NON-OPERATIVE TREATMENT FOR PERFORATED DUODENAL ULCER

Abstract

The aim of this study is to review our recent experience with selective non-operative management of perforated duodenal ulcers (PDU). The patients included in this study had PDU treated non-operatively between 1995–2002. The protocol for the management of PDU has been developed based on experience at our department. Our policy of the selective treatment for PDU was that patients over 65 years old had immediate laparoscopic omental patch repair (LOPR) and the other was selected non-operative management. Non-operative management consisted of intravenous fluids, broad-spectrum antibiotics, nasogastric tube suction (occasionally) ultrasound guided percutaneous drainage of intraperitoneal fluids (occasionally) and H2 blockers. All patients had emergency endoscopies before treatments and were made diagnoses of PDU. If evidence of peritonitis progressed, or if there was not evidence of regression by 24–48 hours, laparoscopic surgery was indicated. Endosopic examination was performed on about 4–5th day, and if the perforation sealing was confirmed, oral diet resumption was then started. Helicobacter pylori (HP) status was checked after discharge. One hundred twenty-six PDU patients were evaluated. The patients ranged in age from 17 to 99 years old, with a mean age of 49 years. Males predominated in a ratio of 4:1. Ninety-nine (79%) of the 126 cases with PDU had non-operative treatment. There were 85 men and 14 women. Non-operative treatment was abandoned in 9 cases (9%) due to deteriorating peritonitis and converted to laparoscopic interventions. Mean hospital stay for the 27 patients treated operatively was 30+-22 days; the mean hospital day of the 99 patients primarily treated non-operatively was 20+-11 days. Re-perforation did not occur. The overall mortality rate was 7%. The mortality rate for the patients treated operatively was 26%; the mortality of the patients primarily treated non-operatively was 2%. The1death in this latter group occurred in a man with cardiopulmonary arrest on arrival and the other death occurred in a man with chronic pulmonary failure. Overall positive rate of IgG and HP status was 73 and 56%, respectively. Non-operative management for the relatively younger patients with PDU can be safely performed. We emphasize in our study the labour intensive process that is required to achieve acceptable results.