Smith D, Roeser M, Naranjo J, Carr J A
Department of Surgery, Henry Ford Allegiance Health, 205 N East Avenue, Jackson, MI, 49201, USA.
Department of Statistics, Western Michigan University, 3304 Everett Tower, Mail Stop 5152, Kalamazoo, MI, 49008, USA.
Eur J Trauma Emerg Surg. 2018 Apr;44(2):273-277. doi: 10.1007/s00068-017-0825-3. Epub 2017 Jul 29.
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.
采用网膜修补术（OP）或一期缝合治疗前肠穿孔性溃疡已基本取代迷走神经切断术和幽门成形术/胃窦切除术（VPA）。我们试图确定接受网膜修补术或一期缝合治疗的患者溃疡的自然病程和复发率。
一项为期11年的回顾性研究。
2004年至2015年期间，94例患者患有前肠穿孔性溃疡，其中53例为胃溃疡，41例为十二指肠溃疡。77例（82%）仅接受网膜修补术治疗（研究组），17例（18%）接受VPA治疗（对照组）。所有接受网膜修补术的患者出院时均服用质子泵抑制剂（PPI），但只有86%的患者服用了这些药物，中位时间为22个月（1 - 192个月，标准差40）。网膜修补术组的内镜检查显示9例有复发性溃疡（复发率12%），3例有胃炎（4%）。该组还有3例后来出现复发性穿孔。另有1例复发性溃疡出血导致死亡（晚期死亡率3%）。另外2例患者因复发性疾病/症状需要非急诊再次进行溃疡手术（手术再次干预率4%）。总随访时间中位为44个月（1 - 192个月，标准差40），82例（87%）随访完整。网膜修补术组18例（23%）患者在随访期间出现归因于溃疡病的复发性腹痛，而VPA组为2例（12%）（p = 0.15）。VPA组没有患者出现内镜复发或再次干预。
网膜修补术不能纠正导致前肠穿孔的潜在疾病过程，内镜证实的复发性溃疡率为12%，44个月内复发性症状的发生率为23%。患者在22个月后往往会停止服用PPI，此时他们的风险会增加。
