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Factors influencing prognosis in perforated peptic ulcer
Factors Influencing Prognosis in Perforated Peptic Ulcer James M. McDonough,
MD, Hartford, Connecticut
James H. Foster, MD, Hartford,
Connecticut
Be not the first by whom the new are tried, Nor yet the last to lay the old aside. Alexander
Pope
Essay on Criticism (1711) The necessity of performing an operation which will permanently control the ulcer diathesis when emergency operation is necessary for control of hemorrhage from peptic ulcer has long been accepted. Gastrectomy, and then pyloroplasty and vagotomy, have allowed surgeons to lower mortality rates in the emergency situation, after it was clearly established that simple ligation of the bleeding point was followed by an unacceptable incidence of ulcer complications. In a similar manner Auchincloss [I] and others [Z-d] have suggested that primary definitive operation should also be recommended for patients with perforated peptic ulcer. The basis for this concept rests on two arguments: (1) that postoperative and late ulcer complications would occur in a majority of patients after plication alone; and (2) that emergency definitive operation for perforated peptic ulcer could be accomplished with mortality no higher than that after plication alone. Plication has long been the accepted and usual method of treatment of perforated peptic ulcer on the Surgical Service of Hartford Hospital. Before abandoning this policy, it seemed wise to review the results we had achieved to determine whether, in truth, the postplication course of our patients might justify a more aggressive approach to initial therapy. Perhaps we might also be able to identify a group at high risk for further ulcer problems, which might lead to a selective approach of primary operative treatment. From the Surgical Service, Hartford Hospital, Hartford, Connecticut, Reprint requests should be addressed to Dr Foster, Hartford Hospital, 80 Seymour St. Hartford, Connecticut 06115. Presented at the Fifty-Second Annual Meeting of the New England Surgical Society, Portsmouth, New Hampshire, September 30, October 1 and 2. 1971.
Volume 123, April 1972
Material and Methods A retrospective review was made of all charts of patients with a diagnosis of perforated peptic ulcer treated at the Hartford Hospital between January 1, 1960 and January 1, 1970. The medical history and clinical course were reviewed, including all laboratory and radiologic studies, the operative notes, anesthesia notes, and time of perforation as suggested by sudden onset of abdominal pain. The course of 210 consecutive patients undergoing emergency operation for perforated peptic ulcer during this ten year period was studied. The operative survivors were interviewed by phone, in person, or by mail. The modified Visick classification [5] was used to evaluate the results of each patient’s operation for long-term follow-up. Classification as “unsatisfactory” implies that the patient had moderate or severe symptoms which considerably interfered with work or enjoyment. All cases of proved recurrent ulcer and patients requiring further surgery for peptic ulcer are included in the unsatisfactory category. Long-term follow-up study has been possible in 85 per cent of operative survivors (160 of 189). Multiple factors were then correlated with immediate postoperative morbidity and mortality and long-term morbidity.
Clinical Data Emergency operative intervention for perforated peptic ulcer disease was carried out in 210 patients during the ten year interval examined. There were 148 male and sixty-two female patients, with the age at the time of perforation ranging from fifteen to ninety years. The mean and median ages were the same: fifty-six years. The vast majority of operations were simple plications since only twenty-three patients underwent primary “definitive” operation. Definitive Operatibn. Two definitive procedures were carried out for technical reasons, four were for associated hemorrhage, five were performed for associated obstruction, and five were performed because of a history of prior perforation. Vagotomy and an emptying procedure were carried out in seventeen patients. These patients have done well with no operative deaths and there has been no further ulcer
411
McDonough
and Foster
CASES IO
n ”
I
3
2
Figure 1. Interval forty-four patients.
4
5 6 YEARS
between
7
plication
8
IO
9
and reoperation
in
problem in the fourteen patients in whom follow-ui, was obtained. Six partial gastric resections were performed, one with associated vagotomy. Two of these patients, aged seventy-one and eighty-four years, died postoperatively. A third bled on the first postoperative day and required reoperation. Three operative survivors with follow-up are doing well. Plication. Plication was the operative choice for 187 patients. Nineteen operative deaths occurred. Most of these fatalities occurred in elderly patients with multisystem disease prior to perforation. Eleven deaths were in patients over age seventy. Severe preexisting disease such as carcinomatosis or regional enteritis was present in eleven who died, and these patients also frequently had complications directly related to ulcer perforation and/or plication. Five patients who died had upper gastrointestinal bleeding either at the time of perforation or after plication. Four had intra-abdominal abscess formation, MALES
FEMALES IzI unsatisfktory
AGE
,
~80 70-79 60-69 50-59 40-49 30-39 (30
,
IO Figure 2.
412
1
1
-0
’
I
CASES
IO
Age, sex, and result after plication.
