The current role of surgery in the treatment of gastroduodenal ulcer
Abstract
Surgery for gastroduodenal ulcer disease has been declining in the past few decades and the role of surgery in the treatment of gastroduodenal ulcer has been referred to the treatment of this complications. In this paper, the authors proposed to study the current role of surgery in the treatment of this disease between January 2001 and December 2010. During this period 134 patients were operated, all for complications of gastroduodenal ulcers (83 by perforation, 34 by hemorrhage, 16 by stenosis and 1 by intractability). Patients were mostly male (63.4%) and 67.2% had no known past ulcer. Alcohol habits, medication with NSAIDs and smoking habits were the most prevalent risk factors. Most patients were ASA III or IV and only 36.57% were submitted to definitive surgery. Hemorrhage behaved the highest rate of complications, re-intervention and mortality. Comparing with previous study periods, the medical intractability is today a rare indication for surgery, and the perforation, gastrointestinal hemorrhage and stenosis represent the most common indications. The emergency surgery mostly associated with older patients and their co-morbidities, may have contributed to some of the unfavorable results.
Keywords: Peptic ulcer, gastric ulcer, peptic ulcer perforation, gastrointestinal hemorrhage, piloric stenosis
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References
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Lau, J. Y. et al. Systematic Review of the Epidemiology of Complicated Peptic Ulcer Disease: Incidence, Recurrence, Risk Factors and Mor-
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Johnson, H. D. THE CLASSIFICATION AND PRINCIPLES OF TREATMENT OF GASTRIC ULCERS. The Lancet 270, 518-520
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Csendes, A., Braghetto, I. & Smok, G. Type IV gastric ulcer: a new hypothesis. Surgery 101, 361-366 (1987).
Stewart, D. J. & Ackroyd, R. Peptic ulcers and their complications. Surgery (Oxford) 29, 568-574 (2011).
Majumdar, D. & Atherton, J. Peptic ulcers and their complications. Surgery (Oxford) 24, 110-114 (2006).
GM, D. & Way LW. Stomach & Duodenum. CURRENT Diagnosis & Treatment: Surgery. Chapter 23., (2010).
Arroyo, M. T. et al. The prevalence of peptic ulcer not related to Helicobacter pylori or non-steroidal anti-inflammatory drug use is negligible
in southern Europe. Helicobacter 9, 249-254 (2004).
Bardhan, K. D. & Royston, C. Time, change and peptic ulcer disease in Rotherham, UK. Digestive and Liver Disease 40, 540-546 (2008).
Lee, C. W. & Sarosi, G. A. Emergency Ulcer Surgery. Surgical Clinics of North America 91, 1001-1013 (2011).
Sonnenberg, A. Time trends of ulcer mortality in Europe. Gastroenterology 132, 2320-2327 (2007).
Wang, Y. R., Richter, J. E. & Dempsey, D. T. Trends and outcomes of hospitalizations for peptic ulcer disease in the United States, 1993 to
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Jamieson, G. G. Current status of indications for surgery in peptic ulcer disease. World J Surg 24, 256-258 (2000).
Lassen, A., Hallas, J. & Schaffalitzky de Muckadell, O. B. Complicated and uncomplicated peptic ulcers in a Danish county 1993-2002:
a population-based cohort study. Am. J. Gastroenterol. 101, 945-953 (2006).
Hunt, R. H. & Yuan, Y. Acid-NSAID/aspirin interaction in peptic ulcer disease. Dig Dis 29, 465-468 (2011).
Gisbert, J. P. & Pajares, J. M. Review article: Helicobacter pylori infection and gastric outlet obstruction – prevalence of the infection and
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Malfertheiner, P., Chan, F. K. L. & McColl, K. E. L. Peptic ulcer disease. Lancet 374, 1449-1461 (2009).
Yuan, Y., Padol, I. T. & Hunt, R. H. Peptic ulcer disease today. Nat Clin Pract Gastroenterol Hepatol 3, 80-89 (2006).
Milosavljevic, T., Kostić-Milosavljević, M., Jovanović, I. & Krstić, M. Complications of peptic ulcer disease. Dig Dis 29, 491-493 (2011).
Robson, A. J., Richards, J. M. J., Ohly, N., Nixon, S. J. & Paterson-Brown, S. The Effect of Surgical Subspecialization on Outcomes in
Peptic Ulcer Disease Complicated by Perforation and Bleeding. World Journal of Surgery 32, 1456-1461 (2008).
