Dig Dis 1992;10:10-16
Department of General Surgery. Box Hill Hospital. Melbourne. Australia
Keywords Non-operative Deliberative Anti-secretory agents Non-steroidal anti inflammatory drugs Anti-helicobacter drugs
Perforated Peptic Ulcer The Changing Scene
Abstract
There is a changing scene with perforated peptic ulcer. The older age of presentation, the increased association with non steroidal anti-inflammatory drugs, associated increased debil ity, and resulting higher mortality in the elderly, are causing a rethink in management protocols. Whereas years ago most discussion was on whether urgent definitive surgery was the most effective therapy, nowadays there is a tendency to less invasive measures. A ‘deliberative’ approach, wherein not all patients require surgery, is detailed, and there may be an increasing role for laparoscopic perforation-sealing techniques in the remainder. Anti-secretory and anti-helicobacter drugs have an important role in post-operative care following lesser procedures than definitive surgery.
In 1957. Hermon Taylor [ 1] challenged the traditional concept of simple suture and omental plug formation for the routine emer gency management of a patient with a perfo rated ulcer. He suggested that cessation of spillage of gastroduodenal contents into the peritoneal cavity could equally be achieved by keeping the stomach empty with well-placed nasogastric suction and appropriate intrave nous resuscitation. Reporting on 256 cases, he suggested that 80% had sealed spontaneously and were successfully managed non-operatively for their episode of perforation. He reported an overall mortality of 11 % - al
though this was only 5% if moribund patients were excluded. These figures compared with those of simple suture at that time of up to 20% [2- 6]. Others have tried the non-operative tech nique. but most have tended to reserve this for groups of patients unfit for surgery and. not surprisingly, the results were poor [7-12], More recently there has been a resurgence of interest in this approach, driven particu larly by the increasing age of patients present ing with perforated ulcers. Selected mortality rates of 2.4-5% have been reported [13-17], which are comparable to those of simple su-
John R. Cocks Department of General Surgery Box Hill Hospital Melbourne 3128 (Australia)
© 1992 S. Kargcr AG. Basel 0257-2753/92/ 0101-001052.75/0
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John R. Cocks
shock, other intercurrent illness, and ulti mately, mortality [6, 8. 22, 31.32]. Boey and Wong [22] have defined 3 risk factors for patients with perforated ulcer associated severe illness, pre-operative shock, and a history of perforation greater than 24 h and point out that if none of these 3 risk fac tors is present, the mortality will be 0.4%: if 1. 4.2%; if 2. 40%; and if all 3 risk factors are present, the mortality will be 87% [22], These figures have been elicited for perforated duo denal ulcer, and it is also recognised that there is a generally worse outlook for patients with perforated gastric ulcers [38-42], Mortality rates of up to 28% have been reported in recent years, and particularly is the mortality high if definitive surgery is per formed on the elderly [2. 8, 32]. Secondly, antisecretory agents such as histamine-2 receptor antagonists (H2RAs) and omeprazole have been introduced. These drugs have had the effect of healing ulcers ini tially. but have high recurrence rates. This has had the effect of delaying in time, the onset of complications of ulcer, and contributing to the rise in average age of patients presenting with perforation. They also play a role in the continuing care of the patient with perforation. It has been suggested that, except in specific circum stances. emergency definitive surgery should no longer be an option for perforation, when simple suture and subsequent H2RAs can pro vide such long-term relief, even with chronic ulcers [23, 43. 44], Others have suggested, however, that these drugs make no difference to the rate of recurrence of symptoms leading to definitive surgery, following simple suture of a perforation [45]. However, if a major operation can be avoided at the time of perfo ration, definitive surgery might properly be reserved for patients who have frequent re lapses of ulcer disease while on subsequent H2RAs [46].
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ture. and definitive ulcer curative surgery [18-21], but, of course, avoiding surgery in the majority of patients. Each group has worked on the hypothesis that the continuing leakage into the peritoneal cavity needs to be stopped in the most expedi tious manner. They have shown that if a period of up to 12 h is allowed to a patient with an empty stomach, then spontaneous sealing will occur in up to 70% of cases. If. after 6-12 h. there is no spontaneous sealing, appropriate surgical therapy is advised. The delay in decision-making of 6-12 h. far from being detrimental to the patient, provides ad equate time for optimal resuscitation, and this delay does not increase mortality or mor bidity [14. 15]. However, most of the debate in the last 3 decades has been related to whether definitive surgery should be offered in the emergency circumstances, or whether simple suture should suffice. This debate has mostly been on the basis that 20-40% of patients who have had their ulcer closed by simple suture, have required definitive surgery within a few years of their perforation [11. 22-25]. There seems little doubt that definitive surgery can produce acceptable results with as little as zero mortality, when patients are selected for such major surgery, but it has been stressed the patient should be otherwise fit and young, have only perforated for a short time, and have no other intercurrent illness [18, 22,24. 26-29], Several new factors, however, have emerged in the 1980s, in an ever-changing scene. Firstly, the average age of patients in series being reported has, over the last 4 decades, gradually increased from the decade 40-50 years, to the present 60-70 years [12, 19. 3037], Box Hill Hospital’s last 40 cases have had an average age of 71.3 years. As the age of the patient rises, so do the rates of delayed presentation, pre-operative
12
Cocks
stances, and while it is probable that they have resulted in lessening mortality and mor bidity. it has not always been reflected in results. Post-operative morbidity rates for perforated ulcer have been as high as 50%, including cardiac, renal and infective pro cesses, but there does not appear to be any sta tistical difference between the complication rates of various modes of therapy [ 15]. Our group have noted that while cardiac compli cations and wound infection rates arc higher in those undergoing surgery, the chest infec tion and intraperitoneal collection rates are higher in those treated non-operatively [ 14],
Suggested Management
