Changing trends in perforated peptic ulcer during the past 45 years

Perforated peptic ulcer - an update

Peptic ulcer disease (PUD) affects 4 million people worldwide annually. The incidence of PUD has been estimated at around 1.5% to 3%. Perforated peptic ulcer (PPU) is a serious complication of PUD and patients with PPU often present with acute abdomen that carries high risk for morbidity and mortality. The lifetime prevalence of perforation in patients with PUD is about 5%. PPU carries a mortality ranging from 1.3% to 20%. Thirty-day mortality rate reaching 20% and 90-d mortality rate of up to 30% have been reported. In this review we have summarized the current evidence on PPU to update readers. This literature review includes the most updated information such as common causes, clinical features, diagnostic methods, non-operative and operative management, post-operative complications and different scoring systems of PPU. With the advancement of medical technology, PUD can now be treated with medications instead of elective surgery. The classic triad of sudden onset of abdominal pain, tachycardia and abdominal rigidity is the hallmark of PPU. Erect chest radiograph may miss 15% of cases with air under the diaphragm in patients with bowel perforation. Early diagnosis, prompt resuscitation and urgent surgical intervention are essential to improve outcomes. Exploratory laparotomy and omental patch repair remains the gold standard. Laparoscopic surgery should be considered when expertise is available. Gastrectomy is recommended in patients with large or malignant ulcer.

Perforated peptic ulcer in children: a 20-year experience

BACKGROUND

Although the detection of pediatric peptic ulcer disease (PUD) has recently been increasing, perforated peptic ulcer (PPU) in children is rare. We report our experience with PPU in children.

MATERIALS AND METHODS

The charts of children diagnosed with PPU at our hospital from January 1986 to June 2005 were reviewed. Data were obtained on demographics, coexisting clinical events, perforation sites, delay in surgery, operative findings and methods, and outcomes. The data were analyzed using the chi2, Student t test, and multivariate logistic regression for possible risk factors.

RESULTS

There were 42 male and 10 female patients aged 2 to 18 years (mean, 14.2 years) included in the study. Forty-seven patients were adolescents (90%). Eight patients had coexisting clinical events before PPU. All of the patients manifested acute abdominal pain. Forty-nine patients (94.2%) had peritoneal signs. Radiography showed subdiaphragmatic free air in 43 patients (82.7%); this was the most important tool for establishing diagnosis. Nine patients (17.3%) had postoperative complications. Two patients died (3.8%). Univariate analysis showed that poor outcome was significantly associated with female sex, more coexisting clinical events, no evidence of chronic ulcer, and treatment by simple suture (P < 0.05). Only female sex and simple suture remained statistically significant in multivariate analysis. Although delay in surgery (>12 hours) was not significantly related to complications, there was a greater tendency toward the development of complications.

CONCLUSIONS

PPU should be suspected in adolescents who manifest acute abdominal pain and have peritoneal signs. Children with PPU have a more favorable outcome than adults.

Factors affecting mortality and morbidity in patients with peptic ulcer perforation

BACKGROUND AND AIM

With the introduction of H2 receptor antagonists and proton pump inhibitors, the incidence of elective surgery for peptic ulcer (PU) diseases has decreased, although complications of PU such as perforation and bleeding have remained fairly constant. The purpose of this study was to identify the risk factors that predict morbidity and mortality in patients with perforated PU.

METHODS

The records of 269 patients who were operated on for perforated PU were reviewed retrospectively. The following factors were analyzed in terms of morbidity and mortality: age >65 years; gender; associated medical illness; chronic ingestion of non-steroidal anti-inflammatory drugs, aspirin, corticosteroids or immunosuppressants; alcohol ingestion and smoking habits; American Society of Anesthesiologist (ASA) status; season; delayed operation; site of ulcer perforation; and shock on admission and type of operation.

RESULTS

There were 30 female (11.16%) and 239 male (88.84%) patients. Seventy-one (26.4%) patients had associated diseases. Simple closure was performed in 257 (95.5%) patients; 12 patients (4.5%) underwent definitive operations. A total of 108 postoperative complications were present in 65 (24.2%) patients. Twenty-three patients died (8.55%). Multivariate analysis showed that only age, ASA score, treatment delay, presence of shock and definitive operation were independent predictors of mortality. Significant risk factors that led to morbidity were ASA status, time of surgery, season, presence of shock and type of surgery. There was a significant difference concerning morbidity and mortality between simple closure of the perforation and definitive surgery.

