Acute perforated peptic ulcer syndrome with surgical management

ACUTE PERFORATED PEPTIC ULCER SYNDROME WITH SURGICAL MANAGEMENT REPORT OF DAN

C.

DONALD,

SurgicaI Staffs, Baptist

SURGICAL CASES

124

M.D.

T

Duodenum . Stomach........... GastrojejunaI stoma

* Dr.

88 IO

Male. Female..

93

.

7

M.D.

Baptist

HospitaI

in its reIation to the Iate resuIts folIowing recovery in certain seIected cases. Our report based on a study of 124 cases of perforated uIcer (a11 except eight patients were operated upon and those eight were confirmed at autopsy) corroborates previous studies that the time eIement is the most important factor in the mortaIity of this complication. Age, sex and coIor are important etioIogica1 factors in that 70 per cent of these cases occurred from the third through the fifth decade, 93 per cent occurred in the male, and 82 per cent occurred in the white race. The Iocation of the uIcer was in the duodenum in 88 per cent of the cases, in the stomach in IO per cent, and in the gastrojejuna1 stoma foIIowing gastroenterostomy in 2 per cent. Forty-five and eight-tenths per cent of a11 the cases were drained and the remainder were not. In this tota of 124 cases there was an operative mortaIity rate of 18.5 per cent. Of this tota1, forty were persona1 cases, nineteen of which were private cases and twenty-one from HiIIman (Charity) HospitaI, whiIe sixty-eight were from the genera1 staff of HiIIman HospitaI from 1936 to 1940 and twenty-six from the genera1 staff of the Baptist HospitaI. The foregoing facts are summarized in the foIIowing tabIe :

Per Cent

Sex

BARKETT,*

ALABAMA

HE mortality rate in perforated peptic uIcer shows a wide variation. EIiason and Thigpen, reporting from a series of seventy cases, in&ding both duodenal and gastrrc ulcers, give a mortaIity rate of 2 I .43 per cent. l H. L. Thompson, reporting a series of 500 cases, gives a gross mortaIity of 40 per cent.2 R. R. Graham, reporting fifty-one cases, finds a rate of 1.8 per cent.3 The reports from other writers show similar variations in the death rate of this disease. The mortaIity rate is Iowest in the smaIIer seIected group of cases. In the Iarger groups from urban hospitaIs the rate is higher, due to the deIay of the patient in reaching surgery after perforation occurs, and to Iow physica reserve. During the past severa years the buIk of the Iiterature on perforated uIcers has been concerned with the importance of the interva1 from perforation unti1 operation and the efl?cacy of the simpIe cIosure. It is a recognized axiom that the sooner perforated peptic uIcers are operated upon the better the prognosis, and the consensus has been that simpIe cIosure incorporating the omenta1 graft is the operation of choice. It is our purpose to stress, aIso, the importance of the etioIogica1 factors concerned in the Iocation of this Iesion and its perforating character and the surgical management Per Cent

J.

SurgicaI Resident,

BIRMINGHAM,

Location

S.

AND

and HiIIman HospitaIs

Per Cent

CoIor

White.. CoIored..

82

. ,

.

Age

30to6oyears.....

18

2

Barkett

is now First Lieutenant,

U. S. Army MedicaI Corps, Scott FieId, IIIinois. 406

Per Cent

70

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The tota number of deaths in this series of 124 cases was thirty-one. Eight of the patients were not operated upon and are not considered in caIcuIating the operative mortahty of 18.5 per cent. These cases may be divided into three groups: (I) the eight patients who were not operated upon; (2) those who were operated upon within twelve hours after perforation; (3) those who were not operated upon unti1 more than twelve hours after perforation. An anaIysis of the group of eight patients not operated upon reveals that none sought admission until two or more days foIIowing perforation, and, due to their genera1 condition and widespread infection, surgery was deemed inadvisabIe. In the second group, those operated upon within tweIve hours, there were seven deaths. Of these, one had muItipIe duodena1 uIcers and died of genera1 peritonitis. In one the uJcer was not found and autopsy revealed jejunaI uIcer with genera1 peritonitis. The other Jive died of an overwheJming infection with genera1 peritonitis. An anaIysis of the seven deaths in the second group is of interest because as far as the time eIement is concerned the patients were operated upon soon enough, yet they expired : r:I jew

