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Bose G, Ray A, Ali SN, Ishore K. Profile of gastroduodenal perforation patients admitted in a rural tertiary care hospital: An observational cross-sectional study. JOURNAL OF THE WEST AFRICAN COLLEGE OF SURGEONS 2024; 14:289-294. [PMID: 38988431 PMCID: PMC11232779 DOI: 10.4103/jwas.jwas_140_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/29/2023] [Indexed: 07/12/2024]
Abstract
Background Gastro-duodenal perforation is a common surgical emergency that remains a formidable health burden worldwide with significant morbidity and mortality. Ulcer disease remains the most common cause of gastro-duodenal perforation. Diagnosing the presence of H. pylori can help eradicate the infection from the community at large and thereby reduce the chances of gastro-duodenal perforation. Aims To assess the clinical presentation of gastro-duodenal perforation patients and to evaluate the detection of Helicobacter pylori infection by available investigations. Materials and Methods A descriptive observational study was conducted among 80 patients presenting with clinical features suggestive of gastro-duodenal perforation and confirmed by clinical, radiological basis and operative findings admitted at a rural tertiary care hospital during 2019-2020. Detailed history was taken from the patient/party, clinically examined, and blood/tissue samples were investigated. The patients were managed with standard treatment modality in the studied institute. Data were collected, compiled, and entered MS Excel and analyzed using appropriate software. Descriptive analysis was done in the form of proportion for categorical variables, mean or median for continuous variables. Result Cases of gastro-duodenal perforations were more among middle to later age of life, mostly affecting married male patients hailed from rural area and unskilled workers. History of intake of spicy food, prolonged starvation, history of NSAID use were common among them. Majority of the patients had history of pain abdomen in the past suggesting of PUD and history of taking variety group of acid reducing agents. Most of them presented with epigastric pain, vomiting, abdominal distension along with other signs of peritonitis. Obliteration of liver dullness and free gas under right dome of diaphragm was also noted in large proportion among them. Majority of cases were found positive for H. pylori on Histology (85%), followed by rapid urease test (RUT) (80%) and a positivity of 72.5% and 68.8% on serum IgG and IgA antibody respectively. Rapid Urease Test was more sensitive as well as specific in diagnosing of H. pylori than antibody detection test. Conclusion Early detection of H. pylori infection and treatment with potent anti H. pylori therapy postoperatively has been found to be adequate.
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Affiliation(s)
- Gourab Bose
- Department of Surgery and Community Medicine, North Bengal Medical College and MJN Medical College, West Bengal, India
| | - Amit Ray
- Department of Surgery and Community Medicine, North Bengal Medical College and MJN Medical College, West Bengal, India
| | - Shah Nawaz Ali
- Department of Surgery and Community Medicine, North Bengal Medical College and MJN Medical College, West Bengal, India
| | - Kaushik Ishore
- Department of Surgery and Community Medicine, North Bengal Medical College and MJN Medical College, West Bengal, India
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Idris M, Smiley A, Patel S, Latifi R. Risk Factors for Mortality in Emergently Admitted Patients with Acute Gastric Ulcer: An Analysis of 15,538 Patients in National Inpatient Sample, 2005-2014. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16263. [PMID: 36498337 PMCID: PMC9736004 DOI: 10.3390/ijerph192316263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 11/26/2022] [Accepted: 12/01/2022] [Indexed: 06/17/2023]
Abstract
Background: Patients admitted emergently with a primary diagnosis of acute gastric ulcer have significant complications including morbidity and mortality. The objective of this study was to assess the risk factors of mortality including the role of surgery in gastric ulcers. Methods: Adult (18−64-year-old) and elderly (≥65-year-old) patients admitted emergently with hemorrhagic and/or perforated gastric ulcers, were analyzed using the National Inpatient Sample database, 2005−2014. Demographics, various clinical data, and associated comorbidities were collected. A stratified analysis was combined with a multivariable logistic regression model to assess predictors of mortality. Results: Our study analyzed a total of 15,538 patients, split independently into two age groups: 6338 adult patients and 9200 elderly patients. The mean age (SD) was 50.42 (10.65) in adult males vs. 51.10 (10.35) in adult females (p < 0.05). The mean age (SD) was 76.72 (7.50) in elderly males vs. 79.03 (7.80) in elderly females (p < 0.001). The percentage