- Email: [email protected]
Modern management of acute perforated gastroduodenal ulcers
MODERN MANAGEMENT
OF ACUTE PERFORATED
GASTRODUODENAL DONALD
C. Co~rms,
ULCERS* M.D.
Assistant Professor of Surgery, CoIIege of Medical Evangelists; Chairman, Hospital, OImsted MemoriaI
SurgicaI Service Hollywood Presbyterian
Hollywood, California
I
T has been estimated by Wangensteen24 that approximateIy 10,000 individuaIs died in the United States each year from acute gastroduodena1 uIcers and their compIications. Autopsies revea1 that either a heaIed or an active gastroduodenar ulcer is present in approximateIy -5 per cent of individuaIs examined at the oostmortem tabIe. It is a we11 known fact that acute erosions of the gastric or duodena1 mucosa may occur easiIy. Under experimenta conditions in the laboratory fully deveIoped gastroduodena1 uIcers can be produced within severa hours by aIlowing gastric juice to drip upon a designated unprotected area of gastric or duodena1 mucosa. History records that the first pubfished report of a perforated gastroduodena1 uIcer was made by Bonetil in 1679. Fifty years Iater RawIinsonl* presented a case history of a perforated gastroduodena1 uIcer before the RoyaI Society in London. It was not until ninety-five years after the report of Rawhnson that John Abercrombie’ was able to differentiate between the two types of perforated gastroduodena1 uIcers. Cruvilhier,’ the French pathoIogist, cIearIy differentiated between a simple gastroduodena1 ulcer and an ulcerating gastric carcinoma. It was not unti1 1875 that O’Hara” became the first American to describe and present an exampIe of a perforated I
* From the Departments
gastroduodenal uIcer before the PhiIadeIphra PathoIogicaI Society. The first recorded attempt to cIose such a perforating uIcer surgicaIIy was done by MikuIicz16 in 1880. This first surgica1 attempt was unsuccessfu1. TweIve years later Heussner and Roux” were among the first to report a successfu1 surgical repair of a perforated gastroduodena1 uIcer. Dean8 in 1894 reported a successfu1 surgica1 excision of such an uIcer. Seventeen years after his first published unsuccessfu1 attempt MikuIicz16 was abIe to pubIish a colIected series of 103 operations for the surgica1 repair of perforated peptic uIcers. The majority of these operations were successfu1. Perforated gastroduodenal uIcers have always aroused the great interest of internists and surgeons alike and have constituted one of the most dramatic emergency surgica1 conditions frequentIy encountered. My interest and study in this subject extends back some twenty-one years in the past. In 1933 Rhodes and Ilg presented a report upon ‘$3 consecutive instances of perforated acute gastroduodena uIcers that had come under our care on the emergency service at the San Francisco City and County HospitaI. These patients had been treated during the ten years between I 919 and 1929; I 17 of these individuaIs had been sur-
of Surgery, College of Medical EvangeIists, Los Angeks, Calif., Presbyterian HospitaI, OImsted Memorial, HoIIywood, Calif.
684
American
and The HoIIywood
Journal
of Surgery
Collins--Gastroduodenal gicalIy treated within ten hours following their perforation and 13 per cent of these died. The remaining thirty-eight patients in this series had not received surgical care until more than ten hours had eIapsed following their acute perforation and they TABLE RESLLT
OF
MPDICAI.
THERAPELTIC
repeatedly stressed the fact that a considerabIe number of surgicaIly treated perforated gastroduodena1 uIcers wiII subsequentIy develop symptoms of reactivation of their former ulcer, and a subtota1 gastric resection often wiI1 be necessary in TABLE
I
TREATMENT RES1 LTS
685
Ulcers
IN
OF TOTAL
PEPTIC
ULCER-
OF
PERCENTAGE ADMISSIONS
MATERIAL*
II
PERFORATED FOR
ULCER
A‘MONG
ULCER
AND
PERCENTAGE
ALL
OF
READMlSSIONS Iirsults
Recovcrcd Recovered after relapse Improved..
Poc,rresult. Died........ Not located.
Cases
‘3’
I 2I ~ ‘91 184 99 39
20
3
20 28 15 6
,2lcdical treatment alone cunno~ permanently heal nor prevent the onset of complications in all gastroduodenal ulcers. * From KRAUP, NIELS B. The 1946 Year Book of General Medicine. Pp. 631. Chicago, 1946. The Year Book Publishers, Inc.
had a mortality rate of 68 per cent. WelY found that the causes of mortality in this group of 155 patients were due IargeIy to the folIowing compIications: peritonitis jo per cent; cardiac disease 30 per cent; pneunonia 20 per cent. Forty-six per cent of the surviving patients in this series were traced postoperatively for five or more years foIIowing their corrective surgery and 85 per cent reported themseIves as being either entirely cured or that a prompt return to their prescribed uIcer diet gave prompt reIief from symptoms of mild recurrences. The remaining 15 per cent who repIied to our questionnaire admitted that they had been guiIty of gross neglect and abandonment of the prescribed medica measures designed to prevent recurrences. In the past fourteen years the surgica1 world has witnessed tremendous improvement in the surgica1 management of acute perforated gastroduodena1 uIcers. McNeaIy and Hawser’” as we11 as Karl Meyer and his associates26 have made numerous important contributions toward the better management of this disease. They have
June,
1949
After W’erbal, Kozoll and Meyer
Per cent
Year
Ulcer Patients Admitted AI1 Types
‘crforated Ulcer Patients Sutured and Recovered
Previously Perforatcd Ulcer Patients Readmitted
I
No.
Per cent of TotaI Admissions for Ulcer
~No,
.
I ---~
’ 939 ’ 940 ‘94’ ‘942 ‘943 1944 1945 Total
7’7 809 764 629 549 436 45’ 4,355
-~
96
‘3
35
118 881 891 ,
14
34
12
‘36
‘4
~ 32~
26
I
! 239 1 i I
20 41 37
31.6
The incidence and fairIy constant percentages of reperforation in gastroduodenat ulcers. Closure of the origina perforation is no guarantee against future reperforations.
certain of these individuaIs in order to obtain a compIete and permanent recovery. WerbeI, KozoII and Meyel 26 have drawn our attention to the fact that ina series of 574 patients suffering from acute perforated gastroduodena1 uIcers and in whom a simpIe cIosure of the perforation was done 239 individuals, or 4 I .6 per cent, were forced to return to the Cook County HospitaI for further hospitaIization, because of a recurrence of their previous symptoms. In 86 per cent of their patients pain was IargeIy responsible for their return to the hospita1 and a considerable percentage of these individuaIs suffered from varying degrees of pyIoric obstruction; 17 per cent of these re-admitted
686
CoIIins-Gastroduodenal
patients had two or more acute re-perforations; 34 per cent of the re-admitted patients were suffering from recurrent bIeeding from the ulcer crater. (TabIes I, II and III.) Further gastroduodena1 surgery was necessary in 30 per cent of these 239
UIcers
incIude the dista1 two-thirds of the stomach and the duodenum with its chronic duodenal ulcer, if present, wiI1 be doomed to early faiIure. BiIateraI vagotomy introduced by DragstedP1° has aroused tremendous interest
TABLE III CAUSES
OF DEATH
1X EIGHTEEN
CO.MPLICATIOKS
PATIENTS
FOLLOWING
PERFORATED
AN
WITH
ULCER
EARLIER
ULCER
(After Werbal, Kozoll and ikfeyer) No. Deaths Reperforation. j Second perforation. 3 Third perforation.. I Fifth perforation.. I Reperforation with Hemorrhage (2nd Perforation), 3 Hemorrhage.. 3 EIectivesurgery................... ; Gastric resection. 3 Gastroenterostomy. 2 Liver abscess four months after perforation.. * CerebrovascuIar accident.. I Total......................... 18 Reperforation of a gastroduodena1 ulcer is associated with markedly increased morbidity and mortaIity. These deaths were in the patients shown in TabIe I.
patients who returned to insure them prompt and permanent reIief from their symptoms. (Fig. I .) WerbeI, KozoII and MeyeP were of the definite opinion that a primary subtotal gastric resection at the time of the patient’s origina perforation was not, as a genera1 ruIe, indicated; and that any surgica1 procedure more extensive than a simpIe cIosure wouId Iead to unnecessary deaths. Recent pubIished studies by Samayn,20 MiIaret and EdeIman’j are in sharp variance with this opinion of KarI Meyer and his associates. The technic and the indications for subtota1 gastrectomy has shown marked advancement and refinement in the Iast ten years so that today the consensus of opinion of gastric surgeons in this country is crystaIIized into the definite belief that a subtota1 gastrectomy is necessary for the permanent and successfu1 cure of Iong-standing chronic gastroduodena1 uIcers. In this connection, according to Frank Lahey12 and Lewisohn,13 any subtotal gastric resection which does not
NUMBER
25
OF CASES
” /d
FIG. I. Number and Meyer).
