An Evaluation of Management of Perforated Ulcers at a Community Hospital

Julian D Maendel, MD, William B Hooks, MD, William W Hope, MD, Ashley Adams, MD. New Hanover Regional Medical Center

Although less common than in previous eras, perforated gastric and duodenal ulcers can be a challenging problem for general surgeons. Multiple surgical options exist for treatment. While the role of omental patch using the laparoscopic approach is well established in the treatment of marginal ulcers, recent reports have touted its benefits in treating other gastric and duodenal perforated ulcers. The purpose of this study is to evaluate our community hospital’s approach, outcomes, and utilization of the laparoscopic approach to the management of these non-marginal perforated ulcers.

A retrospective review of all patients with perforated ulcers from 10/2008 to 8/2014 was performed. Marginal ulcers were excluded. Demographic information, clinical presentation, operative management, and outcomes were recorded. Patients undergoing laparoscopic management were compared to those undergoing open repair. Data was reported in means, standard deviations, counts and frequencies.

During the study period, 42 patients underwent surgical treatment for perforated gastric (31) and duodenal (11) ulcers. 20 were excluded as they not meet study criteria. The average age was 64.8 (Range 21-94) and 56.4% were male. 31 patients had at least 1 comorbidity with the most common being HTN, CAD, and GERD, and average wbc on admission was 14.1 (Range2.7-28.5). Shock (SBP<90) was present on admission in 13.5%, with 43.1% reporting symptoms for greater than 24 hours prior to admission. NSAID use was positive in 51% and EtOH use in 23.5%. Laparoscopic approach was performed in 27.9% with a 50% conversion rate. Reasons for conversion were inadequate visualization in 50% and other in 50%. Average operative time was 108 minutes (range 24 to 305). Overall mortality rate was 14% and average length of postoperative hospital stay was 13.2 days (range 5 to 44).

Perforated ulcers are a rare surgical emergency for general surgeons. The majority of patients at our institution undergo open repair, despite recent literature showing favorable outcomes using the laparoscopic approach in select patient populations. This study demonstrates hesitancy among general surgeons at this institution to use laparoscopy in omental patch repair of perforated duodenal and gastric ulcers, and a high conversion rate when laparoscopy is employed. We posit that this is due to a combination of surgeon lack of familiarity with the laparoscopic approach for this indication, and perhaps a need for better patient selection.