A perusal of the literature would suggest that almost uniformly good results can be obtained in fit patients, less than 50 years of age, with immediate simple suture, imme diate appropriate definitive surgery, or our deliberative approach and an attempt at non operative therapy, and there are protagonists for each of these actions. Perhaps the main point at issue in the 1990s, is the question of the best plan of treat ment, for those patients who are not young and fit. bearing in mind that the present mor tality for those patients over 70 years, ap proaches 34%. and may be as high as 47% [7. 32, 33]. Crofts et al. [ 15] have suggested that perfo rated ulcers in this age group are unlikely to seal spontaneously. Our results would suggest a deliberative approach may be appropriate, but the differences with these small numbers are not statistically significant (table 1). In our prospective trial which is continuing, 40 pa tients have been entered with an average age of 71.3 years, and the incidence of ulcers seal ing spontaneously is lower than the overall 68% previously described [14]. It is not clear
Perforated Peptic Ulcer
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In the emergency circumstance, definitive surgery may be advisable if the patient has a chronic ulcer which perforated while taking antisccrctory agents, if there is associated bleeding or stenosis, or if there is a perforated gastric ulcer unsuitable for simple suture and omental plugging. Thirdly, non-steroidal anti-inflammatory drugs (NSAlDs) are playing an increasing part in the aetiology of perforated ulcers. The inci dence of these drugs being ingested by pa tients presenting with perforation is increas ing. and this no doubt, is as a result of. and also contributory to. the increasing age of pre sentation [47, 48], The anti-inflammatory na ture of these drugs, decreasing oedema and reducing the accumulation of granulocytes at the focus of inflammation may well slow down, or inhibit, spontaneous sealing in those patients treated non-operatively [49]. Fourthly, the role of Helicobacter (Campy lobacter) pylori in the aetiology of. and asso ciation with, peptic ulcer is still to be com pletely evaluated. It is hoped that the good results of treatment of peptic ulcer with anti-Helicobacter drugs can be confirmed. Whereas there is a 70-90% recurrence at 3-4 years following a single course of FFRAs. it has been shown that 96% of peptic ulcers can be cured without relapse for 4 years, with a regimen of colloidal bismuth subcitrate, tetra cycline hydrochloride, and metronidazole [50. 51]. This sort of routine may well mean that the perforated ulcer purely needs to be sealed, and appropriate anti-Helicobacter therapy given post-operatively. This again would suggest that the place for definitive sur gery in the emergency management of perfo rated ulcer would be limited. Fifthly, the broadening spectrum, and in creased knowledge, of antibiotic therapy have been applied in these emergency circum stances. Antibiotics have generally been used in both operative and non-operative circum
Table 1. Mortality in patients over 70 years for per forated peptic ulcer. Box Hill Hospital. Melbourne
Mortality (1966-87) Deliberative1 n = 21 Immediate suture n = 14 Immediate definitive n = 8
3(14%) 4(29%) 5(63%)
1 'Deliberative' includes those patients who came to surgery for non-sealing in the 4- 6 h allotted.
Table 2. Protocol for deliberative management of perforated ulcer A Surgery necessary immediately, if
-
associated bleeding or stenosis doubtful diagnosis history of gastric ulcer food after perforation obstructive airways disease, asthmatic, air-gulper perforation longer than 24 h. and patient not improving pre-operative shock
B All other patients
Nasogastric tube to pylorus - half/hourly aspiration Intravenous therapy - to maintain adequate urine output Analgesics Antibiotics Investigations - exclude pancreatitis, cholecystitis, etc. Frequent observation Check subdiaphragmatic x-ray at 4-6 h and contrast radiology, gastrografin swallow Delayed surgery now necessary, if - increase in pneumoperitoneum - gastrografin leak - general condition deteriorates - other complications Try to operate within 24 h of perforation Investigation within 2 weeks - to confirm diagnosis. Reproduced with permission of Aust NZ J Surg [ 14], but modified.
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whether this is due to most patients being on NSAIDs. or whether it is purely age which is the discriminatory factor. NSAIDs did not appear to have a significantly detrimental ef fect on healing in our previous study, when the average age was 60 years. Nevertheless, if there is nothing lost by draining the stomach with naso-gastric aspira tion and adequate resuscitation for 6-12 h, it would seem appropriate to try the delibera tive technique, as outlined in table 2. It may be that more patients will require suture than in the younger age groups, but if 30-50% of the older age groups can be treated success fully non-operatively, the overall results should be improved [ 14, 15], One of the difficulties, not always reported in the literature, is the fact that some elderly patients present in a moribund state, and while they need to be included in any overall results, no form of therapy, operative or non operative, will be adequate for most of them [11,14.52], It will be noted that a non-operative rou tine is inappropriate for those presenting with (a) bleeding or stenosis, (b) doubtful diagno sis. (c) food after perforation, (d) air gulpers. and also for those (e) presenting with pre operative shock, and for those (0 who have perforated for longer than 18-24 h and whose condition is not improving. These patients need immediate operation and adequate peri toneal toilet. The remainder of patients with a clinical diagnosis of perforated ulcer are initially treated non-operatively. If surgery is required, the protocol allows for this to be performed as early as possible after perforation, but certainly within 24 h of the perforation, if achievable. The mortality rises if the perforation is unsealed for more than 12—24 h [8, 11, 22], Some patients present, however, with a history longer than 24 h, and if they are not improving, suggesting
Table 3. Algorithm Perforated ulcer
Diagnosis
Others
Fit patient < 50 years Long history of ulcer Short-time since perforation No other morbid conditions
Any of Associated bleeding or stenosis Doubtful diagnosis History' of gastric ulcer Food after perforation Obstructive airways disease, asthma > 24 h since perforation, and ill Shock at presentation
I Immediate surgery
Yes
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Cocks
I Non-operative for 6 h then reassess
I Any of Enlarged subdiaphragmatic gas shadow Contrast radiology gastrografin leak Patient's condition deteriorates Other complication
No
I
I Early surgery'
spontaneous sealing, they should be submit ted to immediate surgery, after initial ade quate resuscitation. Nevertheless, the deliberative technique is appropriate for the remainder of patients, about 80% of whose ulcers will seal sponta neously, and only 20% will require surgical intervention for their episode of perforation [13,14], A suggested algorithm for the management of an episode of perforation is seen in table 3.
