- Email: [email protected]
Perforated duodenal ulcer
Perforated Duodenal Ulcer Stephen L. Wangensteen, MD, Charlottesville, Virginia Robert C. Wray, MD, Charlottesville, Virginia Gerald T. Golden, MD, Charlottesville, Virginia
Controversy continues over the optimal method of management of perforated duodenal ulcer. Mikulicz [1] in 1880 performed the first closure of a perforated duodenal ulcer. Gastrectomy was first carried out for perforation by Keetly [2] in 1899 and subsequently recommended as the treatment of choice by von Haberer [3]. Wangensteen [4] and Taylor [5] proposed a nonoperative approach to the problem and each reported a series of patients treated successfully. In this country, simple plication of the perforated duodenal ulcer has been the most frequent approach, largely due to the influence of Graham [6]. Nonoperative management still has its proponents [7j, but is principally utilized in patients who are considered not to be suitable candidates for emergency surgery. Current controversy centers on whether to perform a definitive surgical procedure or simple plication at the time of perforation. Several factors appear to have influenced the choice of surgical procedures, Reports have varied widely as to the number of patients requiring subsequent definitive surgery after perforation of duodenal ulcer [8,9]. Moreover, the duration of ulcer symptoms prior to perforation has been correlated with the need for later definitive gastric surgery, and, in this regard, reports have not been uniform. In the present report the course of 131 patients having perforated duodenal ulcer seen at the University of Virginia Medical Center between 1950 and 1965 has been retrospectively reviewed. Material and Methods One hundred nineteen male and twelve female patients (9.9:1) presented for the first time at the University of Virginia Medical Center with free perforation of a duodenal ulcer into the peritoneal cavity. There were 139 per-
From the Department of Surgery, University of Virginia Medical Center, Charlottesville, Virginia 22901. Reprint requests should be addressed to Dr Wangensteen, Department of Surgery, University of Virginia Medical Center, Charlottesville, Virginia 22901.
538
forations in these 131 patients; six patients subsequently presented with a second perforation and one patient had three perforations. The average age was fifty-one years for both sexes and the age range was nineteen to eighty-six years. Recent information was obtained in 120 patients (92 per cent) and the follow-up period ranged from six to twenty-one years, the average being ten years and eleven months. Eighteen patients (13 per cent) had previously had perforation elsewhere for which simple closure was performed. One patient had been treated with a gastroenterostomy for relief of pain prior to presenting with a perforation. Fifty-eight (42 per cent) had been under medical management for symptoms of duodenal ulcer. Nine of these patients had medical management for bleeding and one for prior perforation. Sixty-two patients in this series (44 per cent) had no gastrointestinal symptoms or only mild symptoms before acute perforation. Forty-three patients (31 per cent) had had no symptoms or symptoms for less than three months and ninety-six patients (69 per cent) were symptomatic for longer than three months. In those patients who were symptomatic, the average duration of pain indicative of ulcer disease was six years and two months. Serious concurrent medical problems were present in twenty-four patients (17 per cent). They included: coronary atherosclerosis, eleven patients; alcoholism, seven; pulmonary tuberculosis, two; carcinoma of pancreas, two; carcinoma of prostate, one; diabetes, one. The interval between the acute onset, of pain indicating perforation and presentation in the hospital is given in Table I. In the over-all group the average duration of acute symptoms was twelve hours. The presumptive diagnosis of perforated duodenal ulcer was correct in 130 instances. An incorrect diagnosis of acute appendicitis was made in three instances, perforated colonic diverticulum in three instances, and acute cholecystitis in one instance. The diagnosis was established at autopsy in two patients who were moribund on arrival and died shortly thereafter. Eight patients had gross upper gastrointestinal bleeding concurrent with perforation. The white blood cell count was normal in 111 cases (80 per cent) and above 10,000 per mm3 in twenty-eight instances. Free intraperitoneal air was present in fifty-six of sixty-eight patients who had preoperative radiographs. The perforation was in the first
The American
Journal of Surgery
TABLE
I
interval between Onset of Severe Pain and
TABLE
ii
Methods
Presentation in the Hospital __~. Interval (hours)’
91 27
a
11 2 ~____