of total deceased adults was 1.9% and the percentage of total deceased elderly was 3.7%, a difference by a factor of 1.94. Out of 3283 adult patients who underwent surgery, 32.1% had perforated non-hemorrhagic ulcers vs. 1.8% in the non-surgical counterparts (p < 0.001). In the 4181 elderly surgical patients, 18.1% had perforated non-hemorrhagic ulcers vs. 1.2% in the non-surgical counterparts (p < 0.001). In adult patients managed surgically, 2.6% were deceased, while in elderly patients managed surgically, 5.5% were deceased. The mortality of non-surgical counterparts in both age groups were lower (p < 0.001). The multivariable logistic regression model for adult patients electing surgery found delayed surgery, frailty, and the presence of perforations to be the main risk factors for mortality. In the regression model for elderly surgical patients, delayed surgery, frailty, presence of perforations, the male sex, and age were the main risk factors for mortality. In contrast, the regression model for adult patients with no surgery found hospital length of stay to be the main risk factor for mortality, whereas invasive diagnostic procedures were protective. In elderly non-surgical patients, hospital length of stay, presence of perforations, age, and frailty were the main risk factors for mortality, while invasive diagnostic procedures were protective. The following comorbidities were associated with gastric ulcers: alcohol abuse, deficiency anemias, chronic blood loss, chronic heart failure, chronic pulmonary disease, hypertension, fluid/electrolyte disorders, uncomplicated diabetes, and renal failure. Conclusions: The odds of mortality in emergently admitted geriatric patients with acute gastric ulcer was two times that in adult patients. Surgery was a protective factor for patients admitted emergently with gastric perforated non-hemorrhagic ulcers.
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Affiliation(s)
- Maksat Idris
- New York Medical College, School of Medicine and Westchester Medical Center, Valhalla, NY 10595, USA
| | - Abbas Smiley
- New York Medical College, School of Medicine and Westchester Medical Center, Valhalla, NY 10595, USA
| | - Saral Patel
- New York Medical College, School of Medicine and Westchester Medical Center, Valhalla, NY 10595, USA
| | - Rifat Latifi
- Department of Surgery, University of Arizona, Tucson, AZ 85721, USA
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Asayama N, Nagata S, Kano M, Shigita K, Aoyama T, Fukumoto A, Mukai S. A pilot study to evaluate the effectiveness and safety of urgent endoscopy for gastroduodenal perforation. Surg Endosc 2021; 36:2614-2622. [PMID: 34009476 DOI: 10.1007/s00464-021-08555-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 05/07/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Gastroduodenal perforation is potentially life threatening and requires early diagnosis and treatment. Urgent endoscopy facilitates detecting bleeding sites and achieving hemostasis. However, there is no consensus on urgent endoscopy for gastroduodenal perforation in Japan. METHODS We evaluated the effectiveness and safety of urgent endoscopy for gastroduodenal perforation. We compared clinical characteristics between 140 patients who underwent urgent endoscopy (urgent endoscopy group) and 16 patients did not (no urgent endoscopy group) at Hiroshima City Asa Citizens Hospital between December 2005 and December 2018. RESULTS Endoscopic diagnosis was possible in all urgent endoscopy group. In contrast, correct diagnosis of the perforation site was made on CT in 99 cases (63%). Furthermore, the proportion of cases with correct diagnosis of the perforation site by CT findings differed significantly between the urgent endoscopy group and the no urgent endoscopy group (66% vs. 38%, p < 0.05). No complications of urgent endoscopy were observed. Primary perforation site was gastric in 42 cases and duodenal in 114. In the 42 gastric perforation cases, 12 gastric perforation cases (29%) were managed conservatively, successfully in 9 (75%); 2 cases (17%) required delayed emergency surgery for worsening peritonitis. In the 114 duodenal perforation cases (duodenal ulcer in all cases), 52 cases (46%) were managed conservatively, successfully in 48 (92%); 3 cases (6%) required delayed emergency surgery for worsening peritonitis. A significantly higher proportion of gastric perforation cases than duodenal perforation cases required surgical treatment (76% vs. 57%, p < 0.05). Multivariate analysis revealed localized abdominal pain (no peritonism) (OR 0.25; 95% CI 0.08-0.75; p < 0.01) and perforation diameter ≤ 5 mm (OR 0.13; 95% CI 0.04-0.36; p < 0.01) as significant independent clinical factors for successful conservative management of duodenal ulcer perforation. CONCLUSIONS Urgent endoscopy in gastroduodenal perforation enabled primary diagnosis and perforation site identification, and facilitated deciding the management strategy.