Others
Continue non-operative
Notwithstanding the fact that many pa tients can be treated non-operatively, perfo rated peptic ulcer remains a serious surgical problem. Silen [53] stated, and our group would agree, that it would be dangerous to embark on a policy of non-operative treat ment without the surgeon being involved from the time the patient is first seen, and the patient should continue to be under senior surgical care [53].
Perforated Peptic Ulcer
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Consider definitive ulcer operation
Deliberative
Subsequently, after successful non-opera tive. or simple suture management, about 4367% of ulcers will not heal, or will recur, and thus require further medical or surgical man agement [11, 34], It has been suggested that if a patient still has symptoms 3-12 months after a perforation, consideration should be given to elective definitive ulcer surgery at that stage, in order to prevent further ulcer complications [54], More recently, laparoscopic techniques have been introduced for cholecystectomy, in both elective and emergency circumstances. These techniques have also been tried for per forated ulcers attaching omentum to the site of perforation with an adhesive agent. These techniques also provide for a very adequate and thorough peritoneal toilet. While results of these early endeavours have not yet been published, these techniques are less invasive, and may provide an exciting armamentarium for surgeons in the future, in the emergency management of patients with perforated pep tic ulcer, particularly for the elderly.
Conclusion The management of perforated peptic ul cer is an ever-changing scene. Whereas pre vious debate hinged on the role of immediate definitive surgery, recent emphasis has been on the management of the more elderly popu lation. the interaction of the HyRAs. and now the anti-Helicobacter drugs. With this shift in the population at risk, many of whom are taking NSAIDs. a reassess ment of the more conservative modes of ther apy has occurred. A suggested deliberative plan of manage ment has been presented, with the possibility that the less invasive laparoscopic techniques may be the way for the future, in those in whom the more conservative measures fail in the defined 6- to 12-hour resuscitation period.
1 Taylor H, Guest Lecture: The nonsurgical treatment of perforated peptic ulcer. Gastroenterology 1957: 33:353-368. 2 Editorial: Conservative manage ment of perforated peptic ulcer. Lancet 1989:ii: 1429-1430. 3 DeBakev ME: Acute perforated gas troduodenal ulceration: A statistical analysis and review of the literature. Surgery 1940:8:852-884. 4 Visick AH: Conservative treatment of acute perforated peptic ulcer. Br Med J 1946:2:941-944. 5 Luer CA: Acute perforation of stom ach and small intestine. Surgery 1949;25:404-419. 6 Desmond AM: Perforated peptic ul cer: Selective gastric resection in emergency treatment. Calif Med 1962:96:315-320.
7 Desmond AM. Seargeant PW: The place of primary gastric resection in the treatment of perforated peptic ulcer. Br J Surg 1957:45:283-286. 8 Watkins RM. Dennison AR. Collin J: What has happened to perforated peptic ulcer? Br J Surg 1984:71: 774-776. 9 Hugh TB. Donellan M. Fagan PA: Perforated peptic ulcer. Med J Aust 1969:0:837-840. 10 Donaldson GA. Jarrett F: Perfo rated gastro-duodenal ulcer disease at the Massachussetts General Hos pital 1952-1970. Am J Surg 1970: 120:306-311. 11 Nemanich GJ. Nicoloff DM: Perfo rated duodenal ulcer: Long-term fol low-up. Surgery 1970:67:727-734.
12 Anselme P: Perforated peptic ulcer: An analysis of 246 cases. Aust NZ J Surg 1977:47:81-85. 13 Keane TE. Dillon B. Afdhal NH. ct at: Conservative management of perforated duodena! ulcer. Br J Surg 1988:75:583-584. 14 Cocks JR. Kernutt RH. Sinclair GW. el al: Perforated peptic ulcer: A deliberative approach. Aust NZ J Surg 1989;59:379-385. 15 Crofts TJ. Park KG. Steele RJ. et al: A randomised trial of non-operative treatment for perforated peptic ul cer. N Engl J Med 1989:320:970973. 16 Rigg KM. Stuart RC. Rosenberg IL: Conservative management of perfo rated peptic ulcer. Lancet 1990: 335:673.
