31.9.6 Frequency of Complications of Open Omental Patch Repair for Perforated Duodenal Ulcers

Original Article

 

Open Omental Patch Repair for Perforated Duodenal Ulcers

Frequency of Complications of Open Omental Patch Repair for Perforated Duodenal Ulcers

Bezan Baloch1, Ashiq Hussain2, Nazeer Ahmed Sasoli1, Muhammad Tahir3, Masroor Ahmad4 and Shah Wali5

ABSTRACT

Objective: This study was conducted to determine the frequency of post-operative complications of omentoplasty in patients with perforated duodenal ulcers.

Study Design: Descriptive Study.

Place and Duration of Study: This study was conducted at the Department of General Surgery, Bolan Medical Complex Hospital Quetta from September 2018 to February 2020.

Materials and Methods: A total number of 261 patients with diagnosis of duodenal peptic ulcers having age 18 to 60 years were included in this study. Closure of perforated duodenal ulcers was done by giving a midline laparotomy incision. Following identification of the perforation area, extensive peritoneal toilet was performed using warm saline. Patch repair was then done in standard fashion. Mass closure of fascia was performed using omental patch with 1/0 suture and interrupted closure to skin incision subsequently with proline sutures. Diagnosis of post-operative complications of omentoplasty e.g. organ space infections, sepsis and death rate were noted in the post-operative period.

Results: Mean age of patients was 40.42±9.61 years. There were 144 (55.17%) male and 117 (44.83%) female patients. Mean duration of symptoms of patients was 9.49±4.38 hours. Organ space infections occurred in 16 (6.13%) patients, sepsis in 10 (3.83%) patients and mortality in in 23 (8.81%) patients.

Conclusion: Omental patch repair is simple to perform and yet reliable for closure of much large perforations. Only Patch closure is sufficient for duodenal perforations considering low complications rate. In present study frequency of complications was comparable as mentioned in previous studies.

Key Words: Perforated peptic ulcers, omental patch repair, mortality.

Citation of article: Baloch B, Hussain A, Sasoli NA, Tahir M, Ahmad M, Wali S. Frequency of Complications of Open Omental Patch Repair for Perforated Duodenal Ulcers. Med Forum 2020;31(9):21-24.

 

 

INTRODUCTION

Structurally the duodenum is C shaped segment part of the the gastrointestinal tract and limited to the pylorus. Duodenal perforation is an occasional but fatal illness.1 perforated duodenal ulcer was first described by Muralto in 1688 and reported by Lenepneau.2 There after Dean presented the first case in 1894 which successfully surgical closure of a perforated duodenal ulcer.3 Perforated duodenal ulcer disease is associated with a 2% to 10% mortality rate, with septicaemia being the most common cause of death. Preoperative

 

 

1. Department of Surgery / Microbiology2 / paediatric Medicine3 / Plastic Surgery4 / ENT5, Bolan Medical College Quetta.

 

 

Correspondence: Dr. Bezan Baloch, Assistant Professor of Surgery, Bolan Medical College Quetta.

Contact No: 03337906920

Email: bezanbaloch@gmail.com

 

 

Received:    May, 2020

Accepted:    August, 2020

Printed:        September, 2020

 

 

 

 

 

shock, perforation for greater than 24 hours prior to surgical intervention, and concurrent significant illness have consistently been shown to be predictive of mortality, and the presence of all three risk factors carries a near 100% mortality.4 Perforation and fistulas of the gastrointestinal tract may occur after endoscopic/surgical procedures and disease states perforated peptic ulcer.5 Iatrogenic gastrointestinal tract perforation rates proportionally increase as more GI endoluminal procedures are performed.6 For almost three decades now, the standard of care to treat perforated foregut ulcers has been by simple closure with or without an omental patch (OP) and long-term proton pump inhibitor (PPI) therapy, with antibiotic treatment for Helicobacter pylori eradication if present.7, 8 The expected high morbidity and mortality from such surgical procedures raises a question about the need for less invasive procedures.9 Despite advancements in therapeutic techniques regarding the management of perforated duodenal ulcers, all procedure are still associated with inherent technical and logistic complexity. Clipping of the duodenal ulcers by using an omentum patch has been advocated for sealing larger defects.10, 11 Very little data is published regarding the complications of usage of omental patch for closure of duodenal peptic ulcers. Sepsis, organ space infections and death are common devastating complications of omentoplasty. A study found organ space infection rate of 4.6%, sepsis rate of 4.6% and death rate also 4.6%.12 The wound infections organ space rate of 6.0%, sepsis in 2.0% patients and death rate of 8.0% in patients of perforated duodenal ulcers.13 Very little work has been done regarding the complications of omentoplasty in patients of perforated duodenal ulcers and no data has been published from Pakistan regarding the complications of omentoplasty (omental patch) in patients of duodenal ulcers. The results of this study will help us to determine frequency of complications of omentoplasty in patients of duodenal perforations and will help us to recognize what are the most frequent complications in these patients. By knowing most frequent complications we will be able to adopt preventive measures so that we can reduce the frequency of these complications.

