Perforated Gastroduodenal Ulcers Research Articles

Laparoscopic closure of perforated gastro-duodenal ulcer: 15 years' experience in our centre.

IntroductionThe objective of the study is to share the results and development findings on the laparoscopic closure technique applied in our centre during a 15-year period (1998–2012).AimTo compare statistically the standard parameters (hospitalization, duration of operation) versus conventional surgery, and at the same time we compared mainly morbidity and mortality.Material and methodsDuring the period under review we operated on a total of 259 patients, 115 (44.4%) of them laparoscopically, and 144 (55.6%) of them conventionally. The sample was divided into two groups: patients with ASA physical status classification system 1–3, and patients with ASA 4–5.ResultsThe results favour laparoscopy within the group with ASA 1–3 in terms of several parameters, namely: duration of hospitalization – 7.7 days in the case of laparoscopic intervention, vs. 10.6 days for conventional surgery (p < 0.05); and duration of operation – 61 min vs. 85.1 min respectively (p < 0.05). Total morbidity was 27.5% in the case of patients with conventional surgery, vs. 10.9% with laparoscopic intervention (p < 0.05). The sample of patients with ASA 4–5 suffered a high mortality of 82.7%.ConclusionsLaparoscopic closure of perforated ulcer is a safe therapeutic method, as confirmed by the results of many other studies around the world, which in many aspects favour the laparoscopic technique.

Predicting outcomes in patients with perforated gastroduodenal ulcers: artificial neural network modelling indicates a highly complex disease.

PurposeMortality prediction models for patients with perforated peptic ulcer (PPU) have not yielded consistent or highly accurate results. Given the complex nature of this disease, which has many non-linear associations with outcomes, we explored artificial neural networks (ANNs) to predict the complex interactions between the risk factors of PPU and death among patients with this condition.MethodsANN modelling using a standard feed-forward, back-propagation neural network with three layers (i.e., an input layer, a hidden layer and an output layer) was used to predict the 30-day mortality of consecutive patients from a population-based cohort undergoing surgery for PPU. A receiver-operating characteristic (ROC) analysis was used to assess model accuracy.ResultsOf the 172 patients, 168 had their data included in the model; the data of 117 (70 %) were used for the training set, and the data of 51 (39 %) were used for the test set. The accuracy, as evaluated by area under the ROC curve (AUC), was best for an inclusive, multifactorial ANN model (AUC 0.90, 95 % CIs 0.85–0.95; p < 0.001). This model outperformed standard predictive scores, including Boey and PULP. The importance of each variable decreased as the number of factors included in the ANN model increased.ConclusionsThe prediction of death was most accurate when using an ANN model with several univariate influences on the outcome. This finding demonstrates that PPU is a highly complex disease for which clinical prognoses are likely difficult. The incorporation of computerised learning systems might enhance clinical judgments to improve decision making and outcome prediction.

Re: Gonenc M, Dural AC, Celik F, et al: Enhanced postoperative recovery pathways in emergency surgery: a randomized controlled clinical trial