Duratior pf Perforation !-HOUrS

R‘ZSUltS

I-

Mj

5

M

6ti

\

461W

M

12

.&

40

1 w

M

6

5

44

C

M

3

C

1M

I 6

/561

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I

II

Multiple duodenal ulcers, drained. died of general peritonitis; ulcer closed Duodenal ulcer. simple closure with omentat graft; died 7 days later; general peritonitis Ulcer not found; autopsy revealed ruptured iejunal ulcer with general peritonitis Duodenal ulcer, closed; drained; died 7 days later of general peritonitis Gastric ulcer; excised; drained; died 7 days later of general peritonitis Duodenal ulcer, closed with purse string; died I day following operation; general peritonitis Duodenal ulcer; lived 4 days; died of genera1 peritonitis

In the group not operated more than tweIve hours after

upon unti1 perforation

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there were sixteen cases, a11 of which had been perforated for at Ieast twenty-seven hours. In our tota of thirty-one deaths out of the entire series of 124 cases, there were no patients who had been operated upon between tweIve and twenty-seven hours after perforation. In this Iast group all died of genera1 peritonitis with various compIications, such as pIeurisy, Iung abscess and wound infections. Of this entire group of twenty-three operative deaths, only two patients had pyIoropIasties, seventeen had simpIe cIosures, two had gastric resections and two had gastroenterostomies, in addition to simple cIosure. (Fig. I.) DISCUSSION

In the discussion of peptic ulcer we wish to emphasize the reIationship between its Iocation and pathoIogica1 features and its perforating character. The First or suprapapiIIary portion of the duodenum is the site of perforated peptic uIcers nine times as often as the stomach. This is due in part to the ischemia of its mucous membrane and the corrosive action of the acid gastric juice. Here when irritation is present heaIing occurs more sIowIy. When an ordinary portion of the stomach mucosa is injured there is a production of mucin which serves as a protector and healing readiIy occurs. On the Magenwhere the majority of gastric strasse, ulcers occur and where the mucous membrane is tightIy stretched and no mucin is produced, healing occurs with difhcuIty. Perforated uIcers are occasionally seen here, but it is not the usua1 antecedent complication, since 70 per cent of the uIcers in this Iocation, especially those occurring in proximity to the pyIorus, undergo maIignant changes. Furthermore, as contrasted to the anterior surface or the suprapapiIIary portion of the duodenum, the stomach being in close apposition in the rear to the posterior peritonea1 covering the peritonea1 cavity wiII not IikeIy become flooded from the spiI1 of the uIcer. Thrombosis of the bIood vessels of stomach or bowe1 occurring independently

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or in combination with infected emboIi from oral sepsis is responsibIe for a high percentage of peptic uIcers. A survey of the

FIG. I. Diagram

of stomach

UIcer

of the peptic uIcer probIem, that once peptic uIcer attains the behavior of a perforating uIcer it wiI1 remain such during

and first portion of duodenum

persona1 cases reveaIed that 80 per cent have graded infections of the mouth ranging from a moderate degree of gum irritation to advanced pyorrhea aIveoIaris. Heritage or famiIy predisposition for peptic uIcer development may hoId true in the perforated type of uIcer as in many other diseases. We found some indications that when one member of a famiIy is affected with perforated peptic ulcer, a11 members of the same famiIy affected with peptic uIcers wiI1 have symptoms of the perforative type or may go to actua1 perforation. Such an incidence was found in the group of persona1 cases. Two brothers had acute perforated duodena1 uIcers. Records show the perforations were eighteen months apart. Both were operated upon within six to eight hours after inception of perforation, with recovery. We are informed that a third brother succumbed to operation for perforated peptic uIcer three years Iater. This is interesting evidence, but, of course, not concIusive. The majority of acute peptic uIcers hea quickIy and compIeteIy. From the clinica and x-ray evidence it appears that an ulcer may heal, recur, break down and hea again, the uIcer becoming deeper and more fibrotic with each recurrence. We beIieve, and such opinion is based on a carefu1 study

