Surgery For Perforated Peptic Ulcer Research Articles

Global 30-day morbidity and mortality of surgery for perforated peptic ulcer: GRACE study.

There is little international data on morbidity and mortality of surgery for perforated peptic ulcer (PPU). This study aimed to understand the global 30-day morbidity and mortality of patients undergoing surgery for PPU and to identify variables associated with these. We performed an international study of adults (≥ 18years) who underwent surgery for PPU from 1st January 2022 to 30th June 2022. Patients who were treated conservatively or had an underlying gastric cancer were excluded. Patients were divided into subgroups according to age (≤ 50 and > 50years) and time from onset of symptoms to hospital presentation (≤ 24 and > 24h). Univariate and Multivariate analyses were carried out to identify factors associated with higher 30-day morbidity and mortality. 1874 patients from 159 centres across 52 countries were included. 78.3% (n = 1467) of the patients were males and the median (IQR) age was 49years (25). Thirty-day morbidity and mortality were 48.5% (n = 910) and 9.3% (n = 174) respectively. Median (IQR) hospital stay was 7 (5) days. Open surgery was performed in 80% (n = 1505) of the cohort. Age > 50years [(OR = 1.7, 95% CI 1.4-2), (OR = 4.7, 95% CI 3.1-7.6)], female gender [(OR = 1.8, 95% CI 1.4-2.3), (OR = 1.9, 95% CI 1.3-2.9)], shock on admission [(OR = 2.1, 95% CI 1.7-2.7), (OR = 4.8, 95% CI 3.2-7.1)], and acute kidney injury [(OR = 2.5, 95% CI 1.9-3.2), (OR = 3.9), 95% CI 2.7-5.6)] were associated with both 30-day morbidity and mortality. Delayed presentation was associated with 30-day morbidity [OR = 1.3, 95% CI 1.1-1.6], but not mortality. This study showed that surgery for PPU was associated with high 30-day morbidity and mortality rate. Age, female gender, and signs of shock at presentation were associated with both 30-day morbidity and mortality.

Fast-track recovery after surgery for perforated peptic ulcer safely shortens hospital stay: A systematic review and meta-analysis of six randomized controlled trials and 356 patients.

Postoperative management after surgery for perforated peptic ulcer is still burdened by old traditions. All available data for fast-track recovery in this setting are either very unspecific or underpowered. The aim of this study was to evaluate fast-track recovery in this diagnosis-specific context in a larger sample. Electronic data sources were searched. Eligible studies were randomized controlled trials (RCTs) comparing fast-track recovery and traditional management after surgery for perforated peptic ulcer in adults. A systematic review and meta-analysis was performed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines regulated the process. Quality and risk of bias assessments of individual RCTs were performed by means of the Let Evidence Guide Every New Decision criteria and the Cochrane risk-of-bias tool. Primary endpoints were length of hospital stay and risk of complications. Random or fixed effects modeling were applied as indicated. Outcomes were measured by mean difference and risk difference. Six RCTs with a total cohort of 356 patients were included. Results of our meta-analysis showed significantly shortened length of hospital stay (mean difference -3.50days [95% CI -4.51 to -2.49], p≤0.00001), significantly less superficial and deep surgical-site infections (risk differences -0.12 [95% CI -0.20, -0.05], p=0.002 and -0.03 [95% CI -0.09, 0.03], and p=0.032, respectively), and significantly fewer pulmonary complications (risk difference -0.10 [95% CI -0.17, -0.03], p=0.004) in the fast-track group. This systematic review and meta-analysis shows that fast-track recovery after surgery for perforated peptic ulcer significantly shortened hospital stay in the studied cohort without increasing the risk of postoperative complications.