Kreissler-Haag, D., Schilling, M. K. & Maurer, C. A. [Surgery of complicated gastroduodenal ulcers: outcome at the millennium]. Zentralbl
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Espat, N. J., Ong, E. S., Helton, W. S. & Nyhus, L. M. 1990-2001 US general surgery chief resident gastric surgery operative experience:
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Robson, A. J., Richards, J. M. J., Ohly, N., Nixon, S. J. & Paterson-Brown, S. The Effect of Surgical Subspecialization on Outcomes in
Peptic Ulcer Disease Complicated by Perforation and Bleeding. World Journal of Surgery 32, 1456-1461 (2008).
Thorsen, K., Glomsaker, T. B., von Meer, A., Søreide, K. & Søreide, J. A. Trends in diagnosis and surgical management of patients with
perforated peptic ulcer. J. Gastrointest. Surg. 15, 1329-1335 (2011).
Zittel, T. T., Jehle, E. C. & Becker, H. D. Surgical management of peptic ulcer disease today--indication, technique and outcome. Langen-
becks Arch Surg 385, 84-96 (2000).
Blomgren, L. G. Perforated peptic ulcer: long-term results after simple closure in the elderly. World J Surg 21, 412-414; discussion 414-415
(1997).
Bhogal, R. H., Athwal, R., Durkin, D., Deakin, M. & Cheruvu, C. N. V. Comparison between open and laparoscopic repair of perforated
peptic ulcer disease. World J Surg 32, 2371-2374 (2008).
Sarath Chandra, S. & Siva Kumar, S. Definitive or conservative surgery for perforated gastric ulcer? – An unresolved problem. International
Journal of Surgery 7, 136-139 (2009).
Chan, W. H., Wong, W. K., Khin, L. W. & Soo, K. C. Adverse operative risk factors for perforated peptic ulcer. Ann. Acad. Med. Singap. 29,
164-167 (2000).
Kocer, B. et al. Factors affecting mortality and morbidity in patients with peptic ulcer perforation. J. Gastroenterol. Hepatol. 22, 565-570
(2007).
Noguiera, C. et al. Perforated peptic ulcer: main factors of morbidity and mortality. World J Surg 27, 782-787 (2003).
Møller, M. H., Adamsen, S., Thomsen, R. W. & Møller, A. M. Preoperative prognostic factors for mortality in peptic ulcer perforation:
a systematic review. Scand. J. Gastroenterol. 45, 785-805 (2010).
Gralnek, I. M., Barkun, A. N. & Bardou, M. Management of Acute Bleeding from a Peptic Ulcer. N Engl J Med 359, 928-937 (2008).
Cheung, F. K. Y. & Lau, J. Y. W. Management of Massive Peptic Ulcer Bleeding. Gastroenterology Clinics of North America 38, 231-243 (2009).
Laine, L. & Jensen, D. M. Management of patients with ulcer bleeding. Am. J. Gastroenterol. 107, 345-360; quiz 361 (2012).
Holster, I. L. & Kuipers, E. J. Management of acute nonvariceal upper gastrointestinal bleeding: current policies and future perspectives.
World J. Gastroenterol. 18, 1202-1207 (2012).
Štimac, D., Franjić, N. & Krznarić, Ž. Acid inhibition and peptic ulcer bleeding. Dig Dis 29, 494-498 (2011).
Rutgeerts, P. & Vantrappen, G. The benefits of endoscopy in upper gastrointestinal bleeding. Endoscopy 18 Suppl 2, 15-17 (1986).
Vergara, M. et al. Helicobacter pylori eradication prevents recurrence from peptic ulcer haemorrhage. Eur J Gastroenterol Hepatol 12, 733-
-737 (2000).
Gralnek, I. M. et al. Clinical and economic outcomes of individuals with severe peptic ulcer hemorrhage and nonbleeding visible vessel: an
analysis of two prospective clinical trials. Am. J. Gastroenterol. 93, 2047-2056 (1998).
Hasselgren, G., Carlsson, J., Lind, T., Schaffalitzky de Muckadell, O. & Lundell, L. Risk factors for rebleeding and fatal outcome in elderly
patients with acute peptic ulcer bleeding. Eur J Gastroenterol Hepatol 10, 667-672 (1998).
Röher, H. D., Imhof, M., Goretzki, P. E. & Ohmann, C. [Ulcer surgery ’96-choice of methods in an emergency]. Chirurg 67, 20-25 (1996).
