D. J. Taghipour1,3, G. Ortega1,3, C. K. Zogg2, M. S. Pichardo5, N. R. Changoor1,3, A. Kolluri4, S. M. Siram1, M. Williams1,3, E. E. Cornwell1,3 1Howard University College Of Medicine,Department Of Surgery,Washington, DC, USA 2Yale University School Of Medicine,New Haven, CT, USA 3Howard University College Of Medicine,Howard-Harvard Multidisciplinary Outcomes Research Center, Department Of Surgery,Washington, DC, USA 4Howard University College Of Denistry,Washington, DC, USA 5Howard University College Of Medicine,Washington, DC, USA
Introduction: There has been a declining role for surgery in the treatment of complicated peptic ulcer disease (cPUD) due to increasingly effective medical management. However, when medical therapy fails or is not obtainable secondary to socioeconomic barriers, emergency surgery may still be required. Surgical intervention is typically a Graham patch repair (GPR) alone, and much less frequently an acid-reducing procedure (ARP). Our objective is to analyze the contemporary outcomes of these two procedures in different hospital settings.
Methods: We conducted a retrospective review of the National Inpatient Sample from 2007 to 2012 identifying patients with cPUD who underwent a GPR or ARP. Bivariate analysis was utilized to assess outcomes of these two procedures in each of the following hospital
Settings: safety net, non-safety net, rural, urban teaching, and urban non-teaching. Potential confounders were controlled using multivariate logistic regression and generalized linear regression models.
Results: A total of 62,477 patients had cPUD; a little over 51% (32,094) of which had surgery. Among operative patients, nearly 97% (31,182) underwent a GPR, and fewer than less 3% (912) had an ARP. Confounders such as patient’s age, race, co-morbidities, socioeconomic status, and income were adjusted. Overall, mortality was almost two-fold and morbidity was almost three-fold for patients undergoing ARP (table 1) than for those that underwent GPR. In non-safety net hospitals, patients undergoing ARP also had a two- and three-fold increase in mortality and morbidity respectively. Urban non-teaching hospitals had a two-fold increase in both mortality and morbidity. The disparity in complications was greater still at urban teaching hospitals, where patients undergoing an ARP had a four-fold increase in morbidity and in rural hospitals where there was a five-fold increase in mortality. On bivariate analysis there was no difference in Charlson Comorbidity Index between patients receiving the two different procedures. Mortality differences disappear at all hospital settings when only patients treated at hospitals performing at least one ARP are considered.
Conclusion: In 97% of patient’s undergoing ARP for cPUD, GPR was performed. Patients receiving ARP experienced worse outcomes from those receiving GPR alone in all hospital settings. The extent of the disparities varied among hospital settings with rural hospitals having the worst disparities between the two surgeries. Mortality differences disappear among patients where acid reducing procedures are done. Further studies are warranted to elucidate the direct and indirect impact these factors play.
