,885 admissions).
Weekend admissions were associated with significantly higher in-hospital mortality rates than were weekday admissions among patients with ruptured abdominal aortic aneurysms (42 percent vs. 36 percent, P<0.001), acute epiglottitis (1.7 percent vs. 0.3 percent, P=0.04), and pulmonary embolism (13 percent vs. 11 percent, P=0.009). The differences in mortality persisted for all three diagnoses after adjustment for age, sex, and coexisting disorders. There were no significant differences in mortality between weekday and weekend admissions for the three control diagnoses. Weekend admissions were also associated with significantly higher mortality rates for 23 of the 100 leading causes of death and were not associated with significantly lower mortality rates for any of these conditions.
Patients with some serious medical conditions are more likely to die in the hospital if they are admitted on a weekend than if they are admitted on a weekday.
Over the past several decades, the pharmacologic and endoscopic treatment of peptic ulcer disease (PUD) has dramatically improved. To determine the effects of these and other changes on the operative management of PUD, we reviewed our surgical experience with gastroduodenal ulcers over the past 20 years. A computerized surgical database was used to analyze the frequencies of all operations for PUD performed in two training hospitals during four consecutive 5-year intervals beginning in 1980. Operative rates for both intractable and complicated PUD were compared with those for other general surgical procedures and operations for gastric malignancy. In the first 5-year period (1980 to 1984), a yearly average of 70 upper gastrointestinal operations were performed. This experience included 36 operations for intractability, 15 for hemorrhage, 12 for perforation, and seven for obstruction. During the same time span, 13 resections were performed annually for gastric malignancy. By the most recent 5-year interval (1994 to 1999), the total number of upper gastrointestinal operations had declined by 80% (14 cases), although the number of operations for gastric cancer had changed only slightly. Operations decreased most markedly for patients with intractability, but the prevalence of operations for bleeding, obstruction, and perforation was also decreased. We conclude that improved pharmacologic and endoscopic approaches have progressively curtailed the use of operative therapy for PUD. Elective surgery is now rarely indicated, and emergency operations are much less common. This changed paradigm poses new challenges for training and suggests different approaches for practice.
Medical therapy of peptic ulcer disease (PUD) has improved dramatically during the past 20 years with the introduction of modern antisecretory drugs as well as eradication therapy of Helicobacter pylori. During the 1990s, there has been a 3-fold increase in the consumption of histamine-2-receptor antagonists and proton-pump inhibitors, but also an 8-fold increase in the consumption of nonsteroidal anti-inflammatory drugs (NSAIDs) in Finland.
The incidence of surgery, hospital admissions and mortality for PUD was analysed between 1972 and 1999; the data were collected from the National Research and Development Centre for Welfare and Health and from the National Centre for Statistics. In the analysis, the codes of the Intemational Statistical Classification of Diseases 8-10 were used.
In 1987, 11.9 elective operations (per 10(5) inhabitants) were performed (mean of 2 consecutive years), but only 1.3 in 1997, a reduction of 89%. In 1987, 5.2 emergency operations for ulcer perforation or bleeding were performed, whereas there were 7.5 in 1997, an increase of 44%. The annual hospital admission rate increased from 38.3 admissions (per 10(5) inhabitants) in 1972 (mean +/- s (standard deviation) of 5 consecutive years) to 68.7 in 1992. This 79% increase was mainly due to bleeding from gastric ulcer in elderly women. The overall annual mortality rate increased between 1972 and 1992 from 6.4 to 8.4 deaths (per 10(5) inhabitants), i.e. by 31%. The mortality rate from ulcer perforation and haemorrhage increased from 4.2 deaths in 1972 to 7.3 deaths in 1992, i.e. by 74%.
The increasing incidence rates of emergency surgery, hospital admissions and mortality for PUD in the 1980s and 1990s have started to decrease in the most recent years in Finland. This epidemiologic change probably reflects both the demographic change and an increased consumption of NSAIDs, among the elderly people, in particular. The most recent epidemiologic change may reflect an increased consciousness about the harmful effects of conventional NSAIDs. Regardless of the constantly occurring emergency surgery, elective surgery for PUD is hardly ever required today.