portion of the duodenum in 134 and in the pyloric channel in five instances. Seven of the former group had gastric ulcers discovered at surgery. The methods of initial management are outlined in Table II. Simple closure of the perforation was carried out in eighty-nine cases and a definitive procedure was performed in thirty-seven cases. Four patients had pyloroplasty alone for reasons which are unclear. Five patients were treated with antibiotics and nasogastric suction because of severe medical illness, making the risk of surgery prohibitive. The patient who underwent cholecystoduodenostomy had carcinoma of the head of the pancreas. The mean age of the patients undergoing definitive surgery was forty-five years and the mean age of the patients having plication or nonoperative management was fifty-three years. A specimen for culture of the peritoneal cavity was obtained in thirty-four cases. In twelve cases the cultures were sterile. The remainder grew out mixed colonies of viridans streptococci, enterococci, and Escherichia coli. Results
There were no intraoperative deaths, but eight patients (5.8 per cent) died while in the hospital. This includes the two patients in whom perforation was not discovered until autopsy and the patient who had cholecystoduodenostomy for carcinoma of the pancreas. All of the patients treated by definitive surgery survived. The causes of death are correlated with the mode of treatment in Table III. Two of the five patients (40 per cent) treated without operation died. No deaths were attributable to intra-abdominal complications in the group undergoing surgery. Serious postoperative complications were present in twenty cases (14 per cent). These are depicted in Table IV. As would be expected with intraperitoneal soiling, intra-abdominal abscess was the most frequently encountered complication. It was of interest that abscesses that developed after surgery frequently did not contain the same organisms that were obtained from cultures of the peritoneal cavity at surgery. The next most frequent complication was pneumonia. One patient had obstruction at the site of plication requiring re-exploration. In one patient
Volume 123. May 1972
Duodenal
of initial Treatment --~~
__~
Ulcer
Number of Patients ~__
Treatment
Number of Patients
Less than 6 7-12 13-24 Over 24 Discovered at postmortem examination
Perforated
-__
a9 la 11
Simple closure Vagotomy and pyloroplasty Subtotal gastrectomy Vagotomy and antrectomy Nasogastric suction and antibiotics Pyloroplasty alone None (discovered at postmortem examination) Gastrojejunostomy Cholecystoduodenostomy
a 5 4 2 1 1
perforation recurred in the postoperative period and was associated with upper gastrointestinal bleeding and an incarcerated inguinal hernia. Follow-up results were classified as excellent, good, fair, or poor, using criteria established previously [IO]. (Table V.) Sixty-seven of eighty-four patients were judged to have unsatisfactory results with simple closure or nonoperative management. With definitive surgery, thirty-five of thirty-seven patients had good or excellent results. In fifty-nine cases, a second operation for treatment of persistent ulcer symptoms was required. Fifty-eight of the fiftynine had simple closure or nonoperative primary treatment. Two of these fifty-nine were scheduled for later elective definitive surgery at the time of discharge from the hospital after treatment of their perforated ulcer because of prior perforation elsewhere. One patient who had undergone primary vagotomy and pyloroplasty subsequently required gastric resection for hemorrhage. The indications for secondary operation are presented in Table VI. The time interval between the first perforation and second surgical procedure is given in Table VII. It is readily apparent that the majority of patients in this series required reoperation within five years. The average inTABLE
iii
Causes of Death Correlated Method of Treatment ____ ~~~~~~___ ._
Cause of Death Pneumonia Candida albicans C albicans and E coli Organism unknown Aspiration pneumonitis Carcinoma of pancreas Peritonitis (organism unknown)
Number Of Patients
with the
Method of Treatment
3 1
Pyloroplasty only
1 1
Nonoperative None Simple closure (2) Cholecystoduodenostomy, none
2 2
1
Nonoperative
539
Wangensteen,
Wray, and Golden
terval between simple closure or nonoperative treatment and definitive surgery was three years and eleven months. Comments
In the present series the correct preoperative diagnosis of perforated duodenal ulcer was established in 94 per cent of the cases. In only 1.4 per cent was the correct diagnosis not made during life. The diagnosis was generally made from the classic history elicited from the patient combined with the physical findings indicative of a peritoneal irritation. Pneumoperitoneum was detected in 82 per cent of the patients having radiographs of the chest or abdomen. The over-all mortality from perforated duodenal ulcer in this series was 5.8 per cent, a somewhat lower figure than that reported by others [11,12]. It is noteworthy that none of the patients that had definitive surgery at the time of perforation died in the postoperative period. In 1937 Judin [I31 reported the first large series of 937 patients treated by primary resection, with a mortality of 8.9 per cent. DeBakey [14] in 1940 reviewed 2,392 cases of perforation treated by immediate resection with a mortality of 13.4 per cent as compared with a mortality of 25.9 per cent in 5,589 cases treated by simple closure. In more recent years the advent of antibiotics and improvements in pre- and postoperative care have improved these figures considerably. In 1952 Auchincloss [15] TABLE
