The natural history of perforated foregut ulcers after repair by omental patching or primary closure
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The treatment of perforated foregut ulcers by omental patching (OP) or primary closure has mostly replaced vagotomy and pyloroplasty/antrectomy (VPA). We sought to determine the natural history and recurrence rate of ulceration in patients treated by omental patching or primary closure.
An 11-year retrospective study.
From 2004 through 2015, 94 patients had perforated foregut ulcers, 53 gastric, and 41 duodenal. 77 (82%) were treated by OP alone (study group) and 17 (18%) were treated with VPA (comparison group). All OP patients were discharged on PPIs, but only 86% took the drugs for a median of 22 months (1–192, SD 40). Endoscopy in the OP group showed recurrent ulcers in nine (12% recurrence rate) and gastritis in three (4%) This group also had three later recurrent perforations. Another recurrent ulcer hemorrhaged causing death (3% late mortality). Two other patients required non-emergent re-do ulcer operations for recurrent disease/symptoms (surgical re-intervention rate 4%). Total length of follow-up was median 44 months (1–192, SD 40) and was complete in 82 (87%). 18 (23%) patients in the OP group developed recurrent abdominal pain attributed to ulcer disease during follow-up, compared to 2 (12%) in the VPA group (p = 0.15). No patient in the VPA group had an endoscopic recurrence or re-intervention.
Omental patching does not correct the underlying disease process which causes foregut perforation, and has a 12% endoscopically proven recurrent ulceration rate and a 23% incidence of recurrent symptoms within 44 months. Patients tend to stop taking PPIs after 22 months at which time their risk increases.
KeywordsGastric ulcer Duodenal ulcer Perforation Omental patch Graham patch Recurrence
Carr—conception and design, acquisition, analysis, drafting, revising, approval, accountable. Smith—conception and design, acquisition, analysis, drafting, approval, accountable. Roeser—conception and design, acquisition, drafting, approval, accountable. Naranjo—conception and design, analysis, revising, approval, and accountable.
Compliance with ethical standards
Conflict of interest
The authors, John Carr, Daniel Smith, Mark Roeser, and Joshua Naranjo, have no conflicts of interest, no financial relationships to disclose, and have received no funding or any support to perform this research.
Institutional Review Board and ethical approval was obtained from the Allegiance Health Institutional Review Board prior to starting this study, and this study has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Since the study was retrospective in nature, the need to obtain individual patient consent was waived by the review board.
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