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TRENDS AND OUTCOMES IN MANAGEMENT OF PERFORATED GASTROJEJUNAL ULCERS
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 gastrojejunal (PGJ) ulcers are rare general surgical emergencies. This entity can be seen in both bariatric and non-bariatric surgery patients with a history of gastrojejunostomy. We wished to characterize this patient population and the outcomes associated with both operative and non-operative management.
Methods: The National Inpatient Sample (NIS) database was queried for all patients presenting with perforated GJ ulcer (ICD-9 codes 534.10, 534.11, 534.50 and 534.51) from 2005 - 2011. Patients were evaluated for age, gender, comorbid conditions, operative intervention and post-operative complications.
Results: We identified 5,490 patients satisfying the admitting diagnoses. The average age was 48.1 + 14 years and the patients were mostly female (72%). A smoking history was seen in 22.8% and 53.5% had a history of bariatric surgery. Patients were managed non-operatively 14% of the time. A laparoscopic approach was used 15.5% of the time with a 13% conversion rate. A laparoscopic approach was used in patients without a bariatric surgery history 9.8% of the time. Overall morbidity was 12.4% and mortality was 1.9%. Length of stay was 8 + 9 days. Risk factors for mortality include COPD (OR 6.2, p < 0.001), CAD (OR 2.3, p < 0.001), and CHF (OR2.6, p < 0.001). Obesity (OR 1.7, p < 0.001) and bariatric surgery history (OR 1.4, p < 0.001) were predictive of a laparoscopic approach. A revision of the gastrojejunostomy was performed in 14.7% of patients. Among this subset of patients, there was a significantly higher post-operative morbidity (21%, p < 0.05), but a similar mortality (1.1%, p = NS).
Conclusions: PGJ ulcers are uncommon surgical emergencies. Laparoscopic utilization is modest in this patient population and mortality is low. Obesity and a history of bariatric surgery increase the likelihood of a laparoscopic approach. There was a moderate rate of revision of the gastrojejunostomy with a significantly higher morbidity among this subset.
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