The natural history of perforated foregut ulcers after repair by omental patching or primary closure

Original Article
  • 183 Downloads

Abstract

Background

The treatment of perforated foregut ulcers by omental patching (OP) or primary closure has mostly replaced vagotomy and pyloroplasty/antrectomy (VPA). We sought to determine the natural history and recurrence rate of ulceration in patients treated by omental patching or primary closure.

Study design

An 11-year retrospective study.

Results

From 2004 through 2015, 94 patients had perforated foregut ulcers, 53 gastric, and 41 duodenal. 77 (82%) were treated by OP alone (study group) and 17 (18%) were treated with VPA (comparison group). All OP patients were discharged on PPIs, but only 86% took the drugs for a median of 22 months (1–192, SD 40). Endoscopy in the OP group showed recurrent ulcers in nine (12% recurrence rate) and gastritis in three (4%) This group also had three later recurrent perforations. Another recurrent ulcer hemorrhaged causing death (3% late mortality). Two other patients required non-emergent re-do ulcer operations for recurrent disease/symptoms (surgical re-intervention rate 4%). Total length of follow-up was median 44 months (1–192, SD 40) and was complete in 82 (87%). 18 (23%) patients in the OP group developed recurrent abdominal pain attributed to ulcer disease during follow-up, compared to 2 (12%) in the VPA group (p = 0.15). No patient in the VPA group had an endoscopic recurrence or re-intervention.

Conclusion

Omental patching does not correct the underlying disease process which causes foregut perforation, and has a 12% endoscopically proven recurrent ulceration rate and a 23% incidence of recurrent symptoms within 44 months. Patients tend to stop taking PPIs after 22 months at which time their risk increases.

Keywords

Gastric ulcer Duodenal ulcer Perforation Omental patch Graham patch Recurrence 

Notes

Author contributions

Carr—conception and design, acquisition, analysis, drafting, revising, approval, accountable. Smith—conception and design, acquisition, analysis, drafting, approval, accountable. Roeser—conception and design, acquisition, drafting, approval, accountable. Naranjo—conception and design, analysis, revising, approval, and accountable.

Compliance with ethical standards

Conflict of interest

The authors, John Carr, Daniel Smith, Mark Roeser, and Joshua Naranjo, have no conflicts of interest, no financial relationships to disclose, and have received no funding or any support to perform this research.

Ethical standards

Institutional Review Board and ethical approval was obtained from the Allegiance Health Institutional Review Board prior to starting this study, and this study has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Since the study was retrospective in nature, the need to obtain individual patient consent was waived by the review board.