A O05 Global 30-day morbidity and mortality of surgery for perforated peptic ulcer – GRACE study

Abstract Background Perforated peptic ulcer (PPU) is a surgical emergency with a mortality rate of 16-30% and a morbidity rate of 20-50%. All studies reporting on the outcome of surgery for PPU are either local or national. Most of these are based on small cohort sizes. A few larger studies have been reported, but still limited to a single nation, accounting for the wide variations in the literature. There is a lack of global, multicenter data on this topic. We aimed to assess the global 30-day morbidity and mortality of surgery for PPU and the factors influencing it. Methods We conducted a global observational cohort study of patients who underwent surgery for PPU between 01/01/2022 and 30/06/2022. Adults (≥18 years) who underwent surgery for PPU and those who had a PPU in a bypassed stomach after bariatric surgery were included. We excluded patients with underlying gastric cancer, and those treated conservatively. Patients were divided into subgroups to study the influence of some variables. These were age (≤50 and >50 years), time from onset of symptoms to hospital presentation (≤24 and >24 hours), and surgical technique (open, laparoscopic, and laparoscopic converted to open). Results This is the first global study on this topic and included 1864 patients from 162 centers across 52 countries. Mean age was 49.7 ± 17 years, and males represented 78.3%. The mean hospital stay was 10 ± 9.2 days and the 30-day reoperation rate was 5.4%. The 30-day morbidity rate was 48.5% and mortality rate was 9.3%. On multivariate analysis, age >50 years, presentation >24 hours, female gender, shock on admission, and acute kidney injury were significantly associated with 30-day morbidity. 30-day mortality was significantly associated with age >50 years, female gender, acute kidney injury, and shock on admission. Conclusions Surgery for PPU carries high 30-day morbidity and mortality globally. Age > 50 years old, female gender, acute kidney injury, and signs of shock upon admission are independent factors that can increase the likelihood of 30-day mortality. Laparoscopic surgery appears to be underutilized despite lower morbidity and mortality rates.

Appendix 1: AO05 Global 30-day morbidity and mortality of surgery for perforated peptic ulcer – GRACE study

Appendix 1: AO05 Global 30-day morbidity and mortality of surgery for perforated peptic ulcer – GRACE study

Dispensability of nasogastric tube after perforated peptic ulcer surgery: a randomized controlled trial

Introduction Every year, approximately 4 million individuals are affected by peptic ulcer disease (PUD). Among patients with PUD, the lifetime occurrence of perforation stands at ∼5%. Associated with this complication is a mortality rate spanning from 1.3 to 30%. Whether the surgery was done open or laparoscopic, the postoperative plan of management remained dogmatic for many years, especially regarding the presence of a nasogastric (NG) tube. Patients and methods This prospective, single-center, randomized controlled study of patients with perforated peptic ulcer (PPU) presented to Kasr Alainy Emergency Hospital was conducted to assess the dispensability of NG tube postoperatively in perforated peptic ulcer patients. Patients were randomly allocated into two groups, group A (NG tube control group): 40 patients and group B [Enhanced Recovery after Surgery (ERAS) group]: 34 patients. Results The study revealed a significant decrease in hospital stay by approximately 2 days for patients in the ERAS group, compared with those receiving standard care. This reduction in hospital stay was observed without any increase in postoperative complications among the ERAS group. However, this may be clinically nonsignificant due to a limited number of patients in our study. Conclusion The routine use of NG decompression and delayed oral feeding appears to be unnecessary. These practices contribute to prolonged hospital stays without yielding any beneficial effects on morbidity and mortality rates.

Correlation of serum albumin level on postoperative day 2 with hospital length of stay in patients undergoing emergency surgery for perforated peptic ulcer.

Perforated peptic ulcer (PPU) is a common emergency surgical condition and a significant cause of morbidity and mortality worldwide. While advances in surgical techniques have improved outcomes for patients with PPU, many factors still affect postoperative hospital stay and overall prognosis. One potential factor is the serum albumin (SA) level, a widely utilized marker of nutritional status that has been associated with length of stay and complications in various surgical procedures. To clarify the correlation of SA level on postoperative day 2 with hospital length of stay (HLOS) in patients undergoing emergency surgery for perforated peptic ulcer (PPU). We retrospectively collected and analyzed clinical baseline data, including blood routine and SA levels, of patients who underwent emergency PPU surgery and postoperative treatment at the Lingnan Hospital, the Third Affiliated Hospital of Sun Yat-sen University between December 2012 and September 2021. Patients were grouped according to HLOS with 7 d as the cut-off value, and relevant indicators were analyzed using SPSS 26.0. Of the 37 patients undergoing emergency surgery for PPU referred to our department, 33 had gastric and 4 had duodenal ulcer perforation. The median HLOS was 10 d. There were 8 patients in the ≤ 7-d group (median HLOS: 7 d) and 29 patients in the > 7-d group (median HLOS: 10 d). The ≤ 7-d group had markedly higher SA on postoperative day 2 than the > 7-d group (37.7 g/L vs 32.6g/L; P < 0.05). The SA level on postoperative day 2 was a protective factor for patients with HLOS > 7 d (Odds ratio = 0.629, P = 0.015). The cut-off of SA on postoperative day 2 was 30.6g/L, with an area under the curve of 0.86 and a negative predictive value of 100% for the prediction of HLOS ≤ 7 d. The SA level on postoperative day 2 was associated with the HLOS in patients undergoing emergency surgery for PPU. The pre- and post-operative albumin levels should be monitored, and infusion of human SA should be considered in a timely manner.

