Perforated Ulcer Disease – Opportunities for Improving Outcome

EA Bonin, MD, E Moran, MD, A McConico, CJ Gostout, MD, J Bingener, MD. Mayo Clinic

Background: Since the advent of PPI and H.pylori treatment and increased use of ulcerogenic drugs in older patients, the profile of patients presenting with a perforated PUD likely has changed. Patient age and complications from surgical treatment are risk factors for death from perforated peptic ulcer. Older patients may have an increased benefit from minimally invasive treatments. In the experimental setting, translumenal endoscopic closure is feasible and may be less invasive and technically easier than laparoscopic suturing. The aims of this study were to
1) Describe the current patient profile and outcomes for perforated PUD
2) Assess how many patients may be candidates for a translumenal endoscopic omental patch closure

Methods: A retrospective database review using CPT and ICD 9 codes related to ulcer perforations from January 2005 through March 2010 was performed. Patients with perforations from other causes such as cancer, iatrogenic, anastomotic were excluded. Demographics, comorbidities, ulcer characteristics, operative procedure, and outcomes were recorded. A patient was identified as a potential candidate for transluminal omental patch repair if:
• The patient underwent omental patch repair
• The ulcer was > 1cm
• No contraindication to laparoscopy or endoscopy was encountered
A patient was regarded a potential candidate for transluminal assisted repair if the ulcer was < 1 cm in size and the other criteria above applied.

Results: A total of 104 patients with perforated PU were identified; 62% women, mean age of 68 years (range 16-98), mean ASA 3 (range 1-4). Immunosuppression and NSAID medication was recorded in 57 patients (55%); 12 (12%) and 45 (43%) respectively. Non-operative treatment was chosen in 10 patients and 94 patients underwent an operative procedure: 59/94 (63%) an omental patch (48 primary open, 11 attempted laparoscopic, 4 converted to open), 13/94 (13%) underwent partial gastrectomy due to large ulcers and necrosis, and 22/94 (23%) underwent other procedures such as wedge resection. Ulcer locations were: 55 (59%) duodenal, 33 (35%) gastric, 6 (6%) other. Mean operative duration was 126 min. Thirty-day mortality was 13% and one-year mortality was 34%. Major morbidity (Clavien 3 or 4) was 37%. The mean number of additional operations needed was 1 (range 0-23). Mean postoperative LOS was 27 days (1-269). Of 59 patients with an omental patch repair, 27 had an ulcer > 1cm, which would allow the passage of an endoscope; 32 ulcers were < 1 cm (endoscopic tool assist possible). Ten with an omental patch repair were deemed to be difficult cases due to massive abdominal contamination, associated bowel resection, or bowel ischemia.

Conclusion: Unlike prior reports, the patients in this study were older and predominantly female. Two thirds of patients had medication-related ulcerations. Mortality and morbidity remain high and laparoscopic omental patch repair was infrequently successful. Endoscopic transluminal-assisted repair may provide an additional venue for minimally invasive approach for a number of these patients.

Session: Poster
Program Number: P229
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