of perforations
(after
WerbeI,
KozoII
among surgeons and at first the reports pubIished gave rise to the hope that possibIy this wouId be the idea1 operation for chronic gastroduodenal uIceration. Recent reports by WaItman WaIters23 and WiIensky2’ cast considerabIe doubt as to whether or not the beneficia1 advantages enthusiasticaIIy claimed for the routine use of this operation in cases of chronic gastroduodena1 uIcers are of more than temporary duration. The fact that frequentIy a gastric atomy deveIops, which must be reIieved in many instances by some type of a gastrojejunostomy, casts further doubt as to the eficacy of this new operation. RecentIy it has been cIaimed that there is a return of the patient’s former gastric hyperacidity within a year after vagotomy. Additiona time must be aIIocated for critica evaIuation of the benefits of biIatera1 vagotomy before any definite opinion can be made. There is a that a growing opinion in this country biIatera1 vagotomy shouId be reserved for recurrent stoma1 uIcerations in patients in whom a subtota1 gastrectomy has been done previousIy and in whom the operation was extensive enough to remove most of the acid-secreting area of the stomach and gastrointestina1 continuity was re-estabAmerican
Journal
of Surgery
Collins-PGastroduodenal lished by some type of a gastrojejunostomy. Therefore, at the present time final judgment must be withheId. During the last two vears three articIes have appeared in Britkh medical Iiterature advocating the conservative nonoperative treatment of acute perforated gastroduodena1 ulcers. The pubIication of these articIes aroused considerable interest throughout the medica worId. The chief advocates of this new method of therapy, namely-, Bedford Turner,3 Visick”2 and Herman TavIor,21 have possibly been too \I enthusiastic in their recommendations of this type of therapy. Their combined series of cases numbered Iess than fifty patients and their admitted mortaIity from this method of treatment is still greatly in excess of that obtained from a simple surgical cIosure of acute perforated ulcers in this country. To illustrate what can be done when prompt and energetic surgica1 care is exercised on individuaIs suffering from this pathoIogic entity, BariteI12 reported upon a consecutive series of eighty-eight patients operated upon for acute perforated gastroduodenal uIcers. (Table IV.) There was only one death, a mortality of 1.1 per cent. This mortality is far Iess than that presented by the advocates of conservative medical care for this pathoIogic entity. When a carefu1 study is made of the reported mortality and morbidity in the articles by these three British authors, needless deaths and preventabIe compIications are revealed that wouId not have occurred had they been treated promptly by surgical measures. It was thought that the surgical records of an average private city hospital covering an eleven-year period between 1937 and rg_c- on consecutive unseIected case histories of proven perforated gastroduodenal ulcers might prove of interest; thirty-six such case histories treated surgicaIIy were collected. There were six deaths, or a mortality rate of 16.7 per cent; thirty of these individuaIs were maIes and there were three deaths in both sexes. The thirty June,
1949
687
Ulcers
maIes averaged 39.4 years in age while the remaining six females had an average age of 67.6 years. Twenty-five instances or 69.3 per cent of this pathologic entity occurred during the winter and spring months with four deaths. In the first live-
7
Author
Baritell, A. L. ............... Tilton, B. J ................ Graham, R. R.. PllcCIure. K. D.. &es, \v. L.. and Bennett, B. A. Black, B. hl. and Blackford, R. E. Barber, R. F. and Madden, J. L. HartzelI. J. B. and Sorock. M. 1~. 12larshnII,S. F. and Keleher, P. C. Raw, S. C.. Cohn, R.. Bcrson, H. L. Ross,J.C.. .._....... Paletta, F. X. and Hill, W. R.. DeBakey, hl. and Odom, C. B. Ross. A. and LaTourneau. G. Donald, D. C. and Barkett, S. hl Rieade, R. II.. Timoney-, F. X.. Griswold. A. R. and Antoncic. R. .‘. Faliis, L.‘S. LicCreery, J. A. EIiason, E. L. and Thigpen, G. ix....................... Sangster, A. H.. O’Donoghuc, J. B. and Jacobs,
Per :ent v1ortxality
No. Of
1946 ‘936
1.1 2 0
88 52
I
w
12.8
12.8 I3 0 Il.4 lj.0 Ij.2 IO.0
16.9 ‘7.3 17.7 18. $ 19 I
19.5 I q .6 20 .o 20. j 21.4
23.0
hl...:.................... McCabe.
3.2 7.7 8.7 ’12.0
24.i
F. J. and Xlersheimrr
‘.
hlartz, H. and Foote, hr. H. Parker, E. F.. Davidson. T. C. and Rudder. F F :. Thompson, II. L. HartzelI. J. B. and Sorock. hl. L ......... Reed, J..C .......... Collins, D. C ..............
7
2j.2 20. 0 27.0
$
!
1 4
I
28.0
28.7 28.9
30.
I) I0 7
year period, between 1937 and 1931, there were thirteen exampIes (36.1 per cent) with three deaths; whiIe the years between 1942 and ApriI, 1947, revealed a lowering of the hospital morta1it.y in which there
ColIins-GastroduodenaI had been twenty-three instances (63.9 per cent) with three deaths. This Iowered mortaIity in the past five years may be partiaIIy attributed to the wide spread use of antibiotics and specific chemo-
RESUME
OF
PEPTIC
TABLE
v
ULCER
SURGERY
Gastric
-
I
CaSX
TYPO
TABLE
Fe-
M&S
AGE
-
-
433
8
22
I2
UPON
Non-perf Acute perf.
.
3
0
Tot&.
.
Gastroduodennl
I.190 36 (z-location not stated) ____ 1,226
VI
IN EIGHTY-EIGHT
FOR
PERFORATED
PATIENTS PEPTIC
OPERATED
ULCERS
(After Baritell)
M0rtalitg. Per CtXlt
T
Ape
6.93 z5.00
IJnder
DUObde,
Total
DISTRIBUTION
No.
of
Per cent of Patients
Patients
._
-INon-perf. Acute perf.
foration for Iess than six hours, whiIe the remaining twenty-one or 58.4 per cent presented severe symptoms and sigcs typica of perforation for more than six hours, One-haIf of the patients in this series had correct preoperative diagnoses
(1937-1947)
Ulcers
Deaths
UIcers
Ulcers
64 6
51 3
70
54
0.0
0
20
20-29
I2
30-39 40-49 50-59 b-69 70-79
23 26
3.6 26.
I
29.3
21.6 8.0 I.,
‘9 7 I
13 3
5.37 16.68
16
i.71
made with an exact Iocation of the anatomic site of perforation. There were eight incorrect preoperative diagnoses : five were diagnosed as acute appendicitis, two were thought td be acute choIecystitis and one
__-
RATIOS:
Gastric UIcers Ratio: Non-perf. gastric uIcer to acute perf. gastric uker = 3.60: Ratio: Mortality acute perf. gastric uIcer to 3.6:1 non-perf. gastric uIcer = DuodenaI UIcers Ratio: Non-perf. duod. uIcer to acute perf. duod. uIcer = 34.8: Ratio: MortaIity acute perf. duod. ulcer to 3.o:r non-perf. duod. uIcer = Gastroduodenal uIcers Ratio: Non-perf. gastroduod. uIcers to acute 33.I:I perf. gastroduod. uIcers = Ratio: MortaIity acute perf. gastroduod. uIcers 3.1:1 to non-perf. gastroduod. uIcers =
TABLE TABULATION I
UPON
OF FOR
TIME
VII
EIGHTY-EIGHT
PERFORATED
ELAPSED
SURGERY--WITH
PATIENTS
OPERATED
ULCER-ACCORDING
BETWEEN
PERFORATION
COMPARISON
TO
TO AND
COLLECTED
SERIES
(After Baritell) I
therapy. Twenty-eight patients, or 77.8 per cent, had had uIcer symptoms for more than one year prior to their acute perforation and fourteen (38.9 per cent) of these thirty-six patients admitted under persistent questioning that their symptoms referrabIe to their oId chronic gastroduodena1 uIcer had been present in excess of ten years. (TabIes v to IX.) The duration of acute symptoms of perforation before surgica1 cIosure was performed was as foIIows: fifteen individuaIs or 41.7 per cent had symptoms of per-
?-
CoIIected Series of DeBakey
Our Series Hours EI apsed
No. of Patients
Per cent Patients
MortaIity
Per cent Patients
Per cent Mortality
50.83 31.02 3.03 I.43 13.66 100.00
10.5 21.4 38.5 62.4 61.5 22.4
-. o-6 12-18
I 8-24 Over
38.63
34 37 ‘3 2
O-12
42.04
14.77 2.27 2.27
24
AI1 case!
8:
100.00
I
was considered an acute smaI1 struction. UnfortunateIy these correct diagnoses resuIted in an being made surgica1 incision necessity had to be cIosed in American
Journal
bowe1 obeight inimproper which of seven inof Surgery
ColIins-GastroduodenaI stances and a new one made. This caused a definite lengthening in the patients’ time upon the operating table and was a definitely increased risk to their ultimate recovery. One-haIf of these patients were seen on emergency visits at their homes and TABLE AGE
DlSTRlBUTION LiPOIi
IN
FOR
UIcers
one death. One patient had to have a subsequent disconnection of an anterior gastrojejunostomy. Another male deveIoped a huge peIvic abscess which drained rectaIIy. Two additiona patients had subsequent drainages of Iarge intra-abdom-
VIII
THIRTY-SIX
PERFORATED
PATIENTS PEPTIC
OPERATED
DURATION
No.
of
Per
Patients
TABLE x OF PREVIOUS
SYMPTOMS
ULCERS
I More
ARC
689
cent
of
Patients
Than
~ No.
(yr.1
of
Per
Patients
cent
Total
of
Casts
_~ Under
20
20-29
2.78
1
I
i.$6
12
3o- 39
33.36
40-49
4
Il.,2
50-59 60-69
IO
27.80
4
Il.,2
-)opyy
28 22
77.84 Ol.IO
'4 4
38.92
11.12
1
I
2.78
8.34
3
all of them
received a narcotic injection and the correct diagnosis was not made until a number of hours Iater on a subsequent emergency house calI. Twenty-five per cent of the entire series received multipIe narcotic injections which resuIted in a needless and dangerous deIay before a correct preoperative diagnosis could be made. TABLE SEASOUAL
inal abscesses whiIe two other individuals required drainages of Iarge subdiaphragmatic abscesses before they recovered. AI1 of these Iast six individuals lived. Fifteen patients, or 41.7 per cent suffered TABLE TABULATION I’OR
OF
XI
THIRTY-SIX
PERFORATED El 4PSED
PATIENTS
CLCER
BETWEEU
OPERATED
ACCORDING PERFORATIOI\
SURGERY~WlTH
COMPARISOZ
COLLECTED
I POh
TI\tE
AUD TO
SERIES
I
IX
TO
Coliectcd
INCIDENCE
Our
Series
Series
of
DcR:rkcy Season _
No.
of
Cases __
II ‘4 4
Winter Spring.. Summer. Fall.
