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Peptic Ulcer Disease

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An updated meta-analysis of laparoscopic versus open repair for perforated peptic ulcer.
Zhou, C; Wang, W; Wang, J; Zhang, X; Zhang, Q; Li, B; Xu, Z.
Sci Rep. 2015 Sep 9;5:13976.

Rationale for inclusion: Unlike previous reviews that have found little difference between laparoscopic and open repair, this more recent meta-analysis found high quality evidence that laparoscopic repair is associated with fewer postoperative complications compared to an open approach.

Citations - 5 (as of July 2017)

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.

Citations – 9 (as of July 2017)

Laparoscopic repair for perforated peptic ulcer disease.
Sanabria A, Villegas MI, Morales Uribe CH.
Cochrane Database Syst Rev. 2013 Feb 28;(2):CD004778.

Rationale for inclusion: This Cochrane review summarizes three randomized controlled trials comparing laparoscopy vs. open surgery for perforated peptic ulcer. Although there was no significant difference (likely due to insufficiency sample sizes), there were trends favoring laparoscopy for septic abdominal complications, pulmonary complications, surgical site infection, postoperative ileus, and mortality. The authors conclude that “With the information provided it could be said that laparoscopic surgery results are not clinically different from those of open surgery.

Citations – 95 (as of July 2017)

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, K├Ânig 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.

Citations – 7 (as of July 2017)

Trends and outcomes of hospitalizations for peptic ulcer disease in the United States, 1993 to 2006.
Wang YR, Richter JE, Dempsey DT.
Ann Surg. 2010 Jan;251(1):51-8.

Rationale for inclusion: This Nationwide Inpatient Sample (NIS) study demonstrates that hospitalizations for peptic ulcer disease (PUD) have decreased by 30% since the 1990s. While hemorrhage remains the most common presentation, continues to carry the highest mortality (10.6%). Endoscopic treatment to control bleeding has increased and vagotomy/gastrectomy have decreased.

Citations – 160 (as of July 2017)

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.

Citations – 254 (as of July 2017)

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.

Citations – 500 (as of July 2017)

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.

Citations – 299 (as of July 2017)

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.

Citations – 110  (as of July 2017)

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.

Citations – 73 (as of July 2017)

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