A Comparative study to Assess the Outcome and Complications of Grahams Omental Patch Closure Versus Modified Grahams Omental Patch Closure in Perforated Duodenal Ulcer among Patients admitted in General Surgery Department, Government Rajaji Hospital, Madurai

Abstract

INTRODUCTION: Duodenal ulcer perforation is one of the manifestation of Peptic ulcer disease. Duodenal ulcer represent almost 2/3rd of all peptic ulcer diseases. Perforated duodenal ulcer remains a major health problem world wide. Peptic ulcer disease is primarily associated with H-pylori infection and excessive use of NSAIDs. Since the burden of peptic ulcer disease and its complications are significant worldwide, it is important to conduct a study based on peptic ulcer disease. Life prevalence of duodenal ulcer has found to be 11-14% for males and 8-10% for women. Male to female ratio of duodenal ulcer have reduced from 10:1 to 1.5:1. Duodenal ulcer have been characterized by the presence of a well demarcated break in the mucosa that may extend into muscularis propriya of the duodenum. Duodenal perforation is the second most common complication of PUD and occurs in as many as 10% of patients with PUD. My study compares the outcome and complications of two surgical procedures done for perforated duodenal ulcer namely Grahams Omental Patch Repair and Modified Grahams Omental Patch Closure. AIM OF THE STUDY: The aim of this study is to compare outcome and complications of Graham’s Omental Patch Closure Versus Modified Graham’s Omental Patch Closure for treating perforated duodenal ulcers. OBJECTIVES: To compare outcome and complications of Graham’s Omental Patch Closure Versus Modified Graham’s Omental Patch closure for treating perforated duodenal ulcers. MATERIALS AND METHODS: Study Design: Period of Study: 6 months (April 2018 – September 2018). Place of Study: Government Rajaji Hospital, Madurai. Selection of Study Subjects: All patients diagnosed with peritonitis secondary to hollow viscus perforation who are willing for definitive surgery. Sample Size: 60 patients. Data Collection: Data regarding history, clinical examination,laboratory values & postoperative analysis. METHODS: Prospective comparitative study. ELIGIBILITY CRITERIA: Inclusion Criteria: All patients with perforated duodenal ulcer size < 20 mm who are admitted in general surgery department GRH, Madurai. Exclusion Criteria: Duodenal perforation of other origin such as traumatic and neoplasia. Large duodenal perforation > 20 mm, Posterior duodenal perforation, Sealed duodenal perforation, Patient who expired before definitive surgery, Patient not willing for definitive surgery, Patient not willing for the study. MATERIALS USED: Proforma containing patient history, clinical examination, Informed consent forms. METHODOLOGY: After obtaining clearance and approval from the institutional ethical committee and patients fulfilling the inclusion / exclusion criteria were included in the study after obtaining informed consent. • Patients admitted in surgery department who are diagnosed with perforated duodenal ulcer are grouped into group 1 and group 2. • Non probability purposive sampling technique was used to allocate the subjects into group 1(Grahams omental patch closure) and group 2 (Modified Graham’s omental patch closure). • Initial preoperative work up and resuscitation with intravenous fluids, antibiotics, analgesics, nasogastric decompression was done in all the cases. DISCUSSION In our study we included 60 patients. 30 patients were under Group 1 (GRAHAMS OMENTAL PATCH REPAIR) and 30 patients under Group 2 (MODIFIED GRAHAMS OMENTAL PATCH REPAIR). Age distribution of the patients affected ranged from 13-70 years in the present study. The maximum number of cases studied were in the age group of 31 to 40 (25%). In group 1 mean age was 40.7 (SD – 15.020). In group 2 the mean age was 40.83 (SD-23.181). The two tailed P value equals 0.9795. This difference is considered to be statistically not significant. Most of the patients were males (males 51%). Male female ratio was 51:9. Comparing the two groups chi square statistics is 3.268. The p value is 0.70645. This result is not significant at p < 0.05. Majority of patients presented with symptoms of abdominal pain for 1 to 2 days. (mean days of presentation- 1.68 days). 9 out of 60 patients were diabetic, 3 out of 60 patients were hypertensive. 41 patients out of 60 patients studied had history of smoking (68.3%). 9 out of 60 patients had history of NSAID abuse (15%). The mean duration of ventilator support was 0.3667 days in group 1 and 0.43333 days in group 2. Comparing the two groups the two tailed p value is 0.9409. This result is not statistically significant at p < 0.05. Patients in group 1 have return of bowel activity in an average of 3.43 days. Patients in group 1 have return of bowel activitiy in an average of 3.966 days. Comparing the two groups the two tailed p value is 0.3788. This result is not statistically significant at p < 0.05. 8 out of 30 patients in group 1 developed surgical site infection, while 6 out of 30 patients in group 2 developed surgical site infection. Comparing the two groups chi square statistics is 0.3727 the p value is 0.541552. This result is not statistically significant at p < 0.05. 2 out of 30 patients in group 1 developed metabolic abnormalities post operatively. 2 out of 30 patients in group 2 developed metabolic abnormalities post operatively Comparing the two groups chi square statistics is 0 .the p value is 1. This result is not statistically significant at p < 0.05. Average days of hospital stay in group 1 is 9.9 days. Average days of hospital stay in group 2 is 8.46 days. Comparing the two groups. The two tailed p value is 0.7840. This result is not statistically significant at p < 0.05. 4 out of 30 patients in group 1 died during hospital stay. 4 out of 30 patients in group 2 died during hospital stay. Comparing the two groups chi square statistics is 0 .the p value is 1. This result is not statistically significant at p < 0.05. CONCLUSION: The outcome and complication of both surgeries for perforated duodenal ulcer, that is GRAHAMS OMENTAL PATCH REPAIR and MODIFIED GRAHAMS OMENTAL PATCH REPAIR are independent of the method of surgery done. Thus it is the surgeons choice to select one of the two methods. The major contributing factor for outcome and complication of surgery are the age, day of presentation, peritonitis index and comorbidities of patient rather than the type of surgery done