7
Per
cent
~___
Deaths ._
I I
18.0 II.1
EIapsed
I,
3
I
1Q.j
I 949
Pa-
PZI-
tients
tients
No.
Per cent
per cent P:ttients
Iler 1 cent ) hlor~t&t\
I
The operating time upon these patients varied from 13 minutes to 185 minutes. The average operating time for these patients was in the neighborhood of one hour; 41.7 per cent of a11 the patients in this series Ieft the operating room before forty minutes had eIapsed. (TabIes x to XIV.) The postoperative compIications and the morbidity in this series are of interest. Two patients suffered from a post-operative eventration of their wound with .June,
( No. ( per / hlorta’itr ’ cent ~-~~ ’ of
I
30.5
~
Hours
_~
o-6
‘5
o-12
6
12-18
4
IS-24
I IO
Owr All
24 casts
36
II.12 2.78 27.80 100.00
I 3 6
1.431 62.4 30 13.66i 61.5 16.68 100 00' 22.4
from varying degrees of infection of their surgica1 incisions. Four persons deveIoped postoperative bronchia pneumonia; three aditiona1 persons suffered from acute pneumonitis and three cases had postoperative genitourinary tract infections.
CoIIins-GastroduodenaI
UIcers
There were 45 surgical procedures performed upon these thirty-six patients (Figs. 2 to 6); fourteen individuaIs, or 38.9 per cent, had a simpIe cIosure of the perforation empIoying mattress sutures of one
three of these died. Twenty-seven and eight-tenths per cent of this series had had preoperative x-ray scout fiIms taken of the abdomen and eight of the ten individuaIs thus studied reveaIed the presence of free
TABLE XII
TABLE XIV OPERATIVE PROCEDURES
-
OPERATIVE
-
No.
Total Time (min.)
TIME*
of Cases
Deaths
Per cent
Operation
vo. 0 f
Per cent
Cases _-
O-20 21-40 41-60 61-80 81-100
2
*3 IO 4 3
IOI-120
0
121-140 141-160 161-180 181-200
I
I I I
8.34
SimpIe cIosure. OmentaI graft sutured over perforation. PyIorectomy, post. gastroenterostomy..............
2.78 2.78 2.78 2.78
PyIorectomy, duodenectomy, Finney oper. . PyIoropIasty, Judd type.. . Purse-string cIosure.. . .. Two suture row forma1 closure
5.56 36.14 27.80 11.12
38.92
IO
27.80
I
2.78
2
5.56 8.34 8.34 8.34
3 3 3 -
* Apparently, prolonged operative time is not a major factor in mortahty in acute perforated gastroduodenal ulcers.
type or another, with three deaths; ten patients, or 27.8 per cent, were treated by the method of WerbeI, KozoII and Meyerz5 using a free omenta1 graft sutured over the perforation, with one death. The remaining operative procedures are Iisted on TabIe XIV and are seIf-expIanatory. Thirty-
ON
TABLE xv ANESTHESIA FORTY-FIVE OPERATIONS THIRTY-SIX PATIENTS
Per cent
Condition
15 3 4 3
41. IO 8.34 11.12 8.34
five operative procedures, or 77.9 per cent, were performed under spina anesthesia; TabIe xv cites the additiona data concerning the types of anesthesia used. Concerning the probIem of draining the peritonea1 cavity, thirteen patients or 36.1 per cent had drainage of various portions of the peritonea1 cavity, with three resuItTh e remaining twenty-three ing deaths. persons or 63.9 per cent did not have drainage of the peritonea1 cavity and onIy
Agent
SpinaI. .................... Ether ..................... CycIopropane, 0.2. .......... EthyIene, ether, 02 ......... EthyIene, 02 ............... ChIoroform, 02 ............. Local, 1% procaine ........
IN
-
i-
I
I
-
gas beneath the Ieaves of the diaphragm and were of definite diagnostic vaIue. TabIe XVI Iists the size of the perforated gastroduodena1 uIcers encountered in this series and as described in the surgeon’s dictation of his operative findings. There were fourteen uIcers (38.9 per cent) in this series that were situated on the gastric DATA
TABLE XIII POSTOPERATIVE MORBIDITY
Infected wounds.. Acute pneumonitis.. Bronchopneumonia. Genitourinary tract infection.
--
14
-
1Deaths
Pdo. of
cZases
Per cent
35 3
77.9 6.6
I I 1
4.4 2.2 2.2 2.2
2
4.4
2
I )eaths
-
side of the pyIoric ring and the remltining twenty-two (61.2 per cent) were situated in the first portion of the duodenum. Twenty of the duodena1 uIcers were anterior and two were stated as being on the posterior wall of the first portion. Figure 7 gives the saIient points on the anatomic Iocation of these ulcers. Since 1942 when the use of specific chemAmerican
Journal
of Surgery
CoIlins-GastroduodenaI
F.
Svtvrrt
Ulcers
hi.d
FIGS. z to 6. These depict a recommended operative technic that in our experience has proved to be the safest method of treating acute perforated gastroduodenal uIcers. The sagittal section of the peritoneal cavity in Figure s depicts seven areas within the peritonea1 cavity that are always systematically aspirated dry to minimize the occurrence of dangerous postoperative intra-abdominal abscesses.
CoIlins-GastroduodenaI
692
otherapy made its appearance and when the intraperitonea1 impIantation of various types of steriIe suIfonamide powders was begun, there has been a definite Iowering of the mortaIity rate. Eighteen patients
Ulcers
The extremes in hospita1 stay of those who survived their surgica1 treatment varied between 5 and 144 days. The average hospita1 stay for a11 hospita1 cases was 22.6 days; seven patients stayed in the
POSTERIOR DATA
FIG. 7. Anatomic Iocations of thirty-six Iocation of two ulcers not stated.
TABLE OF
DIAMETER
Gastric
Ulcers
Cases
Size (cm.)
OF
XVI
-
ULCER
PERFORATIONS
Duodenal Ulcers
/
Size (cm.)
Cases
_ Not stated
TABLE
XVII
WHITE
BLOOD
W.B.C.
Cases
,‘e’n’,
Over 20,000 Over 15,000 Over 10,000 Over 5,000
9 13 II
25.02 36.14 30.58 5.56
2
COUNTS
P.M.N.%
IO0
Over Over Over Over Over
Cases
I
90 85 80 70 50
I2 ‘3 2 5 3
Per cent
2.78 33.36 36.14 5.56 13.90 8.34
peptic ulcers;
(30 per cent) were so treated, using specific chemotherapy and onIy two patients died. The intraperitonea1 use of peniciIIin was begun in 1945. It has been empIoyed in eight patients with no deaths. Streptomycin was first empIoyed in 1946 and has
SlZE
ON
0.5
Not stated Pin point
8 I
I.0
0.25
2
1.3
0.5
5
2.0
0.75
3.0
I.0
3 2
5.0
I
been administered to four patients with no deaths. Thus, specific chemotherapy has been used in eighteen patients with two deaths and antibiotics have been used in the past two years in an additiona tweIve patients with no deaths. It is beIieved that the use of specific chemotherapy and specific antibiotics has done much to Iower the postoperative mortality in thirty (83.4 per cent) of the thirty-six patients comprising this series.
hospita1 Iess than nine days, six of whom died. The Iaboratory studies (Table XVII) on this group of patients were of interest. The preoperative urine anaIyses of sixteen individuaIs (44.5 per cent) showed positive aIbumen reactions and an additiona seventeen patients (47.3 per cent) had positive gIycosuria tests; six patients gave positive acetone reactions in the urine and three reveaIed a positive urinary test for diacetic acid. The white bIood count was of (25.0 per diagnostic vaIue : nine patients cent) had white bIood counts over 20,000; thirteen (36.1 per cent) had white counts varying from 15 to 20,000; eIeven patients (30.6 per cent) reveaIed white blood counts varying between IO and 15,000 and two patients (5.6 per cent) had norma bIood counts between 5 and 10,000; finaIIy, one patient (2.8 per cent) had a Ieukopenia of 3,350 white ceIIs. This patient died. The differentia1 poIymorphonucIear neutrophile ceI1 counts reveaIed the folIowing data: one individua1 (2.8 per cent) had 100 per cent; tweIve persons (33.4 per cent) were between 90 and IOO per cent; thirteen patients (36.1 per cent) were between 85 and 90 per cent; two individuaIs (5.6 per cent) were between 80 and 85 per cent and the eight remaining (22.2 per cent) Iay in the range of normaI. KarI Meyer and his associates26 emphaAmerican
Journal
of Surgery
ColIins-Gastroduodenal
antibiotic medications. Seventeen different surgeons operated upon this series of thirty-six patients. Seven surgeons performed twenty-six or
TABLE REPORTED
LATE RESULTS
OF ACUTE
693
tunately, all three patients survived under a regimen of massive chemotherapy and
size that in their large series of patients re-perforation in previous acute perforating gastroduodena1 ulcers is usually in the neighborhood of 4 per cent. Three patients (8.3 per cent) in this series had had previous acute perforating gastroduodena1 PREVIOUSLY
Ulcers
XVIII PERFORATED
PEPTIC ULCER TREATED
BY SIMPLE
SUTURE
(After Baritell)
Ebason and Thigpen ......................... Cable, J. V. ................................. Thompson, Il. L ........................... Parker,E.F ................................. Harrison, C. and Cooper, W., Jr ............... Estes, W. L. and Bennett, B. A., .............. Williams, A. C. .............................. lllingsworth, C. F. W., Jan&son, R. A. and Scott, L.D .................................... Forty,Frank ................................. Collins, D. C .................................