IV
Postoperative
reported thirteen cases of immediate resection without any deaths. Jordan, DeBakey, and Cooley [16] reviewed 351 cases of perforation treated by resection from 1950 to 1962 with a mortality of 2 per cent. Rogers [17] reported one death in seventy-five patients treated by vagotomy and a drainage procedure for perforation, and Kincannon, McLenathen, and Weinburg [18] reported no deaths in thirty patients treated by immediate vagotomy and pyloropIasty. There are now numerous reports indicating that emergency definitive surgery can be accomplished safely after perforation in selected patients. All deaths in our series of patients occurred in those treated by simple closure or nasogastric suction and antibiotics. Three of the six patients dying in the postoperative period had severe associated disease, such as alcoholism, chronic brain syndrome, and carcinoma of the pancreas, whereas the over-all incidence of associated disease was only 17 per cent. The decision to proceed with definitive surgery in the present series of patients was based on the general good health of the patient prior to perforation and the absence of excessive peritoneal soiling at operation. It appears that it was this judgment and not the type of surgical procedure that influenced the outcome in the postoperative period. It has been reported that the mortality after perforation is directly proportional to the time interval between perforation and treatment [12]. The interval between the acute onset of symptoms and treatment was less than
Complications TABLE
Complications
V
Method
Treatment Intra-abdominal abscess Subphrenic abscess Staphylococcus aureus Diphtheroids C albicans and S viridans S albus and S viridans E coli lntermesenteric abscess, S aureus and Klebsiella lntermesenteric and subphrenic abscesses, E coli Pneumonia E coli and D pneumoniae E coli S albus Aerobacter Dehiscence Urinary tract infection Congestive heart failure Obstruction at site of closure of perforation Reperforation Upper gastrointestinal bleeding > Incarcerated inguinal hernia
540
of Treatment
and Results
Number of Patients
a a 2 1 1 1 1 1 1 5 1 2 1 1 2 2 1 1 1
and Results
Number of Patients
_-___ Simple closure or nonoperative treatment Excellent Good Fair Poor Lost to follow-up study Vagotomy and pyloroplasty, subtotal gastrectomy, or vagotomy and pyloroplasty Excellent Good Fair Poor No treatment (discovered at postmortem examination) Gastrojejunostomy Lost to follow-up study Pyloroplasty alone Excellent Good Poor Cholecystoduodenostomy Poor
94
a 1
a 67 10 37 27
a 1 1 2 1 1 4 1 2 1 1 1
The American Journal of Surgery
Perforated
twelve hours in five of our six patients who died in the postoperative period. Bacterial or aspiration pneumonia was the most common cause of death although intra-abdominal infection was the most common postoperative complication. It is noteworthy that the only patient who died due to intra-abdominal sepsis had nonoperative primary treatment. The reported rate of recurrence of duodenal ulcer disease after perforation has varied widely. From 34 [8] to 76 per cent [9] of patients having simple closure of a perforated ulcer have been reported to have symptoms indicative of recurrent ulcer. Approximately 80 per cent of our patients had persistence of ulcer symptoms after closure or nonoperative treatment of their perforated duodenal ulcer. From 13 [19] to 60 per cent [20] of patients having simple closure of a perforated duodenal ulcer have been reported to require a second operation for control of ulcer symptoms. Sixty-nine per cent of our patients who had simple closure or nonoperative primary treatment required a subsequent definitive surgical procedure for control of intractable pain complications of their ulcer diathesis whereas only one patient who had a definitive ulcer operation as primary treatment required a second operation for control of recurrent ulcer problems, The percentage of patients requiring a second operation has been shown to rise with time [12,21]. Although the majority of patients in the present series had surgical correction of recurrent ulcer within five years after perTABLE
VI
Indications for Secondary Operations for Ulcer Number of Patients
Indications Primary treatment: simple closure by nonoperative means Pain Reperforation Hemorrhage Obstruction Biopsy, gastric ulcer Primary treatment: vagotomy and pyloroplasty Hemorrhage
TABLE VII
blnterval
20 16 13 8 1 1
Interval between the First Perforation and the Secondary Operation fbr Ulcer Symptoms ~____ (yr)
o-1 2-5 6-l 0 Greater than 10
Volume 123, May 1972
Number of Patients ~_~__ 19 25 8 7
Duodenal
Ulcer