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References
30 Goggon D. Lambert P. l.angman M: 20 years of hospital admission for peptic ulcer in England and Wales. Lancet 1981 :i: 1302-1304. 31 Cohen MM: Treatment and mortal ity of perforated peptic ulcer - A survey of 852 cases. Can Med Ass .1 1971:'l 05:263-269. 32 Irvin T: Mortality and perforated peptic ulcer: Case for risk stratifica tion in elderly patients. Br .1 Surg 1989:76:215-218. 33 Ball AB, Thomas PA. Evans SJ: Operative mortality after perforated peptic ulcer. Br J Surg 1989:76:521522. 34 Kay PH, Moore KT. Clarke RG: The treatment of perforated duode nal ulcer. Br J Surg 1978:65:801 — 803. 35 Illingworth CF, Scott LD. Jamieson RA: Progress after perforated peptic ulcer. Br Med J 1946; 1:787-'»90. 36 Cassell P: The prognosis of the acute duodenal ulcer. Gut 1969; 10:572— 574. 37 Dark JH. MacArthur K: Perforated peptic ulcer in South West Scotland 1966-1980. J R Coll Surg Edinb 1983:28:19-23. 38 Schein M. Saadia R. Jamieson J, et al: Perforated gastric ulcers. A retro spective study of 32 patients. Am Surg 1986:52:551-554. 39 McGee G. Sawyers J: Perforated gastric ulcers. Arch Surg 1987:122: 555-561. 40 Heslop TS. Bullough AS. Burn C: The treatment of perforated ulcer: A comparison of two parallel unse lected groups. BrJ Surg 1952:40:52— 58. 41 Lanng C, Palnaes Hansen C, Chris tensen A. et al: Perforated gastric ulcer. BrJ Surg 1988:75:758-759. 42 Svanes C. Salvcsen H, Espehaug B. ct al: A multifactorial analysis of fac tors related to lethality after treat ment of perforated gastro-duodenal ulcer. Ann Surg 1989:209:418-423. 43 Simpson CJ. Lamont G. Macdonald I. et al: Effect of cimetidinc on prog nosis after simple closure of perfo rated duodenal ulcer. Br J Surg 1987:74:104-105.
44 Bornman P. Theodorou N, Jeffery P. cl al: Simple closure of perforated duodenal ulcer: A prospective evalu ation of a conservative management policy. BrJ Surg 1990;77:73-75. 45 Gillen P. Ryan W, Peel AL. et al: Duodenal ulcer perforation - The effect of Hi antagonists? Ann R Coll Surg Engl ¡986:68:240-242. 46 Sherlock DJ. Holl-Allen RT: Duo denal ulcer perforation whilst on cimetidine therapy. Br J Surg 1984: 71:586-588. 47 Armstrong CP. Blower AL: Non-ste roidal anti-inflammatory drugs and life threatening complications of peptic ulceration. Gut 1987:28:527— 532. 48 Smedlcy FH. Taube M. Leach R. et al: Non-steroidal anti-inflammatory drug ingestion: Retrospective study of 272 bleeding or perforated peptic ulcers. Postgrad Med .1 1989:65: 892-895. 49 Pariente EA: Non-operative treat ment of perforated peptic ulcer. N Engl .1 Med 1989:321:1050. 50 George LL. Borody TJ. Andrews P. et al: Cure of duodenal ulcer after eradication of Helicobacter pylori. Med J Aust 1990:153:145-149. 51 Lane MR. Lee SP: Recurrence of duodenal ulcer after medical treat ment. Lancet 1988;i: 1147—1149. 52 Kristensen ES: Conservative treat ment of 155 cases of perforated pep tic ulcer. Acta Clin Scand 1980:146: 189-193. 53 Silen W: Non-operative treatment for perforated peptic ulcer. N Engl J Med 1989:321:1050. 54 King PM, Ross AH: Perforated duo denal ulcer: Long term results of omental patch closure. J R Coll Surg Edinb 1987;32:79-83.
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Perforated Peptic Ulcer
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17 Bccnc TV. Donovan AJ: Non-oper ative treatment of perforated duode nal ulcer. Arch Surg 1989:124:830— 832. 18 Jordan GL Jr. DeBakey ME. Dun can JM Jr: Surgical management of perforated peptic ulcer. Ann Surg 1974:179:628-633. 19 Boey J. Wong J. Ong GB: A prospec tive study of operative risk factors in perforated duodenal ulcers. Ann Surg 1982:195:265-269. 20 Sawyers Jl.. Herrington JL. Mulheim JL Jr. et al: Acute perforated duodenal ulcer: An evaluation of surgical management. Arch Surg 1975;110:527-530. 21 Coutsoftides T. Himal HS: Perfo rated gastroduodenal ulcers. Am .1 Surg 1976:132:575-576. 22 Boev J. Wong J: Perforated duode nal ulcers. World J Surg 1987:11 : 319-324. 23 Raintes SA. Devlin HB: Perforated duodenal ulcer. Br J Surg 1987:74: 81-82. 24 Boey J. Lee N, Koo J. el al: Imme diate definitive surgery for perfo rated duodenal ulcers: A prospective controlled trial. Ann Surg 1982:196: 338-344. 25 Steiger E. Cooperman AM: Consid erations in the management of per forated peptic ulcers. Surg Clin North Am 1976:56:1395-1401. 26 Jordan PH Jr: Proximal gastric va gotomy without drainage for treat ment of perforated duodenal ulcer. Gastroenterology 1982:83:179-183. 27 Sawyers JL. Herrington JL Jr: Perfo rated duodenal ulcer managed by proximal gastric vagotomy and su ture plication. Ann Surg 1977:185: 656-660. 28 Gorcy T. Lennon F, Heffcman S: Highly selective vagotomy and duo denal ulceration and its complica tions: A 12-year review. Ann Surg 1984:200:181-184. 29 Donovan AJ. Vinson TL, Maulsby GO. et al: Selective treatment of du odenal ulcer with perforation. Ann Surg 1979:189:627-636.
