Influence of body mass index on mortality after surgery for

perforated peptic ulcer.

Buck DL
1
, Mller MH; Danish Clinical Register of Emergency Surgery.
Author information
Abstract
BACKGROUND:
Body mass index (BMI) is a strong predictor of mortality in the general population. In
spite of the medical hazards of obesity, a protective effect on mortality has been
suggested in surgical patients: the obesity paradox. The aim of
the present nationwide cohort study was to examine the association between BMI
and mortality in patients treated surgically for perforated peptic ulcer (PPU).
METHODS:
This was a national prospective cohort study of all Danish patients treated surgically
for PPU between 1 February 2003 and 31 August 2009, for whom BMI
was registered. Non-surgically treated patients and those with malignant ulcers were
excluded. The primary outcome measure was 90-day mortality. The association
between BMI and mortality was calculated as crude and adjusted relative risks (RRs)
with 95 per cent confidence intervals (c.i.).
RESULTS:
Of 2668 patients who underwent surgical treatment for PPU, 1699 (63.7 per cent)
had BMI recorded. Median age was 69.4 (range 17.6-100.9) years and 53.7 per cent
of the patients were women. Some 1126 patients (66.3 per cent) had at least one of
six co-morbid diseases; 728 (42.8 per cent) had an American Society
of Anesthesiologists grade of III or more. A total of 471 patients (27.7 per cent) died
within 90days of surgery. Being underweight was associated with a more
than twofold increased risk of death following surgery for PPU (adjusted RR 2.26, 95
per cent c.i. 1.37 to 3.71). Nostatistically significant association was found between
obesity and mortality.
CONCLUSION:
Being underweight was associated with increased mortality in patients with PPU,
whereas being overweight or obese was neither protective nor an adverse
prognostic factor.
Abstract
OBJECTIVES:
To evaluate if esomeprazole prevents recurrent peptic ulcer in adult patients with a
history of peptic ulcerreceiving low-dose acetylsalicylic acid (ASA, aspirin) for
cardiovascular protection in East Asia.
METHODS:
In this prospective, randomised, double-blind, placebo-controlled trial conducted in
Japan, Korea and Taiwan, eligible patients receiving low-dose ASA for
cardiovascular protection (81-324 mg/day) were randomised to esomeprazole 20
mg/day or placebo for 72 weeks. All patients received concomitant mucosal
protection (gefarnate 100 mg/day). Theprimary endpoint was time to ulcer recurrence
(Kaplan-Meier analysis). Efficacy findings are presented up to week 48, as per a
planned interim analysis within the study protocol.
RESULTS:
A total of 364 patients (79.9% men; mean age, 67.1 years) comprised the full
analysis set (esomeprazole, n=182; placebo, n=182). There was a statistically
significant difference in the time to ulcer recurrence between esomeprazole and
placebo (HR 0.09; 96.65% CI 0.02 to 0.41; p<0.001). The estimated ulcer-free rate at
week 12 was 99.3% (esomeprazole) and 89.0% (placebo). The high estimated ulcer-
free rate for esomeprazole was maintained through to week 48 (98.3% vs. 81.2% of
placebo-treated patients). No factors, other than female gender, reduced time to
ulcer recurrence in addition to the effect of esomeprazole (p<0.001). Treatment with
esomeprazole was generally well tolerated.
CONCLUSIONS:
Daily esomeprazole 20 mg is efficacious and well tolerated in reducing the
recurrence of peptic ulcer in East-Asian patients with a history of ulcers who are
taking low-dose ASA for cardiovascular protection.
CLINICALTRIALGOV IDENTIFIER:
NCT01069939.
Published by the BMJ Publishing Group Limited. For permission to use (where not
alread
Reconstruction after proximal gastrectomy for early gastric
cancer in the upper third of the stomach: an analysis of our 13-
year experience.
Nakamura M
1
, Nakamori M
1
, Ojima T
1
, Katsuda M
1
, Iida T
1
, Hayata K
1
, Matsumura S
1
, Kato
T
1
, Kitadani J
1
, Iwahashi M
1
, Yamaue H
2
.
Author information
Abstract
BACKGROUND:
Fundoplication during esophagogastrostomy (EG) after proximal gastrectomy (PG) is
a useful procedure to prevent reflux esophagitis, but it is unclear how much of the
remnant stomach should be wrapped around the esophagus.
METHODS:
We analyzed data from 101 patients who underwent PG for upper third early gastric
cancer between 1999 and 2011. In all, 64 patients underwent EG, 25
underwent jejunal interposition (JI), and 12 underwent jejunal pouch interposition
(JPI). We compared intraoperative details and postoperative outcomes, and
investigated the relationships between the degree of the fundoplication during EG
and endoscopic findings.