First suggested for patients with perforated gastric ulcers in 1894, 1 Bennet W.H. A case of ruptured gastric ulcer successfully treated by immediate suture. Lancet. 1894; 2: 21-22 Abstract Scopus (4) Google Scholar omental patch closure of a perforated duodenal ulcer was popularized by Graham in 1937 2 Graham R.R. The treatment of perforated duodenal ulcers. Surg Gynecol Obstet. 1937; 64: 235-238 Google Scholar and has remained a surgical mainstay. Over time and before the descriptions of Helicobacter pylori, H2-receptor antagonists, and proton-pump inhibitors, omental patch closure was one of the 4 operations used to treat perforated gastroduodenal ulcers. These included gastrectomy for perforated gastric ulcers and truncal vagotomy and pyloroplasty, truncal vagotomy and resection, and proximal gastric vagotomy with omental patch closure for perforated duodenal ulcers. 3 Feliciano D.V. Surgical options and results of treatment of perforated ulcers. Problems Gen Surg. 1987; 4: 301-307 Google Scholar , 4 Feliciano D.V. Do perforated duodenal ulcers need an acid-decreasing surgical procedure now that omeprazole is available?. Surg Clin N Am. 1992; 72: 369-380 PubMed Google Scholar , 5 Jordan Jr., G.L. DeBakey M.E. Duncan Jr., J.M. Surgical management of perforated peptic ulcers. Ann Surg. 1974; 179: 628-633 Crossref PubMed Scopus (49) Google Scholar These “definitive” operations were used from the 1940s to the 1990s because of the following problems or limitations of omental patch closure as follows: (1) technical difficulties in patching gastric or large duodenal perforations; (2) early reperforation or bleeding; (3) recurrent symptoms (73% of patients) postoperatively 5 Jordan Jr., G.L. DeBakey M.E. Duncan Jr., J.M. Surgical management of perforated peptic ulcers. Ann Surg. 1974; 179: 628-633 Crossref PubMed Scopus (49) Google Scholar ; (4) late reperforation (9% of patients) 6 Griffin G.E. Organ Jr., C.H. The natural history of the perforated duodenal ulcer treated by suture plication. Ann Surg. 1976; 183: 382-385 Crossref PubMed Scopus (46) Google Scholar ; and (5) a large number of reoperations (48% of patients). 7 Skovgaard S. Late results of perforated duodenal ulcer treated by simple suture. World J Surg. 1977; 1: 521-526 Crossref PubMed Scopus (12) Google Scholar Enhanced postoperative recovery pathways in emergency surgery: a randomised controlled clinical trialThe American Journal of SurgeryVol. 207Issue 6PreviewEnhanced recovery pathways are now widely used in elective surgical procedures. The feasibility of enhanced postoperative recovery pathways in emergency surgery for perforated peptic ulcer disease was investigated in this randomized controlled clinical trial. Full-Text PDF

Helicobacter pylori in gastroduodenal perforation

Background:peptic ulcers were earlier believed to be caused by dietary factors, gastric acid, and stress. However, in 1983, Warren and Marshall identified the correlation between Helicobacter pylori (H. pylori) and peptic ulcers. It is now well established that most of the peptic ulcers occur as a result of H. pylori infection. But the co-relation between perforated peptic ulcer and H. pylori infection is not yet fully established. Aims and objectives : to study the prevalence of H. pylori infection in patients with perforated peptic ulcer. Materials and methods: this was a prospective study carried out in all cases of perforated peptic ulcer reporting in surgical wards of a medical college during 2008-2010. A total of 50 cases, presenting as acute perforation of duodenum and stomach during this period, formed the study group. After resuscitation, all the cases were subjected to emergency exploratory laparotomy. The exact site of perforation was identified, biopsy was taken from the ulcer margin from 2-3 sites and the tissue was sent for H. pylori culture and histopathological examination. Simple closure of perforation, omentoplasty, thorough peritoneal lavage and drainage was carried out. Results: out of the 50 cases of perforated peptic ulcer, 38 happened to be males, and only 12 were females. The age of the patients ranged from 20 to 70 years. All the patients underwent only emergency laparotomy. As many as 46 cases (92%) turned out to be positive for H. pylori and only four cases (8%) were negative for this infection. Postoperatively, patients who were found to be positive for H. pylori were put on anti-H. pylori treatment. Conclusion: there was a high prevalence of H. pylori infection in patients with perforated gastroduodenal ulcers.

Natural orifice transluminal endoscopic surgery for intra-abdominal emergency conditions