MAY, 19~.

with circulation.

its period of existence. HeaIing of such uIcer is interfered with in the foIIowing ways: (I) the irritative effect of the acid gastric juice; (2) the necrotic Iayer on the base of the ulcer which covers the granuIating tissue and provides no footing for the ingrowing epitheIium, and (3) the dense scar tissue which prevents the approximation of the edges. SYMPTOMS

The symptoms of acute perforation, as so aptIy set forth by Graham,4 are (I) the upper abdomina1 rigidity, (2) pain in this area associated with tenderness, and (3) inabiIity to turn from side to side in bed because of accentuation of pain. In this subacute type of perforation the pain is not as a rule as excruciating nor is the prostration as profound as in that associated with acute perforation. EarIy examination reveaIs, however, the same board-Iike rigidity and marked upper abdomina1 tenderness. Within two to ten hours after the perforation has occurred the symptoms may have subsided and the patient may be fan-Iy comfortabIe. If the patient is seen for the first time in this quiescent period, and especiaIIy if an opiate has been administered, the presence of the abdomina1 catastrophe may not be

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suspected. The degree of local peritoneal irritation and disabihty is dependent upon the amount of gastric and duodenal content that has escaped. Local peritonitis and subphrenic and perigastric abscesses are not uncommon. They may be the origin of many cryptogenic, hepatic and subphrenic abscesses and external perigastric adhesions. Those cases in which the uIcer heaIs cause no further troubIe and Ieave IittIe, if any, evidence of the former existence of ulcers. Chronic perforation occurs in 23 per cent of the cases of chronic peptic uIcer, and in 3.5 per cent of gastric carcinomas that are surgicahy verified. If the pain is of a continued boring nature, if the usua1 mode of obtaining reIief is ineffectua1, if the so-calIed pain-food-ease sequence is less distinctive, and especiaIJy if the originaIly localized pain extends toward the region of the liver posteriorIy, or upward into the chest-or in the case of the jejuna1 uIcer downward toward the peIvis-the possibIe presence of a deep penetration or sIow perforation shouId be seriousIy considered. DIAGNOSIS

Other abdomina1 catastrophes which must be considered in any differentia1 diagnosis of perforated uIcer are acute hemorrhagic pancreatitis, gaIIbIadder disease, appendicitis, ruptured ectopic pregnancy, voIvuIus of stomach or omentum and abdomina1 crisis in tabes. Extraabdomina1 Iesions which must be considered are pIeurodynia, Iobar pneumonia, measIes, arachnodism, herpes Zoster and coronary occlusion. The presence of the associated signs characteristic of these conditions pIus a carefu1 history usuahy estabIishes the diagnosis. TREATMENT

The treatment is essentiaIIy surgica1 with operation as soon after perforation as possibIe. A prime consideration, we beIieve, based on persona1 experience, is that an opiate shouId be withheId unti1 diagnosis h,‘LS been definiteIy made and surgery

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scheduled. We recaI1 a specific case in which there was an associated heart condition to which an opiate was administered. The symptoms were masked so that the patient was judged improved, sent home five days after admission to the hospita1, and exprred there on or about the tenth day. Autopsy revealed a perforated gastric uIcer with generaIized peritonitis, left subphrenic abscess, Ieft pelvic abscess and moderate spiII along the left colon gutter. Furthermore, disturbing diagnostic procedures such as fluoroscopy should be avoided, for they not only consume time, but aggravate an abdomen which shouId be kept at rest. We do favor, however, a hat x-ray plate of the abdomen immediateIv on admission to the hospita1, with the patient in standing or sitting posture, for possible detection of air under the diaphragm, which is considered pathognomonic of a perforated viscus in these cases. PreoperativeIy, intravenous Auids should be administered to combat dehydration and impending shock. Nothing, of course, should be given by mouth. If immediate operation has been decided on, a hypodermic or morphine gr. !,i and atrophine gr. ${a0 shouId be given. ACUTE