505
which in one was associated with recurrent bowel obstruction. Aspiration pneumonia and duodenal fistula were related to mortality in two patients. These complications directly related to the perforation were associated, in those who died postoperatively, with myocardial infarction, acute tubular necrosis with renal failure, pulmonary infarction, adult respiratory distress syndrome, and even acute cholecystitis. Follow-up study of the operative survivors after plication was complete in all but twenty-nine patients. An “unsatisfactory” result was obtained in fifty-five patients. Of these, forty-four required reoperation for continued ulcer intractability or other complications. In the first month after plication four patients were reoperated upon for bleeding peptic ulcer. Most patients who came to reoperation did so within two years after plication. (Figure 1.) Followup was evaluated on a year to year basis. There was no significant difference in unsatisfactory results on long-term follow-up between patients operated upon more than six years ago (1960 to 1965) and patients operated updn more recently (1965 to 1970). The patient’s age and sex at the time of perforation are related to the eventual outcome in Figure 2. The likelihood of an unsatisfactory result is slightly greater in men than women in all age groups. This difference is most pronounced ,and is statistically significant in patie’nts fifty to seventy years of age. (Tables I and II.) Table III relates the duration of ulcer distress present before perforation to the eventual outcome after perforation. The difference noted with ulcer history of more or less than five years is not statistically significant, but when the results are related to an ulcer history preceding perforation of more or less than three months the difference is highly significant (p = < .005). Associated Hemorrhage and Obstruction. The course of patients who presented with a history of bleeding was examined. Eleven patients had bleeding with the episode of perforation, and in eight hemorrhage occurred at a p‘rior time. Fifteen such patients underwent plication. In three of these patients instability of the cardiovascular system was demonstrated intraoperatively. Three patients bled after plication and required reoperation. Operative death occurred in three patients: in one with intraoperative cardiovascular instability and in another patient who required reoperation for bleeding in the postoperative period. Ten patients with bleeding who survived plication had long-term follow-up study. Five of these patients were eventually reoperated upon for ulcer complications: three for intractability or obstruction at four months, eight months,
The American Journal of Surgery
Perforated
and three years after plication, respectively, and two for later bleeding episodes. Two other patients were classed as having “unsatisfactory” results with ulcer recurrence or bleeding not requiring reoperation; and the remainder (three patients) did well after plication. Four patients with associated gastrointestinal bleeding underwent definitive operation. There was one operative death in an eighty-four year old man who underwent subtotal gastric resection. One patient was lost to follow-up study, and the remaining two did well after definitive operation. Obstruction in the patients who underwent emergency surgery for perforated peptic ulcer was present preoperatively in three elderly men. One patient underwent plication and required definitive operation after a two year interval for further obstruction. Plication and gastroenterostomy were performed in the second patient, who required vagotomy and gastroenterostomy after a sixteen month interval. Vagotomy and gastrojejunostomy were used primarily in the third patient, who has enjoyed an excellent result. Obstruction was present postoperatively in ten patients. In one patient undergoing vagotomy and pyloroplasty, relief of obstruction was slow, but this patient eventually obtained an excellent long-term result. After plication nine patients exhibited signs of obstruction postoperatively with emesis and the need for prolonged nasogastric aspiration. All of the seven patients with late follow-up have had recurrent ulcers, with six requiring reoperation. Four of these patients have been reoperated upon for obstruction. Steroid Therapy. Fourteen patients in this series had perforation of an ulcer, while they were receiving steroid therapy. Thirteen patients were initially treated by plication of the ulcer perforation, and one underwent vagotomy and pyloroplasty. Six patients receiving steroids for rheumatoid arthritis did well in the immediate postoperative period. Four had good results at late follow-up study, one patient had mild symptoms, and one patient required reoperation for reperforation at forty-one months. Three patients who were receiving steroids for carcinomatosis had plication, with one operative death and two late deaths at eight and fourteen months, respectively, which were unrelated to the ulcer diathesis. Three patients with asthma treated by steroids had plication with one operative death associated with wound dehiscence, one late death unrelated to ulcer problems, and one satisfactory result at six years after plication. One patient treated with steroids for cirrhosis underwent plication after perforation and died postoperatively. One patient with back pain treated with steroids underwent plication but had an unsatisfactory long-term course with gastrointestinal
Volume 123, April 1972
TABLE I
Peptic Ulcer
Age and Result Patients
Age W) Less than 50 50-70 Over 70
TABLE II
Result
Male
Female
33 18 14 20 7 5
13 7 13 3 8 4
Satisfactory Unsatisfactory Satisfactory Unsatisfactory Satisfactory Unsatisfactory
Age and Results in Male Patients Only Result
~__
Age (yr)
Satisfactory
50-59 All others
Unsatisfactory
7 76
14 29
bleeding three years after plication which was medically treated. Differential Diagnosis. Delay in diagnosis, although not frequent, occurred in this series and was associated with an inadequate or confused history, a dearth of abdominal findings, and/or no free air seen in roentgenograms of the abdomen or chest. In only 19 per cent of patients who had rokntgenograms taken (38 of 196) was no free air seen on the abdominal or chest film. Radiopaque gallstones were noted on the abdominal roentgenograms of four patients in this series. In an unfortunate combination of radiologic findings, three-quarters of the patients exhibiting gallstones on initial x-ray examination of the abdomen failed to demonstrate free air on these films. In six cases the diagnosis of cholecystitis was confused with that of perforated peptic ulcer, with a resultant delay in diagnosis from one to eight days. Of these six patients, all failed to demonstrate free air radiologically. Four had a short history of pain not typical of ulcer distress. Three had tenderness in the upper part of the abdomen with rather mild lower TABLE III
Duration of Ulcer Symptoms prior to Perforation versus Result after Plication Result
Distress prior to Perforation
Satisfactory
Greater than 5 yr Less than 5 yr
15 (48%) 58 (65%)
16 (52%) 31 (35%)
Greater than 3 mo Less than 3 mo
31 (47%) 42 (78%)
35 (53%) 12 (22%)
Unsatisfactory