References

  1. 1.
    Satoh K, Yoshino J, Akamatsu T, et al. Evidence-based clinical practice guidelines for peptic ulcer disease 2015. J Gastroenterol. 2016;51:177–94.CrossRefPubMedGoogle Scholar
  2. 2.
    Wang YR, Richter JE, Dempsey DT. Trends and outcomes of hospitalizations for peptic ulcer disease in the United States, 1993 to 2006. Ann Surg. 2010;251:51–8.CrossRefPubMedGoogle Scholar
  3. 3.
    Lo HC, Wu SC, Huang HC, et al. Laparoscopic simple closure alone is adequate for low risk patients with perforated peptic ulcer. World J Surg. 2011;35:1873–8.CrossRefPubMedGoogle Scholar
  4. 4.
    Ng EK, Lam YH, Sung JJ, et al. Eradication of Helicobacter pylori prevents recurrence of ulcer after simple closure of duodenal ulcer perforation. Ann Surg. 2000;231:153–8.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Malkov IS, Zaynutdinov AM, Veliyev NA, et al. Laparoscopic and endoscopic management of perforated duodenal ulcers. J Am Coll Surg. 2004;198:352–5.CrossRefPubMedGoogle Scholar
  6. 6.
    Stabile BE. Redefining the role of surgery for perforated duodenal ulcer in the Helicobacter pylori era. Ann Surg. 2000;231:159–60.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Tokunaga Y, Hata K, Ryo J, et al. Density of Helicobacter pylori infection in patients with peptic ulcer perforation. J Am Coll Surg. 1998;186:659–63.CrossRefPubMedGoogle Scholar
  8. 8.
    Datsis AC, Rogdakis A, Kekelos S, et al. Simple closure of chronic duodenal ulcer perforation in the era of Helicobacter pylori: an old procedure, today’s solution. Hepatogastroenterology. 2003;50:1396–8.PubMedGoogle Scholar
  9. 9.
    Gibson JB, Behrman SW, Fabian TC, et al. Gastric outlet obstruction resulting from peptic ulcer disease requiring surgical intervention is infrequently associated with Helicobacter pylori infection. J Am Coll Surg. 2000;191:32–7.CrossRefPubMedGoogle Scholar
  10. 10.
    Brock J, Sauaia A, Ahnen D, et al. Process of care and outcomes for elderly patients hospitalized with peptic ulcer disease: results from a quality improvement project. JAMA. 2001;286:1985–93.CrossRefPubMedGoogle Scholar
  11. 11.
    Wong CS, Chia CF, Lee HC, et al. Eradication of Helicobacter pylori for prevention of ulcer recurrence after simple closure of perforated peptic ulcer: a meta-analysis of randomized controlled trials. J Surg Res. 2013;182:219–26.CrossRefPubMedGoogle Scholar
  12. 12.
    Yoon SB, Park JM, Lee JY, et al. Long-term pretreatment with proton pump inhibitor and Helicobacter pylori eradication rates. World J Gastroenterol. 2014;20:1061–6.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Chan CC, Chien NH, Lee CL, et al. Comparison of 10-day sequential therapy with 7-day standard triple therapy for Helicobacter pylori eradication in inactive peptic ulcer disease and the efficiency of sequential therapy in inactive peptic ulcer disease and non-ulcer dyspepsia. BMC Gastroenterol. 2015;15:170–5.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Gopal R, Elamurugan TP, Kate V, et al. Standard triple versus levofloxacin based regimen for eradication of Helicobacter pylori. World J Gastrointest Pharmacol Ther. 2013;4:23–7.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Othman F, Card TR, Crooks CJ. Proton pump inhibitor prescribing patterns in the UK: a primary care database study. Pharmacoepidemiol Drug Saf. 2016;25:1079–87.CrossRefPubMedGoogle Scholar
  16. 16.
    Jackson LR, Peterson ED, McCoy LA, et al. Impact of proton pump inhibitor use on the comparative effectiveness and safety of prasugrel versus clopidogrel: insights from the treatment with adenosine diphosphate receptor inhibitors: longitudinal assessment of treatment patterns and events after acute coronary syndrome (TRANSLATE-ACS) study. J Am Heart Assoc. 2016;5:17–23.CrossRefGoogle Scholar
  17. 17.
    Sherwood MW, Melloni C, Jones WS, et al. Individual proton pump inhibitors and outcomes in patients with coronary artery disease on dual antiplatelet therapy: a systematic review. J Am Heart Assoc. 2015;4:78–83.CrossRefGoogle Scholar
  18. 18.