 

MATERIALS AND METHODS

This is Descriptive Study was completed at Department of Surgery, Bolan Medical Complex Hospital, Quetta from September 2018 to February 2020. First of all, approval was taken from the ethical committee of the hospital. After approval, a total number of 261 patients who presented in department of emergency surgical unit of Bolan Medical Complex Hospital Quetta fulfilling the inclusion criteria were included in this study. Besides, non-probability, Consecutive sampling were used for sample collection. Both male and female patients with diagnosis of duodenal peptic ulcers having age 18 to 60 years also included. Patients planned to undergo re-do operations for perforated duodenal ulcers were excluded. Closure of perforated duodenal ulcers was done. Diagnosis of post-operative complications of omentoplasty e.g. organ space infections, sepsis and death rate were made according the criteria given in the operational definitions. Data regarding age, and gender of patients was also calculated.

Data was analyzed using SPSS v17. Frequency and percentage were used to present gender, organ space infections, sepsis and operative mortality. While age, and duration of symptoms was presented as mean + standard deviation. Effect modifiers such as age, gender of patients and duration of symptoms were controlled by stratification. Post-stratification Chi-square test was applied to determine the effect of these effect modifiers on complications of omentoplasty e.g. organ space infections, sepsis and operative mortality. P-value <0.05 was considered as significant effect.

RESULTS

Mean age of patients included in this study was 40.42±9.61 years. Minimum age was 18 years and maximum age was 60 years (Table 1).

Table No. 1: Descriptive Statistics of Age

Age (Years)

Mean

40.42

S.D.

9.61

Minimum

18

Maximum

60

Mean duration of symptoms of patients was 9.49±4.38 hours. Minimum duration of symptoms was 02 hours and maximum duration of symptoms was 24

hours. There were more males as compared to the females. There were 144 (55.17%) male and 117 (44.83%) female patients. Figure. 1 is demonstrating the organ space infections occurred in 16 (6.13%) patients and remaining 245 (93.87%) patients has no organ space infection.

Figure No. 1: Frequency of Organ Space

Table No.2: Stratification of Age to Determine the Association of Age with Organ Space Infections, Sepsis and Mortality

 

 

Age Group

P-value

18-40 Years

41-60 Years

Organ Space

Yes

10

06

 0.42

No

120

125

Sepsis

Yes

03

07

 0.33

No

127

124

Mortality

Yes

13

10

0.64

No

117

121

Regarding frequency of Sepsis, there were 10 (3.83%) patients who were diagnosed with sepsis and remaining 251 (96.17%) patients did not suffered from sepsis. Mortality occurred in 23 (8.81%) patients out of 261 patients. Stratification of age was performed, in patients having age 18-40 years, organ space infections occurred in 10 patients and in patients having age 41-60 years, organ space infections occurred in 06 patients with significant p-value of 0.42. In patients having age 18-40 years, sepsis occurred in just 03 patient and in patients having age 41-60 years, sepsis occurred in 07 patients with insignificant p-value of 0.33. In patients having age 18-40 years, mortality occurred in 13 patients and in patients having age 41-60 years, mortality occurred in 10 patients with insignificant p-value of 0.64
(Table 2).

Stratification of gender was performed, in male patients, space organ was occurred in 10 patients and in female patients, space organ infections occurred in 06 patients with statistically insignificant p-value of 0.543. In male patients, sepsis occurred in 05 patients and in female patients, sepsis occurred in 05 patients with statistically significant p-value of 0.737. Regarding mortality, mortality occurred in 12 male patients and in 11 female patients with statistically insignificant p-value of 0.762 (Table 3).

