Long-Term Results Of Simple Closure Of Perforated Duodenal Ulcer In The Era Of Proton Pump Inhibitor And Anti-H.Pylori Therapy
N Gujar, P Chougule, S Bhosale, H Mane, S Paighan, V Balachandran
helicobacter pylori, peptic ulcer perforation, proton pump inhibitors, simple closure.
N Gujar, P Chougule, S Bhosale, H Mane, S Paighan, V Balachandran. Long-Term Results Of Simple Closure Of Perforated Duodenal Ulcer In The Era Of Proton Pump Inhibitor And Anti-H.Pylori Therapy. The Internet Journal of Surgery. 2012 Volume 28 Number 3.
Prior to the use of H2 blockers, simple closure of perforated duodenal ulcer was associated with recurring ulcer symptoms in 40 to 80% of patients and about 40 to 60% required subsequent definitive operation.1, 2 The efficacy of simple closure of perforated peptic ulcers has been compared with definitive surgery in several randomized trials.2 Ulcer recurrence has been reported to occur in 61% and 6% of cases following simple closure and definitive surgical treatment, respectively.3 This high recurrence rate after simple closure of the ulcer has been the basis of argument in favour of the addition of some definitive surgical procedure.4
However, there is an obvious return from definitive anti-ulcer surgery to simple closure of the perforation followed by anti-secretory and antibacterial medication in recent years.5, 1, 6 Simple closure followed by
It therefore seemed appropriate to review the long-term results of duodenal ulcer patients treated with simple closure followed by PPI and anti-
Materials And Methods
The study was approved by the Ethics Committee of Krishna Hospital and Medical Research Center, Karad, and informed patient consent was obtained.
Simple random sampling was employed to select the 50 cases for the study and SPSS software v1.0 was used to facilitate statistical analysis.
Every attempt was made to follow the patients either through letters, phone, personal contacts or through hospital workers and relatives. History regarding duration of pain, previous similar episodes, alcohol consumption, tobacco chewing or smoking, working time, occupation, history of anti-inflammatory drug intake, history of treatment of acid peptic ulcer disease and other associated diseases were noted.
During the follow-up period, patients were interrogated about recurrence of ulcer symptoms and graded as follows:
Grade I: No symptoms, excellent results
Grade II: Mild symptoms, good results
Grade III: Moderate symptoms, easily controlled by medication.
Grade IV: Severe symptoms, requiring constant medication or reoperation
Any associated conditions with duodenal ulcer like
Investigations such as barium meals or upper gastro-intestinoscopy were carried out whenever indicated and relevant investigations were done in patients with associated diseases (e.g. ultrasonography for gallstones and pancreatitis).
All the patients who did not have any symptoms during the follow-up period were not advised any treatment. Those with symptoms were treated accordingly.
During the follow-up period, out of 50 patients, 47 patients got complete follow-ups, one died in the immediate post-operative period, one died due to other medical causes within the first five years and one patient was lost in the follow-up.
There were no additional deaths due to perforated duodenal ulcers or due to ulcer-related complications.
Post-operative follow-up ranged from 12 to 15 years.
Mean follow-up period was 12.91years.
Our results according to Modified Visick`s grading were as follows:
Excellent and good results were seen in: Grade I + II = 18 +19 = 37 patients (78.72 %)
Seven patients (14.89%) were having moderate symptoms which were easily controlled by medication and only three patients (6.38%) needed constant medication or definitive surgery.
In this study, cumulative relapse rates increased with the increase in the follow- up period as shown in above figure.
Taking into account the various data from literature and comparing it with the present series, a few interesting facts were revealed.
