Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan.
Trauma and Emergency Center, China Medical University Hospital, No. 2 Yuh-Der Road, Taichung, Taiwan, 404, Republic of China.
J Gastrointest Surg. 2020 Nov;24(11):2587-2595. doi: 10.1007/s11605-019-04442-3. Epub 2019 Nov 19.
The management of perforated peptic ulcer (PPU) has shifted from vagotomy/drainage to simple closure, followed by postoperative proton pump inhibitors (PPIs) and Helicobacter pylori (HP) eradication. Few studies have focused on the long-term impacts of this trend shift. We hypothesize that simple closure with PPIs is sufficient and does not carry an elevated rate of repeated surgery in non-HP-infected PPU patients.
Hospitalized PPU patients who underwent simple closure or truncal vagotomy/pyloroplasty (TVP) in the National Health Insurance Research Database (NHIRD) from 2000 to 2008 were collected. The index date was defined as the date of ulcer admission. Patients who underwent other ulcer surgeries (e.g., gastrectomy, highly or selective vagotomy), who had a history of HP infection, or who were < 18 or > 100 years old were excluded. Additionally, the distributions of postoperative nonsteroidal anti-inflammatory drug (NSAID) and PPI use were calculated using the Longitudinal Health Insurance Database (LHID).
After exclusion, a total of 66,413 patients were enrolled. There were 7232 (10.9%) patients who underwent TVP and 59,181 (89.1%) patients who underwent simple closure. The incidences of repeated ulcer-associated surgery were 5.10 and 23.05 versus 5.11 and 15.77 per 1000 person-years in the TVP cohort vs. the simple closure cohort before and after propensity score matching, respectively. When adjusted for age, sex, comorbidity, and Charlson comorbidity index score, the TVP cohort had a 68% (HR) and 66% (sHR) decreased risk compared with the simple closure cohort before propensity score matching, with a 67% decreased risk after propensity score matching in Cox proportional subdistribution hazard analysis and a 66% decreased risk in Fine-Gray proportional subdistribution hazard analysis. The LHID analysis showed a lower rate of postoperative NSAID use and a higher rate of postoperative PPI use in simple closure patients.
Our findings suggest that in the Asian population, simple closure increases the risk of repeated ulcer-associated surgery in non-HP-infected PPU patients compared with TVP patients. However, further studies are warranted.
穿孔性消化性溃疡（PPU）的治疗策略已从迷走神经切断术/引流术转变为单纯缝合，随后进行质子泵抑制剂（PPIs）和幽门螺杆菌（HP）根除治疗。很少有研究关注这种治疗策略转变的长期影响。我们假设，对于非 HP 感染的 PPU 患者，单纯缝合联合 PPI 治疗足矣，且不会增加重复手术的风险。
从 2000 年至 2008 年，我们在国家健康保险研究数据库（NHIRD）中收集了接受单纯缝合或胃大部切除术/幽门成形术（TVP）治疗的 PPU 住院患者。将溃疡入院日期定义为索引日期。排除接受其他溃疡手术（如胃切除术、高选择性或选择性迷走神经切断术）、有 HP 感染史或年龄<18 岁或>100 岁的患者。此外，我们还使用纵向健康保险数据库（LHID）计算了术后非甾体抗炎药（NSAID）和 PPI 的使用分布。
排除后，共纳入 66413 例患者。其中 7232 例（10.9%）患者接受 TVP 治疗，59181 例（89.1%）患者接受单纯缝合。在倾向评分匹配前后，TVP 组和单纯缝合组的溃疡相关手术再次发生率分别为 5.10 和 23.05 例/1000人年和 5.11 和 15.77 例/1000人年。在校正年龄、性别、合并症和 Charlson 合并症指数评分后，在倾向评分匹配前，TVP 组与单纯缝合组相比，风险比（HR）为 0.68（95%置信区间[CI]：0.58-0.81），校正后 HR（sHR）为 0.66（95%CI：0.55-0.80）；在 Cox 比例亚分布风险分析中，倾向评分匹配后 TVP 组的风险降低了 67%，在 Fine-Gray 比例亚分布风险分析中，风险降低了 66%。LHID 分析显示，单纯缝合组患者术后 NSAID 使用率较低，PPI 使用率较高。
在亚洲人群中，与 TVP 相比，非 HP 感染的 PPU 患者单纯缝合增加了溃疡相关手术再次发生的风险。但是，还需要进一步的研究。
