PEPTİK ÜLSER PERFORASYONLARINDA MORBİDİTE VE MORTALİTEYE ETKİ EDEN FAKTÖRLER

Öz

Günümüzde H2-reseptör blokerleri ve proton pompa inhibitörlerinin kullanımı sonucu peptik ülser hastalığında elektif cerrahi gereksinimi azalmıştır. Ancak komplikasyonlara bağlı acil cerrahi sıklığında herhangi bir değişiklik olmamıştır. Perforasyon meydana gelen hastalarda morbidite ve mortalite halen büyük bir problemdir. İzmir Bozyaka Eğitim ve Araştırma Hastanesi Genel Cerrahi Kliniği’nde 2008-2013 yılları arasında peptik ülser perforasyonu nedeniyle ameliyat edilen hastaların dosya ve elektronik kayıtları retrospektif olarak incelendi. Toplam 50 hastanın 41 %82 'i erkek 9 %18 'u kadındı. Yaş ortalaması 48.9 idi. Ortalama hastanede kalış süresi 7.8 gündü. Peptik ülser perforasyonu en sık yaz mevsimi %32 ve Ağustos ayında %12 görüldü. Kasım ayında 5yıl boyunca perforasyon görülmedi.Perforasyon en sık, 31 %62 hastada olmak üzere duodenumda görüldü. Bunu 17 %34 hasta ile jukstapilorik ve 2 %4 hasta ile anastomoz hattı perforasyonları izledi. İki hasta tekrarlayan perforasyon nedeniyle ameliyat edildi. Tüm hastalara antibiyotik tedavisi yapıldı. Perforasyon deliği çapı 39 %78 hastada 1cm altı,7 %14 hastada 1-2 cm arası, 4 %8 hastada 2 cm ve üstü olarak bulundu. Ameliyat öncesi, 38 %72 hastada lökositoz, dokuz %18 hastada kreatin yüksekliği ve 11 %22 hastada amilaz yüksekliği tespit edildi. Ameliyat sonrası üç hastada yara yeri infeksiyonu, iki hastada pnömoni, bir hastada deliriyum tablosu, dört hastada akut böbrek yetmezliği, bir hastada sepsis ve bir hastada evisserasyon gelişti. Toplam 4 %8 hasta eks oldu. Morbidite ve mortalite gelişen hastaların çoğu ileri yaş grubunda olup yandaş hastalıklara sahiptiler. Yandaş hastalığa sahip, ileri yaş ve gecikmiş perforasyonu olan hastalarda morbidite ve mortalite oranı artmaktadır. Ameliyat öncesi lökositoz, yüksek amilaz değeri ve kreatin yüksekliği preoperatif dönemde morbidite ve mortalitenin tahmininde kullanılabilinir

Anahtar Kelimeler

• Peptik ülser perforasyonu,morbidite,peptik ülser hastalığı

FACTORS AFFECTING THE MORBIDITY AND MORTALITY IN PERFORATED PEPTIC ULSER DISEASE

Abstract

Today, as a result of the use of H2-receptor blockers and proton pump inhibitors in peptic ulcer disease has decreased the need for elective surgery. However, there is no change in the frequency emergency surgery due to complications. Morbidity and mortality in patients with perforation occurring is still a major problem. We reviewed retrospectively the patients who underwent surgery for peptic ulcer perforation with files and computer records between 2008- 2013 in İzmir Bozyaka Training and Research Hospital General Surgery Department. Total of 50 patients, 41 82% were male and 9 18% were women. The mean age was 48.9 years. Average hospital stay was 7.8 days. Peptic ulcer perforations were seen most common in summer season and August. There was no perforation for 5 years in November. Perforations were seen most common in duodenum in 31 62% patients. That followed by the perforations of juxtapyloric in 17 34% patients and anastomosis in 2 4% patients. Two patients were operated due to recurrent perforation. All patients were treated with antibiotics. Perforation hole diameter were found in 39 78% patients below 1 cm, in 7 14% patients between 1-2 cm and 4 8% patients 2 cm and above. There was leukocytosis in 38 72% patients, increased creatinine in 9 18% patients and increased amylase in 11 22% patients. There was wound infection in three patients, pneumonia in two patients, delirium in one patient, acute renal failure in four patients, sepsis in one patient, evisceration in one patient after surgery. Total 4 8% patients had died. Most of the patients with morbidity and mortality in the elderly group had concomitant diseases. Morbidity and mortality is increasing in patients with co-morbid disease, advanced age and delayed perforation. Preoperative leukocytosis, increased amylase and increased creatinine can be used to predict morbidity and mortality