Department of General Surgery. Box Hill Hospital. Melbourne. Australia
Keywords Non-operative Deliberative Anti-secretory agents Non-steroidal anti inflammatory drugs Anti-helicobacter drugs
Perforated Peptic Ulcer The Changing Scene
Abstract
There is a changing scene with perforated peptic ulcer. The older age of presentation, the increased association with non steroidal anti-inflammatory drugs, associated increased debil ity, and resulting higher mortality in the elderly, are causing a rethink in management protocols. Whereas years ago most discussion was on whether urgent definitive surgery was the most effective therapy, nowadays there is a tendency to less invasive measures. A ‘deliberative’ approach, wherein not all patients require surgery, is detailed, and there may be an increasing role for laparoscopic perforation-sealing techniques in the remainder. Anti-secretory and anti-helicobacter drugs have an important role in post-operative care following lesser procedures than definitive surgery.
In 1957. Hermon Taylor [ 1] challenged the traditional concept of simple suture and omental plug formation for the routine emer gency management of a patient with a perfo rated ulcer. He suggested that cessation of spillage of gastroduodenal contents into the peritoneal cavity could equally be achieved by keeping the stomach empty with well-placed nasogastric suction and appropriate intrave nous resuscitation. Reporting on 256 cases, he suggested that 80% had sealed spontaneously and were successfully managed non-operatively for their episode of perforation. He reported an overall mortality of 11 % - al
though this was only 5% if moribund patients were excluded. These figures compared with those of simple suture at that time of up to 20% [2- 6]. Others have tried the non-operative tech nique. but most have tended to reserve this for groups of patients unfit for surgery and. not surprisingly, the results were poor [7-12], More recently there has been a resurgence of interest in this approach, driven particu larly by the increasing age of patients present ing with perforated ulcers. Selected mortality rates of 2.4-5% have been reported [13-17], which are comparable to those of simple su-
John R. Cocks Department of General Surgery Box Hill Hospital Melbourne 3128 (Australia)
© 1992 S. Kargcr AG. Basel 0257-2753/92/ 0101-001052.75/0
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John R. Cocks
shock, other intercurrent illness, and ulti mately, mortality [6, 8. 22, 31.32]. Boey and Wong [22] have defined 3 risk factors for patients with perforated ulcer associated severe illness, pre-operative shock, and a history of perforation greater than 24 h and point out that if none of these 3 risk fac tors is present, the mortality will be 0.4%: if 1. 4.2%; if 2. 40%; and if all 3 risk factors are present, the mortality will be 87% [22], These figures have been elicited for perforated duo denal ulcer, and it is also recognised that there is a generally worse outlook for patients with perforated gastric ulcers [38-42], Mortality rates of up to 28% have been reported in recent years, and particularly is the mortality high if definitive surgery is per formed on the elderly [2. 8, 32]. Secondly, antisecretory agents such as histamine-2 receptor antagonists (H2RAs) and omeprazole have been introduced. These drugs have had the effect of healing ulcers ini tially. but have high recurrence rates. This has had the effect of delaying in time, the onset of complications of ulcer, and contributing to the rise in average age of patients presenting with perforation. They also play a role in the continuing care of the patient with perforation. It has been suggested that, except in specific circum stances. emergency definitive surgery should no longer be an option for perforation, when simple suture and subsequent H2RAs can pro vide such long-term relief, even with chronic ulcers [23, 43. 44], Others have suggested, however, that these drugs make no difference to the rate of recurrence of symptoms leading to definitive surgery, following simple suture of a perforation [45]. However, if a major operation can be avoided at the time of perfo ration, definitive surgery might properly be reserved for patients who have frequent re lapses of ulcer disease while on subsequent H2RAs [46].
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ture. and definitive ulcer curative surgery [18-21], but, of course, avoiding surgery in the majority of patients. Each group has worked on the hypothesis that the continuing leakage into the peritoneal cavity needs to be stopped in the most expedi tious manner. They have shown that if a period of up to 12 h is allowed to a patient with an empty stomach, then spontaneous sealing will occur in up to 70% of cases. If. after 6-12 h. there is no spontaneous sealing, appropriate surgical therapy is advised. The delay in decision-making of 6-12 h. far from being detrimental to the patient, provides ad equate time for optimal resuscitation, and this delay does not increase mortality or mor bidity [14. 15]. However, most of the debate in the last 3 decades has been related to whether definitive surgery should be offered in the emergency circumstances, or whether simple suture should suffice. This debate has mostly been on the basis that 20-40% of patients who have had their ulcer closed by simple suture, have required definitive surgery within a few years of their perforation [11. 22-25]. There seems little doubt that definitive surgery can produce acceptable results with as little as zero mortality, when patients are selected for such major surgery, but it has been stressed the patient should be otherwise fit and young, have only perforated for a short time, and have no other intercurrent illness [18, 22,24. 26-29], Several new factors, however, have emerged in the 1980s, in an ever-changing scene. Firstly, the average age of patients in series being reported has, over the last 4 decades, gradually increased from the decade 40-50 years, to the present 60-70 years [12, 19. 3037], Box Hill Hospital’s last 40 cases have had an average age of 71.3 years. As the age of the patient rises, so do the rates of delayed presentation, pre-operative
12
Cocks
stances, and while it is probable that they have resulted in lessening mortality and mor bidity. it has not always been reflected in results. Post-operative morbidity rates for perforated ulcer have been as high as 50%, including cardiac, renal and infective pro cesses, but there does not appear to be any sta tistical difference between the complication rates of various modes of therapy [ 15]. Our group have noted that while cardiac compli cations and wound infection rates arc higher in those undergoing surgery, the chest infec tion and intraperitoneal collection rates are higher in those treated non-operatively [ 14],
Suggested Management
