Surgical treatment of perforated duodenal ulcer: A prospective trial between simple closure and definitive surgery

Abstract

Seventy-eight patients with perforated duodenal ulcer were prospectively studied between 1977 and 1982. Patients were alternately allocated to receive simple closure (Group I, 33 patients) and definitive surgery (Group II, 32 patients). High-risk patients and those whose conditions dictated a definitive operation were excluded. All patients in Group II had a truncal vagotomy and drainage except one who had a proximal gastric vagotomy. There was no death in Group I or Group II; the complication rate and postoperative course were similar. Twenty-seven patients in Group I and 26 patients in Group II were available for follow-up 12 to 80 months after operation, mean 39 months. Good/excellent results were achieved in 30 per cent of Group I compared with 81 per cent of Group II (P less than 0.01). Eighty-five per cent of Group I patients developed recurrent ulcer symptoms and 33 per cent had already had a second definitive operation. Two patients (8 per cent) in Group II were reoperated upon for recurrent ulcer due to an incomplete vagotomy. In a population of patients where long-term follow-up and medical treatment for duodenal ulcer is unsatisfactory, truncal vagotomy with drainage should be the treatment of choice for perforation. Simple closure should be reserved for high-risk patients or when the surgeon is inexperienced.

Primary Definitive Surgery in Perforated Peptic Ulcer: Is it Necessary?

“…The recurrence rate after HSV in the present study is high compared to previous studies [18,19,30]. However, the success rate of a HSV clearly depends on the experi ence of the surgeon [20], Because today's medical treat ment for peptic ulcer disease has nearly made surgery in symptomatic peptic ulcer disease superfluous, the possi bility for a surgeon to become experienced in performing a HSV has drastically diminished.…”

Ulcer surgery – what remains?

“…In der Ära vor Erkennung der kausalen Bedeutung von Helicobacter pylori für die Ulkuskrankheit haben zwei prospektive Studien gezeigt, dass die definitive chirurgische Therapie beim perforierten Ulcus duodeni bessere klinische Langzeitergebnisse bringt als die alleinige Übernähung [7,52] [18]). Anastomoseninsuffizienzen und Nachblutungen sind bei Magenresektion nach Billroth I selten geworden, in gleicher Weise ist das früher bei Billroth II als Nachteil angesehene Risiko einer Duodenalstumpfinsuffizienz bei dem heutigen maschinellen Verschluss äußerst gering.…”

Which Operation for Perforated Duodenal Ulcer?

“…Two recent prospective controlled trials achieved considerably better long-term results in the groups of patients who underwent definitive surgery, with no ex cess in operative mortality [4,5]. However these trials were done in the Far East and the mean age of the patients was only 42 and 44 years.…”