Keywords

• Peptic ulcus perforation,morbidity,peptic ulcus disease

References

1. ) Lau JY, Sung J, Hill C, Henderson C, Howden CW, Metz DC. Systematic review of the epidemiology of complicated peptic ulcer disease: incidence, recurrence, risk factors and mortality. Digestion 2011; 84: 102-13.
2. ) Wadaani HA. Emergent laparoscopy in treatment of perforated peptic ulcer: a local experience from a tertiary centre in Saudi Arabia. World J Emerg Surg 2013; 8:10.
3. ) Suriya C, Kasatpibal N,Kunaviktikul W, Kayee T. Diagnostic indicators for peptic ulcer perforation at a tertiary care hospital in Thailand. Clin Exp Gastroenterol 2011; 4: 283–89.
4. ) Wysocki A, Budzyński P, Kulawik J, Drożdż W. Changes in the localization of perforated peptic ulcer and its relation to gender and age of the patients throughout the last 45 years. World J Surg 2011; 35: 811-6.
5. ) Graham DY, Lew GM, Malaty HM, Evans DG, Evans DJ Jr, Klein PD, et al. Factors influencing the eradication of H. pylori with triple therapy. Gastroenterolgy 1992; 102: 493-6.
6. ) Zelickson MS, Bronder CM, Johnson BL, Camunas JA, Smith DE, Rawlinson D, Von S, Stone HH, Taylor SM. Helicobacter pylori is not the predominant etiology for peptic ulcers requiring operation. Am Surg 2011; 77: 1054-60.
7. ) Higham J, Kang JY, Majeed A. Recent trends in admissions and mortality due to peptic ulcer in England: increasing frequency of haemorrhage among older subjects. Gut 2002; 50: 460-4.
8. ) Bae S, Shim KN, Kim N, Kang JM, Kim DS, Kim KM, et al. Incidence and short-term mortality from perforated peptic ulcer in Korea: a population-based study. J Epidemiol 2012; 22: 508-16.

9. ) Rajesh V, Chandra SS, Smile SR: Risk factors predicting operative mortality in perforated peptic ulcer disease. Trop Gastroenterol 2003; 24: 148–50.
10. ) Chou NH, Mok KT, Chang HT, Liu SI, Tsai CC, Wang BW, et al. Risk factors of mortality in perforated peptic ulcer. Eur J Surg 2000; 166:149–53.
11. ) Moller MH, Vester- Andersen M, Thomsen RW. Long-term mortality following peptic ulcer perforation in the PULP trial. A nationwide follow-up study. Scand J Gastroenterol 2013; 48: 168-75.
12. ) Boey J, Lee NW, Wong J, Ong GB. Perforations in acute abdominal ulcers. Surg Gynecol Obstet 1982; 155: 193-6.
13. ) Yıldırım M, Engin O, Ilhan E, Coskun A. Risk factors and Mannheim Peritonitis
14. Index for the prediction of morbidity and mortality in patients with peptic ulcer perforation. Nobel Med 2009; 5: 74-81.
15. ) Gökakın AK, Kurt A, Atabey M, Koyuncu A, Topçu O, Aydın C, et al. The impact of Ramadan on peptic ulcer perforation. Ulus Travma Acil Cerrahi Derg 2012; 18: 339-43. 15) Bener A, Derbala MF, Al Kaabi S, Taryam LO, Al- Ameri MM, Al- Muraikhi, et al. Frequency of peptic ulcer disease during and after Ramadan in a United Arab Emirates hospital. East Mediterr Health J 2006;12: 105-11.
16. ) Marshall C, Ramaswamy P, Bergin FG, Rosenberg IL, Leaper DJ. Evaluation of a protocol for the non-operative management of perforated peptic ulcer. Br J Surg 1999; 86: 131-4.
17. ) Watanabe Y, Aoyama N, Shirasaka D, Maekawa S, Kuroda K, Miki I et al. Levofloxacin based triple therapy as a second line treatment after failure of H. pylori eradication with standart triple therapy. Dig Liver Dis 2003; 35: 711-5.
18. ) Jamieson GG. Current status of indications for surgery in peptic ulcer disease. World J Surg 2000; 24: 256-8.
19. ) Mouret P, Francois Y, Vignal J, Barth X, Lombard-Platet R: Laparoscopic
20. treatment of perforated peptic ulcer. Br J Surg 1990, 77:1006.
21. ) Busić Z, Servis D, Slisurić F, Kristek J, Kolovrat M, Cavka V, et al. Laparoscopic repair of perforated peptic duodenal ulcer. Coll Antropol 2010; 34: 279-81.
22. ) Guglielminotti P, Bini R, Fontana D, Leli R. Laparoscopic repair for perforated peptic ulcers with U-CLIP®. World J Emerg Surg 2009; 4: 28.
23. ) Ishida H, Ishiguro T, Kumamoto K, Ohsawa T, Sobajima J, Ishibashi K, Haga N. Minilaparotomy for perforated duodenal ulcer. Int Surg 2011; 96: 194-200.
24. ) Sanabria AE, Morales CH, Villegas MI. Laparoscopic repair for perforated peptic ulcer disease. Cochrane Database Syst Rev 2005;19: CD004778.