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Affiliation(s)
- Naoki Asayama
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan.
| | - Shinji Nagata
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Mikihiro Kano
- Department of Surgery, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Kenjiro Shigita
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Taiki Aoyama
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Akira Fukumoto
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Shinichi Mukai
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
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4
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Abstract
Perforated peptic ulcer is a common emergency condition worldwide, with associated mortality rates of up to 30%. A scarcity of high-quality studies about the condition limits the knowledge base for clinical decision making, but a few published randomised trials are available. Although Helicobacter pylori and use of non-steroidal anti-inflammatory drugs are common causes, demographic differences in age, sex, perforation location, and underlying causes exist between countries, and mortality rates also vary. Clinical prediction rules are used, but accuracy varies with study population. Early surgery, either by laparoscopic or open repair, and proper sepsis management are essential for good outcome. Selected patients can be managed non-operatively or with novel endoscopic approaches, but validation of such methods in trials is needed. Quality of care, sepsis care bundles, and postoperative monitoring need further assessment. Adequate trials with low risk of bias are urgently needed to provide better evidence. We summarise the evidence for perforated peptic ulcer management and identify directions for future clinical research.
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Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Kenneth Thorsen
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Ewen M Harrison
- MRC Centre for Inflammation Research, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Morten H Møller
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Michael Ohene-Yeboah
- Department of Surgery, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Jon Arne Søreide
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
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5
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Treatment for perforated gastric ulcer: a multi-institutional retrospective review. J Gastrointest Surg 2013; 17:2074-81. [PMID: 24114679 DOI: 10.1007/s11605-013-2362-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 09/19/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND The optimal treatment for patients with perforated gastric ulcer (PGU) remains controversial. This study therefore investigated the treatment status for this disease in clinical practice. METHODS We retrospectively reviewed 183 patients with PGU from 1998 to 2007 across 15 institutions, and analyzed patient characteristics and short- and long-term outcomes according to treatments received. RESULTS Of the 183 patients, 57 who were treated conservatively had less abdominal tenderness, lower levels of serum C-reactive protein, and shorter time to presentation than the 126 patients who underwent emergency surgery. There was no significant difference in baseline characteristics between the 41 successful patients and 16 failed patients in the conservative treatment group; however, the latter had a longer average hospital stay. Eighty-three of the emergency surgery patients who underwent gastrectomy had longer surgical times, greater blood loss, and shorter time to resumption of diet than the 57 patients undergoing stomach-preserving surgery; however, there was no significant difference in postoperative complications and hospital stay between these groups. Of 91 patients who received stomach-preserving treatment, only three had treatment failure in the long-term follow-up period. CONCLUSION Strictly selected patients should be initially considered for conservative treatment. The short-term outcomes of stomach-preserving surgery are comparable to gastrectomy; however, further evaluation of the long-term outcomes of stomach-preserving treatment is required.
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Tan KK, Quek TJL, Wong N, Li KKW, Lim KH. Early Outcome Following Emergency Gastrectomy. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2012. [DOI: 10.47102/annals-acadmedsg.v41n10p451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Introduction: Emergency gastrectomy has been shown to be associated with poor morbidity and mortality rates. The aims of this study were to review the outcomes of emergency gastrectomy in our institution and to determine any factors that were associated with worse perioperative outcomes. Materials and Methods: A retrospective review of all patients who underwent emergency gastrectomy for various indications from October 2003 to April 2009 was performed. All the complications were graded according to the classification proposed by Clavien and group. Results: Eighty-five patients, median age 70 (range, 27 to 90 years), underwent emergency gastrectomy. The indications for the surgery included perforation, bleeding and obstruction in 45 (52.9%), 32 (37.6%) and 8 (9.4%) patients, respectively. The majority of the patients (n = 46, 54.1%) had an American Society of Anesthesiologists (ASA) score of 3. Partial or subtotal, and total gastrectomy were performed in 75 (88.2%) and 10 (11.8%) patients, respectively. Malignancy was the underlying pathology in 33 (38.8%) patients. The perioperative mortality rate was 21.2% (n = 18) with another 27 (31.8%) patients having severe complications. Twelve (14.1%) patients had a duodenal stump leak. The independent factors predicting worse perioperative complications included high ASA score and in perforation cases. Other factors such as malignancy, age and extent of surgery were not significantly related. The presence of a duodenal stump leak was the only independent factor predicting mortality. Conclusion: Emergency gastrectomy is associated with dismal morbidity and mortality rates. Patients with high ASA scores and perforations fared worse, and duodenal stump leak increases the risk of mortality.
