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November 1990, Volume 40, Issue 11

Editorial

SHOULD DUODENAL PERFORATION BE TREATED BY SIMPLE CLOSURE OR DEFINITIVE SURGERY?

Waquaruddin Ahmed  ( PMRC Research Centre, Jinnah Postgraduate Medical Centre, Karachi-35. )

The ideal treatment for the perforation of duodenal ulcer has not yet been established. Accepted methods vary from simple closure to immediate definitive surgery. Simple closure is the general standard procedure against which other methods are evaluated. It is simple, safe and effective for the treatment of emergency problem but provides no protection on long term basis. Several studies have shown that 34 — 76% of patients treated with simple closure become symptomatic1,2 and 60 — 80% require further surgical treatment, if followed up for 5 years or longer3. In each year of follow-up about 1% would bleed and 2% reperforate and these figures rose to 9% when patients were followed upto 17 years4,5. Another aspect leading to dissatisfaction with simple closure is increased immediate morbidity and death when there is coexisting haemorrhage, obstruction or a large chronic ulcer6. Conservative or nonoperative management was first introduced in 18707 and later recommended by others8,9 who proposed continuous nasogastric suction and use of antibiotics. The results of this procedure are uncertain and it also does not provide any protection for the future. Non-operative management has its place in the manage­ment of perforated duodenal ulcer in patients unfit to undergo emergency surgery. Gastrectomy was first carried out for perforation in 190210 and subsequently recom­mended as the treatment of choice in various reports11-13. The major criticism for this treatment was that an extensive gastric resection is performed in many cases who may never have recurrence or who might be comfortable on a reasonable medical regimen. Gastrectomy is associated with problems of its own and may not be the ideal treatment for perforated duodenal ulcer. Later vagotomy and pyio­roplasty was tried with encouraging results without any mortality and little morbidity like dumping syndrome in 11%14-16. Current controversy centres on whether to perform a definitive surgical procedure or simple closure at the time of perforation. Experiences over the past several years have shown that several factors influence the choice of surgical procedures. A patient with a chronic ulcer history, who has an interval of less than 12 hours between perforation and treatment, has no concurrent disease and is less than 60 years of age should tolerate definitive procedure such as vagotomy and pyloroplasty17. If there is extensive peri­toneal contamination, unexpected anaesthetic problems and when there is no/short (<3 months) history of ulcer symptoms prior to perforation, simple closure alone maybe a better choice18,19. Despite the adoption of the principle of immediate definitive surgery by many centres in the West for the past 40 years, majority of perforated duodenal ulcers in our country are still being treated by simple closure as high­lighted in an article in this issue of JPMA. Although simple closure is a life saving procedure, the long term results of this procedure need a close scrutiny and review.

REFERENCES

1. Jirzik, H. Erfahrungen bei 327 freinen Magen-Zwo!ff ingerdarm Geschwursper forationen. Arch. Kim. Chir., 1954 ; 227: 611.
2. Turner, F.P. Acutc perforations of stomach duodenum, and jejunum. An analysis of 224 cases with late follow-up date on 147 cases of acute perforated peptic ulcer. Surg. Gynecol. Obstet., 1951;92:281.
3. Mark, J.B. Factors influencing the treatment of perforated duo­denal ulcer. Surg. Gynecol. Obstet., 1969; 129: 325.
4. illingworth, C.F.W., Scott, L.D.W. and Jamieson, R.A. Progress after perforated peptic ulcer. Br. Med. J., 1946; 1: 787.
5. Griffin, G.E. and Organ, C.H. The natural history of perforated duodenal ulcer treated by suture plication. Ann. Surg., 1976; 183:382.
6. Burdette, WJ. and Rasmussen, B. Perforated peptic ulcer. Surgery, 1968; 63 : 576.
7. Redwood, T.H. Two cases of perforation of the stomach. One recovery. Lancet, 1870; 1: 647.
8. Wangensteen, O.H. Nonoperative treatment of localized perfora­tions, of the duodenum. Minn. Med., 1935; 18: 477.
9. Taylor, H. Perforated peptic ulcer treated without operation. Lan­cet, 1946; 2 : 447.
10. Kelly, C.B. Surgery of non-malignant gastric ulcer and perforation. Lancet, 1902; 1: 885.
11. Cooley, D.A., Jordan, G.L., Brockman, L., DeBakey, M.E. Gastrec­tomy in acute gastroduodenal perforation. Analysis of 112 cases. Ann. Surg., 1955; 141 : 840.
12. Jordan, G.L. Jr., Angel, R.T. and DeBakey, M.E. Acute gastro­duodenal perforation; comparative study of treatment with simple closure, sub-total gastrectomy and hernigastrectomy and vagotomy. Arch. Surg., 1966; 92 : 449.
13. Jordan, G.L. Jr. and DeBakey, M.E. The surgical management of acute gastroduodenal perforation. Am. J. Surg., 1961 ; 101 : 317.
14. Kincannon, W.N., McLenathen, C.W. and Weinberg, J.A. Vago­tpmy and pyloroplasty for acute perforated duodenal ulcer. Am. Surg., 1963; 29: 692.
15. Wangesteen, S.L., Wray, R.C. and Golden, G.T. Perforated duo­denal ulcer. Am. J. Surg., 19 72; 123: 538.
16. Bose, S.M. and Rup Chand,T. Long term results of perforated duodenal ulcer following surgery. IndianJ. Gastroenterol., 1988; 7: 227.
17. Nemanich, G.J. and Nicotoff, D.M. Perforated duodenal ulcer; long-term follow-up. Surgery, 1970; 67: 727.
18. Mark, J.B.D. Factors influencing the treatment of perfqrated duodenal ulcer. Surg. Gynecol. Obstet., 1969; 129 :325.
19. Cassell, P. The prognosis of the perforated acute duodenal ulcer. Gut, 1969; 10 : 572.

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