413
McDonough
and Foster
abdominal findings; one had a tender palpable mass in the right upper quadrant with radiopaque gallstones; another had nonvisualization of the gallbladder with oral cholecystogram. Four of these patients died postoperatively, three after plication and the other after subtotal gastrectomy. Comments
A retrospective review of the records of patients undergoing emergency operation must suffer from the incompleteness of information gathered from patients often rushed from the emergency room to the operating room within an hour or two of hospitalization. The patients included in this review were cared for by many different surgeons, each with his own approach to this problem. Patients with perforated ulcers who never came to operation are not included in this series. Yet, even with these limitations, this experience is large enough, and the initial and follow-up information is complete enough, to allow certain conclusions. It would appear from this data that primary definitive operation can be offered to patients with perforated peptic ulcer with the expectation of an acceptable survival rate. Primary definitive operation eliminated subsequent ulcer problems in all of those surviving operation with adequate follow-up information. However, a look at the course of 144 patients surviving plication and followed up for one to ten years reveals that 61 per cent had satisfactory results after plication alone. When the results are further broken down to consider factors of age, sex, and duration of ulcer symptoms prior to perforation, it is possible to identify a high risk group of patients who have a statistically significantly increased risk of postplication TABLE IV
Guidelines in the Management of Perforated Peptic Ulcer
1. No operation In presence of irreversible shock 2. Simple closure In most women When history of ulcer is less than 3 months When patient is on steroid therapy Whenever patient is considered a poor risk 3. Definitive operation When patient’s condition is stable and there is: Remote or current history of hemorrhage A history of obstruction Obstruction occurring after simple closure A history of prior perforation A technical problem with closure Relative indications exist with a: Man between 50 and 70 years of age Long history of ulcer
414
ulcer problems-a risk which exceeds 60 per cent in male patients between the ages of fifty and seventy years who have had ulcer symptoms for more than three months prior to perforation. Hemorrhage and/or obstruction associated with perforation are almost certain portents of further trouble unless definitive operation is undertaken. W’omen in all age groups fare better than do men after plication. To our surprise, the small group of patients in whom ulcers perforated while they were on adrenal steroid therapy did as well after plication alone as did those patients not on steroid therapy. Our prejudice was that patients with a long history of ulcers prior to perforation would be more likely to eventually require definitive operation. Statistical analysis does not show a significant difference between those with a preperforation history of ulcers of more or less than five years. However the percentage of unsatiefactory results in those with a history of ulcers more than three months prior to perforation is significantly greater than that in patients with a history of less than three months of distress. Others [4,6,7] have suggested that recurrent ulcer problems after plication alone will increase with the number of years the patients are followed. This was not true in this series. When a second operation was required to control the ulcer diathesis after initial plication, it was performed within two years of plication in 75 per cent of patients. If one eliminates the high risk groups of patients with associated hemorrhage and obstruction and male patients between fifty and seventy years of age with ulcer histories of more than three months, there are left 111 patients who survived plication with adequate follow-up information. In this group only 25 per cent had a long-term unsatisfactory result. Although definitive operation can apparently be offered to patients with perforated peptic ulcer without an increase in immediate mortality, we believe that pyloroplasty-vagotomy and antrectomy-vagotomy are not innocuous procedures and should be avoided if plication alone can be performed with anticipation of a satisfactory result in a majority of patients. Patients with obstruction or a history of hemorrhage accompanying perforation should have primary definitive operation. Patients with postplication obstruction should probably be scheduled for elective definitive operation even if obstruction subsides, because of the high incidence of late complications requiring reoperation. Male patients between the age of fifty and seventy years with a long history of ulcer may be offered a primary definitive operation in selected instances. However, we believe that plication should remain as the operation of choice for patients with a short history of ulcer distress prior to
The American Journal of Surgery
Perforated
perforation, male
for female
patients
under
tion unaccompanied (Table IV.)
patients fifty
years
of all ages,
and for
of age with
perfora-
by hemorrhage
or obstruction.
Summary 1. Two
hundred
ten patients
for perforated peptic ulcer with a 10 per cent immediate 2. One tion
hundred
of their
ly, 61 per
eighty-seven
ulcers.
cent
Thirty-nine
Of those
had
with
ulcer disease
in forty-four
period
had
plica-
postoperative-
long-term
had significant
eventual
operation year
patients followed
a satisfactory
per cent
symptoms
underwent
over a ten mortality.
result.
continued
reoperation
ulcer
required
for
patients.
3. Twenty-three patients underwent primary definitive operations with a 9 per cent operative mortality and no subsequent distress from ulcers in the survivors who were followed.
4. Patients with associated struction, patients with history than tients
three
months
between
prior to perforation,
the
were more likely after plication.
hemorrhage and obof ulcer distress more
ages
to have
of fifty
and male pa-
and
subsequent
seventy ulcer
years
problems
5. Plication is a satisfactory patients with perforated peptic tions are made for the selection
operation for most ulcer. Recommendaof primary definitive
operation
as most
in patients
fer continued
distress
identified
liable
to suf-
after plication.
References 1. Auchincloss l-f: Immediate subtotal gastrectomy for acute perforated peptic ulcer. Ann Surg 135: 134. 1952. 2. Cooler DA, Jordan GL, Brockman HL, DeBakey ME: Gastrectomy in acute gastroduodenal perforation. Ann Surg 141: 640, 1955. 3. Mark JBD: Factors influencing the treatment of perforated duodenal ulcer. Surg Gynec Obstet 129: 325, 1969. 4. Nemanich GJ. DeMetre NM: Perforated duodenal ulcer: long term follow up. Surgery 67: 727, 1970. 5. Visick AH: Study of failures after gastrectomy; Hunterian lecture. Ann Roy Co// Surg Engl3: 266, 194.6. 6. Hofkin GA: Course of patients with perforated duodenal ulcer. Amer J Surg 111 :_193, 1966. 7. Donaldson GA, Jarrett F: Perforated gastroduodenal ulcer disease at the Massachusetts General Hospital from 1952 to 1970. Amer J Surg 120: 306, 1970.