CONCLUSIONS

Age, delayed surgery, presence of shock, ASA risk and definitive surgery are factors significantly associated with fatal outcomes in patients undergoing emergency surgery for perforated PU. Therefore, proper resuscitation from shock, improving ASA grade, decreasing delay and reserving definitive surgery for selected patients is needed to improve overall results.

Perforated peptic ulcer: main factors of morbidity and mortality

It is well stated in the literature that medical treatment for peptic ulcer is based on a combination of proton pump inhibitors (PPIs) and antibiotics to eradicate Helicobacter pylori. This treatment is associated with a high rate of immediate success and a low rate of recurrence at 12 months, although it is not effective in all patients. Peptic ulcer (PU) perforation is a serious problem that leads to high complication and mortality rates. Surgical treatment, with its various possibilities, constitutes the ideal treatment. Surgical intervention in these cases, however, can be directed to treating the perforation alone, or it can offer definitive treatment of the ulcer itself. With the hope of establishing why such complications and mortality were seen in the patients in our hospital population, we gathered the facts about PU perforations and the types of surgery performed. We studied 210 consecutive patients (150 men, 60 women) who had undergone surgery at our hospital because of perforation between January 1, 1990 and December 31, 2000. The patients' median age was 53.0 +/- 20.6 years (men 47.7 +/- 17.3 years; women 66.3 +/- 22.0 years). Altogether, 86 patients had significant associated illnesses, 62 were admitted more than 24 hours after the perforation, and 25 were admitted in shock. We performed resections in 10 patients; 88 patients were treated by suturing the perforation with or without a patch of epiploon; and 112 underwent a troncular vagotomy with drainage (VT + Dr). A total of 21 patients died (10%). Significant risk factors that led to complications were identified by statistical studies. They were a perforation that had been present more than 24 hours, the coexistence of significant associated illnesses, and resection surgery. The significant risk factors that led to death were the presence of shock at admission, the coexistence of significant illnesses, and resection surgery. There was no statistically significant difference concerning morbidity and mortality between simple closure of the perforation and definitive surgery (VT + Dr).

Laparoscopic repair for perforated peptic ulcer: a randomized controlled trial

OBJECTIVE

To compare the results of open versus laparoscopic repair for perforated peptic ulcers.

SUMMARY BACKGROUND DATA

Omental patch repair with peritoneal lavage is the mainstay of treatment for perforated peptic ulcers in many institutions. Laparoscopic repair has been used to treat perforated peptic ulcers since 1990, but few randomized studies have been carried out to compare open versus laparoscopic procedures.

METHODS

From January 1994 to June 1997, 130 patients with a clinical diagnosis of perforated peptic ulcer were randomly assigned to undergo either open or laparoscopic omental patch repair. Patients were excluded for a history of upper abdominal surgery, concomitant evidence of bleeding from the ulcer, or gastric outlet obstruction. Patients with clinically sealed-off perforations without signs of peritonitis or sepsis were treated without surgery. Laparoscopic repair would be converted to an open procedure for technical difficulties, nonjuxtapyloric gastric ulcers, or perforations larger than 10 mm. A Gastrografin meal was performed 48 to 72 hours after surgery to document sealing of the perforation. The primary end-point was perioperative parenteral analgesic requirement. Secondary endpoints were operative time, postoperative pain score, length of postoperative hospital stay, complications and deaths, and the date of return to normal daily activities.

RESULTS

Nine patients with a surgical diagnosis other than perforated peptic ulcer were excluded; 121 patients entered the final analysis. There were 98 male and 23 female patients recruited, ages 16 to 89 years. The two groups were comparable in age, sex, site and size of perforations, and American Society of Anesthesiology classification. There were nine conversions in the laparoscopic group. After surgery, patients in the laparoscopic group required significantly less parenteral analgesics than those who underwent open repair, and the visual analog pain scores in days 1 and 3 after surgery were significantly lower in the laparoscopic group as well. Laparoscopic repair required significantly less time to complete than open repair. The median postoperative stay was 6 days in the laparoscopic group versus 7 days in the open group. There were fewer chest infections in the laparoscopic group. There were two intraabdominal collections in the laparoscopic group. One patient in the laparoscopic group and three patients in the open group died after surgery.

CONCLUSIONS

Laparoscopic repair of perforated peptic ulcer is a safe and reliable procedure. It was associated with a shorter operating time, less postoperative pain, reduced chest complications, a shorter postoperative hospital stay, and earlier return to normal daily activities than the conventional open repair.