    Fraser LA, Leslie WD, Targownik LE, et al. The effect of proton pump inhibitors on fracture risk: report from the Canadian Multicenter Osteoporosis Study. Osteoporos Int. 2013;24:1161–8.CrossRefPubMedGoogle Scholar
  19. 19.
    Mutlu GM, Mutlu EA, Factor P. Prevention and treatment of gastrointestinal complications in patients on mechanical ventilation. Am J Respir Med. 2003;2:395–411.CrossRefPubMedGoogle Scholar
  20. 20.
    McCarthy DM. Comparative toxicity of nonsteroidal anti-inflammatory drugs. Am J Med. 1999;107:37S–46S.CrossRefPubMedGoogle Scholar
  21. 21.
    Masuda E, Kawano S, Michida T, et al. Plasma and gastric mucosal endothelin-1 concentrations in patients with peptic ulcer. Dig Dis Sci. 1997;42:314–8.CrossRefPubMedGoogle Scholar
  22. 22.
    Iaquinto G, Giardullo N, Taccone W, et al. Role of endogenous endothelin-1 in ethanol-induced gastric mucosal damage in humans. Dig Dis Sci. 2003;48:663–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Fennerty MB. Pathophysiology of the upper gastrointestinal tract in the critically ill patient: rationale for the therapeutic benefits of acid suppression. Crit Care Med. 2002;30:S351–5.CrossRefPubMedGoogle Scholar
  24. 24.
    Tytgat GN. Etiopathogenetic principles and peptic ulcer disease classification. Dig Dis. 2011;29:454–8.CrossRefPubMedGoogle Scholar
  25. 25.
    Bashinskaya B, Nahed BV, Redjal N, et al. Trends in peptic ulcer disease and the identification of Helicobacter pylori as a causative organism: population-based estimates from the US Nationwide Inpatient Sample. J Glob Infect Dis. 2011;3:366–70.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Smith JW, Mathis T, Benns MV, et al. Socioeconomic disparities in the operative management of peptic ulcer disease. Surgery. 2013;154:672–8.CrossRefPubMedGoogle Scholar
  27. 27.
    Zelickson MS, Bronder CM, Johnson BL, et al. Helicobacter pylori is not the predominant etiology for peptic ulcers requiring operation. Am Surg. 2011;77:1054–60.PubMedGoogle Scholar
  28. 28.
    Smith BR, Wilson SE. Impact of nonresective operations for complicated peptic ulcer disease in a high-risk population. Am Surg. 2010;76:1143–6.PubMedGoogle Scholar
  29. 29.
    Schroder VT, Pappas TN, Vaslef SN, et al. Vagotomy/drainage is superior to local oversew in patients who require emergency surgery for bleeding peptic ulcers. Ann Surg. 2014;259:1111–8.CrossRefPubMedGoogle Scholar
  30. 30.
    Yoon K, Kim N, Nam RH, et al. Ultimate eradication rate of Helicobacter pylori after first, second, or third-line therapy in Korea. J Gastroenterol Hepatol. 2015;30:490–5.CrossRefPubMedGoogle Scholar
  31. 31.
    Yee JK. Helicobacter pylori colonization of the oral cavity: a milestone discovery. World J Gastroenterol. 2016;22:641–8.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Raymond J, Thiberge JM, Dauga C. Diagnosis of Helicobacter pylori recurrence: relapse or reinfection? Usefulness of molecular tools. Scand J Gastroenterol. 2016;51:672–8.CrossRefPubMedGoogle Scholar
  33. 33.
    Chung WC, Jeon EJ, Kim DB, et al. Clinical characteristics of Helicobacter pylori-negative drug-negative peptic ulcer bleeding. World J Gastroenterol. 2015;21:8636–43.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Bornman PC, Theodorou NA, Jeffery PC, et al. Simple closure of perforated duodenal ulcer: a prospective evaluation of a conservative management policy. Br J Surg. 1990;77:73–7.CrossRefPubMedGoogle Scholar
  35. 35.
    El-Nakeeb A, Fikry A, Abd el-Hamed TM, et al. Effect of Helicobacter pylori eradication on ulcer recurrence after simple closure of perforated duodenal ulcer. Int J Surg. 2009;7:126–9.CrossRefPubMedGoogle Scholar
  36. 36.
    Schuster KM, Feuer WJ, Barquist ES. Outcomes of cocaine-induced gastric perforations repaired with an omental patch. J Gastrointest Surg. 2007;11:1560–3.CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany 2017

Authors and Affiliations

  1. 1.Department of SurgeryHenry Ford Allegiance HealthJacksonUSA
  2. 2.Department of StatisticsWestern Michigan UniversityKalamazooUSA

Personalised recommendations