A perusal of the literature would suggest that almost uniformly good results can be obtained in fit patients, less than 50 years of age, with immediate simple suture, imme diate appropriate definitive surgery, or our deliberative approach and an attempt at non operative therapy, and there are protagonists for each of these actions. Perhaps the main point at issue in the 1990s, is the question of the best plan of treat ment, for those patients who are not young and fit. bearing in mind that the present mor tality for those patients over 70 years, ap proaches 34%. and may be as high as 47% [7. 32, 33]. Crofts et al. [ 15] have suggested that perfo rated ulcers in this age group are unlikely to seal spontaneously. Our results would suggest a deliberative approach may be appropriate, but the differences with these small numbers are not statistically significant (table 1). In our prospective trial which is continuing, 40 pa tients have been entered with an average age of 71.3 years, and the incidence of ulcers seal ing spontaneously is lower than the overall 68% previously described [14]. It is not clear
Perforated Peptic Ulcer
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In the emergency circumstance, definitive surgery may be advisable if the patient has a chronic ulcer which perforated while taking antisccrctory agents, if there is associated bleeding or stenosis, or if there is a perforated gastric ulcer unsuitable for simple suture and omental plugging. Thirdly, non-steroidal anti-inflammatory drugs (NSAlDs) are playing an increasing part in the aetiology of perforated ulcers. The inci dence of these drugs being ingested by pa tients presenting with perforation is increas ing. and this no doubt, is as a result of. and also contributory to. the increasing age of pre sentation [47, 48], The anti-inflammatory na ture of these drugs, decreasing oedema and reducing the accumulation of granulocytes at the focus of inflammation may well slow down, or inhibit, spontaneous sealing in those patients treated non-operatively [49]. Fourthly, the role of Helicobacter (Campy lobacter) pylori in the aetiology of. and asso ciation with, peptic ulcer is still to be com pletely evaluated. It is hoped that the good results of treatment of peptic ulcer with anti-Helicobacter drugs can be confirmed. Whereas there is a 70-90% recurrence at 3-4 years following a single course of FFRAs. it has been shown that 96% of peptic ulcers can be cured without relapse for 4 years, with a regimen of colloidal bismuth subcitrate, tetra cycline hydrochloride, and metronidazole [50. 51]. This sort of routine may well mean that the perforated ulcer purely needs to be sealed, and appropriate anti-Helicobacter therapy given post-operatively. This again would suggest that the place for definitive sur gery in the emergency management of perfo rated ulcer would be limited. Fifthly, the broadening spectrum, and in creased knowledge, of antibiotic therapy have been applied in these emergency circum stances. Antibiotics have generally been used in both operative and non-operative circum
Table 1. Mortality in patients over 70 years for per forated peptic ulcer. Box Hill Hospital. Melbourne
Mortality (1966-87) Deliberative1 n = 21 Immediate suture n = 14 Immediate definitive n = 8
3(14%) 4(29%) 5(63%)
1 'Deliberative' includes those patients who came to surgery for non-sealing in the 4- 6 h allotted.
Table 2. Protocol for deliberative management of perforated ulcer A Surgery necessary immediately, if
-
associated bleeding or stenosis doubtful diagnosis history of gastric ulcer food after perforation obstructive airways disease, asthmatic, air-gulper perforation longer than 24 h. and patient not improving pre-operative shock
B All other patients
Nasogastric tube to pylorus - half/hourly aspiration Intravenous therapy - to maintain adequate urine output Analgesics Antibiotics Investigations - exclude pancreatitis, cholecystitis, etc. Frequent observation Check subdiaphragmatic x-ray at 4-6 h and contrast radiology, gastrografin swallow Delayed surgery now necessary, if - increase in pneumoperitoneum - gastrografin leak - general condition deteriorates - other complications Try to operate within 24 h of perforation Investigation within 2 weeks - to confirm diagnosis. Reproduced with permission of Aust NZ J Surg [ 14], but modified.
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whether this is due to most patients being on NSAIDs. or whether it is purely age which is the discriminatory factor. NSAIDs did not appear to have a significantly detrimental ef fect on healing in our previous study, when the average age was 60 years. Nevertheless, if there is nothing lost by draining the stomach with naso-gastric aspira tion and adequate resuscitation for 6-12 h, it would seem appropriate to try the delibera tive technique, as outlined in table 2. It may be that more patients will require suture than in the younger age groups, but if 30-50% of the older age groups can be treated success fully non-operatively, the overall results should be improved [ 14, 15], One of the difficulties, not always reported in the literature, is the fact that some elderly patients present in a moribund state, and while they need to be included in any overall results, no form of therapy, operative or non operative, will be adequate for most of them [11,14.52], It will be noted that a non-operative rou tine is inappropriate for those presenting with (a) bleeding or stenosis, (b) doubtful diagno sis. (c) food after perforation, (d) air gulpers. and also for those (e) presenting with pre operative shock, and for those (0 who have perforated for longer than 18-24 h and whose condition is not improving. These patients need immediate operation and adequate peri toneal toilet. The remainder of patients with a clinical diagnosis of perforated ulcer are initially treated non-operatively. If surgery is required, the protocol allows for this to be performed as early as possible after perforation, but certainly within 24 h of the perforation, if achievable. The mortality rises if the perforation is unsealed for more than 12—24 h [8, 11, 22], Some patients present, however, with a history longer than 24 h, and if they are not improving, suggesting
Table 3. Algorithm Perforated ulcer
Diagnosis
Others
Fit patient < 50 years Long history of ulcer Short-time since perforation No other morbid conditions
Any of Associated bleeding or stenosis Doubtful diagnosis History' of gastric ulcer Food after perforation Obstructive airways disease, asthma > 24 h since perforation, and ill Shock at presentation
I Immediate surgery
Yes
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Cocks
I Non-operative for 6 h then reassess
I Any of Enlarged subdiaphragmatic gas shadow Contrast radiology gastrografin leak Patient's condition deteriorates Other complication
No
I
I Early surgery'
spontaneous sealing, they should be submit ted to immediate surgery, after initial ade quate resuscitation. Nevertheless, the deliberative technique is appropriate for the remainder of patients, about 80% of whose ulcers will seal sponta neously, and only 20% will require surgical intervention for their episode of perforation [13,14], A suggested algorithm for the management of an episode of perforation is seen in table 3.