foration, the interval was greater than six years in 25 per cent and greater than ten years in 12 per cent. Intractable pain has been the indication for definitive surgery in approximately 60 per cent of previously reported series [12,22] whereas only 34 per cent of patients in this series had pain as the indication for subsequent surgery. This lower figure may reflect a conservative attitude by our referring physicians concerning relief of pain as an indication for surgery. Another possible explanation for the low figure is that most patients in this series reside in rural areas and the peptic ulcer diathesis may be more virulent in this stoic group of patients. Conversely, the rate of re-perforation, hemorrhage, and late obstruction was much higher in our series than in most other reports. It has been reported that if ulcer symptoms prior to perforation are of short duration, the rate of recurrent ulcer problems is much lower [23]. In the present study, 73 per cent of patients having pre-perforation symptoms of greater than three months’ duration required definitive surgery and 64 per cent of patients having either no pre-perforation symptoms or symptoms of less than three months required corrective surgery. These values are not significantly different. The mortality and morbidity for antrectomy and vagotomy [12] or vagotomy and pyloroplasty [11] performed in selected cases of perforated ulcer approach the mortality after these procedures performed electively. Because of this low mortality and the fact that the majority of patients in the present series required further surgery, we believe that an-’ trectomy and vagotomy or vagotomy and pyloroplasty should be performed for a perforated duodenal ulcer unless specific contraindications exist. The principal contraindication to definitive surgery is, in our opinion, extensive soilage of the peritoneal cavity due to the perforation. The degree of soilage is not necessarily related ‘to the time interval from perforation. In this regard, the size of the perforation and the patient’s dietary intake prior to perforation appear important. Summary
The records of 131 patients with perforated duodenal ulcer have been reviewed. Sixty-seven per cent of these patients were treated by simple closure of the ulcer or nonoperatively. Of this subgroup, 80 per cent had significant symptoms of peptic ulcer disease requiring medical or surgical treatment and 69 per cent required a second surgical procedure. Thirtyseven patients were treated by a definitive surgical procedure for duodenal ulcer at the time of perforation and all survived. In this group of patients, only
541
Wangensteen,
Wray,
and Golden
one required further surgery for complications of peptic ulcer. We believe that antrectomy and vagotomy or pyloroplasty and vagotomy should be utilized in the treatment of perforated duodenal ulcer unless specific contraindications are present.
11.
References
13.
1. Mikulicz J: Zur operativen Behandlung des stenosirenden Magengeschivurs. Verh Deufsch Ges Chir 16: 337, 1667. 2. Keetly CB: Surgery of non-malignant gastric ulcer and perforation. Lancet 1: 685. 1902. 3. von Haberer H: Zur Therapie akuter gesohwursperforationen des Magens und Duodenums in die freie Bauhhohle. Wein Klin Wschr32: 413, 1919. 4. Wangensteen OH: Non-operative treatment of localized perforations of the duodenum. Minn Med 18: 477, 1935. 5. Taylor H: Perforated peptic ulcer treated without operation. Lancet 2: 447,1946. 6. Graham RR: The treatment of perforated duodenal ulcers. Surg Gynec Obsfet 64: 235, 1937. 7. Seeley SF: Views on non-operative management of perforated ulcer, p 836. Surgery of the Stomach and Duodenum, (Harkins HN and Nyhus LM, ed.) Boston, Little Brown, 1969. 8. Jirzik H: Erfahrungen bei 327 freinen Magen-Zwolffingerdarm-Geschwursperforationen. Arch k/in Chir 277: 611, 1954. 9. Turner FP: Acute perforations of stomach, duodenum and jejunum. Analysis of 224 cases with late follow-up data on 147 cases of acute perforated peptic ulcer. Surg Gynec Obstet 92: 281, 1951. 10. Whittaker LD Jr, Judd ES, Stauffer MH: Analysis of use of
14.
542
12.
15. 16.
17.
18.
19. 20. 21.
22. 23.
vagotomy with drainage procedure in surgical management of duodenal ulcer. Surg Gynec Obstef 125: 1018, 1967. Burdette WJ, Rasmussen B: Perforated peptic ulcer. Surgery 63: 576, 1968. Nemanich GJ, Nicoloff DM: Perforated duodenal ulcer: long-term follow-up. Surgery 67: 727, 1970. Judin SS: Partial gastrectomy in acute perforated peptic ulcer. Surg Gynec Obsfef 64: 64, 1937. DeBakey ME: Acute perforated gastroduodenal ulceration: statistical analysis and a review of the literature. Surgery 8:852, 1940. Auchincloss H Jr: Immediate subtotal gastrectomy for acute perforated peptic ulcer. Ann Surg 135: 134, 1952. Jordan GL, DeBakey ME, Cooley DA: The role of resective therapy in the management of acute gastroduodenal perforation. Amer J Surg 105: 396, 1963. Rogers FA: Factors affecting the mortality from acute gastroduodenal perforation. Surg Gynec Obstet 111: 771, 1960. Kincannon WM, McLenathen CW, Weinburg JW: Vagotomy and pyloroplasty for acute perforated duodenal ulcer. Amer Surg 29: 692, 1963. Martinis AJ, Olson HH, Harkins HN: The treatment of perforated peptic ulcer. West J Surg 65: 72, 1957. Mark JBD: Factors influencing the treatment of perforated duodenal ulcer. Surg Gynec Obstet 129: 325.1969. Norberg PB: Results of the surgical treatment of peptic ulcer. A clinical and roentgenological study. Acta Chir Stand Suppl249: 1, 1959. Cassell P: Perforated duodenal ulcer in Reading from 19501959. Guf 10: 454, 1969. Cassell P: The prognosis of the perforated acute duodenal ulcer. Guf 10: 572, 1969.