Key words: Emergency, Gastrectomy, Surgery, Treatment outcome
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Affiliation(s)
- Ker Kan Tan
- National University Health System, Singapore
| | | | | | | | - Khong Hee Lim
- Nexus Surgical Associates, Mount Elizabeth Medical Centre, Singapore
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Tan KK, Quek TJL, Wong N, Li KK, Lim KH. Emergency surgery for perforated gastric malignancy: An institution's experience and review of the literature. J Gastrointest Oncol 2012; 2:13-8. [PMID: 22811822 DOI: 10.3978/j.issn.2078-6891.2011.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2010] [Accepted: 01/05/2011] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES The aim was to evaluate the outcome of patients who underwent surgery for perforated gastric malignancies. METHODS A review of all patients who underwent surgery for perforated gastric malignancy was performed. RESULTS Twelve patients (nine gastric adenocarcinoma and three B-cell lymphoma) formed the study group. Ten (83.3%) had subtotal gastrectomy performed, while two (16.7%) underwent total gastrectomy. All eight patients with adenocarcinoma who survived the initial operation fared poorly. The two patients with lymphoma who survived the surgery underwent subsequent chemotherapy has no disease recurrence currently. CONCLUSION Surgery in perforated gastric malignancy is fraught with numerous challenges.
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Affiliation(s)
- Ker-Kan Tan
- Digestive Disease Centre, Department of General Surgery, Tan Tock Seng Hospital, Singapore
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8
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Hakeam H, O'Regan P, Al-Hshash G, Al-Hussieni H. Duodenal perforation in a patient with non-small cell lung cancer receiving Pemetrexed-Cisplatin combination. J Surg Case Rep 2011; 2011:1-4. [PMID: 24950503 PMCID: PMC3649297 DOI: 10.1093/jscr/2011.9.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Pemetrexed is increasingly used in combination with platinum antineoplastic agents for the treatment of certain lung malignancies. Its use was associated with favorable hematological adverse reaction compared to standard regimens. Non-hematological life-threatening complications such as gastrointestinal perforations are extremely rare with pemetrexed use and tend to develop in the distal bowel in patients at risk. We report the case of a 56-years old Arab male, heavy smoker newly diagnosed with Stage IV non-small cell lung cancer with no comorbidities, treated with pemetrexed-cisplatin combination. Four days after the first cycle of chemotherapy, the patient developed a small duodenal perforation that required emergency laparoscopy repair. Clinicians should have a high index of suspicion should be taken for alimentary tract perforation in patients presenting with acute abdominal pain during pemetrexed therapy.
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Affiliation(s)
- Ha Hakeam
- King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Pj O'Regan
- King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - G Al-Hshash
- King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - H Al-Hussieni
- King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
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9
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Chander B, Aslanian HR. Gastric perforations associated with the use of crack cocaine. Gastroenterol Hepatol (N Y) 2010; 6:733-735. [PMID: 21437024 PMCID: PMC3033546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
- Bani Chander
- Department of Internal Medicine Section of Digestive Diseases Yale University School of Medicine New Haven, Connecticut
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10
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Schuster KM, Feuer WJ, Barquist ES. Outcomes of cocaine-induced gastric perforations repaired with an omental patch. J Gastrointest Surg 2007; 11:1560-3. [PMID: 17701263 DOI: 10.1007/s11605-007-0257-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2007] [Accepted: 07/19/2007] [Indexed: 01/31/2023]
Abstract
Crack cocaine has been associated with acute gastric perforation. The appropriate surgical treatment and long-term outcomes remain unclear. A retrospective chart review of all gastroduodenal perforations associated with crack cocaine use was performed. Data abstracted included details of short- and long-term outcomes. Kaplan-Meier methods were used to evaluate surgical outcomes. Over the 14-year period ending December 2005, 16 cases of crack-induced gastric perforations were identified. Most (75%) were treated with an omental patch. The other patients underwent a formal antiulcer operation, including one vagotomy and pyloroplasty (V&P), one vagotomy and antrectomy, one subtotal gastrectomy, and one ulcer excision and V&P. All patients after antiulcer procedures were followed for a median of 63 months (range 27-120) with no recurrences. Follow-up data were available in 75% of the omental patch patients. Recurrence of disease was observed in 56% of these omental patch patients at a median of 20 months (range 11-39). Those without recurrence were followed for a median of 67 months (range 12-96). The recurrence rate was borderline lower in the antiulcer group (P = 0.072). Omental patch closure results in a recurrence rate over 50% compared with no recurrence for formal antiulcer procedures.
