Original scientific article
Comparative Analysis of Vagotomy and Drainage Versus Vagotomy and Resection Procedures for Bleeding Peptic Ulcer Disease: Results of 907 Patients from the Department of Veterans Affairs National Surgical Quality Improvement Program Database

https://doi.org/10.1016/j.jamcollsurg.2005.09.001Get rights and content

Background

The purpose of this study was to determine postoperative outcomes and risk factors for morbidity and mortality in patients requiring surgery for bleeding peptic ulcer disease (PUD). Vagotomy and drainage procedures are technically simpler but are usually associated with higher ulcer recurrence rates. In contrast, vagotomy and resection approaches offer lower ulcer recurrences but represent much more challenging operations and are associated with considerable morbidity and mortality.

Study design

Data collected through the Department of Veterans Affairs National Surgical Quality Improvement Program database from 1991 to 2001 were submitted for stepwise logistic regression analysis for prediction of 30-day postoperative morbidity and mortality, rebleeding, and postoperative length of stay. The study population included all patients operated on for bleeding PUD within an 11-year period.

Results

The 30-day morbidity, mortality, and rebleeding rates were comparable between surgical groups. Age, American Society of Anesthesiologists class, presence of ascites, coma, diabetes, functional status, hemiplegia, and history of steroid use were predictors of postoperative death. Risk factors for rebleeding included dependent functional status, history of congestive heart failure, smoking, steroid use, and preoperative transfusions. Having a resective procedure, American Society of Anesthesiologists class, hemiplegia, history of COPD, and requiring ventilator-assisted respirations before surgery were positively associated with increased length of hospital stay.

Conclusions

No differences were observed in 30-day mortality, morbidity, or rebleeding rates between surgical groups. Having a resective procedure was a predictor of prolonged postoperative stay. Dependent status and chronic use of steroids were predictors of both rebleeding and postoperative mortality.

Section snippets

Research protocol and study population

The research protocol was performed after approval by the Executive Committee in accordance with the NSQIP policies and the Durham Veterans Affairs Medical Center’s Institutional Review Board. Analysis of the data was done at the NSQIP Denver Data Analysis Center under supervision of a senior statistician (WGH). The data set used was a compilation of procedures from assessed patients in the database from fiscal years 1991 to 2001 (fiscal year is October 1 to September 30). Surgical patients

Results

From the information on 3,698 patients obtained from the NSQIP data set who required surgery for peptic ulcer, 907 had been operated on for bleeding PUD. Fifty-seven percent of these (n = 518) were categorized in the vagotomy and drainage (VD) group; the remaining 43% (n = 389) were vagotomy and resection (VR) patients. The majority of patients in both study groups were Caucasian, with an average 28% of non-Caucasian individuals (ie, NSQIP defines non-Caucasian, as Hispanic Caucasian; Hispanic

Discussion

With the nearly ubiquitous use of potent antiulcerogenic drugs and improved endoscopic tools, the need for elective surgery in PUD has declined. After initial resuscitative measures and endoscopic therapy, the majority of patients can be managed successfully, and the indication for surgery has been narrowed to patients in whom aggressive medical management has not been successful. Among all complications of PUD, intractable bleeding is a common indication for surgical intervention.15 In this

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    Competing Interests Declared: None.

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