The management of perforated duodenal ulcers: operative vs non-operative?

Chung KT, Shelat VG. Perforated peptic ulcer – an update. World J Gastrointest Surg. 2017 Jan 27;9(1):1-12. doi: 10.4240/wjgs.v9.i1.1.

Mortality is a serious complication in PPU. As we mentioned before, PPU carries a mortality ranging from 1.3% to 20%[9,10]. Other studies have also reported 30-d mortality rate reaching 20% and 90-d mortality rate of up to 30%[11,12].

Significant risk factors that lead to death are presence of shock at admission, co-morbidities, resection surgery, female, elderly patients, a delay presentation of more than 24 h, metabolic acidosis, acute renal failure, hypoalbuminemia, being underweight and smokers[11,127-131]. The mortality rate is as high as 12%-47% in elderly patients undergoing PPU surgery[132-134]. Patients older than 65 year-old were associated with higher mortality rate when compared to younger patients (37.7% vs 1.4%)[131]. A study involving 96 patients with PPU also showed that there was a ninefold increase in postoperative complications in patients with comorbidities[119]. In another large population study, patients with diabetes had significantly increased 30-day mortality from PPU[135]. (Chung, 2017, p. 8)

Lay PL, Huang HH, Chang WK, Hsieh TY, Huang TY, Lin HH. Outcome of nonsurgical
intervention in patients with perforated peptic ulcers. Am J Emerg Med. 2016 Aug;34(8): 1556-60. doi: 10.1016/j.ajem.2016.05.045.

Full-text for Emory users.

Results: The overall mortality rate of conservative treatment was 40%. Eleven patients remained hospitalized less than 2 weeks; among them, patients with a high (≥IV) American Society of Anesthesiologists class at admission had higher mortality than those with a low (<IV) American Society of Anesthesiologists class (83.3% vs 0%, P=.015). However, when patients remained hospitalized longer than 2 weeks, the mortality rates did not differ between patients with the low and high American Society of Anesthesiologists classes. Eight patients presented with a high American Society of Anesthesiologists class, of which 3 received early enteral feeding, and all of them survived. In contrast, the survival of patients without early enteral feeding was 0%, suggesting that early enteral feeding improved survival of patients with the high American Society of Anesthesiologists class (P=.018).

CONCLUSIONS: A higher American Society of Anesthesiologists class correlated with mortality in patients undergoing conservative treatment during the first 2 weeks of hospitalization. Early enteral feeding might improve the outcome of conservative treatment in patients with high American Society of Anesthesiologists class.

Donovan AJ, Berne TV, Donovan JA. Perforated duodenal ulcer: an alternative therapeutic plan.  Arch Surg. 1998 Nov;133(11):1166-71.

Full-text for Emory users.

Perforated DU algorithm

See also: Donovan AJ, et al. Selective treatment of duodenal ulcer with perforation. Ann Surg. 1979 May;189(5):627-36.

Berne TV, Donovan AJ. Nonoperative treatment of perforated duodenal ulcer. Arch Surg. 1989 Jul;124(7):830-2.

Full-text for Emory users.

This report concerns 35 adult patients in whom perforation of a duodenal or prepyloric ulcer was treated nonoperatively between July 1979 and April 1988 at the Los Angeles County–University of Southern California Medical Center, Los Angeles. Each patient had pneumoperitoneum with clinical evidence of peritonitis, and a gastroduodenogram documented a sealed perforation. The ulcer was believed to be acute in 27 patients and chronic in 8. These 35 cases represent 12% of 294 cases of duodenal and prepyloric peptic ulcers with perforation treated during the same period. An intra-abdominal abscess developed in 1 of the 35 patients. Reperforation did not occur. The mortality rate for the 259 cases treated operatively during this period was 6.2%; the mortality rate of the 35 cases treated nonoperatively was 3%. Duodenal ulcer can be safely treated nonoperatively when a gastroduodenogram documents self-sealing.

More PubMed results on management of perforated duodenal ulcers.

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