Evaluating the Evolving Morbidity of Omentoplasty for Perforated Peptic Ulcer Disease

Mortality for perforated peptic ulcer (PPU) surgery ranges from 2-22% with morbidity ranging from 15-45%. Traditionally, these had been repaired with vagotomy and antrectomy or pyloroplasty with smaller perforations repaired with an omentoplasty. Laparoscopic repair has become increasingly prevalent and demonstrated to have shorter length of stay (LOS) and fewer complications. We are evaluating the surgical repair of PPU with omentoplasty to determine trends of utilization and surgical outcomes. We conducted a 13-year (2005-2017) retrospective review, utilizing the National Surgical Quality Improvement Program database. A total of 6873 patients had open or laparoscopic repair of a PPU, with 2285 patients identified as utilizing omentoplasty. Five hundred eighty-eight omentoplasty patients were further identified as having a laparoscopic technique. We compared patient demographics, comorbidities, and perioperative morbidity and mortality for surgical patients between 2005-2011 and 2012-2017. We trended the perioperative outcomes across the study intervals. Parametric and nonparametric tests were used to evaluate outcomes. Between 2005 and between 2017, laparoscopic surgical repair with omentoplasty has increased from 3.8% to 34.6%. Overall mortality for open operations declined during this interval (12.7%-9.3%) while it remained unchanged for laparoscopic operations (4.6%-4.2%), there was not a significant difference between the laparoscopic and open 30-day mortality. Both open surgery and laparoscopic surgery are being used on an increasingly healthy cohort (increased functional status decreased predicted perioperative morbidity). Relative to the 2005-2011, the laparoscopic surgery 2012-2017 cohort had increases in both serious and overall morbidity, although this was not statistically significant. Compared to the 2005-2011, the 2012-2017 open surgery cohort had increasing serious morbidity (OR 2.03) and overall morbidity (OR 1.91). There was a trend of decreasing LOS and increased return to the operating room for patients with laparoscopic surgery. Laparoscopic Graham patch repair of peptic ulcers significantly increased, although open repair still constitutes the majority of the cases. Despite Graham patch repair being utilized on a healthier patient population, morbidity and mortality for laparoscopic repair have remained unchanged. Postoperative morbidity and mortality for open surgery have increased. This indicates that laparoscopic repair is more commonly utilized for low- or medium risk patients, leaving an increasingly sick patient population selected to open repair.

Graham Patch Versus Modified Graham Patch in the Management of Perforated Duodenal Ulcer

Introduction: Peptic ulcer perforation is a serious complication which affects 2-10% of peptic ulcer patients. It presents with an overall mortality of 10% although various authors had reported incidence between 1.3% and 20%. Being a life threatening complication of peptic ulcer disease, it needs special attention with prompt resuscitation and appropriate surgical management if morbidity and mortality are to be contained. Aims and objectives: To compare outcome and complications in Graham patch and Modified Graham patch repair in perforated duodenal ulcer.Material and Methods: A prospective randomized controlled trial was conducted to compare the outcome and complication viz. leakage, obstruction after Graham's patch repair and modified Graham's patch repair undergoing duodenal ulcer perforation in various surgical units of Nepalgunj Medical College Teaching Hospital. Out of these 60 patients; one group (30 cases) underwent Graham's patch repair and another group (30 cases) underwent modified Graham's patch repair. The outcome of procedure was measured in terms of complication like leakage, obstruction and mortality.Results: Duodenal ulcer perforation in group A was more common in male; 58(96.66%) patients were male 2 (3.33%) were female (M:F=29:1). The mean age was 46.80(SD 13.9) years. In Group B it was more common in male; 58(96.66%) patients were male 2(3.33%) were female (M:F=29:1). The mean age was 48.60(SD 14.04) years. Incidence of complication was more common in Group B, no statistically significant difference was found between two groups. The incidence of post operative leakage was 1(3.33%) and in Group B were 2(6.70%). The chi square test was used to compute the p value using SPSS 19. The chi square p value was calculated as 0.554. Hence there was no significant difference between the Group A and Group B. The incidence of burst abdomen was same 2(6.70%) in both the groups.Conclusion: The analysis of results of present study consisting of altogether 60 patients undergoing duodenal ulcer perforation repair showed that Graham's patch repair is as effective as modified Graham's patch repair in terms of morbidity and mortality. Hence there is no statistically significant difference in undergoing either procedure of repair. It is concluded that either procedure can be undertaken depending upon surgeon preference.Journal of Nepalgunj Medical College Vol.13(1) 2015: 28-31

Roscoe Reid Graham (1890 to 1948): A Canadian Pioneer in General Surgery

Roscoe Reid Graham, a Canadian surgeon trained at the University of Toronto, was a true pioneer in the field of general surgery. Although he may be best known for his omental patch repair of perforated duodenal ulcers—often referred to as the “Graham patch”—he had a number of other significant accomplishments that decorated his surgical career. Dr. Graham is credited with being the first surgeon to successfully enucleate an insulinoma. He ventured to do an essentially brand new operation based solely on his patient's symptoms and physical findings, a courageous move that even some of the most talented surgeons would shy away from. He also spent a large portion of his career dedicated to the study of rectal prolapse, working tirelessly to rid his patients of this awful affliction. He was recognized by a number of different surgical associations for his operative successes and was awarded membership to those both in Canada and the United States. Despite all of these accolades, Dr. Graham remained grounded and always fervent in his dedication to the patient and their presenting symptom(s), reminding us that to do anything more would be “meddlesome.” In an age when medical professionals are often all too eager to make unnecessary interventions, it is imperative that we look back at our predecessors such as Roscoe Reid Graham, for they will continually redirect us toward our one and only obligation: the patient.