One study reported most of the patients with perforated duodenal ulcers in the third decade of life.7
There is a shift of age towards elderly patients in other parts of the world. It may be due to the difference in life styles such as smoking, alcohol, psychological stress etc. 8,5
Langman, in 1974, noted that since 1959 both gastric and duodenal ulcers had become more frequent in lower socio-economic groups in the UK and USA.10
According to Aird et al. from Edinburgh, perforations were most frequent in mid-winter.11
A peak incidence in the month of December was reported from the south-west areas of Scotland and Glasgow.13
Mackay has also reported such a peak incidence during Christmas and Mitra reported 60% of perforations occurring during October to March.13, 12
In the present series, 90% of patients gave a positive history of tobacco use in any form and 58% were alcoholics. As such, a positive history of tobacco was reflected in the high morbidity and mortality rates in the present series. All patients with associated respiratory disease gave a positive history for tobacco usage.
Twenty patients (42.55%) who gave a history of persistent symptoms of acid peptic disease post-operatively were found to be chronic smokers or alcoholics. Similar associations were observed in other studies.12, 13
In the present series, there were five patients (10%) who gave a definitive history of consumption of ulcerogenic drugs. Out of these drugs, three (6%) had taken phenylbutazone for arthritis and two (4%) had taken steroids.
Similar findings were observed by Mitra (1982).12
Complications occurred mostly in the group where pain to surgery interval was more than 12 hours. In the present series, all patients (100%) who had a pain-surgery interval of more than 48 hours had complications; 66.6% of complications occurred when the interval was between 25 to 48 hours, 42.9% when the interval was between 12 to 25 hours and 17.9% when the interval was less than 11 hours.
Boey et al. from Hong Kong (1982) observed that old age and late exploration significantly increased the risk of infection. Neither peritoneal soiling nor a positive culture was likely to be clinically important when exploration was likely to be performed within two days of perforation. 17
In another study, post-operative complications were in seen in 65 patients (24.2%). Pneumonia and wound infections were the commonest complications in 40 (37.04%) and 20 (18.52%), respectively, followed by sepsis in nine patients (8.34%), leakage in six patients (5.55%), intra-abdominal abscesses in two patients (1.86%) and bleeding in one patient (0.92%).19
In the present series, wound infection was seen in eight patients (16%) and chest infection in seven patients (14%), burst abdomen occurred in one patient (2%), paralytic ileus was seen in one patient (2%), sub-phrenic abscess developed in one patient (2%) and pelvic abscess developed in one patient (2%). In total, postoperative complications were seen in 19 patients (38%). Hypertrophied scar developed in two patients (4%) and incisional hernias in two patients (4%) as a late complication.
The mean prevalence of
There is a continuing debate in literature regarding the preferred surgical procedure for patients with perforated duodenal ulcers. Simple closure of perforation can be readily performed by relatively inexperienced surgeons often operating on an ill patient.20
Prior to the use of H2-blockers, simple closure of perforated duodenal ulcer was associated with recurrent ulcer symptoms in 40 to 80 % of patients and about 40 to 60% required subsequent definitive surgeries.1, 2
It is the high incidence of recurrent symptoms following simple suturing of perforated duodenal ulcer that makes some authors advocate definitive operation at the time of initial surgery. 21, 22
However, in our study, excellent and good results were obtained in: Grade I + II = 18 +19 = 37 (78.72 %) patients.
Seven patients (14.89%) were having moderate symptoms which were easily controlled by medication and only three patients (6.38%) required constant medication or definitive surgery.
The higher satisfactory result in the present series was attributed to the advent of H2-receptor antagonists and proton pump inhibitors like omeprazole and the relatively recent discovery of
In this follow-up study, the cumulative relapse rate increased with increase in follow-up period which is comparable with other studies.9
Illingworth showed that the number of symptomatic patients increased with each year of follow-up and also complications occurred after 5 years of the original operation in 50 cases and outcome of plication was more favourable in patients with a short history of symptoms prior to perforations. 23
A simple closure of the perforation reinforced by omental patch and followed by eradication of
The authors heartily thank the Dean, Krishna Medical College and Research Center Karad, and all the surgical staff for their co-operation in this study.