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.
Résume
La fréquence de la perforation qui complique environ 5% des ulcères duodénaux n'a pas diminuée proportionnellement à la diminution globale de la maladie ulcéreuse. Pour définir la place du traitement chirurgical immédiat et définitif, les auteurs ont conduit plusieurs études prospectives de manière à identifier les facteurs de risque qui augmentent la mortalité opératoire ainsi que les facteurs associés à la récidive après simple suture de la perforation. Parmi une série consécutive de 613 malades plusieurs faits: une affection médicale majeure, un état de choc, une perforation datant de plus de 24 heures ont constitué des variables déterminantes permettant une classification de malades en groupes différents de risques. L'exérèse gastrique aussi bien que la simple suture a entrainé un taux de mortalité inférieur à 0.7% alors que ce taux a atteint 86.7% après simple suture dès lors que les 3 facteurs de risque étaient reunis.
La nécessité d'un traitement chirurgical définitif a été évaluée en comparant les taux de récidive après simple suture en fonction de la chronicité, de l'âge au début, et de l'histoire familiale de la maladie ulcéreuse. L'analyse de ces variables a démontré que la chronicité et que l'existence d'une diathèse ulcéreuse familiale étaient des facteurs de pronostic qui permettaient de prévoir avec vraisemblance la récidive ulcéreuse après simple suture. Les bénéfices de la chirurgie immédiate à visée curatrice ont été corroborés par un essai contrôlé prospectif. Il a démontré que la vagotomie hautement sélective avec suture de la perforation et la vagotomie tronculaire avec opération de drainage étaient des interventions aussi bénignes que la simple suture de la perforation alors mÊme que les risques de récidive étaient réduits de manière significative.
En conclusion la chirurgie immédiate à visée curatrice, à l'exclusion de la résection, est indiquée chez le sujet en bon état général alors que la simple suture doit Être pratiquée dès qu'un facteur de risque est présent.
Resumen
La incidencia de perforatión, complicatión que ocurre en 5% de las Úlceras duodenales, no ha disminuido en forma proportional a la declination global que se observa en la enfermedad péptica. Con el objeto de definir el rol de la cirugía inmediata y definitiva, hemos realizado estudios prospectivos para identificar los factores de riesgo que aumentan la mortalidad operatoria así como factores de predictión asociados con la recurrencia que ocurre después del simple cierre o plicatión de la Úlcera perforada. En un estudio sobre 613 pacientes consecutivos, se encontró que las enfermedades graves asociadas, el shock preoperatorio, y las perforaciones de más de 24 horas fueron las variables determinantes que permitieron la categorizatión de los pacientes en diferentes grupos de riesgo. La cirugía definitiva o el cierre simple realizados en ausencia de alguno de los factores de riesgo tuvieron una tasa de mortalidad de menos de 0.7%, en tanto que el cierre o plicatión presentó una tasa de mortalidad de 86.7% cuando los 3 factores estuvieron presentes.
La necesidad de cirugía definitiva fue evaluada mediante el análisis de las tasas de recurrencia después de cierre simple en pacientes que exhibían diferencias en cuanto a cronicidad, edad al comienzo de la enfermedad, e historia familiar. El análisis multivariable reveló que la cronicidad y una historia familiar definitiva fueron los factores de predictión independientes de posibilidad de recurrencia después del cierre simple. Los beneficios de la cirugía definitiva para casos de perforatión en lesiones crónicas fue corroborado mediante un ensayo clínico prospectivo y controlado en el cual la vagotomía gástrica proximal simultánea con el cierre o la vagotomía troncular con drenaje gástrico, probaron ser tan seguras como el cierre solo, pero significativamente más efectivas en cuanto a la reducción de la frecuencia de relapso postoperatorio.
La cirugía immediata de tipo no resectivo está indicada en pacientes en buen estado que desarrollan perforation de Úlceras duodenales crónicas. Sin embargo, el cierre representa una conducta más prudente en pacientes que presentan cualquiera de los factores de riesgo.
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Supported by grants from the University and Medical Faculty Research Grants Committee, University of Hong Kong.
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Boey, J., Wong, J. Perforated duodenal ulcers. World J. Surg. 11, 319–324 (1987). https://doi.org/10.1007/BF01658109
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DOI: https://doi.org/10.1007/BF01658109