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Affiliation(s)
- Kevin M Schuster
- Division of Trauma, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, USA.
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11
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Testini M, Portincasa P, Piccinni G, Lissidini G, Pellegrini F, Greco L. Significant factors associated with fatal outcome in emergency open surgery for perforated peptic ulcer. World J Gastroenterol 2003; 9:2338-40. [PMID: 14562406 PMCID: PMC4656491 DOI: 10.3748/wjg.v9.i10.2338] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the main factors associated with mortality in patients undergoing surgery for perforated peptic ulcer referred to an academic department of general surgery in a large southern Italian city.
METHODS: One hundred and forty-nine consecutive patients (M:F ratio = 110:39, mean age 52 yrs, range 16-95) with peptic ulcer disease were investigated for clinical history (including age, sex, previous history of peptic ulcer, associated diseases, delayed abdominal surgery, ulcer site, operation type, shock on admission, postoperative general complications, and intra-abdominal and/or wound infections), serum analyses and radiological findings.
RESULTS: The overall mortality rate was 4.0%. Among all factors, an age above 65 years, one or more associated diseases, delayed abdominal surgery, shock on admission, postoperative abdominal complications and/or wound infections, were significantly associated (χ2) with increased mortality in patients undergoing surgery (0.0001 < P < 0.03).
CONCLUSION: Factors such as concomitant diseases, shock on admission, delayed surgery, and postoperative abdominal and wound infections are significantly associated with fatal outcomes and need careful evaluation within the general workup of patients admitted for perforated peptic ulcer.
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Affiliation(s)
- Mario Testini
- Section of General Surgery and Vascular Surgery and Clinical Oncology, Department of Applications in Surgery of Innovative Technologies (DACTI), University Medical School, Bari, Italy.
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12
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Tramèr MR, Moore RA, Reynolds DJ, McQuay HJ. Quantitative estimation of rare adverse events which follow a biological progression: a new model applied to chronic NSAID use. Pain 2000; 85:169-82. [PMID: 10692616 DOI: 10.1016/s0304-3959(99)00267-5] [Citation(s) in RCA: 246] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Randomised controlled trials (RCTs) alone are unlikely to provide reliable estimates of the incidence of rare events because of their limited size. Cohort, case control, and other observational studies have large numbers but are vulnerable to various kinds of bias. Wanting to estimate the risk of death from bleeding or perforated gastroduodenal ulcers with chronic usage of non-steroidal anti-inflammatory drugs (NSAIDs) with greater precision, we developed a model to quantify the frequency of rare adverse events which follow a biological progression. The model combined data from both RCTs and observational studies. We searched systematically for any report of chronic (>/=2 months) use of NSAIDs which gave information on gastroduodenal ulcer, bleed or perforation, death due to these complications, or progression from one level of harm to the next. Fifteen RCTs (19364 patients exposed to NSAIDs for 2-60 months), three cohort studies (215076 patients redeeming a NSAID prescription over a 3-12 month period), six case-control studies (2957 cases) and 20 case series (7406), and case reports (4447) were analysed. In RCTs the incidence of bleeding or perforation in 6822 patients exposed to NSAIDs was 0.69%; two deaths occurred. Of 11040 patients with bleeding or perforation with or without NSAID exposure across all reports, 6-16% (average 12%) died; the risk was lowest in RCTs and highest in case reports. Death from bleeding or perforation in all controls not exposed to NSAIDs occurred in 18 out of 849489 (0.002%). From these numbers we calculated the number-needed-to-treat for one patient to die due to gastroduodenal complications with chronic (>/=2 months) NSAIDs as 1/((0.69x¿6-16%, average 12%¿)-0.002%))=909-2500 (average 1220). On average 1 in 1200 patients taking NSAIDs for at least 2 months will die from gastroduodenal complications who would not have died had they not taken NSAIDs. This extrapolates to about 2000 deaths each year in the UK.
