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TRENDS AND OUTCOMES IN THE MANAGEMENT OF PERFORATED PEPTIC ULCER DISEASE
John Afthinos1, Aleksandra Ogrodnik*2, Karen E. Gibbs2
1Surgery, Long Island Jewish Forest Hills, Forest Hills, NY; 2Surgery, Staten Island University Hospital, Staten Island, NY
Introduction: Perforated peptic ulcer disease (PUD) is not infrequently encountered by the general surgeon. Though the incidence has declined with medical treatment regimens, it remains an important aspect of acute care general surgery. We sought to characterize the patient population requiring hospital level care and evaluate trends in the management and utilization of laparoscopy in perforated PUD.
Methods: The Nationwide Inpatient Sample (NIS) database was used to examine outcomes of patients with perforated peptic ulcer disease from 2005 to 2011. Multivariate analysis was performed to compare outcomes of these patients. Utilization of laparoscopy in the management of these cases was also evaluated.
Results: A total of 100,768 patients were identified, of which 45,224 (44.9%) were perforated gastric ulcers (PGU); this group was slightly younger than the perforated duodenal ulcer (PDU) group (60.4 + 18 years vs 61.4 + 19 years, p < 0.0001) and had more females (55.7% vs. 46.9%, p < 0.05). Both the PGU and PDU groups had a high post-operative morbidity rate, 24% and 22.8%, respectively. The PGU group also had a higher mortality rate (10% vs. 8.6%, p < 0.05). LOS was similar for both groups (10.7 + 11 d vs. 10.6 + 11 d, p = 0.15). Non-operative management was employed in 26.5% of PGU and 19.7% of PDU patients. Laparoscopic approach was used in 3.5% of PGU and 2.5% of PDU patients. Conversion rate was lower for PGU (10.4% vs. 15.1%, p < 0.05). Overall, laparoscopic utilization is small but increasing. Risks factors for mortality among both PDU and PGU patients included COPD (OR 1.6), CKD (OR 2), CHF (OR 1.7) and severe liver disease (SLD) (OR 3.7). Risk factors for operative management included smoking (OR 1.45) and peripheral vascular disease (OR 1.35). Risk factors for operative management include smoking (OR 1.45) and PVD (OR 1.36). Exploratory laparotomy was a risk factor for mortality (OR 1.4) for both groups. Factors predictive of laparoscopic approach in PGU included obesity (OR 3.4, p < 0.001) and bariatric surgical history (OR 4.6, p < 0.001). Factors predictive of laparoscopic approach in PDU included a bariatric surgical history (OR 3.9, p < 0.001).
Discussion: Perforated PUD carries a high morbidity and mortality rate. Laparoscopic utilization remains low; however, there is an overall increase over time. Mortality is increased among patients with COPD, PVD, CKD and SLD. Exploratory laparotomy appears to be a risk factor for mortality when compared to a laparoscopic approach. This entity should be considered in the differential diagnosis even for patients who have had a gastrojejunostomy in the past.
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