Nonsteroidal anti-inflammatory drugs (NSAIDs) can cause peptic ulcer disease and upper GI bleeding. Acid suppression medications effectively treat NSAID-induced ulcers. However, it is unknown what effect the availability of proton pump inhibitors and over-the-counter preparations of NSAIDs and histamine type 2 receptor antagonists have had on population rates of hospitalization and mortality from GI toxicity. This study examines trends in hospitalization and mortality rates from GI toxicity during the 1990s.
We performed an analysis of secular trends of hospitalization and mortality rates from peptic ulcer disease, upper GI bleeding, and any GI bleeding using data from the National Hospital Discharge Survey, comparing them with sales of NSAIDs, aspirin, and acid suppression medications from 1992 to 1999.
From 1992 to 1999, annual rates of hospitalization and mortality per 100,000 population for peptic ulcer disease declined from 205 to 165 and 7.7 to 6.0, respectively; calendar year was negatively correlated with both peptic ulcer disease hospitalization rates (p = -0.88, p = 0.007) and mortality rates (p = -0.71, p = 0.058). In contrast, these correlations did not reach statistical significance for upper or any GI bleeding (p > 0.1 for all comparisons). Sales of acid suppression medications were negatively correlated with peptic ulcer disease hospitalization rates (p = -0.76, p = 0.037) and mortality rates (p = -0.83, p = 0.015). Sales of NSAIDs were not positively correlated with hospitalization or mortality rates from peptic ulcer disease or GI bleeding (p > 0.2 for all comparisons).
Despite changing patterns of use of NSAIDs and acid suppression medications during the 1990s, mortality rates from GI bleeding and peptic ulcer disease have been relatively stable, with an apparent decline in hospitalization rates and mortality from peptic ulcer disease. Changing rates of peptic ulcer disease morbidity and mortality were temporally related to increasing sales of antiulcerants but not to change in sales of NSAIDs.
The aim was to assess the current opinion of surgeons, by subspecialty, towards vagotomy and the practice of Helicobacter pylori testing, treatment and follow-up, in patients with bleeding or perforated duodenal ulcer.
A postal questionnaire was sent to 1073 Fellows of the Association of Surgeons of Great Britain and Ireland in 2001.
Some 697 valid questionnaires were analysed (65.0 per cent). Most surgeons did not perform vagotomy for perforated or bleeding duodenal ulcer. There was no statistical difference between the responses of upper gastrointestinal surgeons and those of other specialists for perforated (P = 0.35) and bleeding (P = 0.45) ulcers. Respondents were more likely to perform a vagotomy for bleeding than for a perforated ulcer (P < 0.001). Although more than 80 per cent of surgeons prescribed H. pylori eradication treatment after operation, fewer than 60 per cent routinely tested patients for H. pylori eradication. Upper gastrointestinal surgeons were more likely to prescribe H. pylori treatment and test for eradication than other specialists (P < 0.01).
Most surgeons in the UK no longer perform vagotomy for duodenal ulcer complications.
The almost complete disappearance of benign gastric ulcer disease has led to the perception that there may be an insufficient gastric surgery experience for surgery residents. This study analyzed resident-reported gastric procedure experience by chief residents from U.S. programs. The Resident Statistic Summaries (Report C) for 1990-2001 were compiled and analyzed. Results are expressed as the average number of operations performed per resident, standard deviation (SD), and the percentage (%) of total gastric operative cases. For all gastric-related surgery, the average reported cases per chief resident ranged from 9.8-12.4 with a peak in 1990 and a nadir in 1999; in 2001 the reported case average was 11.3 (SD ranged from 6-8). Over the same interval, vagotomy decreased from 24% in 1990 to 7% in 2001, whereas gastric-reduction operations increased from 5%-34%. Total gastrectomy remained a constant less than 1.0 per chief resident (range 0.6-0.8), whereas partial gastric resection (PGR) was unchanged. The percentage of all types of gastric resections slightly diminished from 34% in 1990 to 29% in 2001. U.S. surgical chief residents report a widely variable experience in gastric surgery over the period analyzed. However, their overall experience has not significantly diminished since 1990 although specific procedural volume has varied.