No. of AII
No. of Cases Well
No. of Cases Not Well
~ Followed
7(30%) *2(98(x) 37(75.6%~ r*(67%)
4(r8%) 4(r6%) 2(40/c) 6(33%)
1944 ’ 944
15(700/L) 2(8%) 12(*4.40/c) 6(33%) 7(17.50/c) 3(5.6%) 28(280/c)
1946 1946 1947
77(ro%) 47(47%) 27(75 %)
Year Reported
Author
No. of Cases hollowed
‘938 ‘938 1939 1941 1942
TABLE
Cases Having Reopcration
1 32(82.5%) 5o(94.4%) 72(72%) 54’(70%) 38(38%) 6(17%)
8(r5%)
I I(1 I ‘;;I I ~
r55(2o%) x4(15%) 3(8%)
XIX
DEATHS
T Cases
I _~
Correct preoperative
diagnosis.
Elapsed time of perforation. Location of ulcer. Anaesthesia. Upper right rectus incision.. Operation time (min.). Postmortem
__-
3
2
4
0
5
~-
Yes
No *
Yes
Yes
Yes
168 hr. ___,__ Post-G.U. Spinal
60 hr.
735 hr.
60 hr.
17 hr.
Ant. D.U. Spinal
Ant. G.U. Spinal
Ant. G.U. Spinal
Yes 60 Yes
NO
Yes
z
Yes
Ant.
D.U. Spinal Yes 34 Yes
Yes
NO 9
rhr.
Ant. D.U. Chloroform, 01 -No 75 No
I * Underlined portions of this table are beIieved to be possible major factors in the causation of deaths in this study.
ukers which previousIy had been repaired surgicaIIy. Two individuak were maIes, aged sixty-two and forty years. The third person was a woman, aged Iifty-one. The two maIes had had a previous repair of an acute perforated gastroduodena1 uker three and five years previousIy, respectiveIy. The remaining woman had had a former acute perforation twenty-eight days prior to her entry into this hospita1. ForJune,
1949
72.3 per cent of the operations, with four deaths. One surgeon operated upon nine patients with one fatality. (Tables XVIII and XIX.) CONCLUSIONS I. A report is presented detailing the experiences encountered in an average metropoIitan hospita1 in which thirty-six instances of acute perforated gastroduo-
694
CoIIins-Gastroduodenal
dena uIcers occurred between the years of 1936 and April, 1947. Six patients died, or a tota mortality of 16.7 per cent. This mortality figure compares favorably with that reported in surgica1 literature but shouId be markedIy reduced in the future. 2. Most of the fataIities in this series occurred in patients who were not seen by the surgeon unti1 a very considerabIe Iapse of time had occurred between the onset of their acute perforation and its surgica1 closure. SeveraI of these fataIities were needIess, because the patients had persistentIy faiIed to foIIow the advice given by their physician to have their chronic gastroduodena1 uIcer corrected surgicaIIy when there wouId have been a minimal mortality in the hands of the competent surgeon. 3. Indications point out that probably in the near future the excessive mortaIity resuIting from acute perforating gastroduodenal uIcers may be markedIy Iowered by the skiIIfu1 empIoyment of various specific chemotherapeutic agents and specific antibiotics which are now freeIy avaiIabIe for civihan use. 4, A sincere plea is made not to treat these patients by conservative medica methods, empIoying intragastric suction and intravenous fIuids as has been recommended recentIy by severa authors in British medica literature. The prompt employment of a simple surgica1 closure of the perforation wiII definitely resuIt in lowered mortality and less postoperative morbidity than the use of conservative medical measures. A publication6 describes the histories of five patients treated by medical measures only and who were later referred to me in extremis. This inadequate medical care caused a needIess marked financial loss to the patients as we11 as pIacing their Iives in needIess grave jeopHeroic measures were necessary ardy. before these five patients could be removed from the critica list and dismissed weI1. 5. It is beIieved that a simiIar study presented ten years hence wiI1 undoubtedIy show a marked reduction in the operative
Ulcers
mortaIity and postoperative morbidity in patients surgicalIy treated for acute perforated gastroduodenal ulcers in the future years at this same hospita1. 6. The saIient points of this study have been summarized in chart form and are seIf-expIanatory. 7. The ratio of non-perforated gastroduodenal uIcers to acute perforated instances in this study was 33. I : I. Therefore, it required I, 191.6 operations performed upon non-perforated gastroduodenaIuIcers, before the thirty-six instances of acute perforated gastroduodena1 uIcers were encountered in this study which covered a period of eleven years. 8. The fact that the operative mortaIity of acute perforated gastroduodenal ulcers as contrasted to that of non-perforated exampIes was 3.1: I testifies to the importance of operating upon patients with gastro-duodenal uIcers before acute perforation occurs. REFERENCES I.
2.
3. 4. 5. 6.
7. 8.
ABERCROMBIE, JOHN. Contributions to the pathology of the stomach, pancreas and spleen. Edinburgh M. et* S. J., 21: 1-14, 1824. BARITELL, A. LAMOKT. Perforated gastroduodena1 ulcer. SUrger_V,21 : 24-33, 1947. BEDFORD-TURNER. Quoted by Visick.22 BONETI. THEOPHILE. The Sepdchretum. L. Choncr. Geneva, p. 798, 1679. _ BRUNNER, F. Quoted by McNeaIy and Howser.r4 COLLINS, DONALD C. The danger of treating perforated peptic uIcers by non-surgical methods. J. Inlerflat. Coil. .Surgeons. (In press). CRUVEILHIER, J. Pathologique du Corps Humain. Paris, 1829. J. B. BaIIiere. DEAN, HARRY PERCY. A case of perforation of a chronic uIcer of the duodenum successfuIIy treated by excision. Brit. M. J., I: ror4-1015, 1894.
9. DRAGSTEDT, LESTER R. Vagotomy 10.
I I. 12.
13. ‘4.
for gastroduodena uIcer. Am. Surg., 122: 973-989, 1945. DRAGSTEDT, LESTER R., CLARK, JAMES and STORER, EDWARD. Section of vagus nerves to the stomach in treatment of peptic uIcer. Proc. Inst. Med. Chicago, 16: 146, 1946. HEUSSNER and ROIJX. Quoted by Brunner.s LAHEY, FRANK H. Treatment of duodenal ulcers; partial gastrectomy versus paIIiative resection. .>. A. M: A., 134: 574-575, 1947. LEWISOHN. RICHARD.Treatment of duodenal ulcers, partial gastrectomy versus paIIiative resection. J. A. M. A., 134: 571-574, 1947. MCNEALY, RAYMOND W. and HOWSER, JOHN W. Perforation in peptic uIcer. A critica review of
American
Journal
of Surgery
Collins-Gastroduodenal
,<.
J,~:y~les and ~I>IZI.MAI\, GILL% Indications for emergency gastrectomy in the treatment of perforated gastric and duodenal ulcers. J. de l’H&el-Dieu de Montreal, I : r-7, ,947. 16. MIKULICZ, J. VON. Quoted by Brunner.5 I 7. O’FIARA, H. Perforating or corrosive ulcer of the duodenum. Tr. Path. Sot. Philadelphia, 6: 37738, IH;j. 18. RAWLINSON, CHRISTOPHER. Quoted by W:ltson.26 IO. RHODES. GEORGE K. and COLLINS. DOVALD C. Acute’ perforated peptic ulcers. k&f. P+ West. &led., 39: 1-13, 1933. 21). SAMAYN. Traitement des ulceres par la gastrectom&. Aeta c&r. belg., 45: 198-205, 1946. 2 I. TAYLOR, HERMAN. Treatment of perforated peptic Ulcer. L_0?Ir?/,2 j I 1441-444, 1940.
UIcers
A. f ~eo~.eu. Conscrvativc treatmt’nt of :rcutr perforated peptic ulcer. Hrit. ,I{. J.. 2:
22.
VISICK,
23.
WALTMAN. Vagotomy for peptic ulcer. Proc. Staff Meet., Mayo Cl&., 22: 281-289, 1947. WANGENSTEEN,0. H. The role of the surgeon in the management of peptic ulcer. Internnt. Ahstr. Surg., 85: 145.“47, 1947. ~VATSON, JOHN Ii. Acute perforating duodenal and gastric ulcers. hit. M. J., 2: (69-173, r93o. WERBEL, ERNEST IV., KOZOLL, DONALD D. and MIXER, KAKL A. Surgical sequelae folIowing recovery from a perforated peptic ulcer. S. Clin. North America, 27: 93-108, 1947. WILENSKY, ABRAHAM 0. Vagotomy for gastroduodenal ulcer. Rev. Gastroenterol., r4: $70~572, 1947.
04
%~lALAFWI',
NOT
all bleeding
with arteriosclerosis less immediately Clinically,
and hypertension,
and there whether therefore (Richard
June,
19.49
cannot
likelihood contract. M.D.)
especially
using I ,300 cc.
and presumably of spontaneous In any event
will those
will bleed to death is effectively
are needed, the patient
obvi-
has been erodecl
of the hemorrhage,
or only partia1Iy
immediate
if hc
or less of bIood per
a large artery cessation
un-
controlled.
suspect he is dealing with such a patient
the vesse1 wall is sclerosed
A. Leonardo,
the vast majority
occasionally
If larger transfusions
extensively
is Iittle
27.
a stabIe circulation
once daiIy.
because
26.
upon and the bleeding
one can reasonably
ously is bleeding
25.
medical regimen. Older patients,
operated
is unable to maintain transfusion
24.
I 944. 1946.
