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PubMed2004

Costs of treating bleeding and perforated peptic ulcers in The Netherlands.

OBJECTIVE: Gastrointestinal toxicity of nonsteroidal antiinflammatory drugs includes perforations and bleeds. Several preventive strategies are being tested for cost-effectiveness, but little is known about the costs of the complications they are trying to prevent. We estimated the direct costs of hospital treatment of bleeding and perforated ulcers in a university hospital, from data in discharge letters and the hospital management information system. METHODS: Eligible patients had been treated in the VU University Medical Center between January 1997 and August 2000 for an ulcer bleed or perforation (International Classification of Diseases code 531-4). Resource use comprised hospitalization days and diagnostic and therapeutic interventions. Insurance claim prices determined the costs from the payers' perspective. In a secondary analysis we excluded resource use that was clearly related to the treatment of comorbid illness. RESULTS: Fifty-three patients with a bleeding (n = 35) or perforated ulcer (n = 15) or both (n = 3) were studied, including 14 with comorbidity; 22 complications occurred in the stomach, 29 in the duodenum, one in both stomach and duodenum, and one after partial gastrectomy. A simultaneous bleed and perforation was most expensive (26,000 euro), followed by perforation (19,000 euro) and bleeding (12,000 euro). A bleed in the duodenum was more expensive than in the stomach (13,000 euro vs 10,000 euro), while the opposite was seen for perforations (13,000 euro vs 21,000 euro). Comorbidity increased costs substantially: even after correction for procedures unrelated to the ulcer complication, comorbidity more than doubled the costs of treatment. CONCLUSION: Treatment of complicated ulcers is expensive, especially in patients with comorbid conditions.

Adult↗
PubMed1989

Surgical treatment of bleeding and perforated peptic ulcer diseases.

From 1977 to 1988, 556 patients underwent emergency surgery for complicated peptic ulcers. Among them, 409 patients were for treated perforations and 147 for hemorrhages. In the perforated ulcer category, the morbidity rate was 12.5% and mortality rate 6.8%. For bleeding ulcers, the morbidity rate was 27.2% and mortality rate 14.9%. Several risk factors, such as age, interval of time between perforation and surgery, blood loss, associated disease, and shock were found to have created a higher operative risk. A definitive surgery including vagotomy and drainage, vagotomy and antrectomy, partial gastrectomy and highly selective vagotomy could be safely performed with an acceptable mortality for properly selected cases. Follow-up results also indicated better scores in this group of patients. We concluded that a definitive ulcer operation is safe, acceptable and curative for low risk patients with perforated or bleeding ulcers.

Adult↗
PubMed1993

Staged antrectomy and thoracoscopic truncal vagotomy for perforated peptic ulcer disease.

We report the case of a 40-year-old man with a perforated duodenal ulcer who underwent antrectomy at laparotomy, and in whom standard truncal vagotomy was not technically possible due to an intraabdominal abscess. Thoracoscopic truncal vagotomy performed at the level of the inferior pulmonary vein was successful in completely eliminating symptoms due to peptic ulcer disease without producing clinically significant morbidity. The minimal morbidity and short hospital stay suggest that thoracoscopic truncal vagotomy provides a reasonable alternative in patients with complicated intraabdominal abscesses due to peptic ulcer disease.

Adult↗
PubMed1991

Peptic ulcer perforation as the presentation of Zollinger-Ellison syndrome.

We examined the characteristics of patients with Zollinger-Ellison syndrome who developed a perforation prior to diagnosis to determine whether any clinical features were useful markers of the syndrome. Of 160 patients with Zollinger-Ellison syndrome, perforation occurred prior to the diagnosis being made in 11 (7%). At surgery, perforations were found in the duodenum in six cases and in the jejunum in five. In no case was tumor identified at emergency surgery, and the diagnosis of Zollinger-Ellison syndrome was made only in the postoperative period when excessive gastric secretions were noted. Neither acid output nor serum gastrin concentration were useful predictors for perforation. The patients, six men and five women, were 27-61 years old (median 48) and one had MEN-1. Three patients had no symptoms prior to the perforation. The other eight had symptoms for 1-15 years, with diarrhea occurring in 45% of the cases. Following the diagnosis of Zollinger-Ellison syndrome, patients were given medication to control gastric acid hypersecretion. Eight patients remained well, but the three patients who had had a partial gastrectomy had a complicated course despite medical therapy. Although features of perforation in Zollinger-Ellison syndrome are not specific, jejunal perforation or perforation associated with a history of diarrhea is suggestive of the diagnosis. Serum gastrin should be measured in every case and a partial gastrectomy avoided.

Adult↗
PubMed1989

Perforated peptic ulcer: a deliberative approach.

Between 1966 and 1987, 116 patients with 119 episodes of perforation were admitted to Box Hill Hospital into one surgical unit, and 91 patients with 92 episodes were admitted into the other, with patients being admitted in alternate weeks. In the former unit, in order to avoid surgery in those patients whose ulcers had sealed spontaneously, a deliberative approach was followed according to a strict protocol--involving a deliberate time delay in surgical decision-making. In the latter unit, a more conventional approach was adopted, and patients in that unit are used as a retrospective comparison. In the first unit, of 115 episodes which followed the protocol, six were unresuscitable, 15 needed immediate surgery and 94 followed a delayed approach. Of that 94, 12 needed surgery at 4-6 h, and a further eight needed later surgery. Seventy-four (68% of 'operable' patients) did not require corrective surgery at all, for their episode of perforation. The operable mortality rate was lower (6% compared with 13%), the bedstay was shorter, the prolonged bedstay rate was lower, and the morbidity was no worse, than those patients treated more conventionally in the second unit.

Adolescent↗
PubMed2005

Management strategies, early results, benefits, and risk factors of laparoscopic repair of perforated peptic ulcer.

The primary goal of this study was to describe epidemiology and management strategies of the perforated duodenal ulcer, as well as the most common methods of laparoscopic perforated duodenal ulcer repair. The secondary goal was to demonstrate the value of prospective and retrospective studies regarding the early results of surgery and the risk factors. The tertiary goal was to emphasize the benefits of this operation, and the fourth goal was to clarify the possible risk factors associated with laparoscopic repair of the duodenal ulcer. The Medline/Pubmed database was used. Review was done after evaluation of 96 retrieved full-text articles. Thirteen prospective and twelve retrospective studies were selected, grouped, and summarized. The spectrum of the retrospective studies' results are as follows: median overall morbidity rate 10.5 %, median conversion rate 7%, median hospital stay 7 days, and median postoperative mortality rate 0%. The following is the spectrum of results of the prospective studies: median overall morbidity rate was slightly less (6%); the median conversion rate was higher (15%); the median hospital stay was shorter (5 days) and the postoperative mortality was higher (3%). The risk factors identified were the same. Shock, delayed presentation (> 24 hours), confounding medical condition, age > 70 years, poor laparoscopic expertise, ASA III-IV, and Boey score should be considered preoperative laparoscopic repair risk factors. Each of these factors independently should qualify as a criterion for open repair due to higher intraoperative risks as well as postoperative morbidity. Inadequate ulcer localization, large perforation size (defined by some as > 6 mm diameter, and by others as > 10 mm), and ulcers with friable edges are also considered as conversion risk factors.

Digestive System Surgical Procedures↗