Are Patients with Perforated Peptic Ulcers Who are Negative for Helicobacter pylori at a Greater Risk?

Background: The link between Helicobacter pylori infection and peptic ulceration is well established. Recent studies have reported a decrease of H. pylori-related peptic ulcer disease; Helicobacter pylori eradication is likely the cause of this decrease. We hypothesized that patients with H. pylori-positive perforated peptic ulcer disease (PPUD) requiring surgical intervention had worse outcomes than patients with H. pylori-negative PPUD. Patients and Methods: A prospectively collected Acute and Critical Care Surgery registry spanning the years 2008 to 2015 was searched for patients with PPUD and tested for H. pylori serum immunoglobulin G (IgG) test. Patients were divided into two cohorts: H. pylori positive (HPP) and H. pylori negative (HPN). Demographics, laboratory values, medication history, social history, and esophagogastroduodenoscopy were collected. Student t-test was used for continuous variables and χ2 test was used for categorical variables. Linear regression was applied as appropriate. Results: We identified 107 patients diagnosed with PPUD, of whom 79 (74%) patients had H. pylori serum IgG testing. Forty-two (53.2%) tested positive and 37 (46.8%) tested negative. Helicobacter pylori-negative PPUD was more frequent in females (70.27%, p = 0.004), whites (83.78%, p = 0.001) and patients with higher body mass index (BMI) 28.81 ± 8.8 (p = 0.033). The HPN group had a lower serum albumin level (2.97 ± 0.96 vs. 3.86 ± 0.91 p = 0.0001), higher American Society of Anesthesiologists (ASA; 3.11 ± 0.85 vs. 2.60 ± 0.73; p = 0.005), and Charlson comorbidity index (4.81 ± 2.74 vs. 2.98 ± 2.71; p = 0.004). On unadjusted analysis the HPN cohort had a longer hospital length of stay (LOS; 20.20 ± 13.82 vs. 8.48 ± 7.24; p = 0.0001), intensive care unit (ICU) LOS (10.97 ± 11.60 vs. 1.95 ± 4.59; p = 0.0001), increased ventilator days (4.54 ± 6.74 vs. 0.98 ± 2.85; p = 0.004), and higher rates of 30-day re-admission (11; 29.73% vs. 5; 11.91%; p = 0.049). Regression models showed that HPN PPUD patients had longer hospital and ICU LOS by 11 days (p = 0.002) and 8 days (p = 0.002), respectively, compared with HPP PPUD. Conclusion: In contrast to our hypothesis, HPN patients had clinically worse outcomes than HPP patients. These findings may represent a difference in the baseline pathophysiology of the peptic ulcer disease process. Further investigation is warranted.

Is the Platelet to Lymphocyte Ratio a Potential Biomarker for Predicting Mortality in Peptic Ulcer Perforation?

Background: Despite surgical treatment of peptic ulcer perforation (PUP), the high rates of morbidity and mortality have motivated researchers to search for new laboratory markers to predict morbidity and mortality. The aim of this study was to investigate the relation between pre-operative laboratory values and demographic factors and post-operative mortality in patients undergoing surgery for PUP. Patients and Methods: A retrospective study was made of the clinical findings and laboratory data of patients operated on for a diagnosis of PUP in the general surgery clinic between 2014 and 2018. The patients were separated into two groups according to survival (PUP-S) or mortality (PUP-M) and the differences between the groups were evaluated. Result: In the analysis of the patient data, age (p = 0.014), female gender (p = 0.005), length of stay in hospital (p = 0.009), platelet to lymphocyte ratio (PLR) (p = 0.09), and neutrophil to lymphocyte ratio (NLR) (p = 0.010) values were determined to be high and lymphocyte count was low (p = 0.046) in the PUP-M group. A positive correlation was determined between mortality and age, length of stay in hospital, PLR, and NLR (p < 0.05). A substantial negative correlation was determined between mortality and gender and lymphocyte count (p < 0.05). As a result of the receiver operating characteristic (ROC) curve analysis, it was determined that a PLR value <322.22 (p = 0.009) and lymphocyte count <0.67 × 103 microliter (p = 0.035) could have diagnostic value in the prediction of the possibility of mortality in patients operated on because of PUP. Conclusion: This study results suggested that PLR, NLR, and lymphocyte count values could be used as new biomarkers to identify the mortality risk in patients operated on for peptic ulcer perforation.

Diverticular Perforation: A Fatal Complication to Forestall in Cushing Syndrome.

Context: Patients taking exogenous glucocorticoids are at risk for gastrointestinal (GI) complications, including peptic ulcer disease with perforation and gastric bleeding. However, little is known about the GI comorbidity in patients with endogenous hypercortisolemia. Case Descriptions: We describe six patients with endogenous Cushing syndrome (CS) who developed sudden perforation of colonic diverticula necessitating urgent exploratory laparotomy. Most of these patients shared the following features of CS: skin thinning, severe hypercortisolemia (24-hour urinary free cortisol ≥10 times the upper limit of normal), ectopic secretion of ACTH, and severe hypokalemia. At the time of diagnosis of diverticular perforation (DP), these patients had minimal signs of peritonitis and lacked fever or marked leukocytosis. The diagnosis of DP was established by having a low threshold for obtaining an imaging study for evaluation of nonspecific abdominal pain. Conclusions: Patients with CS can develop spontaneous surgical abdomen with rapid decompensation within hours. Prompt recognition is critical in the successful treatment of these patients.

