Combined endoscopic and radiologic intervention for management of acute perforated peptic ulcer: a randomized controlled trial

Said Negm, Hatem Mohamed, Ahmed Shafiq, Taha AbdelKader, Adel Ismail, Mahmoud Yassin, Bassam Mousa, Mohamed Abozaid, Yasser A Orban, Mazoun Al Alawi, Ahmed Farag, Said Negm, Hatem Mohamed, Ahmed Shafiq, Taha AbdelKader, Adel Ismail, Mahmoud Yassin, Bassam Mousa, Mohamed Abozaid, Yasser A Orban, Mazoun Al Alawi, Ahmed Farag

Abstract

Background: Peptic ulcer perforation is a common life-threatening surgical emergency. Graham omental patch is performed for plugging of perforated peptic ulcer. Many endoscopic methods have been used to treat acute perforated peptic ulcer such as over the scope clips, standard endoscopic clips, endoscopic sewing and metallic stents. The main idea in endoscopic management of acute perforated peptic ulcer is early decontamination and decrease sepsis by interventional radiologic drainage.

Methods: This is a prospective randomized controlled clinical trial. This study included patients who were developed acute perforated peptic ulcer manifestations and were admitted to our hospital between December 2019 and August 2021. Sample size was 100 patients divided into 2 equal groups. Endoscopic group (EG): included 50 patients who were subjected to endoscopic management. Surgical group (SG): included 50 patients who were subjected to surgical management.

Results: One hundred patients were randomized into 2 groups: SG (50) and EG (50). Median age of patients was 36 (range 27:54) and 47 (range 41:50) years-old in SG and EG, respectively. Males constituted 72% and 66% in SG and EG, respectively. Median length of postoperative hospital stay was 1 (range: 1-2) days in EG, while in SG was 7 (range 6-8) days. Postoperative complications in SG patients were 58% in form of fever, pneumonia, leak, abdominal abscess, renal failure and incisional hernia (11%, 5%, 5%, 3%, 2% and 3%, respectively). Postoperative complications in EG patients were 24% in form of fever, pneumonia, leak, abdominal abscess, renal failure and incisional hernia (10%, 0%, 2%, 0%, 0% and 0%, respectively).

Conclusion: Combined endoscopic and interventional radiological drainage can effectively manage acute perforated peptic ulcer without the need for general anesthesia, with short operative time, in high risk surgical patients with low incidence of morbidity & mortality.

Trial registration: ClinicalTrials.gov NCT05051683.

Keywords: Clipping; Endoscopy; Peptic ulcer; Stent; Surgical emergency.

Conflict of interest statement

The authors declare that they have no competing interests.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Need for general anesthesia in group A ( EG) & group B ( SG)
Fig. 2
Fig. 2
Box plot to compare operative time and hospital stay between group A (EG) Group B (SG)
Fig. 3
Fig. 3
Box plot to compare operative time between Groups A (EG) and B (SG)
Fig. 4
Fig. 4
Box plot to compare operative time between groups A (EG) and B (SG)
Fig. 5
Fig. 5
Decrease in CRP & WBCs in group A(EG) & group B ( SG)

References

    1. Lanas A, Chan FKL. Peptic ulcer disease. Lancet. 2017;390:613–624. doi: 10.1016/S0140-6736(16)32404-7.
    1. Chung KT, Shelat VG. Perforated peptic ulcer - an update. World JGastrointest Surg. 2017;9:1–12. doi: 10.4240/wjgs.v9.i1.1.
    1. Sivaram P, Sreekumar A. Preoperative factors influencing mortality and morbidity in peptic ulcer perforation. Eur J Trauma Emerg Surg. 2018;44:251–257. doi: 10.1007/s00068-017-0777-7.
    1. Jensen DM, Ohning GV, Kovacs TO, et al. Doppler endoscopic probe as a guide to risk stratification and definitive hemostasis of peptic ulcer bleeding. Gastrointest Endosc. 2016;83:129–136. doi: 10.1016/j.gie.2015.07.012.
    1. Das R, Sureshkumar S, Sreenath GS, et al. Sequential versus concomitant therapy for eradication of Helicobacter Pylori in patients with perforated duodenal ulcer: A randomized trial. Saudi J Gastroenterol. 2016;22:309–315. doi: 10.4103/1319-3767.187605.
    1. Manno M, Mangiafico S, Caruso A, et al. First-line endoscopic treatment with OTSC in patients with high-risk non-variceal upper gastrointestinal bleeding:preliminary experience in 40 cases. Surg Endosc. 2016;30:2026–2029. doi: 10.1007/s00464-015-4436-y.
    1. Nelms DW, Pelaez CA. The Acute Upper Gastrointestinal Bleed. Surg Clin North Am. 2018;98:1047–1057. doi: 10.1016/j.suc.2018.05.004.
    1. Spahn DR, Bouillon B, Cerny V, et al., The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care. 2019;23:98.
    1. Sarah L , Kiran K , John Z , et al.,(2021): Risk factor of Gastrointestinal Leak after Perforated Peptic Ulcer Disease operative repair. Am Surg J. 2021;87:1879–1885.
    1. M. Clinton Miller, Ph.D, Rebecca G. Knapp: Clinical epidemiology and biostatistics, published by Williams & Wilkins, Maryland: 3rd edition 1992.
    1. Kobra H, Mori H, Nishiyama N, et al. Over-the-scopeclip system: a review of 1517 cases over 9 years. J Gastroenterol Hepatol. 2019;34(1):22–30. doi: 10.1111/jgh.14402.
    1. Basha J , Appasani S, Sinha SK, et al. Mega stents: a new option for management of leaks following laparoscopic sleeve gastrectomy. Endoscopy. 2014;46(Suppl 1)UCTN:E49-50
    1. Van Boeckel PG, Sijbring A, Vleggaar FP, et al. Systemic review: temporary stent placement for benign rupture or anastomotic leak of the oesophagus. Aliment Pharmacol Ther. 2011;33(12):1292–301. doi: 10.1111/j.1365-2036.2011.04663.x.

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