Incidence and Outcomes of Perforated Peptic Ulcers in Children: Analysis of the Kid's Inpatient Database and Report of Two Cases Treated by Laparoscopic Omental Patch Repair.

INTRODUCTION: Peptic ulcer disease (PUD) is a rare condition in children. Perforated peptic ulcer (PPU), a complication of PUD has an estimated mortality between 1.3% and 20%. We evaluate incidence and outcomes of PPU in children using an administrative database, perform a review of the literature, and report our technique for laparoscopic omental patch repair for PPU in two pediatric patients. MATERIALS AND METHODS: Kids' inpatient database (KID's) was analyzed for demographics, incidence, and outcomes. Incidence for each year was calculated based on the reported pediatric population in the United States for 2000, 2003, 2006, 2009, and 2012 by the U.S. Census Bureau. Additionally, we present two PPU cases, accompanied by a comprehensive review of the literature. RESULTS: The annual number of primary discharge diagnosis of PPU in the KID was 178 cases for 2000, 252 for 2003, 255 for 2006, 299 for 2009, and 266 for 2012. An increase trend over time was noted between 2000 and 2009; however, it was not statistically significant (0.05). PPU appears to be more common in Caucasian teenage boys. The mean length of stay was 8.02 days and with a statistically significant increase in healthcare charges ($33,187 versus $78,142, P = .002) when comparing year 2000-2012. DISCUSSION: PPU is a rare cause of abdominal pain in children, but still a PUD complication that requires surgery. PPU should be included in the differential diagnosis in patients presenting with acute abdominal pain of uncertain etiology and pneumoperitoneum. Laparoscopy is both diagnostic and therapeutic. Laparoscopic omental patch repair is a safe and effective treatment for PPUs.

A prospective randomized controlled trial of laparoscopic repair versus open repair for perforated peptic ulcers.

BACKGROUND: Although laparoscopic repair (LR) of perforated peptic ulcers (PPUs) has long been accepted, clinical evidence comparing LR versus open repair (OR) remains lacking. Consequently, this study compared the clinical outcomes and cost-effectiveness of LR versus OR. METHODS: From January 2010 to June 2014, 119 patients with PPU were divided randomly into LR (58 patients) and OR (61 patients) groups that were comparable in age, sex, smoking and drinking history, symptom duration, comorbidity, American Society of Anesthesiologists grade, Boey score, and white blood cell count. RESULTS: The operative times for LR versus OR did not differ greatly (70 [interquartile range 60-90] vs 75 [60-90] minutes, respectively, P = .692), nor did postoperative complications. The LR group, however, required substantially less fentanyl than the OR group (0.74 ± 0.33 mg vs 1.04 ± 0.39 mg, P < .001). Moreover, the duration of hospital stay for the LR group was much shorter than those of the OR group (7 [5-9] vs 8 [7-10] days, respectively, P < .001). Although total hospital costs were similar (P = .465), the median intraoperative costs were greater for LR than for OR patients, at ¥6772 and ¥5626, respectively (P < .001). The median cost of ward stay tended to be ¥865 less in the LR group but was not statistically relevant. CONCLUSION: LR and conventional OR are comparable in terms of operative duration and complications. The obvious advantage of LR is the greatly decreased hospital stay and less postoperative pain, at similar total hospital costs. Therefore, LR may be preferable for treating PPU in selected patients.

Cost-efficiency and outcomes in the treatment of perforated peptic ulcer disease: laparoscopic versus open approach.

PURPOSE: Laparoscopic treatment of perforated peptic ulcer disease (perfPUD) has demonstrated comparable operative outcomes with an open approach though the cost-efficiency of this method has not been studied. METHODS: Data were obtained from the Nationwide Inpatient Sample (2007-2010). Patients who underwent operation for perfPUD were divided on the basis of laparoscopic or open approach. The primary outcome measures were hospital duration of stay, mortality, and total charges. RESULTS: A total of 5,361 patients with perfPUD were identified: 5,219 in the open group and 142 in the laparoscopic group. Patients in the laparoscopic group were younger (50.5 vs 60.0, P < .001) and had a lesser incidence at presentation of sepsis (8.5 vs 14.8%, P = .034) and shock (2.1 vs 7.7%, P = .012). On univariate analysis, the laparoscopic group had decreased duration of stay (7.0 vs 8.0 days, P < .001), lesser rates of mortality (3.5 vs 8.1%, P = .048), and were discharged to home more frequently (79.6 vs 68.1%, P = .025). Mean total charges were less in the laparoscopic group ($44,095 vs $52,055, P = .019). Multivariate analyses failed to show a difference between groups for any of the outcome variables. CONCLUSION: The laparoscopic treatment of perfPUD is associated with equivalent costs and outcomes compared with the open technique when we corrected for presentation variables.

Costs of treating bleeding and perforated peptic ulcers in The Netherlands.