WALTERS,
ulcers require surgica1 treatment;
do well under conservative
693
surgery
severed
and
is indicated.
OF ACUTE PERFORATED
GASTRODUODENAL DONALD
C. Co~rms,
ULCERS* M.D.
Assistant Professor of Surgery, CoIIege of Medical Evangelists; Chairman, Hospital, OImsted MemoriaI
SurgicaI Service Hollywood Presbyterian
Hollywood, California
I
T has been estimated by Wangensteen24 that approximateIy 10,000 individuaIs died in the United States each year from acute gastroduodena1 uIcers and their compIications. Autopsies revea1 that either a heaIed or an active gastroduodenar ulcer is present in approximateIy -5 per cent of individuaIs examined at the oostmortem tabIe. It is a we11 known fact that acute erosions of the gastric or duodena1 mucosa may occur easiIy. Under experimenta conditions in the laboratory fully deveIoped gastroduodena1 uIcers can be produced within severa hours by aIlowing gastric juice to drip upon a designated unprotected area of gastric or duodena1 mucosa. History records that the first pubfished report of a perforated gastroduodena1 uIcer was made by Bonetil in 1679. Fifty years Iater RawIinsonl* presented a case history of a perforated gastroduodena1 uIcer before the RoyaI Society in London. It was not until ninety-five years after the report of Rawhnson that John Abercrombie’ was able to differentiate between the two types of perforated gastroduodena1 uIcers. Cruvilhier,’ the French pathoIogist, cIearIy differentiated between a simple gastroduodena1 ulcer and an ulcerating gastric carcinoma. It was not unti1 1875 that O’Hara” became the first American to describe and present an exampIe of a perforated I
* From the Departments
gastroduodenal uIcer before the PhiIadeIphra PathoIogicaI Society. The first recorded attempt to cIose such a perforating uIcer surgicaIIy was done by MikuIicz16 in 1880. This first surgica1 attempt was unsuccessfu1. TweIve years later Heussner and Roux” were among the first to report a successfu1 surgical repair of a perforated gastroduodena1 uIcer. Dean8 in 1894 reported a successfu1 surgica1 excision of such an uIcer. Seventeen years after his first published unsuccessfu1 attempt MikuIicz16 was abIe to pubIish a colIected series of 103 operations for the surgica1 repair of perforated peptic uIcers. The majority of these operations were successfu1. Perforated gastroduodenal uIcers have always aroused the great interest of internists and surgeons alike and have constituted one of the most dramatic emergency surgica1 conditions frequentIy encountered. My interest and study in this subject extends back some twenty-one years in the past. In 1933 Rhodes and Ilg presented a report upon ‘$3 consecutive instances of perforated acute gastroduodena uIcers that had come under our care on the emergency service at the San Francisco City and County HospitaI. These patients had been treated during the ten years between I 919 and 1929; I 17 of these individuaIs had been sur-
of Surgery, College of Medical EvangeIists, Los Angeks, Calif., Presbyterian HospitaI, OImsted Memorial, HoIIywood, Calif.
684
American
and The HoIIywood
Journal
of Surgery
Collins--Gastroduodenal gicalIy treated within ten hours following their perforation and 13 per cent of these died. The remaining thirty-eight patients in this series had not received surgical care until more than ten hours had eIapsed following their acute perforation and they TABLE RESLLT
OF
MPDICAI.
THERAPELTIC
repeatedly stressed the fact that a considerabIe number of surgicaIly treated perforated gastroduodena1 uIcers wiII subsequentIy develop symptoms of reactivation of their former ulcer, and a subtota1 gastric resection often wiI1 be necessary in TABLE
I
TREATMENT RES1 LTS
685
Ulcers
IN
OF TOTAL
PEPTIC
ULCER-
OF
PERCENTAGE ADMISSIONS
MATERIAL*
II
PERFORATED FOR
ULCER
A‘MONG
ULCER
AND
PERCENTAGE
ALL
OF
READMlSSIONS Iirsults
Recovcrcd Recovered after relapse Improved..
Poc,rresult. Died........ Not located.
Cases
‘3’
I 2I ~ ‘91 184 99 39
20
3
20 28 15 6
,2lcdical treatment alone cunno~ permanently heal nor prevent the onset of complications in all gastroduodenal ulcers. * From KRAUP, NIELS B. The 1946 Year Book of General Medicine. Pp. 631. Chicago, 1946. The Year Book Publishers, Inc.
had a mortality rate of 68 per cent. WelY found that the causes of mortality in this group of 155 patients were due IargeIy to the folIowing compIications: peritonitis jo per cent; cardiac disease 30 per cent; pneunonia 20 per cent. Forty-six per cent of the surviving patients in this series were traced postoperatively for five or more years foIIowing their corrective surgery and 85 per cent reported themseIves as being either entirely cured or that a prompt return to their prescribed uIcer diet gave prompt reIief from symptoms of mild recurrences. The remaining 15 per cent who repIied to our questionnaire admitted that they had been guiIty of gross neglect and abandonment of the prescribed medica measures designed to prevent recurrences. In the past fourteen years the surgica1 world has witnessed tremendous improvement in the surgica1 management of acute perforated gastroduodena1 uIcers. McNeaIy and Hawser’” as we11 as Karl Meyer and his associates26 have made numerous important contributions toward the better management of this disease. They have
June,
1949
After W’erbal, Kozoll and Meyer
Per cent
Year
Ulcer Patients Admitted AI1 Types
‘crforated Ulcer Patients Sutured and Recovered
Previously Perforatcd Ulcer Patients Readmitted
I
No.
Per cent of TotaI Admissions for Ulcer
~No,
.
I ---~
’ 939 ’ 940 ‘94’ ‘942 ‘943 1944 1945 Total
7’7 809 764 629 549 436 45’ 4,355
-~
96
‘3
35
118 881 891 ,
14
34
12
‘36
‘4
~ 32~
26
I
! 239 1 i I
20 41 37
31.6
The incidence and fairIy constant percentages of reperforation in gastroduodenat ulcers. Closure of the origina perforation is no guarantee against future reperforations.
certain of these individuaIs in order to obtain a compIete and permanent recovery. WerbeI, KozoII and Meyel 26 have drawn our attention to the fact that ina series of 574 patients suffering from acute perforated gastroduodena1 uIcers and in whom a simpIe cIosure of the perforation was done 239 individuals, or 4 I .6 per cent, were forced to return to the Cook County HospitaI for further hospitaIization, because of a recurrence of their previous symptoms. In 86 per cent of their patients pain was IargeIy responsible for their return to the hospita1 and a considerable percentage of these individuaIs suffered from varying degrees of pyIoric obstruction; 17 per cent of these re-admitted
686
CoIIins-Gastroduodenal
patients had two or more acute re-perforations; 34 per cent of the re-admitted patients were suffering from recurrent bIeeding from the ulcer crater. (TabIes I, II and III.) Further gastroduodena1 surgery was necessary in 30 per cent of these 239
UIcers
incIude the dista1 two-thirds of the stomach and the duodenum with its chronic duodenal ulcer, if present, wiI1 be doomed to early faiIure. BiIateraI vagotomy introduced by DragstedP1° has aroused tremendous interest
TABLE III CAUSES
OF DEATH
1X EIGHTEEN
CO.MPLICATIOKS
PATIENTS
FOLLOWING
PERFORATED
AN
WITH
ULCER
EARLIER
ULCER
(After Werbal, Kozoll and ikfeyer) No. Deaths Reperforation. j Second perforation. 3 Third perforation.. I Fifth perforation.. I Reperforation with Hemorrhage (2nd Perforation), 3 Hemorrhage.. 3 EIectivesurgery................... ; Gastric resection. 3 Gastroenterostomy. 2 Liver abscess four months after perforation.. * CerebrovascuIar accident.. I Total......................... 18 Reperforation of a gastroduodena1 ulcer is associated with markedly increased morbidity and mortaIity. These deaths were in the patients shown in TabIe I.
patients who returned to insure them prompt and permanent reIief from their symptoms. (Fig. I .) WerbeI, KozoII and MeyeP were of the definite opinion that a primary subtotal gastric resection at the time of the patient’s origina perforation was not, as a genera1 ruIe, indicated; and that any surgica1 procedure more extensive than a simpIe cIosure wouId Iead to unnecessary deaths. Recent pubIished studies by Samayn,20 MiIaret and EdeIman’j are in sharp variance with this opinion of KarI Meyer and his associates. The technic and the indications for subtota1 gastrectomy has shown marked advancement and refinement in the Iast ten years so that today the consensus of opinion of gastric surgeons in this country is crystaIIized into the definite belief that a subtota1 gastrectomy is necessary for the permanent and successfu1 cure of Iong-standing chronic gastroduodena1 uIcers. In this connection, according to Frank Lahey12 and Lewisohn,13 any subtotal gastric resection which does not
NUMBER
25
OF CASES
” /d
FIG. I. Number and Meyer).
