Peptic Ulcer Disease - The Eastern Association for the Surgery of Trauma

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Eastern Association for the Surgery of Trauma

Peptic Ulcer Disease

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Optimal Timing of Feeding After Endoscopic Hemostasis in Patients With Peptic Ulcer Bleeding: A Randomized, Noninferiority Trial (CRIS KCT0001019)

Gong EJ, Lee SJ, Jun BG, Seo HI, Park JK, Han KH, Kim YD, Jeong WJ, Cheon GJ, Park SY.

Am J Gastroenterol. 2020 Apr;115(4):548-554.

Rationale for Inclusion: Non-inferiority RCT that shows no difference between early feeding (<24shrs) vs after 48hrs

Citations - To review the number of citations for this landmark paper, visit Google Scholar.

Delay in Source Control in Perforated Peptic Ulcer Leads to 6% Increased Risk of Death Per Hour: A Nationwide Cohort Study

Boyd-Carson H, Doleman B, Cromwell D, Lockwood S, Williams JP, Tierney GM, Lund JN, Anderson ID; National Emergency Laparotomy Audit Collaboration

World J Surg. 2020 Mar;44(3):869-875.

Rationale for Inclusion: This epidemiologic analysis of 3809 patients from a prospective registry of emergency laparotomies for PPU found that hourly delay to the OR was independently associated with an increased odds of death.

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Perforated and bleeding peptic ulcer: WSES guidelines.

Tarasconi A, Coccolini F, Biffl W, Tomasoni M, Ansaloni L, Picetti E, Molfino S, Shelat V, Cimbanassi S, Weber D, Abu-Zidan F, Campanile F, Saverio S, Baiocchi G, Casella C, Kelly M, Kirkpatrick A, Leppaniemi A, Moore E, Peitzman A, Fraga G, Ceresoli M, Maier R, Wani I, Pattonieri V, Perrone G, Velma G, Sugrue M, Sartelli M, Kluger Y, Catena F.

World J Emerg Surg. 2020 Jan 7;15:3.

Rationale for inclusion: Using GRADE methodology, this paper makes recommendations for the diagnosis and management of peptic ulcer disease.

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Validation of prognostic scoring systems for predicting 30-day mortality in perforated peptic ulcer disease

Patel S, Kalra D, Kacheriwala S, Shah M, Duttaroy D.

Turk J Surg. 2019 Dec 16;35(4):252-258.

Rationale for Inclusion: Prospective observational study comparing various prognostic scoring systems.

Citations - To review the number of citations for this landmark paper, visit Google Scholar.

Laparoscopic omental patch for perforated peptic ulcer disease reduces length of stay and complications, compared to open surgery: A SWSC multicenter study

Saleh AA, Esquivel EC, Lung JT, Eaton BC, Bruns BR, Barmparas G, Margulies DR, Raines A, Bryant C, Crane CE, Scherer EP, Schroeppel TJ, Moskowitz E, Regner J, Frazee R, Campion EM, Bartley M, Mortus J, Ward J, Almekdash MH, Dissanaike S.

Am J Surg. 2019 Dec;218(6):1060-1064.

Rationale for Inclusion: Multi-institutional, non-randomized study of 491 patients supporting laparoscropic graham patch.

CAVEAT: Not RCT

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A comparative study of risk of pneumonia and mortalities between nasogastric and jejunostomy feeding routes in surgical critically ill patients with perforated peptic ulcer

Wu SC, Hsieh P, Chen YW, Yang MD, Wang YC, Cheng HT, Tzeng CW, Hsu CH, Muo CH.

PLoS One. 2019 Jul 3;14(7):e0219258.

Rationale for Inclusion: Retrospective study of 136 critically ill PPU disease patients showing non-inferiority of NGT feeds.

CAVEAT: Not RCT

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Surgical repair of perforated peptic ulcers: laparoscopic versus open approach.

Vakayil V, Bauman B, Joppru K, Mallick R, Tignanelli C, Connett J, Ikramuddin S, Harmon JV.

Surg Endosc. 2019 Jan;33(1):281-292.

Rationale for inclusion: this 12 yrs NSQIP retrospective review evidenced that while laparoscopic approach is used less often, it is associated with shorter LOS, SSI, wound dehiscence and mortality.

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Vagotomy/drainage is superior to local oversew in patients who require emergency surgery for bleeding peptic ulcers.

Schroder VT, Pappas TN, Vaslef SN, De La Fuente SG, Scarborough JE.

Ann Surg. 2014 Jun;259(6):1111-8.

Rationale for inclusion: This study examined 3611 patients (775 bleeding ulcers and 2374 perforated ulcers) in 2005-2011 ACS NSQIP database. After controlling for patient-related factors in multivariable regression analysis, the authors found that simple repair(presumably with post-operative H. pylori eradication and medical acid suppression) had outcomes equivalent to vagotomy/drainage, but with shorter postoperative hospitalization. However, for bleeding ulcers, vagotomy/drainage had lower mortality rates than local oversew alone.

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Management of the difficult duodenal stump in penetrating duodenal ulcer disease: a comparative analysis of duodenojejunostomy with "classical" stump closure (Nissen-Bsteh).