Patient benefits from natural orifice transluminal endoscopic surgery (NOTES) are of interest in acute-care surgery. This review provides an overview of the historical development of NOTES procedures, and addresses their current uses and limitations for intra-abdominal emergency conditions. A PubMed search was carried out for articles describing NOTES approaches for appendicectomy, percutaneous gastrostomy, hollow viscus perforation and pancreatic necrosectomy. Pertinent articles were reviewed and data on available outcomes synthesized. Emergency conditions in surgery tax the patient's cardiovascular and respiratory systems, and fluid and electrolyte balance. The operative intervention itself leads to an inflammatory response and blood loss, thus adding to the physiological stress. NOTES provides a minimally invasive alternative access to the peritoneal cavity, avoiding abdominal wall incisions. A clear advantage to the patient is evident with the implementation of an endoscopic approach to deal with inadvertently displaced percutaneous endoscopic gastrostomy tubes and perforated gastroduodenal ulcer. The NOTES approach appears less invasive for patients with infected pancreatic necrosis, in whom it allows surgical debridement and avoidance of open necrosectomy. Transvaginal appendicectomy is the second most frequently performed NOTES procedure after cholecystectomy. The NOTES concept has provided a change in perspective for intramural and transmural endoscopic approaches to iatrogenic perforations during endoscopy. NOTES approaches have been implemented in clinical practice over the past decade. Selected techniques offer reduced invasiveness for patients with intra-abdominal emergencies, and may improve outcomes. Steady future development and adoption of NOTES are likely to follow as technology improves and surgeons become comfortable with the approaches.

Laparoscopic versus open repair of perforated gastroduodenal ulcer: a National Surgical Quality Improvement Program analysis

BackgroundSurgical repair of perforated gastroduodenal ulcers remains a common indication for emergent surgery. The aim of this study was to test the hypothesis that the laparoscopic approach (LA) would be associated with reduced length of stay compared to the open approach. MethodsPatients with acute, perforated gastroduodenal ulcer were identified in the National Surgical Quality Improvement Program database, of whom 50 had the LA. One-to-one case/control matching on the basis of age, American Society of Anesthesiologists class, gender, and cardiac disease was evaluated for outcome analysis. ResultsAfter matching, the 2 groups had similar characteristics. The rates of wound complications, organ space infections, prolonged ventilation, postoperative sepsis, return to the operating room, and mortality tended to be lower for the LA, although not significantly. Length of hospital stay was, however, significantly shorter for the LA by an average of 5.4 days. ConclusionsThe LA appears to be safe in mild to moderately ill patients with perforated peptic ulcer disease and is associated with reduced use of hospital resources.

Therapeutic management of perforated gastro-duodenal ulcer: Literature review

Management of perforated gastro-duodenal ulcer (GDU) is not consensual, from no operative treatment to surgery by simple closure, gastrectomy and vagotomy. The purpose of this study is to report results of the literature concerning management of perforated GDU. Two authors, identified in the databases Pubmed and Embase studies, related to the therapeutic management of perforated GDU. The data were extracted from articles published between 1940 and 2012. Non-operative treatment is feasible for patients in good general condition and in good local circumstances without evolved peritonitis with a success rate more than 50%. Simple closure is the standard method. Laparoscopy is a safe and feasible method for patient with delay of treatment less than 24 hours and without associated complications with a success (meaning non conversion) of 80% and a mortality less than 1%. Rate of conversion is 7.9%, and increases in case of ulcer size >6 mm, frail ulcer edges, bleeding associated, unusual location and septic shock. Helicobacter pylori eradication is essential. Gastric tube, abdominal irrigation and drainage are still debated. Two-stage treatment for perforated gastric carcinoma, which represents 10 to 16% of gastric perforation, is a good option for frail patients with resectable tumors. Management of perforated GDU is still a subject of debate without guidelines but with several possibilities of treatment depending of local circumstances of peritonitis and size of defect >20 mm, general conditions, surgeon patterns and experience.

Comparison of clinical effect of perforated gastroduodenal ulcer treatment by laparoscopy and traditional open repair

Objective To compare the clinical effects of perforated gastroduodenal ulcer treatment by laparoscopy and traditional open repair.Methods 70 cases of patients with perforated diagnosed as gastroduodenal ulcer were selected and divided into laparoscopic group and open group by different operation type.Laparoscopy was used in laparoscopic group,while traditional open repair was used in open group.The mean time in operation,intraoperative blood loss and intraoperative and peostoperative complications were observed and recorded.Results There was no difference in operative mean time between the two groups(P ＞ 0.05),but intraoperative blood loss was less in laparoscopic group than that in open group (P ＜ 0.05),exhaust time and hospitalization time in laparoscopic group were shorter than that in open group(P ＜ 0.05),and no complication was found in laparoscopic group(0.00％),while 10 cases in open group(22.73％),the rate in the former group was lower than that in the latter group(P ＜0.05).Conclusion Using laparoscopy to repair perforated gastroduodenal ulcer had little trauma,less pain,less complication,shorter recover time and safe.It is worthy of clinical. Key words: Peptic ulcer perforation; Laparoscopy; Digestive system surgical procedures