Discussion of Papers by Drs Jarrett and Donaldson and by Drs McDonough and Foster Frederick P. Ross (Fitchburg, Mass): When Dr Donaldson gave me the manuscript of his and Dr Jarrett’s excellent paper, and asked me to open the discussion, I do not believe that he realized that I have never performed primary resection for perforated duodenal ulcer, although I have carried out a handful of resections for perforated gas-
Volume 123, April 1872
Peptic
Ulcer
tric ulcer, and a few palliative resections for perforated gastric cancer. Perhaps it is time I changed my thinking! Their paper and that of Drs McDonough and Foster are remarkably similar. Forty per cent or more of patients treated with simple plication had long-term satisfactory results, approximately another 40 per cent had further difficulty and required definitive surgery later on, and perhaps 20 per cent are still in limbo with the eventual result not determinable. Also it seems obvious that the longer a patient has had ulcer trouble before perforation, the more apt he is to have difficulty afterwards. Excellent results were obtained in the relatively small number of patients who had definitive surgery at the time of perforation. However, these results were obtained at the Massachusetts General Hospital and the Hartford Hospital, and I wonder if the results would be as good if these papers influenced every community surgeon to attempt gastrectomy at the time of perforation? If the trend towards primary resection enlarges, certainly many resections will be carried out on patients who will have no further difficulty. Also, we must remember that there are undesirable postoperative symptoms after a small percentage of definitive gastric operations. I have set up a little protocol for myself. If I have an ulcer that perforates, I will gladly put myself in the hands of Drs Jarrett and Donaldson, and rely on their good judgement. I think I would hope for simple plications, and that I was in the 40 to 50 per cent of people who will have no further difficulty. On the other hand if I were traveling outside of New England and there was no member of the New England Surgical Society to help me out, I think I would insist that only plication be performed. Then I would come back to Drs Jarrett and Donaldson, or Drs McDonough and Foster, and await further developments before submitting myself to their capable ministrations! Claude E. Welch (Boston, Mass): I am reminded of the words of Grantley Taylor who, when he was asked, “What do you think about this problem?” answered “I haven’t heard myself talking about it yet, so I don’t know what to think.” Some of us are certainly still in this confused state, wondering which operation is the correct one. It does make a great deal of difference, however, if we operate upon the patient with the expectation of performing gastric resection with vagotomy rather than simple plication. Preparations for the operation will be entirely different and the procedure will be conducted accordingly. It is entirely possible that the old operation of plication of an ulcer may be discarded in the next decade or two. There are several indications pointing in that direction. For example, the mortality with simple plication still remains around 9 or 10 per cent. If this is a good operation, it would be expected, considering the availability of all the ancillary aids from antibiotics and better anesthesia to electrolyte replacement, that this figure should have dropped considerably. Furthermore, if one notes the figures of Dr Hinshaw shown by Dr Donaldson, in which the incidence of resection was extremely high and that of simple closure of the perforation very low, the mortality was about as low as
415
McDonough
and Foster
can be found anywhere in the literature. Some surgeons accustomed to both types of operations believe firmly that the patients who have a definitive operation carried out at the time of the original procedure do much better than those who have simple plication. Why this should happen is very difficult to know, but it is possible that the fact that one spends two hours rather than ten minutes cleaning the peritoneal cavity could be of some importance. I hope that sometime in the near future we may have some absolutely controlled series and find out whether or not in comparable cases a definitive operation such as resection or pyloroplasty with vagotomy will carry a lower mortality than simple plication. Mark A. Hayes (New Haven, Conn): Doctors McDonough and Foster asked me to discuss their findings in this increasingly prevalent complication of duodenal ulcer disease. It is remarkable how similar their findings, for the most part, are to ours which were presented at a meeting of the American Gastroenterological Association in 1959. Our material was composed of 155 surviving patients followed up for five or more years. Gastric resection in these patients was performed for perforation only in the fact of coexistant hemorrhage or obstruction. One hundred twenty-three ulcers were plicated. Five or more years later 20 per cent of the patients were asymptomatic, and 54 per cent would be classified, seen de novo, as nonsurgical. Forty-five per cent would be-seriously considered, from a symptomatic point of view as candidates for operative treatment. If we establish criteria presumed to reflect the severity of ulcer diathesis, use them to judge the type of operative procedure to be employed, and retrospectively apply them to our patients, we have some interesting observations. If only one criterion is employed, you will discover only one patient in ten who will later need definitive surgery and, what is more, will operate unnecessarily in four of ten. If two criteria are employed, definitive surgery will be performed at the time of perforation in seven of ten who subsequently would have required it anyway. Only two of ten will receive an unnecessary definitive surgical procedure. It is particularly interesting to remember what Dr McDonough has told us about the length of history prior to perforation and the necessity for late definitive surgery. As you recall from our criteria of duration of history, we agree with him and are at odds with Drs Jarrett and Donaldson Emergency surgery for perforation is not a panacea. Of our thirty-two patients with resection, twelve failed to gain their preoperative weights, and three were seriously handicapped with dumping. As a matter of fact, two of the twelve had to undergo reresection with vagotomy for jejunal ulcer. I will continue to perform plication for perforation and assume that Drs McDonough, Foster, Jarrett, and Donaldson will probably continue to do so also.
416
Edward D. Frank (Boston, Mass): The last two speakers used the term “irreversible shock” to describe certain patients. This term should never be used at the bedside. There it has no meaning other than acceptance of defeat. Fredric Jarrett (Amsterdam, The Netherlands): We are still unsure about the significance of symptoms in many of these patients. These symptoms are subjective at best, and what is complained of by some patients might be minimized by others. Thus, the need for subsequent surgery is the best objective indication of ulcer activity, although this too is tinged with some subjectivity because physicians advocate or do not advocate some kind of therapy according to their own feelings and experience. As long as these patients present a spectrum of reactions to their symptoms, and as long as they are followed by different physicians and surgeons, it will be difficult to eliminate this bias. It is very difficult to decide which patients should undergo resection and which should have simple plication of the perforation, and this can often be decided with surety only in the operating room. Doctor Hayes has mentioned some criteria which are very useful in this regard. Other people who have reviewed similar series of patients have found that durations of symptoms are important, as are associated problems such as hemorrhage or obstruction: Hamilton and Harbrecht’s report emphasized that if preperforation symptoms were severe or greater than five years in duration, or if the ulcer was large and sclerotic, only 13 per cent of patients remained symptom-free after plication. We too have not noted very much significance in the age of the patient. In our series I think the most significant factor was the duration of ulcer activity, and this also can be very difficult to appreciate. We have had innumerable patients in the emergency ward, who by a very careful history have denied any symptoms or prior pain; and yet the operating surgeon has found a tremendous amount of duodenal scarring, and realized that the disease has existed for a long time. I do not think that this issue will be resolved very easily, but with care it should be possible to predict which patients are very likely to have further trouble, and to perform definitive surgery in this group rather than subject them to a second operation. Some 40 per cent of our patients required a second operation; and this statistic would be considered unacceptable in dealing with most other organ systems, such as the biliary tract. James M. McDonough (closing): I agree with Dr Frank. What was probably meant by “irreversible shock” was shock that persists, no matter what is done. None of these patients are included in our series. In fact, most nonoperative cases were those concerning patients who appeared three or four days after perforation, and were so healthy that we were embarrassed to operate upon them. Concerning which drainage procedure to use, my experience is not wide in this matter. I would suggest that the best one that can be efficie_ntly arranged be used.