Outcome of Laparoscopic Repair for Perforated Peptic Ulcers in a Resource-Limited Setting.

BackgroundPerforation of peptic ulcers is a common cause of emergency surgery and has significant morbidity and mortality. The use and range of laparoscopic surgery have greatly increased over the past three decades. Laparoscopic approach is an option for perforated peptic ulcers because of the simple nature of the intervention. The aim of this study was to evaluate the outcome of laparoscopic approach for peptic ulcer repair in emergency setting by means of operative time, post-operative pain, mean hospital stay, and post-operative complications.MethodsIn this study, we enrolled patients presenting with perforated peptic ulcers in the emergency department of a tertiary care hospital in Lahore, Pakistan. Approval from the hospital ethical committee and informed consent were taken from all patients. After resuscitation, the patient underwent laparoscopic repair of perforation. Post-operative course of patients was monitored. Duration of surgery, post-operative pain, length of hospital stay, and post-operative complications were noted for all patients.ResultsBetween December 2018 and December 2021, 31 patients with perforated peptic ulcers underwent laparoscopic repair at our hospital. Mean age of patients was 37.25 ± 7.80 years. Most of the patients were male (70.76%). The mean operation time was 109.35 ± 17.02 minutes for laparoscopic repair. Mean duration of hospital stay was 5.10 ± 0.87 days. Mean post-operative pain was 3.55 ± 0.85 assessed using the Visual Analogue Scale. There were no mortalities during the 30-day post-operative window.ConclusionWith proper patient selection, laparoscopic surgery offers better results as compared to open surgery in patients undergoing emergency surgery for perforated peptic ulcers.

Perioperative clinical management in relation to emergency surgery for perforated peptic ulcer: A nationwide questionnaire survey.

Perforation is a severe complication of peptic ulcer disease. Evidence regarding perioperative management of patients undergoing surgery for perforated peptic ulcer is scarce without any clear guidelines. This study aimed to investigate the clinical practice and possible differences in the perioperative management of patients undergoing emergency surgery for perforated peptic ulcers in Denmark. The study was an anonymous, nationwide questionnaire survey. All doctors working at general surgical departments in Denmark were included. The questionnaire consisted of four parts; 1) demographic details including job position, subspecialty, geographic location, and surgical experience, 2) pre- and postoperative use of nasoenteral tubes, 3) routine use of nil-by-mouth (NBM) regime, 4) questions regarding postoperative nutrition.Subgroup analyses were performed according to job position and subspecialty. In total, the questionnaire was answered by 287 surgeons, of which 74% were experienced surgeons being able to perform surgery for perforated peptic ulcers independently.Pre- and postoperative nasoenteral tubes were used routinely by the majority of the respondents. One of five surgeons routinely practiced a postoperative NBM regime. Generally, the respondents allowed clear fluids postoperatively without restrictions but were reluctant to allow free fluids or solid foods. Two of three surgeons routinely used tube- or parental nutrition. The results varied depending on job position and subspecialty. After emergency surgery, the postoperative management of patients with perforated peptic ulcers varies considerably among general surgeons in Denmark. Evidence-based national or international guidelines are needed to standardize and optimize the clinical practice.

