Perforated duodenal ulcers

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Abstract
The incidence of perforation, complicating about 5% of duodenal ulcers, has not decreased proportional to the overall decline in peptic ulcer disease. To define the role of immediate definitive surgery, we conducted several prospective studies to identify risk factors that increase operative mortality as well as predictive factors associated with relapse after simple closure. Among 613 consecutive patients, major medical illnesses, preoperative shock, and perforations exceeding 24 hours' duration were found to be determinant variables that allowed stratification of patients into different risk groups. Definitive surgery or simple closure in the absence of any risk factor had a mortality rate of less than 0.7%, whereas even closure alone incurred a mortality rate of 86.7% when all 3 risk factors were present.The need for definitive surgery was assessed by comparing relapse rates after closure in patients who differed in respect to the chronicity, age at onset, and family history of their ulcer disease. Multivariate analysis revealed chronicity and a positive family history to be the most useful independent predictors of the likelihood of relapse after closure. The benefits of definitive surgery for perforations in chronic lesions were corroborated by a prospective controlled trial in which proximal gastric vagotomy with closure or truncal vagotomy with gastric drainage each proved as safe as closure alone but significantly more effective in reducing the frequency of relapse after operation.Immediate nonresective definitive surgery is indicated in fit individuals who have perforations in chronic duodenal ulcers; however, closure alone is more prudent in patients who have any risk factor.

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