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Affiliation(s)
- M R Tramèr
- Division d'Anesthésiologie, Département APSIC, Hôpitaux Universitaires, CH-1211, Geneva, Switzerland.
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13
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McIntosh JH, Berman K, Holliday FM, Byth K, Chapman R, Piper DW. Some factors associated with mortality in perforated peptic ulcer: a case-control study. J Gastroenterol Hepatol 1996; 11:82-7. [PMID: 8672748 DOI: 10.1111/j.1440-1746.1996.tb00015.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
This study examined the associations of individual coexisting illnesses, septicaemia, intra-abdominal abscess, marital status, smoking and alcohol use, with mortality following perforation of peptic ulcer without pre-operative evidence of haemorrhage. Patients who died in hospital following ulcer perforation (cases; n = 300) were compared with patients who survived following ulcer perforation (controls; n = 276). The controls were frequency-matched to the cases on age, sex and perforation site. Data were analysed by logistic regression. Cardiac, respiratory, cerebrovascular, renal, liver and malignant diseases, and septicaemia and intra-abdominal abscess were associated with mortality and the coexisting illnesses were significantly increased in cases compared to controls both on admission and at the end of hospital stay. During hospitalization, the odds of pneumonia decreased in cases, otherwise there was little change in strengths of associations over this period. Being widowed or never married was positively associated with mortality, and moderate alcohol use was negatively associated. In conclusion, this study identifies several coexisting illnesses, septicaemia and intra-abdominal abscess as risk factors for mortality following ulcer perforation. The results suggest that, with little exception, the same level of mortality risk is associated with coexisting illnesses whether the beginning or end of hospital stay is used as the index time point.
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Affiliation(s)
- J H McIntosh
- Department of Medicine, University of Sydney, New South Wales, Australia
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14
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Svanes C, Lie RT, Svanes K, Lie SA, Søreide O. Adverse effects of delayed treatment for perforated peptic ulcer. Ann Surg 1994; 220:168-75. [PMID: 8053739 PMCID: PMC1234356 DOI: 10.1097/00000658-199408000-00008] [Citation(s) in RCA: 81] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE The authors assessed the consequences of delayed treatment for ulcer perforation with regard to short-term and long-term survival, complication rates, and length of hospital stay. SUMMARY BACKGROUND DATA Important adverse effects of delayed treatment have not been studied previously. Conflicting results have been given with regard to short-term survival. METHODS One thousand two hundred ninety-two patients operated on for perforated peptic ulcer in the Bergen area between 1935 and 1990 were studied. The effect of delay on postoperative lethality and complications adjusted for age, sex, ulcer site, and year of perforation was analyzed by stepwise logistic regression. The effect of delay on duration of hospital stay adjusted for potential confounding factors was analyzed by Cox proportional hazards regression. Observed survival was estimated by the Kaplan-Meier method, and expected survival was calculated from population mortality data. RESULTS Adverse effects increased markedly when delay exceeded 12 hours. Delay of more than 24 hours increased lethality sevenfold to eightfold, complication rate to threefold, and length of hospital stay to twofold, compared with delay of 6 hours or less. The reduced long-term survival for patients treated more than 12 hours after perforation could be attributed entirely to high postoperative mortality. CONCLUSIONS Delayed treatment after peptic ulcer perforation reduced survival, increased complication rates, and caused prolonged hospital stay. To improve outcome after ulcer perforation, an effort should be made to keep delay at less 12 hours, particularly in elderly patients.