RESULTS:
The length of the operation was significantly shorter in the EG group than in the
other 2 groups (P < .05), and the intraoperative blood loss was significantly less in
the EG group (P < .05). The JI and the JPI groups had significantly greaterrates of
early complications than did the EG group (P = .01). Reflux esophagitis
was present in 22% of patients in the EG group, 8% in the JPI group, and none in
the JI group. In the EG group, reflux esophagitis was significantly less common in
patients with a >180 wrap of the remnant stomach around the esophagus than in
patients with a smaller wrap (P = .0008). The rate of body weight loss was
significantly less in the EG group compared with the other 2 groups (P < .05).
CONCLUSION:
Considering the low invasiveness of the procedure and postoperative outcomes, we
consider that EG with a >180 wrap as the optimal reconstructive procedure.
Copyright 2014 Mosby, Inc. All rights reserved.
Effect of proton pomp inhibitor (PPI : Rabeprazole) on reflux
esophagitis after endoscopic injection sclerotherapy (EIS), a
randomized control study (24 hour-pH monitoring).
Akahoshi T, Kawanaka H, Tomikawa M, Saeki H, Uchiyama H, Ikeda T, Shirabe
K, Hashizume M, Maehara Y.
Abstract
BACKGROUND:
Transient esophageal ulceration is a common finding after sclerotherapy of varices.
These ulcers sometimes cause pain, ulcer bleeding, and stricture formation.
Gastroesophageal reflux (GER) after Endoscopic injection sclerotherapy (EIS) is a
known cause of worsening ulcer formation. Therefore, an efficient drug for GER is
desirable to improve the quality of life of patients with esophageal varices.
METHODS:
We randomized 18 Japanese cirrhotic patients who had risky esophageal varices.
The patients were randomly allocated into two groups, and during EIS sessions, one
group was administered proton pump inhibitor(PPI) (Rabeprazole 20 mg a person
once a day), while the other received histamine H2 receptor antagonist (H2-blocker)
(famotidine 20 mg a person, twice a day). Gastroesophageal reflux was monitored
by a 24-h pH-monitoring catheter introduced into the distal esophagus. Ulcer
formation was evaluated using an endoscopic examination. The subjective and
objective symptoms were also compared between the two groups.
RESULTS:
All patients in the H2-blocker group showed an increased percentage of time with pH
< 4.0 after EIS sessions, but no patients in the PPI group showed an increased such
symptoms. The H2-blocker group also experienced a significantly higher number of
days of heartburn and dysphasia than did the PPI group (p = 0.017, p = 0.042). The
rate of ulcerimprovement was found to be faster in Rabeprazole group than in H2
blocker group (p = 0.008).
CONCLUSION:
These results suggest that Rabeprazole treatment prevents EIS-associated
gastroesophageal reflux and promotes ulcer healing. Rabeprazole also improve the
subjective symptoms following EIS.
PMID:

24693675

[PubMed - indexed for MEDLINE]
Reduction of alkaline reflux gastritis and marginal ulcer by
modified Braun enteroenterostomy in gastroenterologic
reconstruction after pancreaticoduodenectomy.
Wang L
1
, Su Ap
1
, Zhang Y
1
, Yang M
1
, Yue Pj
1
, Tian Bl
2
.
Author information
Abstract
BACKGROUND:
The incidence of alkaline reflux gastritis (ARG) after pancreaticoduodenectomy (PD)
is high. Although Braun enteroenterostomy (BEE) may reduce ARG, BEE may result
in marginal ulcers (MUs) due to the additional anastomotic stoma. We conducted this
study to compare clinical outcomes of using a modified BEE (MBEE) with traditional
gastrojejunostomy (TGJ), by inducting a purse-string suture instead of an additional
anastomotic stoma.
MATERIALS AND METHODS:
All 62 patients underwent standard PD at the Department
of Hepatobiliopancreatic Surgery of West China Hospital between January 1, 2008
and January 31, 2012. Demographics, perioperative and postoperative factors, and
follow-up morbidity were compared in those patients who underwent MBEE (n = 32,
three patients were lost to follow-up) to those who underwent TGJ (n = 30, nine
patients were lost to follow-up).
RESULTS:
Patients who underwent the MBEE experienced a decrease in total morbidity
including ARG and MUs, relative to those who underwent TGJ (24.1% versus 58.3%,
P = 0.011). With regard to the MBEE group, the total ARG rate was statistically
significantly lower compared with the TGJ group (13.8% versus 37.5%, P = 0.046).