The American Journal of Surgery
MD, Hartford, Connecticut
James H. Foster, MD, Hartford,
Connecticut
Be not the first by whom the new are tried, Nor yet the last to lay the old aside. Alexander
Pope
Essay on Criticism (1711) The necessity of performing an operation which will permanently control the ulcer diathesis when emergency operation is necessary for control of hemorrhage from peptic ulcer has long been accepted. Gastrectomy, and then pyloroplasty and vagotomy, have allowed surgeons to lower mortality rates in the emergency situation, after it was clearly established that simple ligation of the bleeding point was followed by an unacceptable incidence of ulcer complications. In a similar manner Auchincloss [I] and others [Z-d] have suggested that primary definitive operation should also be recommended for patients with perforated peptic ulcer. The basis for this concept rests on two arguments: (1) that postoperative and late ulcer complications would occur in a majority of patients after plication alone; and (2) that emergency definitive operation for perforated peptic ulcer could be accomplished with mortality no higher than that after plication alone. Plication has long been the accepted and usual method of treatment of perforated peptic ulcer on the Surgical Service of Hartford Hospital. Before abandoning this policy, it seemed wise to review the results we had achieved to determine whether, in truth, the postplication course of our patients might justify a more aggressive approach to initial therapy. Perhaps we might also be able to identify a group at high risk for further ulcer problems, which might lead to a selective approach of primary operative treatment. From the Surgical Service, Hartford Hospital, Hartford, Connecticut, Reprint requests should be addressed to Dr Foster, Hartford Hospital, 80 Seymour St. Hartford, Connecticut 06115. Presented at the Fifty-Second Annual Meeting of the New England Surgical Society, Portsmouth, New Hampshire, September 30, October 1 and 2. 1971.
Volume 123, April 1972
Material and Methods A retrospective review was made of all charts of patients with a diagnosis of perforated peptic ulcer treated at the Hartford Hospital between January 1, 1960 and January 1, 1970. The medical history and clinical course were reviewed, including all laboratory and radiologic studies, the operative notes, anesthesia notes, and time of perforation as suggested by sudden onset of abdominal pain. The course of 210 consecutive patients undergoing emergency operation for perforated peptic ulcer during this ten year period was studied. The operative survivors were interviewed by phone, in person, or by mail. The modified Visick classification [5] was used to evaluate the results of each patient’s operation for long-term follow-up. Classification as “unsatisfactory” implies that the patient had moderate or severe symptoms which considerably interfered with work or enjoyment. All cases of proved recurrent ulcer and patients requiring further surgery for peptic ulcer are included in the unsatisfactory category. Long-term follow-up study has been possible in 85 per cent of operative survivors (160 of 189). Multiple factors were then correlated with immediate postoperative morbidity and mortality and long-term morbidity.
Clinical Data Emergency operative intervention for perforated peptic ulcer disease was carried out in 210 patients during the ten year interval examined. There were 148 male and sixty-two female patients, with the age at the time of perforation ranging from fifteen to ninety years. The mean and median ages were the same: fifty-six years. The vast majority of operations were simple plications since only twenty-three patients underwent primary “definitive” operation. Definitive Operatibn. Two definitive procedures were carried out for technical reasons, four were for associated hemorrhage, five were performed for associated obstruction, and five were performed because of a history of prior perforation. Vagotomy and an emptying procedure were carried out in seventeen patients. These patients have done well with no operative deaths and there has been no further ulcer
411
McDonough
and Foster
CASES IO
n ”
I
3
2
Figure 1. Interval forty-four patients.
4
5 6 YEARS
between
7
plication
8
IO
9
and reoperation
in
problem in the fourteen patients in whom follow-ui, was obtained. Six partial gastric resections were performed, one with associated vagotomy. Two of these patients, aged seventy-one and eighty-four years, died postoperatively. A third bled on the first postoperative day and required reoperation. Three operative survivors with follow-up are doing well. Plication. Plication was the operative choice for 187 patients. Nineteen operative deaths occurred. Most of these fatalities occurred in elderly patients with multisystem disease prior to perforation. Eleven deaths were in patients over age seventy. Severe preexisting disease such as carcinomatosis or regional enteritis was present in eleven who died, and these patients also frequently had complications directly related to ulcer perforation and/or plication. Five patients who died had upper gastrointestinal bleeding either at the time of perforation or after plication. Four had intra-abdominal abscess formation, MALES
FEMALES IzI unsatisfktory
AGE
,
~80 70-79 60-69 50-59 40-49 30-39 (30
,
IO Figure 2.
412
1
1
-0
’
I
CASES
IO
Age, sex, and result after plication.