Profiles and Clinical Outcomes of Perforated Peptic Ulcer with Boey Score 3 Treated with External Drainage in Indonesia

The treatment of peptic ulcers has changed substantially, and the rate of elective surgery for gastroduodenal peptic ulcers has fallen significantly; as a result, the rate of emergency surgery for perforated peptic ulcers has slightly increased. The Boey score is one of the most widely used prognostic scoring systems for predicting death in peptic ulcer perforation patients. The Boey scoring system has a positive connection with mortality risk. Patients with Boey Score 3 are patients who meet the high-risk criteria and have high morbidity and mortality rates. Conservative therapy can be utilized as an alternative to surgery in some cases with perforated gastroduodenal ulcers. In this study, we presented a clinical case of perforated peptic ulcer patient with Boey score 3 treated with external drainage for the conservative treatment.

Enhanced Recovery after Surgery (ERAS) Versus Standard Care in Patients Undergoing Emergency Surgery for Perforated Peptic Ulcer

Enhanced recovery after surgery (ERAS) pathways are widely used in elective surgical procedures. The objective of this study was to evaluate the feasibility and efficacy of ERAS pathways in patients undergoing emergency surgery for perforated peptic ulcer (PPU). The single-centre prospective study was conducted in patients with PPU undergoing emergency open simple closure with Graham’s patch technique were randomized into 42 patients in ERAS group and 43 patients in standard care group in the ratio 1:1. Patients with refractory shock, ASA ≥ 3 and multiple perforation and size > 1 cm were excluded. The outcomes were studied with length of hospitalization (LOH), functional recovery parameters and postoperative morbidity. LOH in ERAS group was significantly shorter (mean difference of 5.31 ± 1.102 days; p < 0.001). Patients in ERAS group had a significantly early functional recovery (days) for the time to first fluid diet (1.904 ± 0.72; p < 0.001), and first semi-solid diet (3.1 ± 0.48; p < 0.001), first stool (3.81 ± 0.76; p < 0.001) and removal of drain (2.19 ± 0.39: p < 0.001). There was a significant reduction in postoperative morbidity rate in ERAS group compared with standard care group. The application of enhanced recovery pathways in patients with perforated peptic ulcer undergoing emergency surgery is safe and feasible.

Laparoscopic surgery for perforated peptic ulcer: an English national population-based cohort study.

Randomized controlled trials have shown that laparoscopic approach to surgery for perforated peptic ulcer (PPU) is associated with improved short-term outcomes; however, there is limited evidence concerning national practice. The aim of this investigation was to evaluate the effect of laparoscopic approach to PPU surgery upon mortality and morbidity in England. Patients with a primary diagnosis of PPU, admitted as an emergency to a hospital in England, and receiving surgical intervention, between 2005 and 2012 were identified from the Hospital Episode Statistics database. Outcomes analyzed included 30-day and 90-day mortality, 30-day complications, and length of hospital stay. Univariate and multivariate analyses were used to identify patient, hospital, and treatment-related factors associated with use of laparoscopy and mortality. The study included 13,022 patients who underwent emergency surgery for PPU in England over an 8-year period. From 2005 to 2012, the utilization of laparoscopic surgery for PPU increased from 0 to 13% and was more commonly used in high volume emergency centers. Laparoscopic surgery was associated with significant reductions in 30-day (7% vs. 15.7%; P < 0.001) and 90-day mortality (8.9% vs. 19.6%; P < 0.001), pneumonia (6% vs. 10.1%; P < 0.001), ischemic cardiac events (1% vs. 2.4%; P = 0.007), as well as length of hospital stay (median 5 vs. 7 days; P < 0.001). Factors associated with a reduced utilization of laparoscopic surgery included age ≥ 70years (Odds ratio (OR) = 0.58 (95% CI) 0.49-0.68) and Charlson Comorbidity Index score ≥ 2 (OR = 0.73; 95% CI 0.57-0.94). The rate of laparoscopic repair of PPU is increasing at a national level and more common in high volume emergency centers. It is associated with reduced rates of mortality; pneumonia and shorter length of hospital stay, highlighting the need for strategies to improve dissemination of laparoscopic techniques necessary for PPU repair.