Feasibility of NOTES omental plug repair of perforated peptic ulcers: results from a clinical pilot trial

Ulcer perforation carries up to a 30 % 1-year mortality rate. Intervention-related adverse events are among statistically significant predictors of 1-year mortality. A natural orifice transluminal endoscopic surgical (NOTES) approach may be less invasive and may decrease procedure-related adverse events by diminishing the so-called second hit, thus leading to decreased morbidity and mortality. We sought to assess the feasibility of an endoscopic transluminal omental plug technique in patients with perforated gastroduodenal ulcers under laparoscopic guidance. Patients with suspected acute gastroduodenal ulcer perforations were offered participation in this prospective pilot study. Closure of the perforation was attempted using the NOTES omental plug technique. Demographic, clinical, endoscopic, and radiographic data were abstracted, as were data for morbidity, mortality, and pilot data regarding quality of life (QOL). From February 2010 through February 2012, a total of 17 patients presented to a tertiary care center with clinically suspected perforated ulcer. Of seven patients (mean age 79 years, range 64-89 years) who consented to the study, three underwent the study procedure. All patients had multiple comorbidities. Two patients presented with 4-6 mm perforated peptic ulcers and underwent successful laparoscopic-assisted NOTES omental and falciform ligament patch closure, respectively. Postoperative radiographic contrast studies showed no leak, and patients were discharged home on postoperative days 3 and 4. The third patient had undergone enterocutaneous fistula repair with herniorrhaphy 6 weeks before. Although a transluminal endoscopic approach was feasible, the omentum was under too much tension to be secured. This procedure was converted to an open omental patch repair. For all but one patient who provided consent, obtaining QOL data was feasible. Initial results from a laparoscopic-assisted NOTES approach for closure of perforated peptic ulcers appear promising and enable swift recovery in selected patients. This is especially important in elderly and/or immunocompromised patients. Technical details and patient selection criteria continue to evolve.

Eradication of Helicobacter pylori for prevention of ulcer recurrence after simple closure of perforated peptic ulcer: A meta-analysis of randomized controlled trials

BackgroundEradication of Helicobacter pylori has become part of the standard therapy for peptic ulcer. However, the role of H pylori eradication in perforation of peptic ulcers remains controversial. It is unclear whether eradication of the bacterium confers prolonged ulcer remission after simple repair of perforated peptic ulcer. MethodsA systematic review and meta-analysis of randomized controlled trials was performed to evaluate the effects of H pylori eradication on prevention of ulcer recurrence after simple closure of perforated peptic ulcers. The primary outcome to evaluate these effects was the incidence of postoperative ulcers; the secondary outcome was the rate of H pylori elimination. ResultsThe meta-analysis included five randomized controlled trials and 401 patients. A high prevalence of H pylori infection occurred in patients with perforated peptic ulcers. Eradication of H pylori significantly reduced the incidence of ulcer recurrence at 8 wk (risk ratio 2.97; 95% confidence interval: 1.06–8.29) and 1 y (risk ratio 1.49; 95% confidence interval: 1.10–2.03) postoperation. The rate of H pylori eradication was significantly higher in the treatment group than in the nontreatment group. ConclusionsEradication therapy should be provided to patients with H pylori infection after simple closure of perforated gastroduodenal ulcers.