Adult gastric duplication: an unknown condition within the spectrum of gastric submucosal lesions.

BACKGROUND: Gastric duplication is an uncommon condition in adults representing only 4-8% of all gastrointestinal duplications. It develops as a cystic growth within the thick gastric wall that is surrounded by a layer of smooth muscle and lined with gastric mucosa. It is usually asymptomatic but may present with nonspecific abdominal symptoms as well as cyst-related complications such as gastrointestinal (GI) bleeding, ulceration and even pancreatitis. They are difficult to distinguish from other gastric submucosal lesions and may also mimic a gastrointestinal tumor (GIST) or mucinous cyst of the pancreas. Endoscopic ultrasound (EUS) is the most widely used diagnostic procedure and histology provides a definitive diagnosis. CASE REPORT: We report the case of a 36-year-old female patient with a history of a "contained" perforated gastric ulcer that was managed conservatively. The patient was diagnosed with a gastric GIST which prompted a laparoscopic subtotal gastrectomy and Roux-en-Y reconstruction with a good postoperative outcome. DISCUSSION: The definitive histological diagnosis was gastric duplication. Thus, the previous diagnosis of a "contained" perforated gastric ulcer was in fact a complication of the gastric duplication itself.

[SURGICAL TREATMENT OF COMPLICATED GASTRODUODENAL ULCER].

Results of operative treatment of 437 patients with complicated gastroduodenal ulcer were summarized. The modern views on the problem of conservative therapy for gas- troduodenal ulcer were presented. A rational individual approach with a certain terms is necessary for conservative treatment of gastroduodenal ulcer. A real way for improve- ment of the patients treatment results--it is a combination of effective conservative treatment with a timely established indications for a planned operative treatment before dangerous complications occur.

Sequential versus concomitant therapy for eradication of Helicobacter Pylori in patients with perforated duodenal ulcer: A randomized trial.

OBJECTIVES: Comparison of Helicobacter pylori eradication rates, side effects, compliance, cost, and ulcer recurrence of sequential therapy (ST) with that of concomitant therapy (CT) in patients with perforated duodenal ulcer following simple omental patch closure. METHODS: Sixty-eight patients with perforated duodenal ulcer treated with simple closure and found to be H. pylori positive on three months follow-up were randomized to receive either ST or CT for H. pylori eradication. Urease test and Giemsa stain were used to assess for H. pylori eradication status. Follow-up endoscopies were done after 3 months, 6 months, and 1 year to evaluate the ulcer recurrence. RESULTS: H. pylori eradication rates were similar in ST and CT groups on intention-to-treat (ITT) analysis (71.43% vs 81.80%,P = 0.40). Similar eradication rates were also found in per-protocol (PP) analysis (86.20% vs 90%,P = 0.71). Ulcer recurrence rate in ST groups and CT groups at 3 months (17.14% vs 6.06%,P = 0.26), 6 months (22.86% vs 9.09%,P = 0.19), and at 1 year (25.71% vs 15.15%,P = 0.37) of follow-up was also similar by ITT analysis. Compliance and side effects to therapies were comparable between the groups. The most common side effects were diarrhoea and metallic taste in ST and CT groups, respectively. A complete course of ST costs Indian Rupees (INR) 570.00, whereas CT costs INR 1080.00. CONCLUSION: H. pylori eradication rates, side effects, compliance, cost, and ulcer recurrences were similar between the two groups. The ST was more economical compared with CT.

TACTICS OF TREATMENT OF PERFORATIVE GASTRODUODENAL ULCER.

The covered perforation of gastroduodenal ulcer constitutes certain difficulties in diag' nosis, causing distortion of clinical symptoms. The diagnosis is usually established with delay. In the clinic during 7 years in 24 patients the covered perforative aperture of gas' troduodenal ulcer was revealed, constituting 6.8% оf total number of perforative ulcers. Pneumoperitoneum was not established. After pneumogastroscopy in 3 patients with a free gas revealed, they were operated on. After analyzing of dynamics in rest of patients their state degradation and the peritoneal symptoms occurrence was noted, what have had demanded performance of operative intervention. Lethality was 4.1%.

Gastrojejunal Anastomosis Complications and Their Management after Laparoscopic Roux-en-Y Gastric Bypass.