In addition, the incidence of MUs was reduced.
CONCLUSIONS:
In patients undergoing PD, the MBEE was safely performed with significantly more
patients havingreduced incidence of ARG and related sequela compared with those
who underwent TGJ. These results support further study of patients undergoing
gastroenterostomy after resection of the distal stomach in larger, randomized
studies.
Copyright 2014 Elsevier Inc. All rights reserved.
A new prognostic scoring system for perforation peritonitis
secondary to duodenal ulcers.
Nomani AZ
1
, Malik AK
2
, Qureshi MS
1
.
Author information
Abstract
OBJECTIVE:
To identify prognostic factors for perforated duodenal ulcers and to devise and
assess a new scoring system.
METHODS:
The observational prospective study was conducted at the Mayo Hospital, Lahore in
two phases: from March 2010 to September 2011; and from October 2011 to July
2012. It included patients with duodenal ulcer perforation who were observed
for identifying factors predicting 30-day prognosis. Each of the predictive factor was
given a score based on its severity to devise a new scoring system. Chi-square was
used for univariate analysis. Multivariate analysis was done using forward stepwise
regression. Accuracy of the new scoring system was calculated
using receiver operating curve analysis and its validity was evaluated in the second
phase of the study.
RESULTS:
Predictors of poor prognosis included multiple gut perforations, size
of largest perforation >0.5cm, amount of peritoneal fluid >1000ml, simple closure,
development of complications, post-operative systemic septicaemia and
winter/autumn season of presentation. Overall 30-day mortality rate was 32.3%
(n=32) and morbidity rate was 21.2% (n=21). The mean score was higher in the
ones with poor prognosis (p=0.001). Similarly, the mean score was greater in those
with grave prognosis (p=0.001). The scoring system had an overall sensitivity of
85.12% and specificity of 80.67% and wasfavourably comparable to other
scoring systems.
CONCLUSION:
The new scoring system is a useful tool in predicting 30-day prognosis for perforated
duodenal ulcers in acid peptic disease.
Optimal use of proton pump inhibitors for treating acid peptic
diseases in primary care.
Tack J
1
, Louis E
2
, Persy V
3
, Urbain D
4
.
Author information
Abstract
Heartburn, reflux and epigastric pain are frequently encountered symptoms in
primary care medicine. Acid peptic diseases such as peptic ulcer and gastrointestinal
reflux disease have a high prevalence, can have important impact on patient quality
of life and represent a considerable health care cost. Proton pump inhibitors (PPIs)
are the most potent pharmacological inhibitors of gastric acid secretion
currently available and are the mainstay medical therapy for acid peptic diseases.
Thisreview summarizes current evidence on treatment of acid-peptic diseases
with proton pump inhibitors and provides primary care clinicians with
best practice guidelines for optimal use of these drugs.
Effect of clopidogrel with or without omeprazole in patients
with carotid artery stenting.
Ma B
1
, Hang L
2
, Chen G
1
, Du Y
1
.
Author information
Abstract
BACKGROUND:
Recent concerns have been raised about the potential for proton pump inhibitors
(PPIs) to blunt the efficacy of clopidogrel. We observed the effect of clopidogrel
plus aspirin with or without omeprazole in patients with carotid stenoses after they
received placement of carotid stents.
METHODS:
Sixty-four consecutive patients treated with percutaneous carotid artery stenting
(CAS) comprised the sample. All enrolled patients underwent the C13 urea breath
test (C13 UBT) before CAS. Patients with Helicobacter pylori infection and
a history of peptic ulcer were assigned dual antiplatelet combination with
omeprazole. Others received dual antiplatelet without omeprazole. Transcranial
Doppler and ultrasonography were performed to assess the middle cerebral artery
and carotid artery in follow-up at three months and six months.
RESULTS:
Eight patients had gastrointestinal bleeding; the event rate was 22.6% without
omeprazole and 3.8% with omeprazole. The rate of gastrointestinal bleeding
was reduced with omeprazole as compared without omeprazole (p = 0.026, p <
0.05). The two groups did not differ significantly in the rate of in-stent restenosis and
thrombus through transcranial Doppler and ultrasonography.
CONCLUSION:
Among patients receiving dual antiplatelet therapy, prophylactic use of omeprazole
reduced the rate of upper gastrointestinal bleeding. There was no apparent
interaction between clopidogrel and omeprazole in patients with carotid artery
stenting.