Postoperative abdominal complications after cardiopulmonary bypass

BackgroundTo summarize the diagnostic and therapeutic experiences on the patients who suffered abdominal complications after cardiovascular surgery with cardiopulmonary bypass(CPB).MethodsA total of 2349 consecutive patients submitted to cardiovascular surgery with CPB in our hospital from Jan 2004 to Dec 2010 were involved. The clinical data of any abdominal complication, including its incidence, characters, relative risks, diagnostic measures, medical or surgical management and mortality, was retrospectively analyzed.ResultsOf all the patients, 33(1.4%) developed abdominal complications postoperatively, including 11(33.3%) cases of paralytic ileus, 9(27.3%) of gastrointestinal haemorrhage, 2(6.1%) of gastroduodenal ulcer perforation, 2(6.1%) of acute calculus cholecystitis, 3(9.1%) of acute acalculus cholecystitis, 4(12.1%) of hepatic dysfunction and 2(6.1%) of ischemia bowel diseases. Of the 33 patients, 26 (78.8%) accepted medical treatment and 7 (21.2%) underwent subsequent surgical intervention. There were 5(15.2%) deaths in this series, which was significantly higher than the overall mortality (2.7%). Positive history of peptic ulcer, advanced ages, bad heart function, preoperative IABP support, prolonged CPB time, low cardiac output and prolonged mechanical ventilation are the risk factors of abdominal complications.ConclusionsAbdominal complications after cardiovascular surgery with CPB have a low incidence but a higher mortality. Early detection and prompt appropriate intervention are essential for the outcome of the patients.

Les péritonites par perforation d’ulcère gastroduodénal chez l’enfant : à propos de 4 observations

Peritonitis due to gastroduodenal ulcer perforation disease is a rare entity in pediatric surgery. In Senegal, no study has been dedicated to ulcer complications in children. The aim of this study was to describe the epidemiology, diagnosis, and treatment of perforated peptic ulcer in patients less than 15 years old. This retrospective study was conducted in the Surgical Emergencies and Paediatric Surgery Department at Aristide Le Dantec University Hospital Center in Dakar, Senegal, during a period of 11 years (January 1999 to December 2010). We found 4 children who presented perforated gastroduodenal ulcer: 3 females and 1 male. The average age of these patients was 9 years (range, 7-14 years). No family history was found. We noted 3 cases of perforated duodenal ulcer and one perforated gastric ulcer. The clinical diagnosis was suspected based on a peritoneal irritation syndrome. A plain x-ray of the abdomen was taken in all patients, which objectified a pneumoperitoneum image in 3 cases. The leukocytosis was constant. Treatment in all patients consisted on pre-, intra-, and postoperative intensive care, supra- and infraumbilical midline laparotomy, which allowed us to perform a debridement-suture of the gap followed by epiploplasty and extensive washing with lukewarm physiologic serum. Adjuvant therapy based on anti-ulcer and antibiotic therapy was initiated. Bacteriological examination of peritoneal fluid isolated a polymicrobial flora. Helicobacter pylori was not isolated. Histological examination of the biopsied perforation edges showed a benign ulcer in all cases. The follow-up endoscopy was performed 4 weeks after surgery and showed cicatrization of the ulcer in all patients. After a mean of 2 years, no recurrence was noted. The gastric or duodenal ulcer in children is rare. It is often discovered at the stage of perforation, a complication for which the essential treatment is surgery. Routine screening would certainly help to reduce the risk of this complication.

Laparoscopic neoplasty for perforation of gastro-duodenal ulcer

Objective To explore the clinical efficacy of laparoscopic neoplasty for perforation of gastro-duodenal ulcer.Methods 98 patients with perforation of gastro-duodenal ulcer were randomly divided into control group and observation group,49 for each group.The control group were treated with conventional laparotomy,while the observation group were treated with laparoscopic neoplasty.The efficacies in both groups were compared.Results The operation time,bleeding volume after surgery,usage of pain killer,time to anus exhaustion after surgery,the first-bowel-movement time,hospitalization time,complications after surgery of the observation group statistically differed from that of the control group(P＜ 0.05).Conclusions Laparoscopic neoplasty for perforation of gastro-duodenal ulcer is easy to handle and command,wounds the patients and disturbs the viscera less,shortens operation time,has less ache,speeds the patients'recovery,and has fewer complications.it is a safe,dependable,effective,and ideal therapeutic method. Key words: Gastro-duodenal ulcer; Perforation; Laparoscope; Celiotomy

Análise epidemiológica e emprego do teste rápido da urease em pacientes com úlcera péptica perfurada