OBJECTIVE: Gastrointestinal toxicity of nonsteroidal antiinflammatory drugs includes perforations and bleeds. Several preventive strategies are being tested for cost-effectiveness, but little is known about the costs of the complications they are trying to prevent. We estimated the direct costs of hospital treatment of bleeding and perforated ulcers in a university hospital, from data in discharge letters and the hospital management information system. METHODS: Eligible patients had been treated in the VU University Medical Center between January 1997 and August 2000 for an ulcer bleed or perforation (International Classification of Diseases code 531-4). Resource use comprised hospitalization days and diagnostic and therapeutic interventions. Insurance claim prices determined the costs from the payers' perspective. In a secondary analysis we excluded resource use that was clearly related to the treatment of comorbid illness. RESULTS: Fifty-three patients with a bleeding (n = 35) or perforated ulcer (n = 15) or both (n = 3) were studied, including 14 with comorbidity; 22 complications occurred in the stomach, 29 in the duodenum, one in both stomach and duodenum, and one after partial gastrectomy. A simultaneous bleed and perforation was most expensive (26,000 euro), followed by perforation (19,000 euro) and bleeding (12,000 euro). A bleed in the duodenum was more expensive than in the stomach (13,000 euro vs 10,000 euro), while the opposite was seen for perforations (13,000 euro vs 21,000 euro). Comorbidity increased costs substantially: even after correction for procedures unrelated to the ulcer complication, comorbidity more than doubled the costs of treatment. CONCLUSION: Treatment of complicated ulcers is expensive, especially in patients with comorbid conditions.

Prevention of complicated ulcer disease among chronic users of nonsteroidal anti-inflammatory drugs: the use of a nomogram in cost-effectiveness analysis.

BACKGROUND: Nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with an increased risk of clinical upper gastrointestinal tract (UGI) events, namely, symptomatic ulcer, perforation, bleeding, and obstruction. Our objective in this study was to compare the cost-effectiveness of several strategies aimed at reducing the risk of clinical UGI events in NSAID users. METHODS: A decision tree model was used for patients requiring long-term treatment with NSAIDs to compare conventional NSAID therapy alone with 7 other treatment strategies to reduce the risk of NSAID-related clinical UGI events (cotherapy with proton-pump inhibitor, cotherapy with misoprostol, cyclooxygenase [COX]-2-selective NSAID therapy, or Helicobacter pylori treatment followed by each of the previous strategies, including conventional NSAID treatment, respectively). The outcome measure is the incremental cost per clinical UGI event prevented compared with conventional NSAID treatment over 1 year. RESULTS: The use of a COX-2-selective NSAID and cotherapy with proton-pump inhibitors were the 2 most cost-effective strategies. However, the incremental cost associated with these strategies was high (>$35 000) in persons with a low risk of clinical UGI event with conventional NSAIDs (eg, 2.5% per year). If the baseline risk of clinical UGI events is moderately high (eg, 6.5%), using a COX-2-selective NSAID becomes the most effective and least costly (dominant) treatment strategy, followed closely by cotherapy with a daily proton-pump inhibitor. Because small changes in costs or assumed efficacy of these drugs could change the conclusions, the incremental cost-effectiveness ratios between any 2 strategies were presented in a nomogram that allows the flexible use of a wide range of values for costs and rates of clinical UGI events. CONCLUSIONS: The risk of clinical UGI events in NSAID users depends on their baseline risk, the added risk associated with the individual NSAID, and the protection conferred by cotherapy. A nomogram can be used to incorporate these factors and derive estimates regarding cost-effectiveness of competing strategies aimed at reducing the risk of clinical UGI events.

Prevalence and cost of hospitalization for gastrointestinal complications related to peptic ulcers with bleeding or perforation: comparison of two national databases.

The purpose of this study was to determine the prevalence and cost of hospitalization for upper gastrointestinal complications, including peptic ulcers with hemorrhage or perforation. Upper gastrointestinal complications and corresponding economic data were obtained from two sources. The first was a 20% sample of all community hospital discharges (about 6 million per year) from 11 states for 1991 and 1992 Hospital Cost Utilization Project; HCUP-3). The second source of data was a claims database for employees of large US corporations and their dependents for 1992, 1993, and 1994 (about 3.5 million covered lives per year; MarketScan). A group of ICD-9 codes for the diagnosis of peptic and gastroduodenal ulcers with bleeding or perforation were used to identify hospital admissions because of upper gastrointestinal complications. Similar patterns were observed across the MarketScan and HCUP-3 databases regarding hospitalization with diagnoses related to gastrointestinal complications identified according to the ICD-9 codes. The average age of patients with upper gastrointestinal complications was 66 years in the HCUP-3 database and 52 years in the MarketScan database. The average annual rates of upper gastrointestinal complications as a primary or secondary diagnosis were 6.4 and 6.7 per 1000 discharges for 1991 and 1992, respectively (HCUP-3), and 4.3, 4.2, and 4.9 per 1000 admissions for 1992, 1993, and 1994, respectively (MarketScan). The average length of stay for upper gastrointestinal complications as a primary diagnosis was 7.8 days in 1991 and 7.5 days in 1992 (HCUP-3) and 6.1, 5.1, and 5.1 days in 1992, 1993, and 1994, respectively (MarketScan). The national average total charge for hospitalization for gastrointestinal problems as a primary diagnosis was $12,970 in 1991 and $14,294 in 1992 (HCUP-3). The average total reimbursement for hospitalizations related to upper gastrointestinal problems was $15,309 in 1992, $12,987 in 1993, and $13,150 in 1994 (MarketScan). Hospital admissions for upper gastrointestinal complications are expensive. The rate and cost per admission are higher for the older population. The results on the elements covered by both databases are consistent. Therefore the databases complement each other on the type of information abstracted.