Others
Continue non-operative
Notwithstanding the fact that many pa tients can be treated non-operatively, perfo rated peptic ulcer remains a serious surgical problem. Silen [53] stated, and our group would agree, that it would be dangerous to embark on a policy of non-operative treat ment without the surgeon being involved from the time the patient is first seen, and the patient should continue to be under senior surgical care [53].
Perforated Peptic Ulcer
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Consider definitive ulcer operation
Deliberative
Subsequently, after successful non-opera tive. or simple suture management, about 4367% of ulcers will not heal, or will recur, and thus require further medical or surgical man agement [11, 34], It has been suggested that if a patient still has symptoms 3-12 months after a perforation, consideration should be given to elective definitive ulcer surgery at that stage, in order to prevent further ulcer complications [54], More recently, laparoscopic techniques have been introduced for cholecystectomy, in both elective and emergency circumstances. These techniques have also been tried for per forated ulcers attaching omentum to the site of perforation with an adhesive agent. These techniques also provide for a very adequate and thorough peritoneal toilet. While results of these early endeavours have not yet been published, these techniques are less invasive, and may provide an exciting armamentarium for surgeons in the future, in the emergency management of patients with perforated pep tic ulcer, particularly for the elderly.
Conclusion The management of perforated peptic ul cer is an ever-changing scene. Whereas pre vious debate hinged on the role of immediate definitive surgery, recent emphasis has been on the management of the more elderly popu lation. the interaction of the HyRAs. and now the anti-Helicobacter drugs. With this shift in the population at risk, many of whom are taking NSAIDs. a reassess ment of the more conservative modes of ther apy has occurred. A suggested deliberative plan of manage ment has been presented, with the possibility that the less invasive laparoscopic techniques may be the way for the future, in those in whom the more conservative measures fail in the defined 6- to 12-hour resuscitation period.
1 Taylor H, Guest Lecture: The nonsurgical treatment of perforated peptic ulcer. Gastroenterology 1957: 33:353-368. 2 Editorial: Conservative manage ment of perforated peptic ulcer. Lancet 1989:ii: 1429-1430. 3 DeBakev ME: Acute perforated gas troduodenal ulceration: A statistical analysis and review of the literature. Surgery 1940:8:852-884. 4 Visick AH: Conservative treatment of acute perforated peptic ulcer. Br Med J 1946:2:941-944. 5 Luer CA: Acute perforation of stom ach and small intestine. Surgery 1949;25:404-419. 6 Desmond AM: Perforated peptic ul cer: Selective gastric resection in emergency treatment. Calif Med 1962:96:315-320.
7 Desmond AM. Seargeant PW: The place of primary gastric resection in the treatment of perforated peptic ulcer. Br J Surg 1957:45:283-286. 8 Watkins RM. Dennison AR. Collin J: What has happened to perforated peptic ulcer? Br J Surg 1984:71: 774-776. 9 Hugh TB. Donellan M. Fagan PA: Perforated peptic ulcer. Med J Aust 1969:0:837-840. 10 Donaldson GA. Jarrett F: Perfo rated gastro-duodenal ulcer disease at the Massachussetts General Hos pital 1952-1970. Am J Surg 1970: 120:306-311. 11 Nemanich GJ. Nicoloff DM: Perfo rated duodenal ulcer: Long-term fol low-up. Surgery 1970:67:727-734.
12 Anselme P: Perforated peptic ulcer: An analysis of 246 cases. Aust NZ J Surg 1977:47:81-85. 13 Keane TE. Dillon B. Afdhal NH. ct at: Conservative management of perforated duodena! ulcer. Br J Surg 1988:75:583-584. 14 Cocks JR. Kernutt RH. Sinclair GW. el al: Perforated peptic ulcer: A deliberative approach. Aust NZ J Surg 1989;59:379-385. 15 Crofts TJ. Park KG. Steele RJ. et al: A randomised trial of non-operative treatment for perforated peptic ul cer. N Engl J Med 1989:320:970973. 16 Rigg KM. Stuart RC. Rosenberg IL: Conservative management of perfo rated peptic ulcer. Lancet 1990: 335:673.