To analyze the epidemiological profile of patients with gastroduodenal ulcer perforation and verify if the presence of H. pylori in the peritoneal and intraluminal secretions of these patients can be assessed by rapid urease test. We conducted a prospective, descriptive, cross-sectional study with data from patients in a hospital at a regional level, in patients with peptic ulcer. During surgery, we collected peritoneal fluid samples (in the vicinity of the perforation) and intraluminal secretion, sending them for culture and rapid urease test. Fourteen patients were analyzed. The average age was 41.06 years, all men, Whites (71.4%), smokers (57.2%), BMI <30 (85.7%), with a history of dyspepsia (78.6%). Serology for H. pylori was positive in 84.6% of cases. The rapid urease test was positive in 78.6% of the samples of the digestive tract and 42.8% of samples from the peritoneal cavity; 41.6% were positive at both sites, 50% only in the digestive cavity and 8.4% only in the peritoneal cavity. Of the 11 patients with positive serology for H. pylori, 100% were positive in at least one of the sites surveyed. It was found that the incidence was lower than expected. There is significant association between infection with H. pylori and the occurrence of perforation. The presence of this pathogen can be assessed both by serology and by the realization of the rapid urease test from fluid collected in the peritoneal cavity and the gastric / duodenal lumen.

Percutaneous drainage in conservative therapy for perforated gastroduodenal ulcers.

The management of peptic ulcers has dramatically changed and the incidence of elective surgery for gastroduodenal peptic ulcers has markedly decreased; hence, the incidence of emergency surgery for perforated peptic ulcers has slightly increased. In select cases, conservative therapy can be used as an alternative for treating perforated gastroduodenal ulcers. In this study, we evaluated the efficacy of percutaneous abdominal drainage for the conservative treatment of perforated gastroduodenal ulcers. We retrospectively studied 51 patients who had undergone conservative therapy for perforated gastroduodenal ulcers. These patients were divided into 2 groups on the basis of the initial treatment with conservative therapy with or without percutaneous drainage: group PD included patients who had undergone percutaneous drainage and group NPD, patients who had undergone non-percutaneous drainage. In the PD group, 14.3% (n=3) of the patients did not respond to conservative therapy, while this value was 43.3% (n=13) in the NPD group. The 2 groups differed significantly with respect to conversion from conservative therapy to surgery (p<0.0352). Conservative therapy for perforated gastroduodenal ulcers should be performed only in the case of patients meeting the required criteria; its combination with percutaneous intraperitoneal drainage is effective as initial conservative therapy.

Results of Surgery for Perforated Gastroduodenal Ulcers in a Dutch Population

Objective: Despite improvements in anesthesiology and intensive care medicine, mortality for perforated gastroduodenal ulcer disease remains high. This study was designed to evaluate the results of surgery for perforated ulcer disease and to identify prognostic factors for mortality in order to optimize treatment. Patients and Methods: The medical records of 272 patients undergoing emergency surgery for perforated ulcer disease from 2000 to 2005 in two large teaching hospitals and one university hospital in the Netherlands were retrospectively analyzed. Information on 89 pre-, peri- and postoperative data were recorded. Statistical analysis was performed using multiple logistic regression analysis. The primary endpoint was 30-day mortality. Results: The 30-day mortality rate was 16%. Variables associated with 30-day mortality were age, shock, tachycardia, anemia and ASA class. Conclusions: A relatively low 30-day mortality rate was achieved. Age, shock, tachycardia and anemia were significantly associated with 30-day mortality. Finding that shock, tachycardia and anemia are independently associated with 30-day mortality could indicate that patients are septic upon admission. Improvements in survival might be achieved by early sepsis treatment.

