Do perforated gastric ulcers require routine intra-operative biopsy?
Date
2018
Authors
Oyomno, Meryl Dache
Journal Title
Journal ISSN
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Abstract
Background.
It is recommended that perforated peptic ulcers undergo intraoperative biopsy to rule
out an occult malignancy. Furthermore, there is a recommendation for routine
postoperative outpatient follow-up gastroscopy to examine and biopsy residual
ulcers. In view of the low incidence of malignancy (<1%) and the changing
epidemiology of perforated gastric ulcers, evidenced by an increased incidence of
patients younger than the typical gastric cancer age group (60-79 years), presenting
with this condition, the question is raised: is it necessary to biopsy all perforated
gastric ulcers at the time of surgical repair?
Objectives
To determine the demographics and potential risk factors for perforated peptic ulcers
as well as the incidence of occult malignancy in these ulcers.
Methods
A retrospective study was carried out from 1 January 2010 to 31 December 2011 in
three public university affiliated hospitals in Johannesburg. Data analysis was
conducted using Microsoft ExcelTM spreadsheet tools. The descriptive analysis was
carried out as follows. First, categorical variables were summarized by frequency
and percentage tabulations and illustrated by means of bar charts. Second,
continuous variables were summarized by mean, standard deviation, median, and
interquartile range and their distribution illustrated by histograms. The X2 test was
used to assess the association between age category, gender, and ulcer location.
Fischer’s exact test was used for 2x2 tables and where the requirements for the
X2 test could not be met. Finally, the Phi coefficient and Cramer’s V were used to
measure the strength of association.
Results
During the study period 171 patients underwent operative management of perforated
ulcers. Most were young (20 – 39 years) with a median age of 42 years, 54.4% of
the ulcers were gastric ulcers and intra-operative biopsy was performed in 72% of
cases. Of these 25 (26.88 %) were adequate biopsies. Of the inadequate biopsies
97.62% had no mucosa in the biopsy specimen. 90.2% of the biopsies were benign
and 2.4% malignant. One case of H. pylori infection was noted. There was a nonattendance
rate of 72% for follow-up gastroscopy. For the perforated gastric ulcers,
the most prevalent risks factors include smoking (55.9%), NSAIDS (40.0%), and
alcohol (34.4%).
Conclusion
A South African protocol for the management of perforated peptic ulcers, recognizing
that most patients do not return for follow-up gastroscopy, should be developed.
Intra-operatively biopsy should be performed in view of the low patient follow-up rate,
however the biopsy specimen must include mucosa to improve the diagnostic rate of
malignancy and H. pylori.
Description
A research report submitted to the Faculty of Health Sciences, University of the
Witwatersrand, in fulfillment of the requirements for the degree of Master of Medicine
(General Surgery).
Johannesburg, 2018.