The American Journal of Surgery
Controversy continues over the optimal method of management of perforated duodenal ulcer. Mikulicz [1] in 1880 performed the first closure of a perforated duodenal ulcer. Gastrectomy was first carried out for perforation by Keetly [2] in 1899 and subsequently recommended as the treatment of choice by von Haberer [3]. Wangensteen [4] and Taylor [5] proposed a nonoperative approach to the problem and each reported a series of patients treated successfully. In this country, simple plication of the perforated duodenal ulcer has been the most frequent approach, largely due to the influence of Graham [6]. Nonoperative management still has its proponents [7j, but is principally utilized in patients who are considered not to be suitable candidates for emergency surgery. Current controversy centers on whether to perform a definitive surgical procedure or simple plication at the time of perforation. Several factors appear to have influenced the choice of surgical procedures, Reports have varied widely as to the number of patients requiring subsequent definitive surgery after perforation of duodenal ulcer [8,9]. Moreover, the duration of ulcer symptoms prior to perforation has been correlated with the need for later definitive gastric surgery, and, in this regard, reports have not been uniform. In the present report the course of 131 patients having perforated duodenal ulcer seen at the University of Virginia Medical Center between 1950 and 1965 has been retrospectively reviewed. Material and Methods One hundred nineteen male and twelve female patients (9.9:1) presented for the first time at the University of Virginia Medical Center with free perforation of a duodenal ulcer into the peritoneal cavity. There were 139 per-
From the Department of Surgery, University of Virginia Medical Center, Charlottesville, Virginia 22901. Reprint requests should be addressed to Dr Wangensteen, Department of Surgery, University of Virginia Medical Center, Charlottesville, Virginia 22901.
538
forations in these 131 patients; six patients subsequently presented with a second perforation and one patient had three perforations. The average age was fifty-one years for both sexes and the age range was nineteen to eighty-six years. Recent information was obtained in 120 patients (92 per cent) and the follow-up period ranged from six to twenty-one years, the average being ten years and eleven months. Eighteen patients (13 per cent) had previously had perforation elsewhere for which simple closure was performed. One patient had been treated with a gastroenterostomy for relief of pain prior to presenting with a perforation. Fifty-eight (42 per cent) had been under medical management for symptoms of duodenal ulcer. Nine of these patients had medical management for bleeding and one for prior perforation. Sixty-two patients in this series (44 per cent) had no gastrointestinal symptoms or only mild symptoms before acute perforation. Forty-three patients (31 per cent) had had no symptoms or symptoms for less than three months and ninety-six patients (69 per cent) were symptomatic for longer than three months. In those patients who were symptomatic, the average duration of pain indicative of ulcer disease was six years and two months. Serious concurrent medical problems were present in twenty-four patients (17 per cent). They included: coronary atherosclerosis, eleven patients; alcoholism, seven; pulmonary tuberculosis, two; carcinoma of pancreas, two; carcinoma of prostate, one; diabetes, one. The interval between the acute onset, of pain indicating perforation and presentation in the hospital is given in Table I. In the over-all group the average duration of acute symptoms was twelve hours. The presumptive diagnosis of perforated duodenal ulcer was correct in 130 instances. An incorrect diagnosis of acute appendicitis was made in three instances, perforated colonic diverticulum in three instances, and acute cholecystitis in one instance. The diagnosis was established at autopsy in two patients who were moribund on arrival and died shortly thereafter. Eight patients had gross upper gastrointestinal bleeding concurrent with perforation. The white blood cell count was normal in 111 cases (80 per cent) and above 10,000 per mm3 in twenty-eight instances. Free intraperitoneal air was present in fifty-six of sixty-eight patients who had preoperative radiographs. The perforation was in the first
The American
Journal of Surgery
TABLE
I
interval between Onset of Severe Pain and
TABLE
ii
Methods
Presentation in the Hospital __~. Interval (hours)’
91 27
a
11 2 ~____
portion of the duodenum in 134 and in the pyloric channel in five instances. Seven of the former group had gastric ulcers discovered at surgery. The methods of initial management are outlined in Table II. Simple closure of the perforation was carried out in eighty-nine cases and a definitive procedure was performed in thirty-seven cases. Four patients had pyloroplasty alone for reasons which are unclear. Five patients were treated with antibiotics and nasogastric suction because of severe medical illness, making the risk of surgery prohibitive. The patient who underwent cholecystoduodenostomy had carcinoma of the head of the pancreas. The mean age of the patients undergoing definitive surgery was forty-five years and the mean age of the patients having plication or nonoperative management was fifty-three years. A specimen for culture of the peritoneal cavity was obtained in thirty-four cases. In twelve cases the cultures were sterile. The remainder grew out mixed colonies of viridans streptococci, enterococci, and Escherichia coli. Results
