Is it possible to reduce the surgical mortality and morbidity of peptic ulcer perforations?

Abstract

INTRODUCTIONWith regard to creating a novel vision for former diseases, our memorizationsshould be updated. Some diseases and their outcomes, which have been previously very well known, are nowadays almost always presented as unexpected cases because of new technologies and evolvements in medicine due to resistant events. Thus, antiulcer medication and presentation of elderly patients have changed in peptic ulcer perforation (PUP) and, transforming the patient profiles with PUP in our era. Therefore, a novel vision to avoid gaps is necessary to evaluate the patients with PUPsas surgeons are coming across newer patient profiles in last decades. Peptic ulcers are focal defects in the stomach and the duodenum extending below the mucosa or deeper (1, 2). They can be acute or chronic; the etiology of the condition is the disruption of balance between gastric acid effect and mucosal defense mechanisms (2, 3). Although medical treatments such as H2 receptor antagonists, proton pump inhibitors, and Helicobacter pylori eradication through antibacterial drugs, have decreased the number of surgeries in non-complicated peptic ulcer cases, the number of patients presenting to the emergency clinics with peptic ulcer perforation has not decreased (1-5).Peptic ulcer perforation is still an important health problem, despite the decreasing incidence of peptic ulcer disease. The aim of this study was to investigate factors affecting the mortality and morbidity of PUPs and specifically determine approaches to decrease mortality. MATERIAL AND METHODSThe data from 112 patients operated with the diagnosis of PUP at our Training and Research Hospital between January 2010 and December 2015 were retrospectively analyzed. Patient age, gender, weight, height, American Society of Anesthesiologists (ASA) score, symptoms, time interval between symptom onset and surgery, accompanying diseases, length of hospital stay, operative technique, laboratory findings, site and diameter of perforation, Acute Physiology and Chronic Health Evaluation (APACHE) II and Mannheim Peritonitis Index (MPI) scores, preoperative shock state, morbidity, and mortality were recorded. MPI (Table 1) and APACHE II scores were calculated for all patients. Patient age, chronic health status, rectal temperature, mean arterial blood pressure, heart rate, respiratory rate, arterial pH, partial oxygen pressure, serum sodium, serum potassium, serum creatinine, hematocrit, white blood cell count, and Glasgow coma score were recorded for determining the APACHE II score. 267Objective: Peptic ulcer perforation is a life-threatening situation requiring urgent surgical treatment. A novel vision in peptic ulcer perforation is necessary to fill the gaps created by antiulcer medication, aging of the patients, and presentation of resistant cases in our era. In this study, we aimed to share our findings regarding the effects of various risk factors and operative techniques on the mortality and morbidity of patients with peptic ulcer perforation. Material and Methods:Data from 112 patient...

Study of factors to assess the mortality and morbidity in perforated peptic ulcer disease

“…Few patients could not be revived even after ventilatory support. Adequate fluid resuscitation & ensuring satisfactory urine output before shifting the patient to surgery especially in patients with raised serum creatinine levels has cut down mortality from 9.8% in study conducted by Hut A et al [7] , and 9% in Lohsiriwat V [9] study to 5% in our study. Therefore, giving considerable attention to age and concomitant diseases, an aggressive pre operative resuscitation from shock, satisfactory urine output, avoiding delay in surgery, good surgical technique, thorough peritoneal lavage and meticulous post-operative care including chest physiotherapy is needed to improve overall results.…”

“…~ 137 ~ group with mortality was significantly higher than that of the morbidity, and the mean age of the morbidity group was significantly higher than that of the no complication group. Sivaram P et al [3] , Bojananpu S et al [5] and several other studies have reported that patients aged 65 years or more have significantly higher rates of mortality compared with younger patients [7,8,12,13] . similar to our study and this finding is believed to be due to the increased incidence of accompanying diseases in the elderly patients.…”

“…The epidemiology of peptic ulcer disease has changed in the past two decades with declining incidence rates [1,2] . Despite better understanding of peptic ulcer disease, effective resuscitation, developments in treatment and prompt surgery under modern anaesthesia techniques [3] , peptic ulcer perforation remains a serious surgical problem with significant mortality and morbidity risk [4][5][6][7][8][9] . Significant proportions of patients still die from complicated peptic ulcer indicating the need for improved preoperative optimization and postoperative care among these patients [4] .…”

“…The combination of older age group, [3,5,7,8,[12][13][14] active cancer, [13,14] hyperbilirubinemia, [14] hypoalbuminemia, [13,14] elevated creatinine and delay from perforation to surgery of >24 hrs [8,11,12,14] are best predictors of mortality. Female gender, [3,15] higher BMI, [7] preoperative shock, [8,11,12] pre-operative organ failure, [5] delayed presentation, [5,8] pre-existing illness like diabetes, hypertension, COPD, ischemic heart disease, [12] definitive surgery, [11] size of perforation more ~ 135 ~ than 1 cm 2 , [3,7,15] post-operative leak & other postoperative complications [13] were found to be significant factors influencing mortality and morbidity [3,5,8] . Comorbidities such as pulmonary disease, Cardiac disease & active cancer were identified as independent risk factors for fatal long-term outcome [3,13] .…”

“…Comorbidities such as pulmonary disease, Cardiac disease & active cancer were identified as independent risk factors for fatal long-term outcome [3,13] . Early diagnosis and treatment [6] , treating associated medical diseases [11] , improving early decisionmaking, reducing preoperative delay, improved perioperative monitoring [16] ensuring adequate proficiency in the various surgical techniques and addressing the unique postoperative circumstances of each patient [7,8] may be beneficial in optimizing outcomes of complicated PUD [4] .…”