Heldwein, W., Schreiner, J., Pedrazzoli, J. & Lehnert, P. Is the Forrest classification a useful tool for planning endoscopic therapy of bleeding
peptic ulcers? Endoscopy 21, 258-262 (1989).
Guglielmi, A. et al. Risk assessment and prediction of rebleeding in bleeding gastroduodenal ulcer. Endoscopy 34, 778-786 (2002).
Chung, I. K. et al. Endoscopic factors predisposing to rebleeding following endoscopic hemostasis in bleeding peptic ulcers. Endoscopy 33,
969-975 (2001).
Abe, N., Takeuchi, H., Yanagida, O., Sugiyama, M. & Atomi, Y. SURGICAL INDICATIONS AND PROCEDURES FOR BLEEDING
PEPTIC ULCER. Digestive Endoscopy 22, S35-S37 (2010).
Nahon, S., Pariente, A., Nalet, B., Hagège, H. & Latrive, J.-P. Causes of mortality related to peptic ulcer bleeding in a prospective cohort of
965 French patients: a plea for primary prevention. Am. J. Gastroenterol. 105, 1902-1903 (2010).
Sung, J. J. Y. et al. Causes of mortality in patients with peptic ulcer bleeding: a prospective cohort study of 10,428 cases. Am. J. Gastroenterol.
105, 84-89 (2010).
Chiu, P. W. Y. et al. Predictors of peptic ulcer rebleeding after scheduled second endoscopy: clinical or endoscopic factors? Endoscopy 38,
726-729 (2006).
Rockall, T. A. Management and outcome of patients undergoing surgery after acute upper gastrointestinal haemorrhage. Steering Group for
the National Audit of Acute Upper Gastrointestinal Haemorrhage. J R Soc Med 91, 518-523 (1998).
Cochran, T. A. Bleeding peptic ulcer: surgical therapy. Gastroenterol. Clin. North Am. 22, 751-778 (1993).
García Sánchez, M. V. et al. [Factors associated with failure of endoscopic therapy in gastric ulcer bleeding]. Gastroenterol Hepatol 26, 227-
-233 (2003).
Lundell, L. Acid secretion and gastric surgery. Dig Dis 29, 487-490 (2011).
Lipof, T., Shapiro, D. & Kozol, R.-A. Surgical perspectives in peptic ulcer disease and gastritis. World J. Gastroenterol. 12, 3248-3252 (2006).
Sarosi, G. A. et al. Surgical therapy of peptic ulcers in the 21st century: more common than you think. The American Journal of Surgery 190,
775-779 (2005).
Lau, J. Y. et al. Systematic Review of the Epidemiology of Complicated Peptic Ulcer Disease: Incidence, Recurrence, Risk Factors and Mor-
tality. Digestion 84, 102-113 (2011).
Johnson, H. D. THE CLASSIFICATION AND PRINCIPLES OF TREATMENT OF GASTRIC ULCERS. The Lancet 270, 518-520
(1957).
Schwartz, S. I. & Brunicardi, F. C. Schwartz’s principles of surgery. (McGraw-Hill, Medical Pub. Division: New York, 2010).
Csendes, A., Braghetto, I. & Smok, G. Type IV gastric ulcer: a new hypothesis. Surgery 101, 361-366 (1987).
Stewart, D. J. & Ackroyd, R. Peptic ulcers and their complications. Surgery (Oxford) 29, 568-574 (2011).
Majumdar, D. & Atherton, J. Peptic ulcers and their complications. Surgery (Oxford) 24, 110-114 (2006).
GM, D. & Way LW. Stomach & Duodenum. CURRENT Diagnosis & Treatment: Surgery. Chapter 23., (2010).
Arroyo, M. T. et al. The prevalence of peptic ulcer not related to Helicobacter pylori or non-steroidal anti-inflammatory drug use is negligible
in southern Europe. Helicobacter 9, 249-254 (2004).
Bardhan, K. D. & Royston, C. Time, change and peptic ulcer disease in Rotherham, UK. Digestive and Liver Disease 40, 540-546 (2008).
Lee, C. W. & Sarosi, G. A. Emergency Ulcer Surgery. Surgical Clinics of North America 91, 1001-1013 (2011).
Sonnenberg, A. Time trends of ulcer mortality in Europe. Gastroenterology 132, 2320-2327 (2007).