PERFORATED

DUODENAL

ULCER

Acute perforated peptic uIcer occurs in the duodenum in 90 per cent of thecases. (Fig. 2.) The simpIe closure of the ulcer with interrupted sutures, incorporating a fold or graft of omenta1 tissue, is the operation most often empIoyed. There are certain essentials in this type of cIosure that shouId be stressed to obviate leakage and maintain the proper circuration in the involved tissues. The sutures are placed in the bowel waI1 a sufficient distance from the ulcer-bearing tissue to assure security of the suture. In the approximation of the omenta1 tissue to the uIcer bed in tying the sutures only sufficient tension should be made to hoId the graft in pIace. Avoid constriction of the tissues that may interfere with their viabiIity. The fibrin deposit as a result of the contact of the tissues will

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sea1 the uIcer. In the hands of the average open-ator, this type of cIosure wiI1 maintain the Iowest operative mortaIity. Many of

FIG. 2. Type of operations

the writers in dealing with the perforated duodena1 uIcer stress the simpIe closure for the reason that acute perforation is an emergency probIem and anything beyond cIosure of the uIcer is meddlesome surgery. Statistics show approximateIy 39 per cent of the patients who have had simpIe cIosure continue to have uIcer symptoms. Aside from the delayed digestive compIaints a smaI1 percentage of the duodena1 uIcers treated in this manner wiI1 reperforate. During a five-year period Graham5 reported fifty-one cases of acute perforated duodena1 uIcer in which the patients were operated upon by the simpIe cIosure with omenta1 graft. Of these, I I patients or 2 I + per cent continued to have digestive compIaints, requiring eIective surgery in the form of gastric resection, pyIoropIasty or gastroenterostomy. For a number of years we empIoyed the simpIe cIosure incorporating 0mentaI tissue excIusiveIy with practicaIIy the same resuits. After due consideration through cIose observation reIative to reperforation and the high percentage of patients who continued to have digestive compIaints, we

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began to aIter our simple cIosuIre to pyI(oropIasty in a certain selected grloup of calses. As a resuIt of this type of therapy our

for perforated

duodenal ulcer.

mortaIity has remained as low or Iower than that observed from simpIe cIosure. The deIayed digestive compIaints have been reduced to Iess than IO per cent with reduction in number of reperforations. We have found pyIoropIasty offers the maximum resuIts in the cases which revea1 the folIowing characteristics : (a) the duodenum is mobiIe; (b) peritonitis is not present; (c) patient is a good surgica1 risk; (d) induration at uIcer area is such that removal of the uIcer wiI1 not sacrifice so much tissue as to interfere with proper cIosure of opening in bowe1 and stomach. By pyIoropIasty an uIcer is excised and oftentimes an accompanying uIcer may be found on the opposite side of bowe1, commonIy caIIed “contact or kissing uIcer,” which can be treated by cautery. The spasm of the pyIorus is overcome by cutting the pyIoric muscIe; the uIcer is excised in a combined rectanguIar-eIIiptica1 incision going we11 on to the stomach; the cIosure of opening in the bowe1 and stomach is in a transverse manner. (This is a modification of the Heineke-MikuIicz pyIoropIasty.) As a resuIt of such cIosure the

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pyloric opening is enlarged, permitting a free refIux of the aIkaIine secretions from the bile, pancreatic and intestina1 juices on the stomach mucosa to reduce the acidity of the thyme. Posterior gastroenterostomy at the time of closure of uIcer shouId be avoided for two reasons: (I) The edema present at the pyloric ring at the time of perforation in the majority of cases rapidIy subsides following closure of the ulcer sufficiently to secure free drainage of the stomach; (2) the gastric juice in perforated ulcer usually shows a higher percentage of free hydrochloric acid than is normally present. This hyperchlorhydria with its constant bathing of the new stoma frequentIy leads to the formation of marginal jejunal ulcer. However, in definite obstruction of the pylorus resulting from the duodenal ulcer with perforation, or in the chronic perforated ulcer, posterior gastrojejunostomy may be indicated. ACUTE IN