The outcome of surgery for perforated peptic ulcer in modern times

Background: A laparotomy for peritonitis due to perforated peptic ulcer is one of the commonest emergency operations done by a general surgeon and is still associated with a marked mortality and morbidity. The aim was to assess the current mortality and morbidity in patients operated for perforated peptic ulcer and to identify the factors associated with increased mortality in these patients.Methods: All adult patients operated for perforated peptic ulcer over a period of one year were included in this prospective observational study. The demographics, clinical presentation, pre-operative laboratory parameters, operative findings, operation done, and the outcomes were noted in pre-designed proforma. Mortality and morbidity was assessed and factors relating to increased mortality were determined using standard statistical tests of significance such as Chi square test and the student’s t test.Results: 55 patients underwent laparotomy for perforated peptic ulcer (23 gastric and 32 duodenal perforations). There were 53 males and only 2 females in the group. Their mean age was 44 years. The mortality was 16% (9/55) and morbidity was 25% (14/55). Complications were encountered in 14 patients, most commonly surgical site infection in 13% cases, entero-cutaneous fistula occurred in 3 patients and one of them expired despite re-exploration due to persistent sepsis. The other two patients survived, and fistula healed spontaneously. The operative procedure done was Graham’s patch or it’s modification. Only 2 patients had antrectomy with Billroth II reconstruction.Conclusions: Despite the advances in management of critically ill patients, the mortality (16%) and morbidity (25%) for this common surgical emergency remains high and is unchanged over the last half century. Presence of comorbidities and low serum albumin are associated with an increased risk of adverse outcome.

The results of perforated peptic ulcer surgery; a single center experience of 86 patients

Objective: At the present time, eradication of the helicobacter pylori infection is dramatically reduced the risk of the peptic ulcer disease. Whereas, complication rate of the peptic ulcer, such as perforations or bleedings have not reduced significantly yet. The aim of the current study is to analysis the surgical treatment outcomes of our experience in 86 patients with peptic ulcer perforation. Material and methods: Between January 2012 and December 2017, 86 patients who were operated emergently for perforated peptic ulcer disease with GrahamÂ’s omental patch procedure in our hospital were included in this study. Demographic, clinical data, diagnostic studies, surgical procedures, operative findings, postoperative complications and patient follow-up were analyzed. Results: The mean age was (41.57±16.09) years. Out of 86 cases there were 65 (75.6%) male patients and 21 (24.4%) female patients. The mean operation time was 66.98±18.61 minutes. The mean hospital stay period was 7.95±2.02. In three months follow- up period, endoscopy was done to all of these patients and peptic ulcer disease was not seen in any of them. Conclusion: Our findings revealed that GrahamÂ’s omental patch repair is still a useful method for perforated peptic ulcer disease. Low complication rates, low duration of hospital stay and also low postoperative morbidity can be achieved with good preoperative and postoperative supportive care in open surgery for peptic ulcer perforation. Laparoscopic surgery should be performed only in the presence of experienced surgeon and also in the presence of sufficient laparoscopic materials.

Perforated peptic ulcer (PPU): a one year review in tertiary care hospital in Uttarakhand, India

Background: Peptic ulcer perforation is a common surgical emergency. The perforation usually involves the anterior wall of duodenum (60%), although, it might occur in antrum (20%) and lesser curvature of stomach (20%). Conventional open surgery involving repair with omental patch remains the gold standard treatment. This study evaluates the patterns and demographic factors associated with this common surgical disease and the outcome analysis of surgery in our state.Methods: The study was undertaken for patients admitted in surgery department in a single unit who underwent open surgery for perforated peptic ulcer. A total of 78 patients were assessed between January 2016 to January 2017.Results: The study found PPU to be a male dominated disease in fifth decade and with significant association with smoking and alcohol consumption. First part of duodenum being the commonest location of PPU, the peritoneal contamination was directly associated with the duration of symptoms. Wound infection was the most frequent post-operative complication. Simple repair with omental patch remains an effective treatment modality.Conclusions: Perforated peptic ulcer disease commonly affects middle aged males especially due to association with alcohol intake. Simple closure with omental patch followed by H. pylori eradication is an effective treatment modality.

Inguinal Sac Abscess Masquerading as a Strangulated Inguinal Hernia after Antrectomy and Proximal Duodenectomy for Perforated Peptic Duodenal Ulcer

Abstract Background: Patients who undergo surgery for a perforated duodenal ulcer are at risk of developing an intra-abdominal abscess. Even in this setting, the possibility of developing an inguinal hernia sac abscess is rare. Case Presentation: We report the case of a 66-year-old male who underwent an antrectomy and proximal duodenectomy, truncal vagotomy, Billroth II gastrojejunostomy, and a Witzel tube jejunostomy for a recurrent perforated duodenal ulcer. Seven days after this operation, he developed symptoms concerning for a strangulated left inguinal hernia. At operation, a hernia sac abscess of Candida glabrata was identified and excision of the hernia sac and McVay herniorrhaphy were performed. Conclusion: An inguinal sac abscess may develop in patients who have undergone surgery for perforated peptic ulcers and can masquerade as a strangulated inguinal hernia. In the post-operative period, it should be considered in patients who develop an acute onset of groin pain. Definitive management should ...