Wang, Y. R., Richter, J. E. & Dempsey, D. T. Trends and outcomes of hospitalizations for peptic ulcer disease in the United States, 1993 to
2006. Ann. Surg. 251, 51-58 (2010).
Jamieson, G. G. Current status of indications for surgery in peptic ulcer disease. World J Surg 24, 256-258 (2000).
Lassen, A., Hallas, J. & Schaffalitzky de Muckadell, O. B. Complicated and uncomplicated peptic ulcers in a Danish county 1993-2002:
a population-based cohort study. Am. J. Gastroenterol. 101, 945-953 (2006).
Hunt, R. H. & Yuan, Y. Acid-NSAID/aspirin interaction in peptic ulcer disease. Dig Dis 29, 465-468 (2011).
Gisbert, J. P. & Pajares, J. M. Review article: Helicobacter pylori infection and gastric outlet obstruction – prevalence of the infection and
role of antimicrobial treatment. Aliment. Pharmacol. Ther. 16, 1203-1208 (2002).
Malfertheiner, P., Chan, F. K. L. & McColl, K. E. L. Peptic ulcer disease. Lancet 374, 1449-1461 (2009).
Yuan, Y., Padol, I. T. & Hunt, R. H. Peptic ulcer disease today. Nat Clin Pract Gastroenterol Hepatol 3, 80-89 (2006).
Milosavljevic, T., Kostić-Milosavljević, M., Jovanović, I. & Krstić, M. Complications of peptic ulcer disease. Dig Dis 29, 491-493 (2011).
Robson, A. J., Richards, J. M. J., Ohly, N., Nixon, S. J. & Paterson-Brown, S. The Effect of Surgical Subspecialization on Outcomes in
Peptic Ulcer Disease Complicated by Perforation and Bleeding. World Journal of Surgery 32, 1456-1461 (2008).
Kreissler-Haag, D., Schilling, M. K. & Maurer, C. A. [Surgery of complicated gastroduodenal ulcers: outcome at the millennium]. Zentralbl
Chir 127, 1078-1082 (2002).
Espat, N. J., Ong, E. S., Helton, W. S. & Nyhus, L. M. 1990-2001 US general surgery chief resident gastric surgery operative experience:
analysis of paradigm shift. J. Gastrointest. Surg. 8, 471-478 (2004).
Robson, A. J., Richards, J. M. J., Ohly, N., Nixon, S. J. & Paterson-Brown, S. The Effect of Surgical Subspecialization on Outcomes in
Peptic Ulcer Disease Complicated by Perforation and Bleeding. World Journal of Surgery 32, 1456-1461 (2008).
Thorsen, K., Glomsaker, T. B., von Meer, A., Søreide, K. & Søreide, J. A. Trends in diagnosis and surgical management of patients with
perforated peptic ulcer. J. Gastrointest. Surg. 15, 1329-1335 (2011).
Zittel, T. T., Jehle, E. C. & Becker, H. D. Surgical management of peptic ulcer disease today--indication, technique and outcome. Langen-
becks Arch Surg 385, 84-96 (2000).
Blomgren, L. G. Perforated peptic ulcer: long-term results after simple closure in the elderly. World J Surg 21, 412-414; discussion 414-415
(1997).
Bhogal, R. H., Athwal, R., Durkin, D., Deakin, M. & Cheruvu, C. N. V. Comparison between open and laparoscopic repair of perforated
peptic ulcer disease. World J Surg 32, 2371-2374 (2008).
Sarath Chandra, S. & Siva Kumar, S. Definitive or conservative surgery for perforated gastric ulcer? – An unresolved problem. International
Journal of Surgery 7, 136-139 (2009).
Chan, W. H., Wong, W. K., Khin, L. W. & Soo, K. C. Adverse operative risk factors for perforated peptic ulcer. Ann. Acad. Med. Singap. 29,
164-167 (2000).
Kocer, B. et al. Factors affecting mortality and morbidity in patients with peptic ulcer perforation. J. Gastroenterol. Hepatol. 22, 565-570
(2007).
Noguiera, C. et al. Perforated peptic ulcer: main factors of morbidity and mortality. World J Surg 27, 782-787 (2003).
Møller, M. H., Adamsen, S., Thomsen, R. W. & Møller, A. M. Preoperative prognostic factors for mortality in peptic ulcer perforation:
a systematic review. Scand. J. Gastroenterol. 45, 785-805 (2010).
Gralnek, I. M., Barkun, A. N. & Bardou, M. Management of Acute Bleeding from a Peptic Ulcer. N Engl J Med 359, 928-937 (2008).