of perforations
(after
WerbeI,
KozoII
among surgeons and at first the reports pubIished gave rise to the hope that possibIy this wouId be the idea1 operation for chronic gastroduodenal uIceration. Recent reports by WaItman WaIters23 and WiIensky2’ cast considerabIe doubt as to whether or not the beneficia1 advantages enthusiasticaIIy claimed for the routine use of this operation in cases of chronic gastroduodena1 uIcers are of more than temporary duration. The fact that frequentIy a gastric atomy deveIops, which must be reIieved in many instances by some type of a gastrojejunostomy, casts further doubt as to the eficacy of this new operation. RecentIy it has been cIaimed that there is a return of the patient’s former gastric hyperacidity within a year after vagotomy. Additiona time must be aIIocated for critica evaIuation of the benefits of biIatera1 vagotomy before any definite opinion can be made. There is a that a growing opinion in this country biIatera1 vagotomy shouId be reserved for recurrent stoma1 uIcerations in patients in whom a subtota1 gastrectomy has been done previousIy and in whom the operation was extensive enough to remove most of the acid-secreting area of the stomach and gastrointestina1 continuity was re-estabAmerican
Journal
of Surgery
Collins-PGastroduodenal lished by some type of a gastrojejunostomy. Therefore, at the present time final judgment must be withheId. During the last two vears three articIes have appeared in Britkh medical Iiterature advocating the conservative nonoperative treatment of acute perforated gastroduodena1 ulcers. The pubIication of these articIes aroused considerable interest throughout the medica worId. The chief advocates of this new method of therapy, namely-, Bedford Turner,3 Visick”2 and Herman TavIor,21 have possibly been too \I enthusiastic in their recommendations of this type of therapy. Their combined series of cases numbered Iess than fifty patients and their admitted mortaIity from this method of treatment is still greatly in excess of that obtained from a simple surgical cIosure of acute perforated ulcers in this country. To illustrate what can be done when prompt and energetic surgica1 care is exercised on individuaIs suffering from this pathoIogic entity, BariteI12 reported upon a consecutive series of eighty-eight patients operated upon for acute perforated gastroduodenal uIcers. (Table IV.) There was only one death, a mortality of 1.1 per cent. This mortality is far Iess than that presented by the advocates of conservative medical care for this pathoIogic entity. When a carefu1 study is made of the reported mortality and morbidity in the articles by these three British authors, needless deaths and preventabIe compIications are revealed that wouId not have occurred had they been treated promptly by surgical measures. It was thought that the surgical records of an average private city hospital covering an eleven-year period between 1937 and rg_c- on consecutive unseIected case histories of proven perforated gastroduodenal ulcers might prove of interest; thirty-six such case histories treated surgicaIIy were collected. There were six deaths, or a mortality rate of 16.7 per cent; thirty of these individuaIs were maIes and there were three deaths in both sexes. The thirty June,
1949
687
Ulcers
maIes averaged 39.4 years in age while the remaining six females had an average age of 67.6 years. Twenty-five instances or 69.3 per cent of this pathologic entity occurred during the winter and spring months with four deaths. In the first live-
7
Author
Baritell, A. L. ............... Tilton, B. J ................ Graham, R. R.. PllcCIure. K. D.. &es, \v. L.. and Bennett, B. A. Black, B. hl. and Blackford, R. E. Barber, R. F. and Madden, J. L. HartzelI. J. B. and Sorock. M. 1~. 12larshnII,S. F. and Keleher, P. C. Raw, S. C.. Cohn, R.. Bcrson, H. L. Ross,J.C.. .._....... Paletta, F. X. and Hill, W. R.. DeBakey, hl. and Odom, C. B. Ross. A. and LaTourneau. G. Donald, D. C. and Barkett, S. hl Rieade, R. II.. Timoney-, F. X.. Griswold. A. R. and Antoncic. R. .‘. Faliis, L.‘S. LicCreery, J. A. EIiason, E. L. and Thigpen, G. ix....................... Sangster, A. H.. O’Donoghuc, J. B. and Jacobs,
Per :ent v1ortxality
No. Of
1946 ‘936
1.1 2 0
88 52
I
w
12.8
12.8 I3 0 Il.4 lj.0 Ij.2 IO.0
16.9 ‘7.3 17.7 18. $ 19 I
19.5 I q .6 20 .o 20. j 21.4
23.0
hl...:.................... McCabe.
3.2 7.7 8.7 ’12.0
24.i
F. J. and Xlersheimrr
‘.
hlartz, H. and Foote, hr. H. Parker, E. F.. Davidson. T. C. and Rudder. F F :. Thompson, II. L. HartzelI. J. B. and Sorock. hl. L ......... Reed, J..C .......... Collins, D. C ..............
7
2j.2 20. 0 27.0
$
!
1 4
I
28.0
28.7 28.9
30.
I) I0 7
year period, between 1937 and 1931, there were thirteen exampIes (36.1 per cent) with three deaths; whiIe the years between 1942 and ApriI, 1947, revealed a lowering of the hospital morta1it.y in which there
ColIins-GastroduodenaI had been twenty-three instances (63.9 per cent) with three deaths. This Iowered mortaIity in the past five years may be partiaIIy attributed to the wide spread use of antibiotics and specific chemo-
RESUME
OF
PEPTIC
TABLE
v
ULCER
SURGERY
Gastric
-
I
CaSX
TYPO
TABLE
Fe-
M&S
AGE
-
-
433
8
22
I2
UPON
Non-perf Acute perf.
.
3
0
Tot&.
.
Gastroduodennl
I.190 36 (z-location not stated) ____ 1,226
VI
IN EIGHTY-EIGHT
FOR
PERFORATED
PATIENTS PEPTIC
OPERATED
ULCERS
(After Baritell)
M0rtalitg. Per CtXlt
T
Ape
6.93 z5.00
IJnder
DUObde,
Total
DISTRIBUTION
No.
of
Per cent of Patients
Patients
._
-INon-perf. Acute perf.
foration for Iess than six hours, whiIe the remaining twenty-one or 58.4 per cent presented severe symptoms and sigcs typica of perforation for more than six hours, One-haIf of the patients in this series had correct preoperative diagnoses
(1937-1947)
Ulcers
Deaths
UIcers
Ulcers
64 6
51 3
70
54
0.0
0
20
20-29
I2
30-39 40-49 50-59 b-69 70-79
23 26
3.6 26.
I
29.3
21.6 8.0 I.,
‘9 7 I
13 3
5.37 16.68
16
i.71
made with an exact Iocation of the anatomic site of perforation. There were eight incorrect preoperative diagnoses : five were diagnosed as acute appendicitis, two were thought td be acute choIecystitis and one
__-
RATIOS:
Gastric UIcers Ratio: Non-perf. gastric uIcer to acute perf. gastric uker = 3.60: Ratio: Mortality acute perf. gastric uIcer to 3.6:1 non-perf. gastric uIcer = DuodenaI UIcers Ratio: Non-perf. duod. uIcer to acute perf. duod. uIcer = 34.8: Ratio: MortaIity acute perf. duod. ulcer to 3.o:r non-perf. duod. uIcer = Gastroduodenal uIcers Ratio: Non-perf. gastroduod. uIcers to acute 33.I:I perf. gastroduod. uIcers = Ratio: MortaIity acute perf. gastroduod. uIcers 3.1:1 to non-perf. gastroduod. uIcers =
TABLE TABULATION I
UPON
OF FOR
TIME
VII
EIGHTY-EIGHT
PERFORATED
ELAPSED
SURGERY--WITH
PATIENTS
OPERATED
ULCER-ACCORDING
BETWEEN
PERFORATION
COMPARISON
TO
TO AND
COLLECTED
SERIES
(After Baritell) I
therapy. Twenty-eight patients, or 77.8 per cent, had had uIcer symptoms for more than one year prior to their acute perforation and fourteen (38.9 per cent) of these thirty-six patients admitted under persistent questioning that their symptoms referrabIe to their oId chronic gastroduodena1 uIcer had been present in excess of ten years. (TabIes v to IX.) The duration of acute symptoms of perforation before surgica1 cIosure was performed was as foIIows: fifteen individuaIs or 41.7 per cent had symptoms of per-
?-
CoIIected Series of DeBakey
Our Series Hours EI apsed
No. of Patients
Per cent Patients
MortaIity
Per cent Patients
Per cent Mortality
50.83 31.02 3.03 I.43 13.66 100.00
10.5 21.4 38.5 62.4 61.5 22.4
-. o-6 12-18
I 8-24 Over
38.63
34 37 ‘3 2
O-12
42.04
14.77 2.27 2.27
24
AI1 case!
8:
100.00
I
was considered an acute smaI1 struction. UnfortunateIy these correct diagnoses resuIted in an being made surgica1 incision necessity had to be cIosed in American
Journal
bowe1 obeight inimproper which of seven inof Surgery
ColIins-GastroduodenaI stances and a new one made. This caused a definite lengthening in the patients’ time upon the operating table and was a definitely increased risk to their ultimate recovery. One-haIf of these patients were seen on emergency visits at their homes and TABLE AGE
DlSTRlBUTION LiPOIi
IN
FOR
UIcers
one death. One patient had to have a subsequent disconnection of an anterior gastrojejunostomy. Another male deveIoped a huge peIvic abscess which drained rectaIIy. Two additiona patients had subsequent drainages of Iarge intra-abdom-
VIII
THIRTY-SIX
PERFORATED
PATIENTS PEPTIC
OPERATED
DURATION
No.
of
Per
Patients
TABLE x OF PREVIOUS
SYMPTOMS
ULCERS
I More
ARC
689
cent
of
Patients
Than
~ No.
(yr.1
of
Per
Patients
cent
Total
of
Casts
_~ Under
20
20-29
2.78
1
I
i.$6
12
3o- 39
33.36
40-49
4
Il.,2
50-59 60-69
IO
27.80
4
Il.,2
-)opyy
28 22
77.84 Ol.IO
'4 4
38.92
11.12
1
I
2.78
8.34
3
all of them
received a narcotic injection and the correct diagnosis was not made until a number of hours Iater on a subsequent emergency house calI. Twenty-five per cent of the entire series received multipIe narcotic injections which resuIted in a needless and dangerous deIay before a correct preoperative diagnosis could be made. TABLE SEASOUAL
inal abscesses whiIe two other individuals required drainages of Iarge subdiaphragmatic abscesses before they recovered. AI1 of these Iast six individuals lived. Fifteen patients, or 41.7 per cent suffered TABLE TABULATION I’OR
OF
XI
THIRTY-SIX
PERFORATED El 4PSED
PATIENTS
CLCER
BETWEEU
OPERATED
ACCORDING PERFORATIOI\
SURGERY~WlTH
COMPARISOZ
COLLECTED
I POh
TI\tE
AUD TO
SERIES
I
IX
TO
Coliectcd
INCIDENCE
Our
Series
Series
of
DcR:rkcy Season _
No.
of
Cases __
II ‘4 4
Winter Spring.. Summer. Fall.