PERFORATED THE

ULCER

STOMACH

In our series of cases IO per cent of the perforations occurred in the stomach. The relationship of the ulcer formation in the stomach to the Magenstrasse area and the tendency for such uIcers in proximity to the pylorus to undergo maIignant changes has been discussed. The surgical management of the perforated ulcer occurring on the anterior waI1 of the stomach is usually accompIished by a simple closure with an omenta1 graft. Should the ulcer present evidence of malignancy, biopsy should be made at the time of closure. Perforated uIcers on the posterior wall of the stomach behave differentIy from those seen on the anterior waI1. NormaIly, the posterior wall of the stomach is in close proximity to the pancreas and posterior peritoneum. When the ulcer becomes inflamed or perforated, protective adhesions are formed at the ulcer bed. In a certain percentage of these cases the formation of the adhesions

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will prevent a spiI1 of the stomach content into the peritoneal cavity. Due to the Iocalization of the infection the ulcer often acquires the characteristics of a subacute ulcer. In case the ulcer is near the lesser curv;tture of the stomach and lacks the protection of adhesions, or when the crater of the uIcer is of such size that the adhesions do not prevent the spill following perforation, peritonitis results. The surgical repair for the perforated ulcer on the posterior wall of the stomach is rendered dill&It and closure is seIdom attempted due to the position, inff ammatory adhesions and inability to secure good closure of the ulcer. Management demands some form of gastric resection, depending on the condition ot the patient, and the inflammatory changes that have taken place about the uIcer. If the case is one in which the general condition of the patient is good and the adhesions and inflammatory changes are not a one-stage resection of the extensive, stomach with a posterior gastrojejunostomy by the Polyb II type operation or Hofmeister subtota1 gastrectomy with gastrojejunal anastomosis will be indicated. Should the patient show evidence ot toxemia and low reserve, accompanied by dense adhesions at the point of perforation and evidence of a recent spill, atwo-stage resection with a posterior gastrojejunostomy should be done, as advocated by Devine.6 At the first-stage operation the stomach should be bisected proximal to the uIcer bed, leaving sufficient tissue on the blind end of the stomach to secure a good closure. After cIosing the lower end of the stomach where the uIcer is located, the proxima1 resected end should be cIosed from the lesser curvature down to a point Ieaving sufficient opening to make an adequate gastrojejunal stoma by an end-toside posterior gastrojejunostomy. If the spil1 of the uIcer bed is sufficient to encourage peritonitis, a penrose drain shouId be placed down to the ulcer bed. At a subsequent date when the patient’s condition will permit-and this wiI1 usually

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require two to three weeks-the bhnd end of the stomach containing the uIcer is removed, in&ding the pyIorus with cIosure of the duodena1 stump. REPORT

OF

EFFICACY

CASE OF

TO

THE

ILLUSTRATE TWO-STAGE

RESECTION

A white male, fifty-six years of age, entered the hospita1 on ApriI I I, I 941. He gave a history of stomach troubIe for severaI years. In February, 1941, the so-caIIed food-ease sequence was replaced by a progressive boring pain in the left upper abdomen, aggravated by taking food, accompanied by nausea and vomiting, with Ioss of eighteen pounds in weight in two months. A Iarge fixed mass was found in the Ieft upper abdomen. Urine examination was negative. BIood picture was that of secondary anemia. The white bIood count was 16,700 ceIIs per cm. of bIood with 80 per cent neutrophiles; the remainder of white cells were normaI. Gastric anaIysis was 24 free hydrochIoric acid and 42 tota acids. X-ray of stomach showed 3349 per cent retention of the six-hour barium mea1 and defect in midportion of stomach. Operation on April 19, 1941, was performed with spina anesthesia. The abdomen was explored through an upper rectus incision, which disclosed a large inffammatory tumor, measuring IO by 12 cm. in diameter at the base. Incorporated in the tumor mass were stomach, pancreas and posterior peritonea1 waII, caused by perforated ulcer on the posterior wall of the stomach. Along the Iower margin of mass peritonitis was present, resulting from spill of the ulcer. Obviously a subtota1 resection of the stomach was indicated. Due to the inflammatory changes and recent spiI1 from the ulcer, a two-stage antral excIusion resection of the stomach with a retrocohc end-to-side gastrojejunoscopy by the PoIyb II type operation with closure of the bIind end of the stomach was done. A penrose drain was pIaced at the point of perforation of the ulcer to care for the peritonitis. The convaIescence was a smooth one. The patient Ieft the hospita1 in two weeks, to return two weeks Iater for the second operation, when the blind end of the stomach incIuding the pyIorus was removed with closure of the duodena1 stump and peritoneaIization of the raw tissues at the bed of the stomach. ConvaIescence was again uninterrupted. By the