Time trends for peptic ulcer disease in Denmark, 1981-1993. Analysis of hospitalization register and mortality data

BACKGROUND

Since the mid-1980s there has been great improvement in the available diagnostic tools and treatments for peptic ulcers. The aim of this study was to determine whether these improvements have been paralleled by decreasing age- and sex-specific hospitalization and death rates for peptic ulcers in Denmark.

METHODS

The study was based on all discharges from Danish somatic hospitals as registered in the National Hospital Discharge Registry and all the death certificates as registered in the Danish National Board of Health from 1981 through 1993, when a diagnosis of peptic ulcer was recorded. The age- and sex-specific and age-adjusted hospitalization and death rates were estimated.

RESULTS

In men the age-adjusted hospitalization rate for all types of peptic ulcers decreased by 0.88, but the mortality increased by 1.19. In women the age-adjusted hospitalization and mortality increased for all types of peptic ulcers. The increasing mortality was mainly due to bleeding and perforated duodenal ulcers. The analysis of the age-specific hospitalization and mortality for peptic ulcer complications showed that the increasing trends mainly occurred among the elderly.

CONCLUSION

The improved medical treatment of peptic ulcers has not been paralleled by decreasing hospitalization or death from complicated peptic ulcers in Denmark. On the contrary, we found an increasing hospitalization and mortality from peptic ulcer complications, particularly in elderly Danish people.

Influence of age, comorbidity, type of operation and other variables on lethality and duration of post-operative hospital stay in patients with peptic ulcer. An analysis of 303 surgically treated patients

Three hundred and three consecutive patients operated on for peptic ulcer for the first time between 1 January 1984 and 31 December 1993 were evaluated in this retrospective study. Eleven variables (Period when operation took place, gender, smoking behaviour, history of former ulcers, ulcerogenic drug intake, ulcer location, epigastric pain, number of blood units substituted, patient's age, type of operation, comorbidity) were investigated regarding their influence on peri- and post-operative mortality and on the length of hospital stay after operation. We found that a high comorbidity score (> 2) and the indication "emergency operation" (vs "elective operation") had an adverse impact on survival. The importance of age was marginal. The duration of post-operative hospital stay in survivors was negatively influenced by age higher than 60 years, more than two red cell units substituted and a high comorbidity score according to Charlson.

Perforated pyloroduodenal ulcers. Long-term results with omental patch closure and parietal cell vagotomy

OBJECTIVE

The authors evaluated parietal cell vagotomy and omental patch closure as treatment for perforated pyloroduodenal ulcers.

BACKGROUND DATA

Since the beginning of the century, there has been a difference of opinion as to whether perforated pyloroduodenal ulcers are best managed with nonoperative treatment, simple closure, or definitive treatment, i.e., a procedure that handles the emergency problem and simultaneously provides protection against further ulcer disease. The criticism of using definitive treatment at the time of perforation has been that some patients who might not have recurrent ulcer, if a definitive operation was not performed, would be at risk of adverse postoperative sequelae, including death. Parietal cell vagotomy as treatment of intractable duodenal ulcer disease was shown to be almost without complications. The objective of this study was to determine if the operation was equally applicable to perforated pyloroduodenal ulcers.

METHODS

A group of 107 selected patients with perforated pyloroduodenal ulcers underwent definitive treatment by omental patch closure and parietal cell vagotomy. The patients were evaluated prospectively on an annual basis up to 21 years. Gastric analyses were performed on each visit for which the patient gave his/her consent. Patients suspected of a recurrent ulcer were examined endoscopically for verification.

RESULTS

There was one death (0.9%). Ninety-three patients were observed for follow-up for 2 to 21 years. The recurrent ulcer rate by life table analysis was 7.4%. The reoperative rate was 1.9%. Postoperative gastric sequelae were insignificant. All but four patients were graded Visick I or II at the time of their last evaluation.

CONCLUSION

This study confirms that the combination of parietal cell vagotomy and omental patch closure is an excellent choice for treatment of patients with perforated pyloroduodenal ulcers, who, by virtue of their age, fitness, and status of the peritoneal cavity are candidates for definitive surgery. Virtually none of the morbidity that occurs with other forms of definitive treatment is inflicted on patients who might never have needed a definitive operation if simple closure was performed. At the same time, it provides definitive therapy for the larger number of patients who subsequently would have required a second operation for continued ulcer disease if simple closure alone was performed. Whether this operation is performed at the time of perforation should depend on the presence or absence of risk factors, rather than whether the ulcer is acute or chronic.