7
Per
cent
~___
Deaths ._
I I
18.0 II.1
EIapsed
I,
3
I
1Q.j
I 949
Pa-
PZI-
tients
tients
No.
Per cent
per cent P:ttients
Iler 1 cent ) hlor~t&t\
I
The operating time upon these patients varied from 13 minutes to 185 minutes. The average operating time for these patients was in the neighborhood of one hour; 41.7 per cent of a11 the patients in this series Ieft the operating room before forty minutes had eIapsed. (TabIes x to XIV.) The postoperative compIications and the morbidity in this series are of interest. Two patients suffered from a post-operative eventration of their wound with .June,
( No. ( per / hlorta’itr ’ cent ~-~~ ’ of
I
30.5
~
Hours
_~
o-6
‘5
o-12
6
12-18
4
IS-24
I IO
Owr All
24 casts
36
II.12 2.78 27.80 100.00
I 3 6
1.431 62.4 30 13.66i 61.5 16.68 100 00' 22.4
from varying degrees of infection of their surgica1 incisions. Four persons deveIoped postoperative bronchia pneumonia; three aditiona1 persons suffered from acute pneumonitis and three cases had postoperative genitourinary tract infections.
CoIIins-GastroduodenaI
UIcers
There were 45 surgical procedures performed upon these thirty-six patients (Figs. 2 to 6); fourteen individuaIs, or 38.9 per cent, had a simpIe cIosure of the perforation empIoying mattress sutures of one
three of these died. Twenty-seven and eight-tenths per cent of this series had had preoperative x-ray scout fiIms taken of the abdomen and eight of the ten individuaIs thus studied reveaIed the presence of free
TABLE XII
TABLE XIV OPERATIVE PROCEDURES
-
OPERATIVE
-
No.
Total Time (min.)
TIME*
of Cases
Deaths
Per cent
Operation
vo. 0 f
Per cent
Cases _-
O-20 21-40 41-60 61-80 81-100
2
*3 IO 4 3
IOI-120
0
121-140 141-160 161-180 181-200
I
I I I
8.34
SimpIe cIosure. OmentaI graft sutured over perforation. PyIorectomy, post. gastroenterostomy..............
2.78 2.78 2.78 2.78
PyIorectomy, duodenectomy, Finney oper. . PyIoropIasty, Judd type.. . Purse-string cIosure.. . .. Two suture row forma1 closure
5.56 36.14 27.80 11.12
38.92
IO
27.80
I
2.78
2
5.56 8.34 8.34 8.34
3 3 3 -
* Apparently, prolonged operative time is not a major factor in mortahty in acute perforated gastroduodenal ulcers.
type or another, with three deaths; ten patients, or 27.8 per cent, were treated by the method of WerbeI, KozoII and Meyerz5 using a free omenta1 graft sutured over the perforation, with one death. The remaining operative procedures are Iisted on TabIe XIV and are seIf-expIanatory. Thirty-
ON
TABLE xv ANESTHESIA FORTY-FIVE OPERATIONS THIRTY-SIX PATIENTS
Per cent
Condition
15 3 4 3
41. IO 8.34 11.12 8.34
five operative procedures, or 77.9 per cent, were performed under spina anesthesia; TabIe xv cites the additiona data concerning the types of anesthesia used. Concerning the probIem of draining the peritonea1 cavity, thirteen patients or 36.1 per cent had drainage of various portions of the peritonea1 cavity, with three resuItTh e remaining twenty-three ing deaths. persons or 63.9 per cent did not have drainage of the peritonea1 cavity and onIy
Agent
SpinaI. .................... Ether ..................... CycIopropane, 0.2. .......... EthyIene, ether, 02 ......... EthyIene, 02 ............... ChIoroform, 02 ............. Local, 1% procaine ........
IN
-
i-
I
I
-
gas beneath the Ieaves of the diaphragm and were of definite diagnostic vaIue. TabIe XVI Iists the size of the perforated gastroduodena1 uIcers encountered in this series and as described in the surgeon’s dictation of his operative findings. There were fourteen uIcers (38.9 per cent) in this series that were situated on the gastric DATA
TABLE XIII POSTOPERATIVE MORBIDITY
Infected wounds.. Acute pneumonitis.. Bronchopneumonia. Genitourinary tract infection.
--
14
-
1Deaths
Pdo. of
cZases
Per cent
35 3
77.9 6.6
I I 1
4.4 2.2 2.2 2.2
2
4.4
2
I )eaths
-
side of the pyIoric ring and the remltining twenty-two (61.2 per cent) were situated in the first portion of the duodenum. Twenty of the duodena1 uIcers were anterior and two were stated as being on the posterior wall of the first portion. Figure 7 gives the saIient points on the anatomic Iocation of these ulcers. Since 1942 when the use of specific chemAmerican
Journal
of Surgery
CoIlins-GastroduodenaI
F.
Svtvrrt
Ulcers
hi.d
FIGS. z to 6. These depict a recommended operative technic that in our experience has proved to be the safest method of treating acute perforated gastroduodenal uIcers. The sagittal section of the peritoneal cavity in Figure s depicts seven areas within the peritonea1 cavity that are always systematically aspirated dry to minimize the occurrence of dangerous postoperative intra-abdominal abscesses.
CoIlins-GastroduodenaI
692
otherapy made its appearance and when the intraperitonea1 impIantation of various types of steriIe suIfonamide powders was begun, there has been a definite Iowering of the mortaIity rate. Eighteen patients
Ulcers
The extremes in hospita1 stay of those who survived their surgica1 treatment varied between 5 and 144 days. The average hospita1 stay for a11 hospita1 cases was 22.6 days; seven patients stayed in the
POSTERIOR DATA
FIG. 7. Anatomic Iocations of thirty-six Iocation of two ulcers not stated.
TABLE OF
DIAMETER
Gastric
Ulcers
Cases
Size (cm.)
OF
XVI
-
ULCER
PERFORATIONS
Duodenal Ulcers
/
Size (cm.)
Cases
_ Not stated
TABLE
XVII
WHITE
BLOOD
W.B.C.
Cases
,‘e’n’,
Over 20,000 Over 15,000 Over 10,000 Over 5,000
9 13 II
25.02 36.14 30.58 5.56
2
COUNTS
P.M.N.%
IO0
Over Over Over Over Over
Cases
I
90 85 80 70 50
I2 ‘3 2 5 3
Per cent
2.78 33.36 36.14 5.56 13.90 8.34
peptic ulcers;
(30 per cent) were so treated, using specific chemotherapy and onIy two patients died. The intraperitonea1 use of peniciIIin was begun in 1945. It has been empIoyed in eight patients with no deaths. Streptomycin was first empIoyed in 1946 and has
SlZE
ON
0.5
Not stated Pin point
8 I
I.0
0.25
2
1.3
0.5
5
2.0
0.75
3.0
I.0
3 2
5.0
I
been administered to four patients with no deaths. Thus, specific chemotherapy has been used in eighteen patients with two deaths and antibiotics have been used in the past two years in an additiona tweIve patients with no deaths. It is beIieved that the use of specific chemotherapy and specific antibiotics has done much to Iower the postoperative mortality in thirty (83.4 per cent) of the thirty-six patients comprising this series.
hospita1 Iess than nine days, six of whom died. The Iaboratory studies (Table XVII) on this group of patients were of interest. The preoperative urine anaIyses of sixteen individuaIs (44.5 per cent) showed positive aIbumen reactions and an additiona seventeen patients (47.3 per cent) had positive gIycosuria tests; six patients gave positive acetone reactions in the urine and three reveaIed a positive urinary test for diacetic acid. The white bIood count was of (25.0 per diagnostic vaIue : nine patients cent) had white bIood counts over 20,000; thirteen (36.1 per cent) had white counts varying from 15 to 20,000; eIeven patients (30.6 per cent) reveaIed white blood counts varying between IO and 15,000 and two patients (5.6 per cent) had norma bIood counts between 5 and 10,000; finaIIy, one patient (2.8 per cent) had a Ieukopenia of 3,350 white ceIIs. This patient died. The differentia1 poIymorphonucIear neutrophile ceI1 counts reveaIed the folIowing data: one individua1 (2.8 per cent) had 100 per cent; tweIve persons (33.4 per cent) were between 90 and IOO per cent; thirteen patients (36.1 per cent) were between 85 and 90 per cent; two individuaIs (5.6 per cent) were between 80 and 85 per cent and the eight remaining (22.2 per cent) Iay in the range of normaI. KarI Meyer and his associates26 emphaAmerican
Journal
of Surgery
ColIins-Gastroduodenal
antibiotic medications. Seventeen different surgeons operated upon this series of thirty-six patients. Seven surgeons performed twenty-six or
TABLE REPORTED
LATE RESULTS
OF ACUTE
693
tunately, all three patients survived under a regimen of massive chemotherapy and
size that in their large series of patients re-perforation in previous acute perforating gastroduodena1 ulcers is usually in the neighborhood of 4 per cent. Three patients (8.3 per cent) in this series had had previous acute perforating gastroduodena1 PREVIOUSLY
Ulcers
XVIII PERFORATED
PEPTIC ULCER TREATED
BY SIMPLE
SUTURE
(After Baritell)
Ebason and Thigpen ......................... Cable, J. V. ................................. Thompson, Il. L ........................... Parker,E.F ................................. Harrison, C. and Cooper, W., Jr ............... Estes, W. L. and Bennett, B. A., .............. Williams, A. C. .............................. lllingsworth, C. F. W., Jan&son, R. A. and Scott, L.D .................................... Forty,Frank ................................. Collins, D. C .................................