There were no intraoperative deaths, but eight patients (5.8 per cent) died while in the hospital. This includes the two patients in whom perforation was not discovered until autopsy and the patient who had cholecystoduodenostomy for carcinoma of the pancreas. All of the patients treated by definitive surgery survived. The causes of death are correlated with the mode of treatment in Table III. Two of the five patients (40 per cent) treated without operation died. No deaths were attributable to intra-abdominal complications in the group undergoing surgery. Serious postoperative complications were present in twenty cases (14 per cent). These are depicted in Table IV. As would be expected with intraperitoneal soiling, intra-abdominal abscess was the most frequently encountered complication. It was of interest that abscesses that developed after surgery frequently did not contain the same organisms that were obtained from cultures of the peritoneal cavity at surgery. The next most frequent complication was pneumonia. One patient had obstruction at the site of plication requiring re-exploration. In one patient
Volume 123. May 1972
Duodenal
of initial Treatment --~~
__~
Ulcer
Number of Patients ~__
Treatment
Number of Patients
Less than 6 7-12 13-24 Over 24 Discovered at postmortem examination
Perforated
-__
a9 la 11
Simple closure Vagotomy and pyloroplasty Subtotal gastrectomy Vagotomy and antrectomy Nasogastric suction and antibiotics Pyloroplasty alone None (discovered at postmortem examination) Gastrojejunostomy Cholecystoduodenostomy
a 5 4 2 1 1
perforation recurred in the postoperative period and was associated with upper gastrointestinal bleeding and an incarcerated inguinal hernia. Follow-up results were classified as excellent, good, fair, or poor, using criteria established previously [IO]. (Table V.) Sixty-seven of eighty-four patients were judged to have unsatisfactory results with simple closure or nonoperative management. With definitive surgery, thirty-five of thirty-seven patients had good or excellent results. In fifty-nine cases, a second operation for treatment of persistent ulcer symptoms was required. Fifty-eight of the fiftynine had simple closure or nonoperative primary treatment. Two of these fifty-nine were scheduled for later elective definitive surgery at the time of discharge from the hospital after treatment of their perforated ulcer because of prior perforation elsewhere. One patient who had undergone primary vagotomy and pyloroplasty subsequently required gastric resection for hemorrhage. The indications for secondary operation are presented in Table VI. The time interval between the first perforation and second surgical procedure is given in Table VII. It is readily apparent that the majority of patients in this series required reoperation within five years. The average inTABLE
iii
Causes of Death Correlated Method of Treatment ____ ~~~~~~___ ._
Cause of Death Pneumonia Candida albicans C albicans and E coli Organism unknown Aspiration pneumonitis Carcinoma of pancreas Peritonitis (organism unknown)
Number Of Patients
with the
Method of Treatment
3 1
Pyloroplasty only
1 1
Nonoperative None Simple closure (2) Cholecystoduodenostomy, none
2 2
1
Nonoperative
539
Wangensteen,
Wray, and Golden
terval between simple closure or nonoperative treatment and definitive surgery was three years and eleven months. Comments
In the present series the correct preoperative diagnosis of perforated duodenal ulcer was established in 94 per cent of the cases. In only 1.4 per cent was the correct diagnosis not made during life. The diagnosis was generally made from the classic history elicited from the patient combined with the physical findings indicative of a peritoneal irritation. Pneumoperitoneum was detected in 82 per cent of the patients having radiographs of the chest or abdomen. The over-all mortality from perforated duodenal ulcer in this series was 5.8 per cent, a somewhat lower figure than that reported by others [11,12]. It is noteworthy that none of the patients that had definitive surgery at the time of perforation died in the postoperative period. In 1937 Judin [I31 reported the first large series of 937 patients treated by primary resection, with a mortality of 8.9 per cent. DeBakey [14] in 1940 reviewed 2,392 cases of perforation treated by immediate resection with a mortality of 13.4 per cent as compared with a mortality of 25.9 per cent in 5,589 cases treated by simple closure. In more recent years the advent of antibiotics and improvements in pre- and postoperative care have improved these figures considerably. In 1952 Auchincloss [15] TABLE
IV
Postoperative
reported thirteen cases of immediate resection without any deaths. Jordan, DeBakey, and Cooley [16] reviewed 351 cases of perforation treated by resection from 1950 to 1962 with a mortality of 2 per cent. Rogers [17] reported one death in seventy-five patients treated by vagotomy and a drainage procedure for perforation, and Kincannon, McLenathen, and Weinburg [18] reported no deaths in thirty patients treated by immediate vagotomy and pyloropIasty. There are now numerous reports indicating that emergency definitive surgery can be accomplished safely after perforation in selected patients. All deaths in our series of patients occurred in those treated by simple closure or nasogastric suction and antibiotics. Three of the six patients dying in the postoperative period had severe associated disease, such as alcoholism, chronic brain syndrome, and carcinoma of the pancreas, whereas the over-all incidence of associated disease was only 17 per cent. The decision to proceed with definitive surgery in the present series of patients was based on the general good health of the patient prior to perforation and the absence of excessive peritoneal soiling at operation. It appears that it was this judgment and not the type of surgical procedure that influenced the outcome in the postoperative period. It has been reported that the mortality after perforation is directly proportional to the time interval between perforation and treatment [12]. The interval between the acute onset of symptoms and treatment was less than
Complications TABLE
Complications
V
Method