Vashist YK, Yekebas EF, Gebauer F, Tachezy M, Bachmann K, König A, Kutup A, Izbicki JR.

Langenbecks Arch Surg. 2012 Dec;397(8):1243-9.

Rationale for inclusion: In this case-control study of 124 patients with penetrating duodenal ulcer and difficult duodenal stump, the authors compared “classical” closure (distal gastric resection with direct closure of the duodenal stump and Roux-en-y gastrojejunostomy) to duodenojejunostomy (DJ) +/- gastroduodenal and biliary diversion. Selection bias notwithstanding, they report significantly decreased anastomotic leakage and mortality in the DJ group. This study provides support for DJ in the treatment of difficult duodenal stump.

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Effects of gastroprotectant drugs for the prevention and treatment of peptic ulcer disease and its complications: a meta-analysis of randomised trials

Scally B, Emberson JR, Spata E, Reith C, Davies K, Halls H, Holland L, Wilson K, Bhala N, Hawkey C, Hochberg M, Hunt R, Laine L, Lanas A, Patrono C, Baigent C

Lancet Gastroenterol Hepatol. 2018 Apr;3(4):231-241.

Rationale for Inclusion: Although only 68% of subjects were inpatient, 24% of all subjects had severe C.diff, so this study may be relevant to our practice. Subgroup analyses favored fidaxomicin for those receiving concomitant antibiotics and in the severe C. diff subgroup.

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Eradication of Helicobacter pylori prevents recurrence of ulcer after simple closure of duodenal ulcer perforation: randomized controlled trial.

Ng EK, Lam YH, Sung JJ, Yung MY, To KF, Chan AC, Lee DW, Law BK, Lau JY, Ling TK, Lau WY, Chung SC.

Ann Surg. 2000 Feb;231(2):153-8.

Rationale for inclusion: This study demonstrates that the majority of patients with perforated duodenal ulcer (81%) are infected with H. pylori. After simple repair and H. pylori eradication, the ulcer recurrence rate was only 4.8%. This study does not support definitive operation (vagotomy) in the era of H. pylori eradication.

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Endoscopic retreatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of bleeding ulcers.

Lau JY, Sung JJ, Lam YH, Chan AC, Ng EK, Lee DW, Chan FK, Suen RC, Chung SC.

N Engl J Med. 1999 Mar 11;340(10):751-6.

Rationale for inclusion: This study enrolled patients who had already undergone endoscopic therapy for bleeding peptic ulcers and had recurrent bleeding. Subjects were than randomized to either endoscopic retreatment or definitive surgery. The success rate of endoscopic retreatment was 73% (35/48) and mortality was not significantly different between groups (5/48 vs. 8/44), though there were significantly fewer complications in the endoscopic retreatment group. Ulcer size > 2cm and hypotension during rebleeding were independent predictors of endoscopic retreatment failure. This study supports endoscopic retreatment for recurrent bleeding.

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A randomized trial of nonoperative treatment for perforated peptic ulcer.

Crofts TJ, Park KG, Steele RJ, Chung SS, Li AK.

N Engl J Med. 1989 Apr 13;320(15):970-3.

Rationale for inclusion: In patients with a clinical diagnosis of perforated peptic ulcer, subjects were randomized to either immediate operation or a 12-h trial of nonoperative therapy (nasogastric suction, IV broad-spectrum antibiotics, and IV ranitidine). While the majority of nonoperative patients had free air until the diaphragm on CXR (35/40), only 28% (11/40) did not improve and require rescue laparotomy. While hospital stay was longer in the nonoperative group, overall morbidity and mortality rates were similar (5%). Deaths in the nonoperative group were unrelated to delay in treatment. This small study provides support for an initial 12-h trial of nonoperative therapy of perforated peptic ulcer.

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Immediate definitive surgery for perforated duodenal ulcers: a prospective controlled trial.

Boey J, Lee NW, Koo J, Lam PH, Wong J, Ong GB.

Ann Surg. 1982 Sep;196(3):338-44.

Rationale for inclusion: Although it is dated and precedes the era of proton pump inhibition and H. pylori eradication, this study is interesting and relevant in cases of peptic ulcers refractory to medical therapy or non-compliant patients in the modern era. In this three-arm randomized trial, subjects underwent duodenal ulcer repair by simple closure, truncal vagotomy and drainage (VD), or proximal gastric vagotomy with closure (PGV). At 39 month follow-up, the cumulative rates of recurrence were 63% (closure), 12% (VD), and 4% (PGV). This study supports the use of definitive treatment (vagotomy with either closure or drainage) without resection over simple closure alone in the treatment of perforated duodenal ulcers for patients who will not receive benefit from modern postoperative medical therapy.

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A rapid method of treatment of perforated duodenal ulcer.

Cellan-Jones CJ.

Br Med J. 1929 Jun 15;1(3571):1076-7.

Rationale for inclusion: This historical article describes the technique of a pedicled omental plug (without primary closure), which many surgeons use as an alternative to primary closure of friable and indurated perforated anterior duodenal ulcers.

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