BACKGROUND: Complications at the gastrojejunal anastomosis after laparoscopic Roux-en-Y gastric bypass (LRYGB) are challenging in terms of diagnosis, therapy, and prevention. This study aims at identifying these complications and discussing their management. METHODS: Data of 228 patients who underwent a LRYGB between October 2008 and December 2011 were reviewed retrospectively to evaluate the frequency and treatment of complications such as stenoses, marginal ulcers, perforated marginal ulcers, or anastomotic leaks related to the operation. RESULTS: Follow-up information was available for 209 patients (91.7%) with a median follow-up of 38 months (range 24-62 months). Of these patients 16 patients (7.7%) experienced complications at the gastrojejunostomy. Four patients (1.9%) had stenoses and 12 patients (5.7%) marginal ulcers, one of them with perforation (0.5%). No anastomotic leaks were reported. One case with perforated ulcer and one with recurrent ulcers required surgical revision. CONCLUSION: Gastrojejunal anastomotic complications are frequent and occur within the first few days or up to several years after surgery. Stenoses or marginal ulcers are usually successfully treated nonoperatively. Laparoscopic repair, meanwhile, is an appropriate therapeutic option for perforated ulcers.

Risk factors associated with conversion of laparoscopic simple closure in perforated duodenal ulcer.

BACKGROUND: Precise patient selection criteria are necessary to guide the surgeon in selecting laparoscopic repair for patients with perforated peptic ulcers. The aims of this study are to report surgical outcomes after surgery for perforated duodenal ulcers and identify risk factors for predicting failure of laparoscopic simple closure for perforated duodenal ulcer. METHODS: In total, 77 patients who underwent laparoscopic simple closure for perforated duodenal ulcers from January 2007 to September 2013 were retrospectively analyzed. Patients were divided into totally laparoscopic and conversion groups. The characteristics of patients, intraoperative findings, postoperative complications, conversion rates and suture leakage rates of each group were investigated. RESULTS: Laparoscopic repair was completed in 69 (89.6%) of 77 patients, while 8 (10.4%) underwent conversion to open repair. Patients in the conversion group had longer perforation time, larger perforation size, more suture leakage, longer hospital stay, and higher 30-day mortality rate than those in the totally laparoscopic group. The size of perforation was the only risk factor for conversion in multivariable analysis. Patients with an ulcer perforation size of ≥9 mm or with perforation duration of ≥12.5 h had a significantly increased risk for conversion and suture leakage. CONCLUSIONS: Ulcer size of ≥9 mm is a significant risk factor for predicting conversion in laparoscopic simple closure. Suture leakage is associated with ulcer size (9 mm) and duration of perforation (12.5 h).

The selective use of laparoscopic repair is safe in high-risk patients suffering from perforated peptic ulcer.

BACKGROUND: The use of laparoscopic repair for perforated peptic ulcer (PPU) was shown to be safe and recommended in low-risk patients. However, whether the approach is safe to apply to high-risk patients is uncertain. STUDY DESIGN: This was a retrospective study of all patients with PPU admitted between January 2002 and December 2012. The laparoscopy-first approach (LFA) was adopted as a routine for all patients. The outcomes of LFA for PPU were reviewed and assessed to determine if the approach was safe in high-risk patients. RESULTS: Three hundred and seventy three patients that suffered from PPU were included into the study and 50.9% received laparoscopic repair. There was a significant increase in the number of operations performed yearly by the LFA (P < 0.001). 25.2% of the patients had a Boey score of ≥2. High-risk patients that received LFA suffered from larger ulcers (P < 0.001) with more severe contamination (P = 0.006) that required conversion (P = 0.002) when compared to the low-risk patients. When compared to open surgery, more high-risk patients in the open group had ASA grade ≥3 (P = 0.007) and suffered from mortality (P = 0.001). The only significant predictor to mortality in high-risk patients was ASA grade ≥3 (P = 0.014). CONCLUSIONS: The adoption of LFA in patients suffering from PPU was associated with acceptable rates of mortality and morbidity. The approach could also be selectively adopted in patients with Boey score ≥2 provided their ASA grading is low and hemodynamically stable.

[Postoperative reflux in treatment of complicated forms of duodenal ulcer disease].

There were examined 46 patients, in whom operative treatment of perforative duodenal ulcer was conducted. Organ-preserving operations were performed in conjunction with selective proxymal or truncal vagotomy. In far-remote terms after the operation in 12 patients gastrooesophageal reflux have occurred, DeMeester index have constituted 17.5-38.5. Impact of operative trauma on antireflux power of gastro-oesophageal junction was noted.

Gastroduodenal perforation.

The cause and management of gastroduodenal perforation have changed as a result of increasing use of nonsteroidal antiinflammatories and improved pharmacologic treatment of acid hypersecretion as well as the recognition and treatment of Helicobacter pylori. As a result of the reduction in ulcer recurrence with medical therapy, the surgical approach to patients with gastroduodenal perforation has also changed over the last 3 decades, with ulcer-reducing surgery being performed infrequently.

[Dynamics of a CD3-lymphocytes contents during intraabdominal sorption-transmembranous dialysis in patients with extended peritonitis].

The analysis of clinical and laboratory material in patients, suffering extended peritonitis,was conducted. There was established, that application of the sorption-transmembranous dialysis and abdominal cavity sanation guarantees the CD3 lymphocytes protection and the endotoxicosis severity reduction.