Treatment Intra-abdominal abscess Subphrenic abscess Staphylococcus aureus Diphtheroids C albicans and S viridans S albus and S viridans E coli lntermesenteric abscess, S aureus and Klebsiella lntermesenteric and subphrenic abscesses, E coli Pneumonia E coli and D pneumoniae E coli S albus Aerobacter Dehiscence Urinary tract infection Congestive heart failure Obstruction at site of closure of perforation Reperforation Upper gastrointestinal bleeding > Incarcerated inguinal hernia
540
of Treatment
and Results
Number of Patients
a a 2 1 1 1 1 1 1 5 1 2 1 1 2 2 1 1 1
and Results
Number of Patients
_-___ Simple closure or nonoperative treatment Excellent Good Fair Poor Lost to follow-up study Vagotomy and pyloroplasty, subtotal gastrectomy, or vagotomy and pyloroplasty Excellent Good Fair Poor No treatment (discovered at postmortem examination) Gastrojejunostomy Lost to follow-up study Pyloroplasty alone Excellent Good Poor Cholecystoduodenostomy Poor
94
a 1
a 67 10 37 27
a 1 1 2 1 1 4 1 2 1 1 1
The American Journal of Surgery
Perforated
twelve hours in five of our six patients who died in the postoperative period. Bacterial or aspiration pneumonia was the most common cause of death although intra-abdominal infection was the most common postoperative complication. It is noteworthy that the only patient who died due to intra-abdominal sepsis had nonoperative primary treatment. The reported rate of recurrence of duodenal ulcer disease after perforation has varied widely. From 34 [8] to 76 per cent [9] of patients having simple closure of a perforated ulcer have been reported to have symptoms indicative of recurrent ulcer. Approximately 80 per cent of our patients had persistence of ulcer symptoms after closure or nonoperative treatment of their perforated duodenal ulcer. From 13 [19] to 60 per cent [20] of patients having simple closure of a perforated duodenal ulcer have been reported to require a second operation for control of ulcer symptoms. Sixty-nine per cent of our patients who had simple closure or nonoperative primary treatment required a subsequent definitive surgical procedure for control of intractable pain complications of their ulcer diathesis whereas only one patient who had a definitive ulcer operation as primary treatment required a second operation for control of recurrent ulcer problems, The percentage of patients requiring a second operation has been shown to rise with time [12,21]. Although the majority of patients in the present series had surgical correction of recurrent ulcer within five years after perTABLE
VI
Indications for Secondary Operations for Ulcer Number of Patients
Indications Primary treatment: simple closure by nonoperative means Pain Reperforation Hemorrhage Obstruction Biopsy, gastric ulcer Primary treatment: vagotomy and pyloroplasty Hemorrhage
TABLE VII
blnterval
20 16 13 8 1 1
Interval between the First Perforation and the Secondary Operation fbr Ulcer Symptoms ~____ (yr)
o-1 2-5 6-l 0 Greater than 10
Volume 123, May 1972
Number of Patients ~_~__ 19 25 8 7
Duodenal
Ulcer
foration, the interval was greater than six years in 25 per cent and greater than ten years in 12 per cent. Intractable pain has been the indication for definitive surgery in approximately 60 per cent of previously reported series [12,22] whereas only 34 per cent of patients in this series had pain as the indication for subsequent surgery. This lower figure may reflect a conservative attitude by our referring physicians concerning relief of pain as an indication for surgery. Another possible explanation for the low figure is that most patients in this series reside in rural areas and the peptic ulcer diathesis may be more virulent in this stoic group of patients. Conversely, the rate of re-perforation, hemorrhage, and late obstruction was much higher in our series than in most other reports. It has been reported that if ulcer symptoms prior to perforation are of short duration, the rate of recurrent ulcer problems is much lower [23]. In the present study, 73 per cent of patients having pre-perforation symptoms of greater than three months’ duration required definitive surgery and 64 per cent of patients having either no pre-perforation symptoms or symptoms of less than three months required corrective surgery. These values are not significantly different. The mortality and morbidity for antrectomy and vagotomy [12] or vagotomy and pyloroplasty [11] performed in selected cases of perforated ulcer approach the mortality after these procedures performed electively. Because of this low mortality and the fact that the majority of patients in the present series required further surgery, we believe that an-’ trectomy and vagotomy or vagotomy and pyloroplasty should be performed for a perforated duodenal ulcer unless specific contraindications exist. The principal contraindication to definitive surgery is, in our opinion, extensive soilage of the peritoneal cavity due to the perforation. The degree of soilage is not necessarily related ‘to the time interval from perforation. In this regard, the size of the perforation and the patient’s dietary intake prior to perforation appear important. Summary
The records of 131 patients with perforated duodenal ulcer have been reviewed. Sixty-seven per cent of these patients were treated by simple closure of the ulcer or nonoperatively. Of this subgroup, 80 per cent had significant symptoms of peptic ulcer disease requiring medical or surgical treatment and 69 per cent required a second surgical procedure. Thirtyseven patients were treated by a definitive surgical procedure for duodenal ulcer at the time of perforation and all survived. In this group of patients, only
541
Wangensteen,
Wray,
and Golden
one required further surgery for complications of peptic ulcer. We believe that antrectomy and vagotomy or pyloroplasty and vagotomy should be utilized in the treatment of perforated duodenal ulcer unless specific contraindications are present.