Early severe digestive complications after lung transplantation

This study aimed to describe and to analyze early severe digestive complications (ESDC) after lung transplantation (LT) in our center. A retrospective study included 351 patients, who underwent LT without cardiopulmonary bypass (CPB) at our center between March 1988 and December 2009. There were 86 double LTs and 265 single LTs. ESDCs were defined as complications (1) occurring during the first 30 days after transplantation or during initial hospitalization if longer; (2) involving the gastrointestinal tract; and (3) jeopardizing survival or requiring invasive therapeutic procedure. Patients' characteristics, associated risk factors, and influence of ESDC on early outcome have been analyzed. During the first 30 days after LT or initial hospitalization if longer, 26 ESDCs occurred in 26 patients (rate 7.4%, sex ratio M/F 66%, mean age 56 ± 6 years). This included 10 acute cholecystitis (38%), four angiocholitis (15%), three perforated gastroduodenal ulcers (11%), three digestive perforations (11%), two intestinal occlusions (8%), two mesenteric ischemia (8%), and two acute pancreatitis (8%). ESDC occurred after a mean postoperative follow-up of 14 days (5-46), required emergency surgical treatment in 20 cases (77%), significantly prolonged the mean duration of hospitalization (96 days with ESDC vs 55 days without ESDC, p < 0.0001), and was responsible for death in five cases (19%). Surgical treatment included cholecystectomy (n = 11), bowel resection (n = 3), ulcer surgery (n = 2), subtotal colectomy (n = 2), Hartmann procedure (n = 1), and open coelioscopy (n = 1). Age and bilateral LT were found to be significant risk factors for ESDC in both uni- and multivariate analyses. ESDC occurred in 7.4% of patients after LT without CPB, and was responsible for longer in-hospital stay. Relevant risk factors included older age and bilateral LT, interfering with current debate regarding recipients' selection and procedure's choice.

The long-term results of radical organpreserving operations compared with resection of the stomach and suturing in elderly patients with complicated gastroduodenal ulcer

Long-term results show a significant superiority of radical organpreserving operations compared with suturing and stomach resection in elderly patients with perforated gastroduodenal ulcer. Quality of life after radical operations in patients older 60 years is remaining high. The long-term syndromes specific to the patients condition after resection or suturing present in minimal percents of cases.

Perforated ulcer in the elderly – is there a generic operation?

Comment on the article J. S. winnik et al.: "Long-term results of radical breast conserving surgery in treatment of perforated gastroduodenal ulcers in patients of elderly and senile age"

Reappraising the Surgical Approach on the Perforated Gastroduodenal Ulcer: Should Gastric Resection Be Abandoned?

BackgroundAdvancements in medical care for peptic ulcer disease (PUD) have reduced the need for invasive surgical procedures such as gastric resection (GR). Community-based PUD studies from a large sampling of PUD patients designed to analyze hospital resource use and outcomes after different surgical procedures have been rare. We aimed to exhaustively reappraise the risk factors and patient demographics that affect PUD patient recoveries after GR compared to those after simple closure (SC).MethodsWe used a Japanese administrative database for 6 consecutive months each year between 2006 and 2010. The database included a total of 68,432 PUD patients; we analyzed 6,334 perforation cases and 3,148 cases of patients who underwent GR or SC. Study variables were demographics, comorbidities, characteristics of PUD, and operative day. Study outcomes that were analyzed included mortality, postoperative complications, ventilation administration, postoperative blood transfusions, length of stay, total charges, operating room (OR) time, and the postoperative fasting period (defined as the day of surgery to the day oral food intake was resumed.) To reduce selection bias in study procedures and to control the variation in hospital practice, a propensity score (PS) matching cohort analysis and a mixed linear regression model were used to assess the effects of GR on the outcomes.ResultsIn 699 hospitals, 322 GRs and 2,826 SCs were observed. Younger age, duodenal ulcers, preexisting anemia and an operative day no more than 24hours were significant associated with the choice of SCs. No significant differences were observed in study outcomes after either GR or SC; more postoperative blood transfusions and longer OR times but shorter postoperative fasting periods were observed after GR. Longer OR times, ventilation and postoperative blood transfusion were significantly associated with mortality. Not GR but longer OR times use of ventilation and complications were the most significant indicators of increased resource use.ConclusionsThere were no major significant differences in GR when compared to SC with regards to patient recoveries. Surgeons should obtain the skills and establish strategies to optimize either type of surgical procedure including minimizing OR time and establishing the best perioperative critical care.KeywordsPeptic ulcer perforation; Simple closure; Gastric resection; Outcome; Resource use