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Perforation
Hospitalization per 100,000 for
duodenal ulcer disease
100
90
80
70
60
Uncomplicated
50
Hemorrhage
40
Perforation
30
20
10
0
1970 1975 1980 1985
Hospitalizations per 100,000 for
gastric ulcer disease
40
35 Influence of
30
NSAIDS
25
Uncomplicated
20
Hemorrhage
15 Perforation
10
5
0
1970 1975 1980 1985
More recent demographics
222 ulcer operations 1981-1998 (UCLA)
No change in mortality (13%)
Decrease in annual number of operations (24 to
11.3)
Increased percentage of patients needing urgent
surgery
No change in percentage of patients explored
for uncontrolled hemorrhage despite endoscopy
Towfigh et al, American Surgeon, 2002
Poland, 1977-81 vs. 1992-96
Decreased surgery overall (360 vs. 246)
Increased operative patient age and
percentage of women in later period
Decreased number of patients with
obstruction
No change in number of patients needing
surgery for bleeding or perforation
Janik, et al, Medical Science Monitor, 2000
UT San Antonio 1980-1999
80 % decrease in number of ulcer
operations performed
70/year early 1980s, 14/year late 1990s
Decreased need for surgery most
pronounced for intractability (95%), but
also diminished for complicated peptic
disease (86% hemorrhage and 36%
perforation)
Schwesinger et al, J Gastrointest Surg, 2001
Bleeding
Ib Oozing bleed
Stigmata>shock>hematemesis>age
(Jaramillo, Am J Gastroenterol 1994)
Risk factors effect on mortality
Other Ulcer Tx > 5 # survive/ Predicted
illness >1cm units mortalities mortality
- - - 181/0 0.1%
- + - 28/0 2.4%
+ + - 13/0 3.5%
- + + 6/0 5.5%
+ - + 15/2 17.9%
+ + + 5/6 46.7%
Branicki, Ann Surg, 1990
Summary of rebleeding risk data
Clinical and endoscopic features can predict
rebleeding and mortality
Early operation an appropriate
consideration, ideally after stabilization, if
rebleeding risk is high
Availability of endoscopic hemostatic
techniques can greatly diminish need for
urgent surgery in many, but not all cases
Value of endoscopic rx and re-rx
80-100% initial hemostasis rates
75% success with endoscopic retreatment
Slight increased risk of perforation with
thermal re-rx
Randomized trial for rebleeding shows decrease in
overall complications and need for surgery with
endoscopic re-rx, with no increase in mortality
Hypotension at randomization and ulcer size>2
cm predictive of higher failure with endo re-rx
Lau et al, NEJM, 1999
Does Endoscopic Rx Affect
Outcome?
Metanalysis all randomized controlled trials
62% reduction rebleeding
64% reduction need for operative intervention
45% reduction mortality
Nonsurgical options
Surgical options
Natural history--peptic gastric
outlet obstruction
Weiland, 1982
? Nonoperative strategies for
peptic GOO
Balloon dilation
ASGE survey: 76% immediate improvement,
but only 38% objective improvement at 3 mos.
Kozarek: 70% asymptomatic over mean follow
up of 2.5 years, however 52% had active/acute
component when dilated and included patients
with anastomotic and NSAID-induced GOO as
well as peptic (Gastrointest Endosc, 1990)
Technique: 15mm balloon, 2 one-minute
inflations
GOO--? Just do the antibiotics
22 consecutive patients with benign peptic
stenosis (16 duodenal, 6 pyloric)
Eradicative triple therapy followed by 8
weeks PPI
20/22 fully resolved clinically and
endoscopically within 2 months
No recurrence at mean follow up of 12
months
Brandimarte et al, Eur J Gastroenterol Hepatol, 1999
GOO--surgical options
Issues
Parietal cell vs. truncal vagotomy
Dilation vs. drainage
Type of drainage procedure
pyloroplasty/duodenoplasty (Heineke-Mikulicz,
Finney)
gastroduodenostomy (Jaboulay)
gastrojejunostomy
antrectomy/anastomosis
Pyloroplasties
GOO--vagotomy
Multiple studies attest PCV minimizes
recurrence when accompanied by drainage
procedure (decreased gastrin), with less
delayed emptying/postgastrectomy sequelae
than seen with TV
Recurrence 0-5%, 95+% of patients Visick I or
II--Bowden, Donahue
Delayed emptying 0 (PCV) vs. 33% (TV)--
Gleysteen
Dilation vs. drainage
Operative dilation (digitally or with Hegar
dilator) has 7% recurrent stenosis rate with
relatively short follow up, even when
combined with parietal cell vagotomy
Drainage procedures therefore more
appropriate
Expert opinion
Peptic perforation
Nonoperative treatment
Operative treatment
risk status
definitive surgery vs. simple closure
? laparoscopy
What about H. pylori?
Nonoperative treatment
Water soluble contrast study documenting
sealed perforation
Age<70
NG tube, antibiotics, acid suppression, IVF
Improving exam and clinical signs within
12 hours
70% success rate in avoiding surgery, 35%
longer hospital stay
Crofts, NEJM 1989; Berne, Arch Surg 1989
Operative treatment--risk
assessment
Multiple studies show mortality a function
of risk status, independent of operation
performed
Age>70, perforation>24 hours, SBP<100,
poorly controlled comorbid conditions define
high risk patient