505
which in one was associated with recurrent bowel obstruction. Aspiration pneumonia and duodenal fistula were related to mortality in two patients. These complications directly related to the perforation were associated, in those who died postoperatively, with myocardial infarction, acute tubular necrosis with renal failure, pulmonary infarction, adult respiratory distress syndrome, and even acute cholecystitis. Follow-up study of the operative survivors after plication was complete in all but twenty-nine patients. An “unsatisfactory” result was obtained in fifty-five patients. Of these, forty-four required reoperation for continued ulcer intractability or other complications. In the first month after plication four patients were reoperated upon for bleeding peptic ulcer. Most patients who came to reoperation did so within two years after plication. (Figure 1.) Followup was evaluated on a year to year basis. There was no significant difference in unsatisfactory results on long-term follow-up between patients operated upon more than six years ago (1960 to 1965) and patients operated updn more recently (1965 to 1970). The patient’s age and sex at the time of perforation are related to the eventual outcome in Figure 2. The likelihood of an unsatisfactory result is slightly greater in men than women in all age groups. This difference is most pronounced ,and is statistically significant in patie’nts fifty to seventy years of age. (Tables I and II.) Table III relates the duration of ulcer distress present before perforation to the eventual outcome after perforation. The difference noted with ulcer history of more or less than five years is not statistically significant, but when the results are related to an ulcer history preceding perforation of more or less than three months the difference is highly significant (p = < .005). Associated Hemorrhage and Obstruction. The course of patients who presented with a history of bleeding was examined. Eleven patients had bleeding with the episode of perforation, and in eight hemorrhage occurred at a p‘rior time. Fifteen such patients underwent plication. In three of these patients instability of the cardiovascular system was demonstrated intraoperatively. Three patients bled after plication and required reoperation. Operative death occurred in three patients: in one with intraoperative cardiovascular instability and in another patient who required reoperation for bleeding in the postoperative period. Ten patients with bleeding who survived plication had long-term follow-up study. Five of these patients were eventually reoperated upon for ulcer complications: three for intractability or obstruction at four months, eight months,
The American Journal of Surgery
Perforated
and three years after plication, respectively, and two for later bleeding episodes. Two other patients were classed as having “unsatisfactory” results with ulcer recurrence or bleeding not requiring reoperation; and the remainder (three patients) did well after plication. Four patients with associated gastrointestinal bleeding underwent definitive operation. There was one operative death in an eighty-four year old man who underwent subtotal gastric resection. One patient was lost to follow-up study, and the remaining two did well after definitive operation. Obstruction in the patients who underwent emergency surgery for perforated peptic ulcer was present preoperatively in three elderly men. One patient underwent plication and required definitive operation after a two year interval for further obstruction. Plication and gastroenterostomy were performed in the second patient, who required vagotomy and gastroenterostomy after a sixteen month interval. Vagotomy and gastrojejunostomy were used primarily in the third patient, who has enjoyed an excellent result. Obstruction was present postoperatively in ten patients. In one patient undergoing vagotomy and pyloroplasty, relief of obstruction was slow, but this patient eventually obtained an excellent long-term result. After plication nine patients exhibited signs of obstruction postoperatively with emesis and the need for prolonged nasogastric aspiration. All of the seven patients with late follow-up have had recurrent ulcers, with six requiring reoperation. Four of these patients have been reoperated upon for obstruction. Steroid Therapy. Fourteen patients in this series had perforation of an ulcer, while they were receiving steroid therapy. Thirteen patients were initially treated by plication of the ulcer perforation, and one underwent vagotomy and pyloroplasty. Six patients receiving steroids for rheumatoid arthritis did well in the immediate postoperative period. Four had good results at late follow-up study, one patient had mild symptoms, and one patient required reoperation for reperforation at forty-one months. Three patients who were receiving steroids for carcinomatosis had plication, with one operative death and two late deaths at eight and fourteen months, respectively, which were unrelated to the ulcer diathesis. Three patients with asthma treated by steroids had plication with one operative death associated with wound dehiscence, one late death unrelated to ulcer problems, and one satisfactory result at six years after plication. One patient treated with steroids for cirrhosis underwent plication after perforation and died postoperatively. One patient with back pain treated with steroids underwent plication but had an unsatisfactory long-term course with gastrointestinal
Volume 123, April 1972
TABLE I
Peptic Ulcer
Age and Result Patients
Age W) Less than 50 50-70 Over 70
TABLE II
Result
Male
Female
33 18 14 20 7 5
13 7 13 3 8 4
Satisfactory Unsatisfactory Satisfactory Unsatisfactory Satisfactory Unsatisfactory
Age and Results in Male Patients Only Result
~__
Age (yr)
Satisfactory
50-59 All others
Unsatisfactory
7 76
14 29
bleeding three years after plication which was medically treated. Differential Diagnosis. Delay in diagnosis, although not frequent, occurred in this series and was associated with an inadequate or confused history, a dearth of abdominal findings, and/or no free air seen in roentgenograms of the abdomen or chest. In only 19 per cent of patients who had rokntgenograms taken (38 of 196) was no free air seen on the abdominal or chest film. Radiopaque gallstones were noted on the abdominal roentgenograms of four patients in this series. In an unfortunate combination of radiologic findings, three-quarters of the patients exhibiting gallstones on initial x-ray examination of the abdomen failed to demonstrate free air on these films. In six cases the diagnosis of cholecystitis was confused with that of perforated peptic ulcer, with a resultant delay in diagnosis from one to eight days. Of these six patients, all failed to demonstrate free air radiologically. Four had a short history of pain not typical of ulcer distress. Three had tenderness in the upper part of the abdomen with rather mild lower TABLE III
Duration of Ulcer Symptoms prior to Perforation versus Result after Plication Result
Distress prior to Perforation
Satisfactory
Greater than 5 yr Less than 5 yr
15 (48%) 58 (65%)
16 (52%) 31 (35%)
Greater than 3 mo Less than 3 mo
31 (47%) 42 (78%)
35 (53%) 12 (22%)
Unsatisfactory