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multipIe-stage operation the patient was carried through surgery with a minimum shock and the elimination of the technica and complications. JEJUNAL

ULCER

diff+,uIties

PERFORATION

There were two cases of jejuna1 uIcer in our series. Of these two, one patient went to surgery and the uIcer was not found unti1 autopsy. The other patient was not operated upon, as he was in extremis when admitted to the hospita1 and died thenext day. Autopsy reveaIed perforated uIcer with peritonitis. JejunaI uIcers occur on the efferent Ioop of the bowel and the majority are perforating in character. History of return of digestive compIaints, after apparent cure of duodenal or gastric uIcer foIIowing gastroenterostomy, pain in the Ieft abdomen, not reheved by taking food and appearance of meIena stools indicate a resolves into jejunal uIcer. Treatment excision of the stoma, cIosing the opening in jejunum in transverse manner, or a resection of the Ioop bowe1 with end-to-end anastomosis if the ulcer crater invoIves too much of the bowe1 waI1. The opening in the stomach shouId be closed to ahow the stomach to drain by the duodena1 route provided the pyIorus is patuIous and the duodena1 uIcer is heaIed. If obstruction of the pvIorus is found or activation of the uIcer “is present, partia1 resection of the stomach by the BiIIroth I type operation gives the best resuIts. Drainage shouId be done only in those cases of perforated peptic ulcer in which definite peritonitis is present or severa hours have eIapsed before surgery and there is unusua1 amount of spiI1 of undigested food from the perforated viscus. In the case in which intraperitonea1 drainage has not been provided, to avoid wound infection, place a rubber tissue drain down to the peritoneum, especiaIIy in the obese type individua1; this wiII reduce the number of abdominal waI1 infections. We beIieve spinal anesthesia for the patient with a perforated peptic uIcer gives the best resuIts, affording a better reIaxa-

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tion of the abdomina1 waII and the peritoneal tissues, thus giving an opportunity for ample exposure. This tends to minimize the time of operation and also reduces the postoperative chest compIications which are frequently seen in inhaIation anesthesia in upper abdomina1 surgery. CONCLUSION

From the anaIysis of this series of cases the folIowing conclusions were drawn: I. Ninety per cent of the perforated peptic ulcers are located within 2 cm. of the pyIorus on the anterior surface of the duodenum. 2. DuodenaI ulcers tend to perforate in this area because of the poor blood supply, constant bathing of the uIcer with acid gastric juice and lack of any anterior protective covering. 3. On the basis of Iate resuIts foIlowing simple cIosure with omenta1 graft this type of operative therapy might be aItered to a pyIoropIasty when the time interva1 of

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perforation has been onIy a few hours, provided peritonitis is absent, the duodenum is mobiIe and the patient is a good surgical risk. 4. Posterior gastrojejunostomy should be done onIy in the obstructive or chronic perforative and not in the acute perforated type. 3. By surgical intervention as soon as possibIe our mortaIity has been decreased to 18.3 per cent in the I 16 operative cases in this tota series of 124 cases. REFERENCES 1.

E. L. and THIGPEN, G. M. The effect of perforation on peptic uker resuIts. Am. J. Surg., 41: 419, 1938. 2. THOMPSON, H. L. Acute perforation of the peptic ulcer, immediate and late results in soo cases. J.A.M. A., rr3:2015, 1939. 3, 4, ;. ~RA,;A, R. R. The treatment of perforated uo ena u cers. Surg., Gym-c. CT Obst., 64: 235, ELIASON,

1937. 6. DEVINE, fi. B. Basic principIes and supreme difficulties in gastric surgery. Surg., Gynec. &* Obst., 40: 1-16, 1923.