11.
References
13.
1. Mikulicz J: Zur operativen Behandlung des stenosirenden Magengeschivurs. Verh Deufsch Ges Chir 16: 337, 1667. 2. Keetly CB: Surgery of non-malignant gastric ulcer and perforation. Lancet 1: 685. 1902. 3. von Haberer H: Zur Therapie akuter gesohwursperforationen des Magens und Duodenums in die freie Bauhhohle. Wein Klin Wschr32: 413, 1919. 4. Wangensteen OH: Non-operative treatment of localized perforations of the duodenum. Minn Med 18: 477, 1935. 5. Taylor H: Perforated peptic ulcer treated without operation. Lancet 2: 447,1946. 6. Graham RR: The treatment of perforated duodenal ulcers. Surg Gynec Obsfet 64: 235, 1937. 7. Seeley SF: Views on non-operative management of perforated ulcer, p 836. Surgery of the Stomach and Duodenum, (Harkins HN and Nyhus LM, ed.) Boston, Little Brown, 1969. 8. Jirzik H: Erfahrungen bei 327 freinen Magen-Zwolffingerdarm-Geschwursperforationen. Arch k/in Chir 277: 611, 1954. 9. Turner FP: Acute perforations of stomach, duodenum and jejunum. Analysis of 224 cases with late follow-up data on 147 cases of acute perforated peptic ulcer. Surg Gynec Obstet 92: 281, 1951. 10. Whittaker LD Jr, Judd ES, Stauffer MH: Analysis of use of
14.
542
12.
15. 16.
17.
18.
19. 20. 21.
22. 23.
vagotomy with drainage procedure in surgical management of duodenal ulcer. Surg Gynec Obstef 125: 1018, 1967. Burdette WJ, Rasmussen B: Perforated peptic ulcer. Surgery 63: 576, 1968. Nemanich GJ, Nicoloff DM: Perforated duodenal ulcer: long-term follow-up. Surgery 67: 727, 1970. Judin SS: Partial gastrectomy in acute perforated peptic ulcer. Surg Gynec Obsfef 64: 64, 1937. DeBakey ME: Acute perforated gastroduodenal ulceration: statistical analysis and a review of the literature. Surgery 8:852, 1940. Auchincloss H Jr: Immediate subtotal gastrectomy for acute perforated peptic ulcer. Ann Surg 135: 134, 1952. Jordan GL, DeBakey ME, Cooley DA: The role of resective therapy in the management of acute gastroduodenal perforation. Amer J Surg 105: 396, 1963. Rogers FA: Factors affecting the mortality from acute gastroduodenal perforation. Surg Gynec Obstet 111: 771, 1960. Kincannon WM, McLenathen CW, Weinburg JW: Vagotomy and pyloroplasty for acute perforated duodenal ulcer. Amer Surg 29: 692, 1963. Martinis AJ, Olson HH, Harkins HN: The treatment of perforated peptic ulcer. West J Surg 65: 72, 1957. Mark JBD: Factors influencing the treatment of perforated duodenal ulcer. Surg Gynec Obstet 129: 325.1969. Norberg PB: Results of the surgical treatment of peptic ulcer. A clinical and roentgenological study. Acta Chir Stand Suppl249: 1, 1959. Cassell P: Perforated duodenal ulcer in Reading from 19501959. Guf 10: 454, 1969. Cassell P: The prognosis of the perforated acute duodenal ulcer. Guf 10: 572, 1969.
The American Journal of Surgery