413
McDonough
and Foster
abdominal findings; one had a tender palpable mass in the right upper quadrant with radiopaque gallstones; another had nonvisualization of the gallbladder with oral cholecystogram. Four of these patients died postoperatively, three after plication and the other after subtotal gastrectomy. Comments
A retrospective review of the records of patients undergoing emergency operation must suffer from the incompleteness of information gathered from patients often rushed from the emergency room to the operating room within an hour or two of hospitalization. The patients included in this review were cared for by many different surgeons, each with his own approach to this problem. Patients with perforated ulcers who never came to operation are not included in this series. Yet, even with these limitations, this experience is large enough, and the initial and follow-up information is complete enough, to allow certain conclusions. It would appear from this data that primary definitive operation can be offered to patients with perforated peptic ulcer with the expectation of an acceptable survival rate. Primary definitive operation eliminated subsequent ulcer problems in all of those surviving operation with adequate follow-up information. However, a look at the course of 144 patients surviving plication and followed up for one to ten years reveals that 61 per cent had satisfactory results after plication alone. When the results are further broken down to consider factors of age, sex, and duration of ulcer symptoms prior to perforation, it is possible to identify a high risk group of patients who have a statistically significantly increased risk of postplication TABLE IV
Guidelines in the Management of Perforated Peptic Ulcer
1. No operation In presence of irreversible shock 2. Simple closure In most women When history of ulcer is less than 3 months When patient is on steroid therapy Whenever patient is considered a poor risk 3. Definitive operation When patient’s condition is stable and there is: Remote or current history of hemorrhage A history of obstruction Obstruction occurring after simple closure A history of prior perforation A technical problem with closure Relative indications exist with a: Man between 50 and 70 years of age Long history of ulcer
414
ulcer problems-a risk which exceeds 60 per cent in male patients between the ages of fifty and seventy years who have had ulcer symptoms for more than three months prior to perforation. Hemorrhage and/or obstruction associated with perforation are almost certain portents of further trouble unless definitive operation is undertaken. W’omen in all age groups fare better than do men after plication. To our surprise, the small group of patients in whom ulcers perforated while they were on adrenal steroid therapy did as well after plication alone as did those patients not on steroid therapy. Our prejudice was that patients with a long history of ulcers prior to perforation would be more likely to eventually require definitive operation. Statistical analysis does not show a significant difference between those with a preperforation history of ulcers of more or less than five years. However the percentage of unsatiefactory results in those with a history of ulcers more than three months prior to perforation is significantly greater than that in patients with a history of less than three months of distress. Others [4,6,7] have suggested that recurrent ulcer problems after plication alone will increase with the number of years the patients are followed. This was not true in this series. When a second operation was required to control the ulcer diathesis after initial plication, it was performed within two years of plication in 75 per cent of patients. If one eliminates the high risk groups of patients with associated hemorrhage and obstruction and male patients between fifty and seventy years of age with ulcer histories of more than three months, there are left 111 patients who survived plication with adequate follow-up information. In this group only 25 per cent had a long-term unsatisfactory result. Although definitive operation can apparently be offered to patients with perforated peptic ulcer without an increase in immediate mortality, we believe that pyloroplasty-vagotomy and antrectomy-vagotomy are not innocuous procedures and should be avoided if plication alone can be performed with anticipation of a satisfactory result in a majority of patients. Patients with obstruction or a history of hemorrhage accompanying perforation should have primary definitive operation. Patients with postplication obstruction should probably be scheduled for elective definitive operation even if obstruction subsides, because of the high incidence of late complications requiring reoperation. Male patients between the age of fifty and seventy years with a long history of ulcer may be offered a primary definitive operation in selected instances. However, we believe that plication should remain as the operation of choice for patients with a short history of ulcer distress prior to
The American Journal of Surgery
Perforated
perforation, male
for female
patients
under
tion unaccompanied (Table IV.)
patients fifty
years
of all ages,
and for
of age with
perfora-
by hemorrhage
or obstruction.
Summary 1. Two
hundred
ten patients
for perforated peptic ulcer with a 10 per cent immediate 2. One tion
hundred
of their
ly, 61 per
eighty-seven
ulcers.
cent
Thirty-nine
Of those
had
with
ulcer disease
in forty-four
period
had
plica-
postoperative-
long-term
had significant
eventual
operation year
patients followed
a satisfactory
per cent
symptoms
underwent
over a ten mortality.
result.
continued
reoperation
ulcer
required
for
patients.
3. Twenty-three patients underwent primary definitive operations with a 9 per cent operative mortality and no subsequent distress from ulcers in the survivors who were followed.
4. Patients with associated struction, patients with history than tients
three
months
between
prior to perforation,
the
were more likely after plication.
hemorrhage and obof ulcer distress more
ages
to have
of fifty
and male pa-
and
subsequent
seventy ulcer
years
problems
5. Plication is a satisfactory patients with perforated peptic tions are made for the selection
operation for most ulcer. Recommendaof primary definitive
operation
as most
in patients
fer continued
distress
identified
liable
to suf-
after plication.
References 1. Auchincloss l-f: Immediate subtotal gastrectomy for acute perforated peptic ulcer. Ann Surg 135: 134. 1952. 2. Cooler DA, Jordan GL, Brockman HL, DeBakey ME: Gastrectomy in acute gastroduodenal perforation. Ann Surg 141: 640, 1955. 3. Mark JBD: Factors influencing the treatment of perforated duodenal ulcer. Surg Gynec Obstet 129: 325, 1969. 4. Nemanich GJ. DeMetre NM: Perforated duodenal ulcer: long term follow up. Surgery 67: 727, 1970. 5. Visick AH: Study of failures after gastrectomy; Hunterian lecture. Ann Roy Co// Surg Engl3: 266, 194.6. 6. Hofkin GA: Course of patients with perforated duodenal ulcer. Amer J Surg 111 :_193, 1966. 7. Donaldson GA, Jarrett F: Perforated gastroduodenal ulcer disease at the Massachusetts General Hospital from 1952 to 1970. Amer J Surg 120: 306, 1970.
