Evaluating the Evolving Morbidity of Omentoplasty for Perforated Peptic Ulcer Disease

Abstract

Mortality for perforated peptic ulcer (PPU) surgery ranges from 2-22% with morbidity ranging from 15-45%. Traditionally, these had been repaired with vagotomy and antrectomy or pyloroplasty with smaller perforations repaired with an omentoplasty. Laparoscopic repair has become increasingly prevalent and demonstrated to have shorter length of stay (LOS) and fewer complications. We are evaluating the surgical repair of PPU with omentoplasty to determine trends of utilization and surgical outcomes. We conducted a 13-year (2005-2017) retrospective review, utilizing the National Surgical Quality Improvement Program database. A total of 6873 patients had open or laparoscopic repair of a PPU, with 2285 patients identified as utilizing omentoplasty. Five hundred eighty-eight omentoplasty patients were further identified as having a laparoscopic technique. We compared patient demographics, comorbidities, and perioperative morbidity and mortality for surgical patients between 2005-2011 and 2012-2017. We trended the perioperative outcomes across the study intervals. Parametric and nonparametric tests were used to evaluate outcomes. Between 2005 and between 2017, laparoscopic surgical repair with omentoplasty has increased from 3.8% to 34.6%. Overall mortality for open operations declined during this interval (12.7%-9.3%) while it remained unchanged for laparoscopic operations (4.6%-4.2%), there was not a significant difference between the laparoscopic and open 30-day mortality. Both open surgery and laparoscopic surgery are being used on an increasingly healthy cohort (increased functional status decreased predicted perioperative morbidity). Relative to the 2005-2011, the laparoscopic surgery 2012-2017 cohort had increases in both serious and overall morbidity, although this was not statistically significant. Compared to the 2005-2011, the 2012-2017 open surgery cohort had increasing serious morbidity (OR 2.03) and overall morbidity (OR 1.91). There was a trend of decreasing LOS and increased return to the operating room for patients with laparoscopic surgery. Laparoscopic Graham patch repair of peptic ulcers significantly increased, although open repair still constitutes the majority of the cases. Despite Graham patch repair being utilized on a healthier patient population, morbidity and mortality for laparoscopic repair have remained unchanged. Postoperative morbidity and mortality for open surgery have increased. This indicates that laparoscopic repair is more commonly utilized for low- or medium risk patients, leaving an increasingly sick patient population selected to open repair.

Surgical Management of Perforated Peptic Ulcer: A Comparative Meta-analysis of Laparoscopic Versus Open Surgery

“…Subsequently, 1466 records were screened; of them, 48 studies were assessed for eligibility against the inclusion/exclusion criteria. However, 9 articles were excluded owing to a lack of primary outcomes, 19,20 lack of access to a full article, 21,22 recruiting specific populations (elderly and pediatrics), 23 article retraction, 24,25 and article writing in a nonEnglish language. 26,27 Concomitantly, 6 articles were identified from the bibliographies of the screened articles, and all those studies were included.…”

A systematic review and meta-analysis comparing postoperative outcomes of laparoscopic versus open omental patch repair of perforated peptic ulcer

“…Of the 29 studies included, there were 9 studies that did not have open conversion, 9,22,25,[28][29][30]36,42,43 12 studies that were analyzed with intention-to-treat analysis, 23,31,32,34,35,[38][39][40][44][45][46][47] 2 studies analyzed with per-protocol analysis, 26,33 3 studies that separately analyzed LOPR with open conversion, 27,37,41 1 study that did not mention whether studies were analyzed based on intention-to-treat or per-protocol analysis, 24 1 study that excluded open conversions in their analysis, 49 and 1 study that did not report on open conversion. 48 For the three studies that analyzed LOPR with open conversion separately, 27,37,41 we analyzed them using per-protocol analysis. Risk of bias assessments for RCTs and NRCTs are summarized in Supplementary Figure S1A and Figure S1B, respectively, http://links.lww.com/TA/C739.…”

Outcomes of surgical management of peptic ulcer perforation using the falciform ligament: A cross-sectional study at a single centre in Vietnam

“…Peptic ulcer perforation is one of the most serious surgical complications that can lead to death. Mortality from PUP surgery ranges from 2 to 22% and contributes to 37% of all peptic ulcer-related deaths [ 6 ]. Imhof's study on 108 patients with duodenal ulcer perforation showed that these patients had a poor prognosis, with mortality rates after 1 month, 1 year, and 5 years of 9.1%, 20.2% and 32.3%, respectively.…”

“…[ 5 ] If newer methods affect the outcome of treatment, should surgery be indicated ? And [ 6 ] Should laparoscopic surgery be indicated? Some methods are used, such as simple perforation sutures, that can suture the PUP and cover it with the omentum (Cellan-Jones repair) or with Graham patches [ 3 ].…”

“…Currently, laparoscopic surgery is the first choice when patients arrive early and have premature ulcers, and this technique is easy to perform. However, for patients who have undergone previous abdominal surgeries, and have large PUPs located in the pylorus or have suspected malignant ulcer perforations, laparoscopy procedures should not be performed, and the treatment should change to open laparotomy [ 6 ].…”