During the past 20 years medical therapy of peptic ulcer disease (PUD) has dramatically improved. Simultaneously there has been a significant improvement in living and dietary habits. Quite presumably, all these significant events are reflected in the incidence and results of surgery for peptic ulcerations.
To study the incidence, methods and mortality of surgery for PUD.
The nationwide data between 1987 and 1999 were obtained from the National Research and Development Centre for Welfare and Health. In the analysis the codes of the ICD 9-10 were used.
The annual incidence of elective surgery for PUD decreased from 15.7 to 1.7 operations (per 10(5) inhabitants, mean of 2 consecutive years) between 1987 and 1999 (p < 0.05). Simultaneously, the annual incidence of emergency surgery increased from 5.2 to 7.0 operations (per 10(5) inhabitants, p < 0.05). In 1987, local procedures (duodeno-/gastrorrhaphy or duodeno-/gastrostomy and suture) were applied in 25% of operations for PUD, whereas in 1999 they were 90% of the methods in PUD surgery. The overall annual mortality from PUD surgery remained 8% between 1987 and 1999.
Elective ulcer surgery has virtually disappeared and parietal cell vagotomy has become history, whereas the incidence of emergency surgery increased significantly between 1987 and 2000, with the exception of the most recent years. Local procedures are overwhelmingly applied in emergency surgery and more extensive surgery is unnecessary. Nevertheless, the overall surgical mortality remained 8% between 1987 and 1999.
The effect of reduced hospital staffing during weekends on in-hospital mortality is not known. We compared mortality rates between patients admitted on weekends and weekdays and whether weekend-weekday variation in rates differed between patients admitted to teaching and nonteaching hospitals in California.
The sample comprised patients admitted to hospitals from the emergency department with any of 50 common diagnoses (N = 641,860). Mortality between patients admitted on weekends and those admitted on weekdays (the "weekend effect") was compared. The magnitude of the weekend effect was also compared among patients admitted to major teaching, minor teaching, and nonteaching hospitals.
The adjusted odds of death for patients admitted on weekends when compared with weekdays was 1.03 (95% confidence interval [CI]: 1.01 to 1.06; P = 0.0050). Three diagnoses (cancer of the ovary/uterus, duodenal ulcer, and cardiovascular symptoms) were associated with a statistically significant weekend effect. None of the 50 diagnoses demonstrated a statistically significant reduction in mortality for weekend admissions as compared with weekday admissions. Mortality was similar among patients admitted to major (odds ratio [OR] = 1.06; 95% CI: 0.94 to 1.19) and minor (OR = 1.03; 95% CI: 0.97 to 1.09) teaching hospitals, compared with nonteaching hospitals. However, the weekend effect was larger in major teaching hospitals compared with nonteaching hospitals (OR =1.13 vs. 1.03, P = 0.03) and minor teaching hospitals (OR = 1.05, P = 0.11).
Patients admitted to hospitals on weekends experienced slightly higher risk-adjusted mortality than did patients admitted on weekdays. While overall mortality was similar for patients admitted to all hospital categories, the weekend effect was larger in major teaching hospitals and is cause for concern.
The frequency of surgery for peptic ulcer disease (PUD) has decreased dramatically during the last 3 decades. The purpose of this study was to characterize the Veteran patients undergoing surgery for peptic ulcer disease in a modern series and to examine the effect of H. pylori status on surgical outcome and recurrence of PUD.
An Institutional Review Board-approved retrospective review of all patients undergoing operations for peptic ulcer disease during a 66-month period at a single Veterans Administration medical center was performed. Patient records were examined for demographics, medication use, Helicobacter pylori status, operative details, and surgical outcomes.