Table No.3: Stratification of Gender to Determine the Association of Gender with Organ Space Infections, Sepsis and Mortality

 

 

Gender

P-Value

Male

Female

Organ Space

Yes

10

06

0.543

No

 134

111

Sepsis

Yes

 05

05

0.737

No

139

112

Mortality

Yes

12

11

0.762

No

132

106

Stratification of duration of symptoms was performed, in patients having duration of symptoms 02-09 hours, organ space infections occurred in 12 patients and in patients having duration of symptoms 10-24 hours, space organ infections occurred in 04 patients. This difference was statistically insignificant with p-value of 0.067. In patients having duration of symptoms 02-09 hours, sepsis occurred in just 04 patients and in patients having duration of symptoms 10-24 hours, sepsis occurred in 06 patients. This difference was statistically insignificant p-value of 0.406. In patients having duration of symptoms 02-09 hours, mortality was occurred in 13 patients and in patients having duration of symptoms 10-24 hours, mortality was occurred in 10 patients. This difference was also statistically of 0.714 (Table 4).

Table No. 4: Stratification of Duration of Symptoms to Determine the Association of Duration of Symptoms with Organ Space, Sepsis and Mortality

 

 

Duration of Symptoms

P-Value

2-9 Hours

10-24 Hours

Organ Space

Yes

12

04

0.067

No

126

119

Sepsis

Yes

04

06

0.406

No

134

117

Mortality

Yes

13

10

0.714

No

125

113

DISCUSSION

Since the introduction of the management of perforated duodenal ulcers by omental (Graham) patch plication in 1937, the surgical technique has been evolved with the introduction of different modifications and approaches which often used the same principle of closure of the perforation combined with extensive peritoneal lavage.14 The approach of open repair of perforated duodenal ulcers remained the gold standard treatment. It was simple and effective and provided long-term regression of the disease when combined with eradication of H. pylori and recess of nonsteroidal anti-inflammatory medication. In these patients, mortality is frequently associated with underlying sepsis and inflammatory response, which correlates with patient risk factors rather than surgical technique or complications.15In present study, we evaluated the complications rate of omental patch repair for management of perforated peptic ulcers. In present study, most common complication was organ space infections occurred in 6.13% patients, followed by sepsis that was diagnosed in 3.83% patients. And mortality occurred in 8.81% patients.  A study conducted by lee et al.12 on outcomes of omental patch repair including 108 patients who underwent open omental patch repair. They reported organ space infections in 4.6% patients, sepsis in 4.6% patients and death also, in 4.6% patients. In another study conducted by Vakayil et al.16 involving 1846 patients who underwent open omental patch repair for management of perforated peptic ulcers, reported organ space infections in 6.2% patients, sepsis in 11.8% patients and mortality in 5.8% patients. In a study conducted in Pakistan by Unar et al.17 on postoperative complications of omental patch repair reported intra-abdominal abscess in 6.2% patients, reoperations in 3.6%, renal failure in 4.1%, post-operative leakage in 3.6% patients and mortality in 5.1% patients after surgery. Etonyeaku et al.18 also reported similar outcomes they reported organ space infections in 8.9% patients, and mortality rate of 13.3%.

Moreover, the factors that can contribute to increased frequency of complications are advanced age, cigarette smoking and delay in surgery after the onset of symptoms.19 In present study we included only those patients who had duration of symptoms <24 hours to minimize the effect of delay in treatment on surgical complications. We did not find any significant association of age, gender and duration of symptoms on post-procedural complications.

CONCLUSION

Omental patch repair is simple to perform and yet reliable for closure of much large perforations. Only Patch closure is sufficient for duodenal perforations considering low complications rate. In present study frequency of complications was comparable as mentioned in previous studies.

 

 

Author’s Contribution:

Concept & Design of Study:

Bezan Baloch

Drafting:

Ashiq Hussain, Nazeer Ahmed Sasoli

Data Analysis:

Muhammad Tahir, Masroor Ahmad, Shah Wali

Revisiting Critically:

Bezan Baloch, Ashiq Hussain

Final Approval of version:

Bezan Baloch

Conflict of Interest: The study has no conflict of interest to declare by any author.

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