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References
30 Goggon D. Lambert P. l.angman M: 20 years of hospital admission for peptic ulcer in England and Wales. Lancet 1981 :i: 1302-1304. 31 Cohen MM: Treatment and mortal ity of perforated peptic ulcer - A survey of 852 cases. Can Med Ass .1 1971:'l 05:263-269. 32 Irvin T: Mortality and perforated peptic ulcer: Case for risk stratifica tion in elderly patients. Br .1 Surg 1989:76:215-218. 33 Ball AB, Thomas PA. Evans SJ: Operative mortality after perforated peptic ulcer. Br J Surg 1989:76:521522. 34 Kay PH, Moore KT. Clarke RG: The treatment of perforated duode nal ulcer. Br J Surg 1978:65:801 — 803. 35 Illingworth CF, Scott LD. Jamieson RA: Progress after perforated peptic ulcer. Br Med J 1946; 1:787-'»90. 36 Cassell P: The prognosis of the acute duodenal ulcer. Gut 1969; 10:572— 574. 37 Dark JH. MacArthur K: Perforated peptic ulcer in South West Scotland 1966-1980. J R Coll Surg Edinb 1983:28:19-23. 38 Schein M. Saadia R. Jamieson J, et al: Perforated gastric ulcers. A retro spective study of 32 patients. Am Surg 1986:52:551-554. 39 McGee G. Sawyers J: Perforated gastric ulcers. Arch Surg 1987:122: 555-561. 40 Heslop TS. Bullough AS. Burn C: The treatment of perforated ulcer: A comparison of two parallel unse lected groups. BrJ Surg 1952:40:52— 58. 41 Lanng C, Palnaes Hansen C, Chris tensen A. et al: Perforated gastric ulcer. BrJ Surg 1988:75:758-759. 42 Svanes C. Salvcsen H, Espehaug B. ct al: A multifactorial analysis of fac tors related to lethality after treat ment of perforated gastro-duodenal ulcer. Ann Surg 1989:209:418-423. 43 Simpson CJ. Lamont G. Macdonald I. et al: Effect of cimetidinc on prog nosis after simple closure of perfo rated duodenal ulcer. Br J Surg 1987:74:104-105.
44 Bornman P. Theodorou N, Jeffery P. cl al: Simple closure of perforated duodenal ulcer: A prospective evalu ation of a conservative management policy. BrJ Surg 1990;77:73-75. 45 Gillen P. Ryan W, Peel AL. et al: Duodenal ulcer perforation - The effect of Hi antagonists? Ann R Coll Surg Engl ¡986:68:240-242. 46 Sherlock DJ. Holl-Allen RT: Duo denal ulcer perforation whilst on cimetidine therapy. Br J Surg 1984: 71:586-588. 47 Armstrong CP. Blower AL: Non-ste roidal anti-inflammatory drugs and life threatening complications of peptic ulceration. Gut 1987:28:527— 532. 48 Smedlcy FH. Taube M. Leach R. et al: Non-steroidal anti-inflammatory drug ingestion: Retrospective study of 272 bleeding or perforated peptic ulcers. Postgrad Med .1 1989:65: 892-895. 49 Pariente EA: Non-operative treat ment of perforated peptic ulcer. N Engl .1 Med 1989:321:1050. 50 George LL. Borody TJ. Andrews P. et al: Cure of duodenal ulcer after eradication of Helicobacter pylori. Med J Aust 1990:153:145-149. 51 Lane MR. Lee SP: Recurrence of duodenal ulcer after medical treat ment. Lancet 1988;i: 1147—1149. 52 Kristensen ES: Conservative treat ment of 155 cases of perforated pep tic ulcer. Acta Clin Scand 1980:146: 189-193. 53 Silen W: Non-operative treatment for perforated peptic ulcer. N Engl J Med 1989:321:1050. 54 King PM, Ross AH: Perforated duo denal ulcer: Long term results of omental patch closure. J R Coll Surg Edinb 1987;32:79-83.
16
Cocks
Perforated Peptic Ulcer
Downloaded by: Karolinska Institutet, University Library 130.237.122.245 - 8/28/2018 3:46:08 AM
17 Bccnc TV. Donovan AJ: Non-oper ative treatment of perforated duode nal ulcer. Arch Surg 1989:124:830— 832. 18 Jordan GL Jr. DeBakey ME. Dun can JM Jr: Surgical management of perforated peptic ulcer. Ann Surg 1974:179:628-633. 19 Boey J. Wong J. Ong GB: A prospec tive study of operative risk factors in perforated duodenal ulcers. Ann Surg 1982:195:265-269. 20 Sawyers Jl.. Herrington JL. Mulheim JL Jr. et al: Acute perforated duodenal ulcer: An evaluation of surgical management. Arch Surg 1975;110:527-530. 21 Coutsoftides T. Himal HS: Perfo rated gastroduodenal ulcers. Am .1 Surg 1976:132:575-576. 22 Boev J. Wong J: Perforated duode nal ulcers. World J Surg 1987:11 : 319-324. 23 Raintes SA. Devlin HB: Perforated duodenal ulcer. Br J Surg 1987:74: 81-82. 24 Boey J. Lee N, Koo J. el al: Imme diate definitive surgery for perfo rated duodenal ulcers: A prospective controlled trial. Ann Surg 1982:196: 338-344. 25 Steiger E. Cooperman AM: Consid erations in the management of per forated peptic ulcers. Surg Clin North Am 1976:56:1395-1401. 26 Jordan PH Jr: Proximal gastric va gotomy without drainage for treat ment of perforated duodenal ulcer. Gastroenterology 1982:83:179-183. 27 Sawyers JL. Herrington JL Jr: Perfo rated duodenal ulcer managed by proximal gastric vagotomy and su ture plication. Ann Surg 1977:185: 656-660. 28 Gorcy T. Lennon F, Heffcman S: Highly selective vagotomy and duo denal ulceration and its complica tions: A 12-year review. Ann Surg 1984:200:181-184. 29 Donovan AJ. Vinson TL, Maulsby GO. et al: Selective treatment of du odenal ulcer with perforation. Ann Surg 1979:189:627-636.
