Introduction: Crack cocaine use is associated with acute gastric perforation. The appropriate surgical treatment and long term outcomes remain unclear. Past authors have advocated simple omental patch repairs, but long term outcomes of these repairs have not been reported.
Methods: We performed a retrospective chart review of all gastric surgery at a large urban medical center. These charts were then reviewed in detail for presentation, recent use of crack cocaine, operative findings, treatment, complications and outcomes including subsequent hospital admissions and operative procedures.
Results: Over the period from January 1991 to December 2005 one hundred and forty three upper GI cases were identified in the operative logs. Sixteen cases of crack induced ulcer complications were identified. Sixteen of these patients were male, 5 had concomitant HIV disease, 5 had peptic ulcer disease, 6 had a history of alcohol abuse, 12 presented with acute onset abdominal pain, and the average age was 45 [range: 32-57]. Although the majority (13) were pyloric channel perforations, two were antral and one was near the gastro-esophageal (GE) junction. Twelve patients were treated with omental patch closure of the ulcer and four were treated with an anti-ulcer operation. Of these 4 one was treated with vagotomy and pyloroplasty (V&P), one with vagotomy and antrectomy (75% gastrectomy), one with sub-total gastrectomy and the GE junction ulcer was treated with excision and V&P. Early complications included one wound infection, one small bowel obstruction and one entero-cutaneous fistula. The average length of hospital stay was 14 [range: 4-87] days. The four patients with the anti-ulcer procedure were followed for a median 63 months [range: 27-120] with no recurrences. Of the twelve patients treated with an omental patch, three never returned for any follow-up visits. Five of the remaining 9 recurred at 11, 20, 20, 27, and 39 months while the four without recurrence were followed for a median of 67 [range 12-96] months. Cumulative Kaplan-Meier proportions with recurrence in the simple patch group were: 11.1% at 12 months, 36.5% at 24 months and 71.9% at 36 months. The recurrence rate was borderline lower in the anti-ulcer group (P=.072, log-rank test).
Conclusions: A simple omental patch closure is not optimal due to a recurrence rate that may be as high as 72% compared with no recurrence when an anti-ulcer operation is performed.