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Affiliation(s)
- C Svanes
- Department of Surgery, Haukeland University Hospital, Bergen, Norway
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15
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Svanes C, Salvesen H, Stangeland L, Svanes K, Søreide O. Perforated peptic ulcer over 56 years. Time trends in patients and disease characteristics. Gut 1993; 34:1666-71. [PMID: 8282252 PMCID: PMC1374459 DOI: 10.1136/gut.34.12.1666] [Citation(s) in RCA: 57] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Perforated gastroduodenal ulcer was studied in 1483 patients in the Bergen area during the years 1935-90 to discover time trends in age and sex, disease characteristics, treatment, and outcome. The male:female ratio fell from 10:1 to 1.5:1, median age increased from 41 to 62 years. Most perforations were found in the duodenum in 1935-64, and in the pyloric and praepyloric area in 1965-90. There was a 10% occurrence of gastric ulcers throughout the study period. Ulcer site was related to age (more gastric and less duodenal perforations with increasing age) and sex (more pyloric and less duodenal ulcers among women). There were twice as many perforations in the evening compared with the early morning. The diurnal variation was more pronounced for duodenal and pyloric than for gastric and praepyloric perforations. Circadian and seasonal variation of ulcer perforation did not change during the 56 years studied. Treatment delay increased from median five hours to median nine hours. Infective complications and mortality fell with the introduction of antibiotics around 1950. General complications has increased in recent years because of the increase of elderly patients. Among patients who died, the proportion with associated disease rose from 27 to 85% during the study period.
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Affiliation(s)
- C Svanes
- Department of Surgery, Haukeland University Hospital, University of Bergen, Norway
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16
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Reinbach DH, Cruickshank G, McColl KE. Acute perforated duodenal ulcer is not associated with Helicobacter pylori infection. Gut 1993; 34:1344-7. [PMID: 8244099 PMCID: PMC1374538 DOI: 10.1136/gut.34.10.1344] [Citation(s) in RCA: 105] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Most patients with chronic duodenal ulcer disease have Helicobacter pylori infection and eradicating it considerably reduces the relapse rate. The prevalence of H pylori in 80 patients (mean age = 52 years, range 17-85) presenting with acute perforated duodenal ulcer was examined and compared with age and sex matched hospital control patients. H pylori state was assessed by serum anti-H pylori IgG (Helico-G kit, Porton) using a titre of 18 or less as negative with a specificity of 89% and sensitivity of 88%. Only 47% of the perforated duodenal ulcer patients were positive for H pylori and this was similar to the value of 50% in the controls. In 51 of the perforated duodenal ulcer patients 14C-urea breath tests were also performed 4-10 weeks after surgery and this confirmed that only 49% were positive for H pylori. None of these patients had received perioperative drugs that might have eradicated the infection. The H pylori positive and H pylori negative perforated duodenal ulcer patients were similar with respect to age (53, 51), smoking (84%, 83%), and consumption of more than 15 units of alcohol per week (42%, 38%). Duodenal ulcer disease had been diagnosed before acute perforation in only 24% of those with H pylori and also 24% of those without the infection. Regular non-steroidal anti-inflammatory drug (NSAID) use was common in both those with (44%) and without (45%) H pylori. In conclusion, the lack of association of acute perforated duodenal ulcer and H pylori infection suggests that perforated duodenal ulcer has a different pathogenesis from chronic duodenal ulcer disease, and that the first should not be regarded simply as a complication of the second.
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Affiliation(s)
- D H Reinbach
- University Department of Surgery, Western Infirmary, Glasgow
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McCloy R, Nair R. Surgery for acid suppression in the 1990s. BAILLIERE'S CLINICAL GASTROENTEROLOGY 1993; 7:129-48. [PMID: 8477110 DOI: 10.1016/0950-3528(93)90034-p] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- R McCloy
- University Department of Surgery, Royal Infirmary, Manchester, UK
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18
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Abstract
The optimal treatment of duodenal ulcer disease today requires familiarity with a variety of operative approaches. Experience and judgment are needed to select the best procedure for the individual patient presenting with a specific ulcer complication. Improved medical therapy has relegated surgery largely to the role of emergency life-saving intervention. Nonetheless, the goal of surgery remains cure of the ulcer diathesis with avoidance of postoperative side effects. Toward this end, proximal gastric vagotomy has proved itself to be the operation of choice, not only for intractable pain, but also for perforation and perhaps for bleeding in selected good-risk patients. Its efficacy in the treatment of obstructing duodenal ulcer has not been demonstrated. Modifications of proximal gastric vagotomy, including the use of laparoscopic techniques, are currently being evaluated in patients with intractable duodenal ulcer pain.
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Affiliation(s)
- B E Stabile
- Department of Surgery, University of California, San Diego School of Medicine
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