Modified Graham’s repair for peptic ulcer perforation: reassessment study

Background: Peptic perforation is an emergency and requires urgent surgical treatment. Many modalities of treatment are available ranging from conservative treatment to laparoscopic repair. There is no consensus on treatment of perforated pylorodudenal ulcer which can be treated with conservative treatment, simple closure of ulcer, closure of ulcer with free omentum, closure of perforation with use of pedicled omentum, definitive treatment with truncal vagotomy and drainage procedures or parietal cell vagotomy. However best treatment is still to be decided.Methods: This study was conducted in department of surgery 60 patients presenting with peptic perforation in last three years. All patients with duodenal perforation in first part (D1) were included in the study. Pyloric perforations, multiple perforations, traumatic perforations and severe co-morbid condition were excluded from study. A pedicled omentum was used in the repair of duodenal perforation. Immediate and late postoperative complications were recorded. The patients were followed for three months.Results: Out of 60 cases there were 50 male patients and 10 female patients. The majority of male patients were in the middle age group between 35 to 45 years of age and the female patients were of older age group between 40 to 65 years of age. These patients presented with history of acute pain abdomen in the epigastric region. All the patients underwent modified Graham’s patch repair. In postoperative period, two patients had burst abdomen on fourth postoperative day. Biliary fistula formation occurred in 2 patients. Wound infection occurred in 4 patients and the hospital stay was 5 to 9 days. There was no mortality recorded in this series.Conclusions: In summary, the surgery for perforated peptic ulcer should use modified Graham’s repair using pedicled omentum giving excellent results in terms of healing, morbidity and mortality.

Interhospital transfer delays emergency abdominal surgery and prolongs stay.

Interhospital transfer of patients requiring emergency surgery is common practice. It has the potential to delay surgical intervention, increase rate of complications and thus length of hospital stay. A retrospective cohort study was conducted of adult patients who underwent emergency surgery for abdominal pain at a large metropolitan hospital in New South Wales (Hospital A) in 2013. The impact of interhospital transfer on time to surgical intervention, post-operative length of stay and overall length of stay was assessed. Of the 910 adult patients who underwent emergency surgery for abdominal pain at Hospital A in 2013, 31.9% (n = 290) were transferred by road ambulance from a local district hospital (Hospital B). The leading surgical procedures performed were appendicectomy (n = 299, 32.9%), cholecystectomy (n = 174, 19.1%), gastrointestinal endoscopy (n = 95, 10.4%), cystoscopy (n = 86, 9.5%), hernia repair (n = 45, 4.9%), salpingectomy (n = 19, 2.1%) and oversewing of perforated peptic ulcer (n = 13, 1.4%). Overall, interhospital transfer (n = 290, 31.9%) was associated with increases in mean time to surgical intervention (14.2 h, P < 0.001), post-operative length of stay (1.1 days, P = 0.001) and overall length of stay (1.6 days, P < 0.001). Delayed surgical intervention was observed across all procedure types except surgery for perforated peptic ulcer, where transferred patients underwent surgery within a comparable timeframe to direct admissions. Interhospital transfer delays surgical intervention and increases length of hospital stay. This mandates attention due to the implications for patient outcomes and added burden to the healthcare system. The system did, however, show capability to appropriately expedite surgery for acutely life-threatening cases.

Long-Term Mortality in Patients Operated for Perforated Peptic Ulcer: Factors Limiting Longevity are Dominated by Older Age, Comorbidity Burden and Severe Postoperative Complications.