No. of AII
No. of Cases Well
No. of Cases Not Well
~ Followed
7(30%) *2(98(x) 37(75.6%~ r*(67%)
4(r8%) 4(r6%) 2(40/c) 6(33%)
1944 ’ 944
15(700/L) 2(8%) 12(*4.40/c) 6(33%) 7(17.50/c) 3(5.6%) 28(280/c)
1946 1946 1947
77(ro%) 47(47%) 27(75 %)
Year Reported
Author
No. of Cases hollowed
‘938 ‘938 1939 1941 1942
TABLE
Cases Having Reopcration
1 32(82.5%) 5o(94.4%) 72(72%) 54’(70%) 38(38%) 6(17%)
8(r5%)
I I(1 I ‘;;I I ~
r55(2o%) x4(15%) 3(8%)
XIX
DEATHS
T Cases
I _~
Correct preoperative
diagnosis.
Elapsed time of perforation. Location of ulcer. Anaesthesia. Upper right rectus incision.. Operation time (min.). Postmortem
__-
3
2
4
0
5
~-
Yes
No *
Yes
Yes
Yes
168 hr. ___,__ Post-G.U. Spinal
60 hr.
735 hr.
60 hr.
17 hr.
Ant. D.U. Spinal
Ant. G.U. Spinal
Ant. G.U. Spinal
Yes 60 Yes
NO
Yes
z
Yes
Ant.
D.U. Spinal Yes 34 Yes
Yes
NO 9
rhr.
Ant. D.U. Chloroform, 01 -No 75 No
I * Underlined portions of this table are beIieved to be possible major factors in the causation of deaths in this study.
ukers which previousIy had been repaired surgicaIIy. Two individuak were maIes, aged sixty-two and forty years. The third person was a woman, aged Iifty-one. The two maIes had had a previous repair of an acute perforated gastroduodena1 uker three and five years previousIy, respectiveIy. The remaining woman had had a former acute perforation twenty-eight days prior to her entry into this hospita1. ForJune,
1949
72.3 per cent of the operations, with four deaths. One surgeon operated upon nine patients with one fatality. (Tables XVIII and XIX.) CONCLUSIONS I. A report is presented detailing the experiences encountered in an average metropoIitan hospita1 in which thirty-six instances of acute perforated gastroduo-
694
CoIIins-Gastroduodenal
dena uIcers occurred between the years of 1936 and April, 1947. Six patients died, or a tota mortality of 16.7 per cent. This mortality figure compares favorably with that reported in surgica1 literature but shouId be markedIy reduced in the future. 2. Most of the fataIities in this series occurred in patients who were not seen by the surgeon unti1 a very considerabIe Iapse of time had occurred between the onset of their acute perforation and its surgica1 closure. SeveraI of these fataIities were needIess, because the patients had persistentIy faiIed to foIIow the advice given by their physician to have their chronic gastroduodena1 uIcer corrected surgicaIIy when there wouId have been a minimal mortality in the hands of the competent surgeon. 3. Indications point out that probably in the near future the excessive mortaIity resuIting from acute perforating gastroduodenal uIcers may be markedIy Iowered by the skiIIfu1 empIoyment of various specific chemotherapeutic agents and specific antibiotics which are now freeIy avaiIabIe for civihan use. 4, A sincere plea is made not to treat these patients by conservative medica methods, empIoying intragastric suction and intravenous fIuids as has been recommended recentIy by severa authors in British medica literature. The prompt employment of a simple surgica1 closure of the perforation wiII definitely resuIt in lowered mortality and less postoperative morbidity than the use of conservative medical measures. A publication6 describes the histories of five patients treated by medical measures only and who were later referred to me in extremis. This inadequate medical care caused a needIess marked financial loss to the patients as we11 as pIacing their Iives in needIess grave jeopHeroic measures were necessary ardy. before these five patients could be removed from the critica list and dismissed weI1. 5. It is beIieved that a simiIar study presented ten years hence wiI1 undoubtedIy show a marked reduction in the operative
Ulcers
mortaIity and postoperative morbidity in patients surgicalIy treated for acute perforated gastroduodenal ulcers in the future years at this same hospita1. 6. The saIient points of this study have been summarized in chart form and are seIf-expIanatory. 7. The ratio of non-perforated gastroduodenal uIcers to acute perforated instances in this study was 33. I : I. Therefore, it required I, 191.6 operations performed upon non-perforated gastroduodenaIuIcers, before the thirty-six instances of acute perforated gastroduodena1 uIcers were encountered in this study which covered a period of eleven years. 8. The fact that the operative mortaIity of acute perforated gastroduodenal ulcers as contrasted to that of non-perforated exampIes was 3.1: I testifies to the importance of operating upon patients with gastro-duodenal uIcers before acute perforation occurs. REFERENCES I.
2.
3. 4. 5. 6.
7. 8.
ABERCROMBIE, JOHN. Contributions to the pathology of the stomach, pancreas and spleen. Edinburgh M. et* S. J., 21: 1-14, 1824. BARITELL, A. LAMOKT. Perforated gastroduodena1 ulcer. SUrger_V,21 : 24-33, 1947. BEDFORD-TURNER. Quoted by Visick.22 BONETI. THEOPHILE. The Sepdchretum. L. Choncr. Geneva, p. 798, 1679. _ BRUNNER, F. Quoted by McNeaIy and Howser.r4 COLLINS, DONALD C. The danger of treating perforated peptic uIcers by non-surgical methods. J. Inlerflat. Coil. .Surgeons. (In press). CRUVEILHIER, J. Pathologique du Corps Humain. Paris, 1829. J. B. BaIIiere. DEAN, HARRY PERCY. A case of perforation of a chronic uIcer of the duodenum successfuIIy treated by excision. Brit. M. J., I: ror4-1015, 1894.
9. DRAGSTEDT, LESTER R. Vagotomy 10.
I I. 12.
13. ‘4.
for gastroduodena uIcer. Am. Surg., 122: 973-989, 1945. DRAGSTEDT, LESTER R., CLARK, JAMES and STORER, EDWARD. Section of vagus nerves to the stomach in treatment of peptic uIcer. Proc. Inst. Med. Chicago, 16: 146, 1946. HEUSSNER and ROIJX. Quoted by Brunner.s LAHEY, FRANK H. Treatment of duodenal ulcers; partial gastrectomy versus paIIiative resection. .>. A. M: A., 134: 574-575, 1947. LEWISOHN. RICHARD.Treatment of duodenal ulcers, partial gastrectomy versus paIIiative resection. J. A. M. A., 134: 571-574, 1947. MCNEALY, RAYMOND W. and HOWSER, JOHN W. Perforation in peptic uIcer. A critica review of
American
Journal
of Surgery
Collins-Gastroduodenal
,<.
J,~:y~les and ~I>IZI.MAI\, GILL% Indications for emergency gastrectomy in the treatment of perforated gastric and duodenal ulcers. J. de l’H&el-Dieu de Montreal, I : r-7, ,947. 16. MIKULICZ, J. VON. Quoted by Brunner.5 I 7. O’FIARA, H. Perforating or corrosive ulcer of the duodenum. Tr. Path. Sot. Philadelphia, 6: 37738, IH;j. 18. RAWLINSON, CHRISTOPHER. Quoted by W:ltson.26 IO. RHODES. GEORGE K. and COLLINS. DOVALD C. Acute’ perforated peptic ulcers. k&f. P+ West. &led., 39: 1-13, 1933. 21). SAMAYN. Traitement des ulceres par la gastrectom&. Aeta c&r. belg., 45: 198-205, 1946. 2 I. TAYLOR, HERMAN. Treatment of perforated peptic Ulcer. L_0?Ir?/,2 j I 1441-444, 1940.
UIcers
A. f ~eo~.eu. Conscrvativc treatmt’nt of :rcutr perforated peptic ulcer. Hrit. ,I{. J.. 2:
22.
VISICK,
23.
WALTMAN. Vagotomy for peptic ulcer. Proc. Staff Meet., Mayo Cl&., 22: 281-289, 1947. WANGENSTEEN,0. H. The role of the surgeon in the management of peptic ulcer. Internnt. Ahstr. Surg., 85: 145.“47, 1947. ~VATSON, JOHN Ii. Acute perforating duodenal and gastric ulcers. hit. M. J., 2: (69-173, r93o. WERBEL, ERNEST IV., KOZOLL, DONALD D. and MIXER, KAKL A. Surgical sequelae folIowing recovery from a perforated peptic ulcer. S. Clin. North America, 27: 93-108, 1947. WILENSKY, ABRAHAM 0. Vagotomy for gastroduodenal ulcer. Rev. Gastroenterol., r4: $70~572, 1947.
04
%~lALAFWI',
NOT
all bleeding
with arteriosclerosis less immediately Clinically,
and hypertension,
and there whether therefore (Richard
June,
19.49
cannot
likelihood contract. M.D.)
especially
using I ,300 cc.
and presumably of spontaneous In any event
will those
will bleed to death is effectively
are needed, the patient
obvi-
has been erodecl
of the hemorrhage,
or only partia1Iy
immediate
if hc
or less of bIood per
a large artery cessation
un-
controlled.
suspect he is dealing with such a patient
the vesse1 wall is sclerosed
A. Leonardo,
the vast majority
occasionally
If larger transfusions
extensively
is Iittle
27.
a stabIe circulation
once daiIy.
because
26.
upon and the bleeding
one can reasonably
ously is bleeding
25.
medical regimen. Older patients,
operated
is unable to maintain transfusion
24.
I 944. 1946.
WALTERS,
ulcers require surgica1 treatment;
do well under conservative
693
surgery
severed
and
is indicated.