Discussion of Papers by Drs Jarrett and Donaldson and by Drs McDonough and Foster Frederick P. Ross (Fitchburg, Mass): When Dr Donaldson gave me the manuscript of his and Dr Jarrett’s excellent paper, and asked me to open the discussion, I do not believe that he realized that I have never performed primary resection for perforated duodenal ulcer, although I have carried out a handful of resections for perforated gas-
Volume 123, April 1872
Peptic
Ulcer
tric ulcer, and a few palliative resections for perforated gastric cancer. Perhaps it is time I changed my thinking! Their paper and that of Drs McDonough and Foster are remarkably similar. Forty per cent or more of patients treated with simple plication had long-term satisfactory results, approximately another 40 per cent had further difficulty and required definitive surgery later on, and perhaps 20 per cent are still in limbo with the eventual result not determinable. Also it seems obvious that the longer a patient has had ulcer trouble before perforation, the more apt he is to have difficulty afterwards. Excellent results were obtained in the relatively small number of patients who had definitive surgery at the time of perforation. However, these results were obtained at the Massachusetts General Hospital and the Hartford Hospital, and I wonder if the results would be as good if these papers influenced every community surgeon to attempt gastrectomy at the time of perforation? If the trend towards primary resection enlarges, certainly many resections will be carried out on patients who will have no further difficulty. Also, we must remember that there are undesirable postoperative symptoms after a small percentage of definitive gastric operations. I have set up a little protocol for myself. If I have an ulcer that perforates, I will gladly put myself in the hands of Drs Jarrett and Donaldson, and rely on their good judgement. I think I would hope for simple plications, and that I was in the 40 to 50 per cent of people who will have no further difficulty. On the other hand if I were traveling outside of New England and there was no member of the New England Surgical Society to help me out, I think I would insist that only plication be performed. Then I would come back to Drs Jarrett and Donaldson, or Drs McDonough and Foster, and await further developments before submitting myself to their capable ministrations! Claude E. Welch (Boston, Mass): I am reminded of the words of Grantley Taylor who, when he was asked, “What do you think about this problem?” answered “I haven’t heard myself talking about it yet, so I don’t know what to think.” Some of us are certainly still in this confused state, wondering which operation is the correct one. It does make a great deal of difference, however, if we operate upon the patient with the expectation of performing gastric resection with vagotomy rather than simple plication. Preparations for the operation will be entirely different and the procedure will be conducted accordingly. It is entirely possible that the old operation of plication of an ulcer may be discarded in the next decade or two. There are several indications pointing in that direction. For example, the mortality with simple plication still remains around 9 or 10 per cent. If this is a good operation, it would be expected, considering the availability of all the ancillary aids from antibiotics and better anesthesia to electrolyte replacement, that this figure should have dropped considerably. Furthermore, if one notes the figures of Dr Hinshaw shown by Dr Donaldson, in which the incidence of resection was extremely high and that of simple closure of the perforation very low, the mortality was about as low as
415
McDonough
and Foster
can be found anywhere in the literature. Some surgeons accustomed to both types of operations believe firmly that the patients who have a definitive operation carried out at the time of the original procedure do much better than those who have simple plication. Why this should happen is very difficult to know, but it is possible that the fact that one spends two hours rather than ten minutes cleaning the peritoneal cavity could be of some importance. I hope that sometime in the near future we may have some absolutely controlled series and find out whether or not in comparable cases a definitive operation such as resection or pyloroplasty with vagotomy will carry a lower mortality than simple plication. Mark A. Hayes (New Haven, Conn): Doctors McDonough and Foster asked me to discuss their findings in this increasingly prevalent complication of duodenal ulcer disease. It is remarkable how similar their findings, for the most part, are to ours which were presented at a meeting of the American Gastroenterological Association in 1959. Our material was composed of 155 surviving patients followed up for five or more years. Gastric resection in these patients was performed for perforation only in the fact of coexistant hemorrhage or obstruction. One hundred twenty-three ulcers were plicated. Five or more years later 20 per cent of the patients were asymptomatic, and 54 per cent would be classified, seen de novo, as nonsurgical. Forty-five per cent would be-seriously considered, from a symptomatic point of view as candidates for operative treatment. If we establish criteria presumed to reflect the severity of ulcer diathesis, use them to judge the type of operative procedure to be employed, and retrospectively apply them to our patients, we have some interesting observations. If only one criterion is employed, you will discover only one patient in ten who will later need definitive surgery and, what is more, will operate unnecessarily in four of ten. If two criteria are employed, definitive surgery will be performed at the time of perforation in seven of ten who subsequently would have required it anyway. Only two of ten will receive an unnecessary definitive surgical procedure. It is particularly interesting to remember what Dr McDonough has told us about the length of history prior to perforation and the necessity for late definitive surgery. As you recall from our criteria of duration of history, we agree with him and are at odds with Drs Jarrett and Donaldson Emergency surgery for perforation is not a panacea. Of our thirty-two patients with resection, twelve failed to gain their preoperative weights, and three were seriously handicapped with dumping. As a matter of fact, two of the twelve had to undergo reresection with vagotomy for jejunal ulcer. I will continue to perform plication for perforation and assume that Drs McDonough, Foster, Jarrett, and Donaldson will probably continue to do so also.
416
Edward D. Frank (Boston, Mass): The last two speakers used the term “irreversible shock” to describe certain patients. This term should never be used at the bedside. There it has no meaning other than acceptance of defeat. Fredric Jarrett (Amsterdam, The Netherlands): We are still unsure about the significance of symptoms in many of these patients. These symptoms are subjective at best, and what is complained of by some patients might be minimized by others. Thus, the need for subsequent surgery is the best objective indication of ulcer activity, although this too is tinged with some subjectivity because physicians advocate or do not advocate some kind of therapy according to their own feelings and experience. As long as these patients present a spectrum of reactions to their symptoms, and as long as they are followed by different physicians and surgeons, it will be difficult to eliminate this bias. It is very difficult to decide which patients should undergo resection and which should have simple plication of the perforation, and this can often be decided with surety only in the operating room. Doctor Hayes has mentioned some criteria which are very useful in this regard. Other people who have reviewed similar series of patients have found that durations of symptoms are important, as are associated problems such as hemorrhage or obstruction: Hamilton and Harbrecht’s report emphasized that if preperforation symptoms were severe or greater than five years in duration, or if the ulcer was large and sclerotic, only 13 per cent of patients remained symptom-free after plication. We too have not noted very much significance in the age of the patient. In our series I think the most significant factor was the duration of ulcer activity, and this also can be very difficult to appreciate. We have had innumerable patients in the emergency ward, who by a very careful history have denied any symptoms or prior pain; and yet the operating surgeon has found a tremendous amount of duodenal scarring, and realized that the disease has existed for a long time. I do not think that this issue will be resolved very easily, but with care it should be possible to predict which patients are very likely to have further trouble, and to perform definitive surgery in this group rather than subject them to a second operation. Some 40 per cent of our patients required a second operation; and this statistic would be considered unacceptable in dealing with most other organ systems, such as the biliary tract. James M. McDonough (closing): I agree with Dr Frank. What was probably meant by “irreversible shock” was shock that persists, no matter what is done. None of these patients are included in our series. In fact, most nonoperative cases were those concerning patients who appeared three or four days after perforation, and were so healthy that we were embarrassed to operate upon them. Concerning which drainage procedure to use, my experience is not wide in this matter. I would suggest that the best one that can be efficie_ntly arranged be used.
The American Journal of Surgery