Perforated peptic ulcer (PPU) is a surgical emergency associated with high short-term mortality. However, studies on long-term outcomes are scarce. Our aim was to investigate long-term survival after surgery for PPU. A population-based, consecutive cohort of patients who underwent surgery for PPU between 2001 and 2014 was reviewed, and the long-term mortality was assessed. Survival was investigated by univariate analysis (log-rank test) and displayed using Kaplan-Meier survival curves. Multivariable analysis of risk factors for long-term mortality was assessed by Cox proportional hazards regression and reported as hazard ratio (HR) with 95% confidence intervals (CI). A total of 234 patients were available for the calculation of ninety-day, one-year and two-year mortality, and the results showed rates of 19.2% (45/234), 22.6% (53/234) and 24.8% (58/234), respectively. At the end of follow-up, a total of 109 of the 234 patients (46.6%) had died. Excluding 37 (15.2%) patients who died within 30days of surgery, 197 patients had long-term follow-up (median 57months, range 1-168) of which 36% (71/197) died during the follow-up period. In multivariable analyses, age >60years (HR 3.95, 95% CI 1.81-8.65), active cancer (HR 3.49, 95% CI 1.73-7.04), hypoalbuminemia (HR 1.65, 95% CI 0.99-2.73), pulmonary disease (HR 2.06, 95% CI 1.14-3.71), cardiovascular disease (HR 1.67, 95% CI 1.01-2.79) and severe postoperative complications (HR 1.76, 95% CI 1.07-2.89) during the initial stay for PPU were all independently associated with an increased risk of long-term mortality. Cause of long-term mortality was most frequently (18 of 71; 25%) attributed to new onset sepsis and/or multiorgan failure. The long-term mortality after surgery for PPU is high. One in every three patients died during follow-up. Older age, comorbidity and severe postoperative complications were risk factors for long-term mortality.

Marginal ulcer perforation: a single center experience.

Marginal ulcer (MU) is defined as ulcer on the jejunal side of the gastrojejunostomy (GJ) anastomosis. Most MUs are managed medically but those with complications like bleeding or perforation require intervention. It is recommended that GJ anastomosis be revised in patients with MU perforation (MUP). The aim of this case series is to study the clinical presentation and management of MUP. Three hundred and thirty-two patients who underwent emergency surgery for perforated peptic ulcer at a single center were studied over a period of 5years. Nine patients (2.7%) presented with MUP. GJ was previously done for either complicated peptic ulcer (n=4) or for suspected gastric malignancy (n=5). Two patients had previously completed H. pylori therapy. None of the patients presented with septic shock. MU was on the jejunal side of GJ in all patients. The median MUP size was 10mm. Four patients (44.4%) had omental patch repair, three (33.3%) had primary closure, and one each had revision of GJ and jejunal serosal patch repair. There were no leaks, intra-abdominal abscess or reoperation and no malignancies. MUP patients do not present with septic shock. Omental patch repair or primary closure is sufficient enough. Revision of Billroth-II-GJ into Roux-en-Y-GJ is not mandatory.

Supplemental Peri-Operative Oxygen and Incision Site Infection after Surgery for Perforated Peptic Ulcer: A Randomized, Double-Blind Monocentric Trial.

The clinical role of hyperoxia for preventing surgical site infection (SSI) remains uncertain because randomized controlled trials on this topic have reported disparate results. One of the principal reasons for this outcome may be that prior trials have entered heterogeneous populations of patients and a variety of procedures. The aim of our study was to assess the influence of hyperoxygenation on SSI using a homogeneous study population. From January 2004 to April 2013, we studied, in a randomized trial, 239 patients, who underwent open surgery for perforated peptic ulcer (PPU). The surgical procedure was performed through an upper abdominal midline incision, and closure of PPU was achieved by suture alone or in combination with an omental patch. Patients were assigned randomly to an oxygen/air mixture with a fraction of inspired oxygen (FiO2) of 30% (n = 120) or 80% (n = 119). Administration was commenced after induction of anesthesia and maintained for 6 hours after surgery. The overall incision infection rate was 38.4% (92 of 239): 61 patients (50.8%) had an infection in the 30% FiO2 group and 31 (26%) in the 80% FiO2 group (p < 0.05). The risk of SSI was 48% lower in the 80% FiO2 group (relative risk 0.51; 95% confidence interval [CI] 0.28-1.08) vs 30% FiO2. Supplemental 80% FiO2 during and for 6 h after open surgery for PPU, which reduces post-operative SSI, should be considered part of ongoing quality improvement activities related to surgical care, with few risks to the patient and little associated cost.