From January 1999 to July 2004, 43 of 128 upper gastrointestinal operations were performed for PUD. Thirty-five operations (81%) were performed for bleeding or perforated ulcers, and 26 (60%) patients had no history of PUD. The mean age was 60 years, and 66% of patients were American Society of Anesthesiologists (ASA) class 3 or 4; 47% were Helicobacter pylori positive, and 54% used nonsteroidal anti-inflammatory (NSAID) medication. Hospital mortality was 23%. By univariate analysis, emergent surgery, higher ASA status, H. pylori status, and absence of a history of ulcer disease were risk factors for mortality (P <.05). Only 36% underwent definitive ulcer surgery. With a median follow-up of 18 months, there has been only 1 single recurrence (3%).
PUD still accounts for 33% of all gastroduodenal surgery performed in a Veterans Administration medical center. The majority of these operations are emergent operations in high-risk patients. In this era of effective acid suppression and H. pylori treatment, definitive ulcer surgery in the emergent setting may not be necessary.
ANVUGIB is a common reason for hospital admission and has been traditionally associated with a mortality rate of 5%-10%. There have been numerous innovations in the prevention and management of ANVUGIB in recent years, although the effect of these innovations on ANVUGIB incidence and outcomes is unknown.
We used the Statistics Canada's Health Person Oriented Information Database [corrected], which contains data characterizing every inpatient hospital admission in Canada between 1993 and 2003. We identified admissions consistent with nonvariceal upper gastrointestinal bleeding using both a broad and narrow ICD-9/ICD-10-based definition. Data were extracted concerning patient demographics, incidence of surgery for complications of upper gastrointestinal bleeding, and overall mortality.
Between 1993 and 2003, ANVUGIB incidence decreased from 77.1 cases to 53.2 per 100,000/y for the broad definition, and from 52.4 to 34.3 cases per 100,000/y for the narrow definition. ANVUGIB incidence rose slightly in 2000, coincident with the introduction of COX-2 inhibitors. The proportion of ANVUGIB subjects requiring surgical intervention declined over the 10 years from 7.1% to 4.5%, although the rate of decline did not increase after the introduction of intravenous proton pump inhibitors (IV PPIs). The mortality rate remained steady at approximately 3.5%.
The incidence of ANVUGIB and the need for operative intervention has been steadily declining since 1993. ANVUGIB-associated mortality remained constant, although at a rate lower than traditionally reported. The impact of IV PPIs on mortality and operative intervention on a population-wide basis is likely minimal.
There is no definite recommendation on the use of dual endoscopic therapy in patients with severe peptic ulcer bleeding. A systematic review and meta-analysis were performed to determine whether the use of two endoscopic hemostatic procedures improved patient outcomes compared with monotherapy.
A search for randomized trials comparing dual therapy (i.e., epinephrine injection plus other injection or thermal or mechanical method) versus monotherapy (injection, thermal, or mechanical alone) was performed between 1990 and 2006. Heterogeneity between studies was tested with chi(2) and explained by metaregression analysis.
Twenty studies (2,472 patients) met inclusion criteria. Compared with controls, dual endoscopic therapy reduces the risk of recurrent bleeding (OR [odds ratio] 0.59 [0.44-0.80], P= 0.0001) and the risk of emergency surgery (OR 0.66 [0.49-0.89], P= 0.03) and showed a trend toward a reduction in the risk of death (OR 0.68 [0.46-1.02], P= 0.06). Subcategory analysis showed that dual therapy was significantly superior to injection therapy alone for all the outcomes considered, but failed to demonstrate that any combination of treatments is better than either mechanical therapy alone (OR 1.04 [0.45-2.45] for rebleeding, 0.49 [0.50-4.87] for surgery, and 1.28 [0.34-4.86] for death) or thermal therapy alone (OR 0.67 [0.40-1.20] for rebleeding, 0.89 [0.45-1.76] for surgery, and 0.51 [0.24-1.10] for death).
Dual endoscopic therapy proved significantly superior to epinephrine injection alone, but had no advantage over thermal or mechanical monotherapy in improving the outcome of patients with high-risk peptic ulcer bleeding.
Giant peptic ulcer: a surgical or medical disease?
- Simeone
NIH Consensus Development Panel on Helicobacter pylori in peptic ulcer disease. Helicobacter pylori in peptic ulcer disease.