Management and outcomes of perforated duodenal ulcers in the North East of England from 2002-2016

Charles Johnson, Ross Mclean, Iain Mcallum, Alexander Phillips

Background
Duodenal perforation is a common surgical emergency. Open repair with omental patch is routine (1), though laparoscopic repair has been shown to be a safe, reliable alternative (2, 3). Non-operative management is generally restricted to patients too unwell for laparotomy or clinically well at initial assessment (4).

We describe changes in management and outcomes for this condition over 15 years, across Northeast England.

Methods
Admission data from trust information departments were collected after necessary approvals, for all emergency admissions to General Surgery across the North East of England from 2002-2016. Cases were identified using ICD-10 codes K26.1, K26.2, K26.5, K26.6. Data regarding demographics, comorbidities, interventions and outcomes were collected and analysed.

Results
Duodenal perforation accounted for 1773 admissions from 9 centres. Median age was 60 years, 59.8% male. 

Management strategy varied significantly over time: 2002-2006 82.7% underwent open repair, 4.8% laparoscopic and 12.5% open. By 2012-2016 55.3% underwent open repair, 20.0% laparoscopic and 20.2% conservative(p<0.001). Inpatient mortality improved: 20.1% 2002-2006 to 11.8% 2012-2016(p=0.001). Mean length of stay(LOS) also improved(p=0.012). Open repair mortality was 15.7%, laparoscopic 4.3%, conservative management 27.3%(p<0.001). Multivariate analysis identified Charlson-comorbidity-score >5(p=0.002), age(P<0.001), management strategy(P<0.001) and admitting trust(p=0.016) as independently significant variables effecting mortality.

Conclusion
There has been an increase in laparoscopic repair and conservative management from 2002-2016. Outcomes(mortality and LOS) have improved significantly over this time. Mortality in the laparoscopic group was best, followed by open surgery then conservative. Although patient selection may play a role, management strategy was an independently significant variable effecting mortality, supporting the growing evidence for laparoscopic surgery for perforated duodenal ulcers.