Abstract
In summary, ZES is a syndrome caused by gastrinoma, usually located within the
gastrinoma triangle and associated with symptoms of peptic ulcer disease, GERD,
and diarrhea. The diagnosis of ZES is made by measuring fasting levels of
serumgastrin, BAO, and the secretin stimulation test. Because of the high
association of ZES and MEN1, HPT must be excluded by obtaining a serum calcium
and parathyroid hormone level. Treatment of ZES consists of medical control of
symptoms with PPIs and evaluation for potentially curative surgical intervention.
Noninvasive imaging studies including SRS, CT, and MRI should
be performed initially to evaluate for metastases and identify resectable disease.
Invasive imaging modalities such as EUS may be performed to further
evaluate primary tumors. IOUS, palpation, and duodenotomy are used for
intraoperative localization of gastrinomas. In patients with MEN1, surgical resection
should be pursued only if there is an identifiable tumor larger than 2 cm and after
surgery for the primary hyperparathyroidism (3 1/2-gland parathyroidectomy). All
patients with resectable localized sporadic gastrinoma should undergo surgical
exploration, even those with biochemical evidence but negative imaging studies.
Tumor is most commonly found in the duodenum, and the cure rate is high. In
patients with liver metastases, surgery should be considered if all identifiable tumor
can be safely removed. A multidisciplinary approach including surgical and
nonsurgical therapies should be taken in patients with ad
Use of proton pump inhibitors for the provision of stress ulcer
prophylaxis: clinical and economic consequences.
Barletta JF
1
, Sclar DA.
Author information
Abstract
The provision of stress ulcer prophylaxis (SUP) for the prevention of clinically
significant bleeding is widely recognized as a crucial component of care in critically ill
patients. Nevertheless, SUP is often provided to non-critically ill patients despite a
risk for clinically significant bleeding of roughly 0.1 %. The overuse of SUP therefore
introduces added risks for adverse drug events and cost, with minimal expected
benefit in clinical outcome. Historically, histamine-2-receptor antagonists (H2RAs)
have been the preferred agent for SUP; however, recent data have revealed proton
pump inhibitors (PPIs) as the most common modality (76 %). There are no
high quality randomized controlled trials demonstrating superiority with PPIs
compared with H2RAs for the prevention of clinically significant
bleeding associated with stress ulcers. In contrast, PPIs have recently been linked to
several adverse effects including Clostridium difficile diarrhea and pneumonia. These
complications have substantial economic consequences and have a marked impact
on the overall cost effectiveness of PPI therapy. Nevertheless, PPI
use remains widespread in patients who are at both high and low risk for clinically
significant bleeding. This article will describe the utilization of PPIs for SUP and
present the clinical and economic consequences linked to th
Gastroduodenal perforation.
Nirula R.
Author information
Abstract
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 performedinfrequently.
Could application of epinephrine improve hemostatic efficacy
of hemoclips for bleeding peptic ulcers? A prospective
randomized study.
Grgov S
1
, Radovanovi-Dini B, Tasi T.
Author information
Abstract
BACKGROUND/AIM:
Bleeding from peptic ulcers can be effectively and safely treated with endoscopic
hemoclips therapy. However, due to certain limiting factors of hemoclips, application
of combination with another endoscopic method may give better results. The aim of
this study was to examine the efficacy and safety of endoscopic hemoclips therapy
and to evaluate potential benefits of this therapy combined with epinephrine in
the treatment of bleeding peptic ulcers.
METHODS:
This prospective randomized study included 70 patients with bleeding gastric or
duodenal ulcer. In 34 of the patients endoscopic hemoclips therapy was applied
(group I), and in 36 of them a combined therapy of hemoclips and epinephrine
(group II).
RESULTS:
Initial hemostasis was achieved in most patients treated with endoscopic hemoclips
therapy (94.1%) as well as in the patients treated with combination therapy (97.2%).
After initial hemostasis achieved rebleeding occurred in 3 (9.3%) patients treated
with hemoclips and in 2 (5.7%) patients treated with combination therapy, but this
difference was notstatistically significant (p > 0.05). The difference in the achieved
final hemostasis between the group I (91.1%) and the group II (94.4%) was not
statistically significant. Also, the differences between the two groups of patients in
the need for bloodtransfusions, length of hospital stay, need for surgery and mortality
were not statistically significant (p > 0.05).
CONCLUSION:
Endoscopic hemoclips therapy is effective and safe in treatment of bleeding peptic
ulcers. Combinationtherapy of hemoclips and epinephrine has no advantage over
hemoclips monotherapy.