Cheung, F. K. Y. & Lau, J. Y. W. Management of Massive Peptic Ulcer Bleeding. Gastroenterology Clinics of North America 38, 231-243 (2009).
Laine, L. & Jensen, D. M. Management of patients with ulcer bleeding. Am. J. Gastroenterol. 107, 345-360; quiz 361 (2012).
Holster, I. L. & Kuipers, E. J. Management of acute nonvariceal upper gastrointestinal bleeding: current policies and future perspectives.
World J. Gastroenterol. 18, 1202-1207 (2012).
Štimac, D., Franjić, N. & Krznarić, Ž. Acid inhibition and peptic ulcer bleeding. Dig Dis 29, 494-498 (2011).
Rutgeerts, P. & Vantrappen, G. The benefits of endoscopy in upper gastrointestinal bleeding. Endoscopy 18 Suppl 2, 15-17 (1986).
Vergara, M. et al. Helicobacter pylori eradication prevents recurrence from peptic ulcer haemorrhage. Eur J Gastroenterol Hepatol 12, 733-
-737 (2000).
Gralnek, I. M. et al. Clinical and economic outcomes of individuals with severe peptic ulcer hemorrhage and nonbleeding visible vessel: an
analysis of two prospective clinical trials. Am. J. Gastroenterol. 93, 2047-2056 (1998).
Hasselgren, G., Carlsson, J., Lind, T., Schaffalitzky de Muckadell, O. & Lundell, L. Risk factors for rebleeding and fatal outcome in elderly
patients with acute peptic ulcer bleeding. Eur J Gastroenterol Hepatol 10, 667-672 (1998).
Röher, H. D., Imhof, M., Goretzki, P. E. & Ohmann, C. [Ulcer surgery ’96-choice of methods in an emergency]. Chirurg 67, 20-25 (1996).
Heldwein, W., Schreiner, J., Pedrazzoli, J. & Lehnert, P. Is the Forrest classification a useful tool for planning endoscopic therapy of bleeding
peptic ulcers? Endoscopy 21, 258-262 (1989).
Guglielmi, A. et al. Risk assessment and prediction of rebleeding in bleeding gastroduodenal ulcer. Endoscopy 34, 778-786 (2002).
Chung, I. K. et al. Endoscopic factors predisposing to rebleeding following endoscopic hemostasis in bleeding peptic ulcers. Endoscopy 33,
969-975 (2001).
Abe, N., Takeuchi, H., Yanagida, O., Sugiyama, M. & Atomi, Y. SURGICAL INDICATIONS AND PROCEDURES FOR BLEEDING
PEPTIC ULCER. Digestive Endoscopy 22, S35-S37 (2010).
Nahon, S., Pariente, A., Nalet, B., Hagège, H. & Latrive, J.-P. Causes of mortality related to peptic ulcer bleeding in a prospective cohort of
965 French patients: a plea for primary prevention. Am. J. Gastroenterol. 105, 1902-1903 (2010).
Sung, J. J. Y. et al. Causes of mortality in patients with peptic ulcer bleeding: a prospective cohort study of 10,428 cases. Am. J. Gastroenterol.
105, 84-89 (2010).
Chiu, P. W. Y. et al. Predictors of peptic ulcer rebleeding after scheduled second endoscopy: clinical or endoscopic factors? Endoscopy 38,
726-729 (2006).
Rockall, T. A. Management and outcome of patients undergoing surgery after acute upper gastrointestinal haemorrhage. Steering Group for
the National Audit of Acute Upper Gastrointestinal Haemorrhage. J R Soc Med 91, 518-523 (1998).
Cochran, T. A. Bleeding peptic ulcer: surgical therapy. Gastroenterol. Clin. North Am. 22, 751-778 (1993).
García Sánchez, M. V. et al. [Factors associated with failure of endoscopic therapy in gastric ulcer bleeding]. Gastroenterol Hepatol 26, 227-
-233 (2003).
Lundell, L. Acid secretion and gastric surgery. Dig Dis 29, 487-490 (2011).
Published
2014-01-17
How to Cite
GOMES, Aline et al.
The current role of surgery in the treatment of gastroduodenal ulcer.
Revista Portuguesa de Cirurgia, [S.l.], n. 26, p. 9-19, jan. 2014.
ISSN 2183-1165.
Available at: <https://revista.spcir.com/index.php/spcir/article/view/320>. Date accessed: 25 apr. 2024.
Section
Original Papers
