Perforated gastric and duodenal ulcers: An analysis of 200 consecutive cases

Abstract

Two hundred patients with perforated ulcers of the stomach and duodenum were seen at University Hospital in a twelve-year period. The overall mortality rate was 26 per cent and 20 per cent for those who underwent operation. Sex, race and seasonal relationship did not show any prognostic trends in this series. The age of the patient was quite important in that the mortality rate rose with the age of the patient. The youngest patient was nineteen and the oldest seventy-six years of age. Sixty-two per cent of the patients were classified as laborers and the absence of the high-strung “ulcer type” patient was noted. Eighty-nine per cent of the patients had a history of previous gastric disturbances and 30 per cent a past history of moderate use of alcohol. Correct diagnosis was made in 95.5 per cent of cases by use of history and examination which revealed a board-like rigidity of the abdomen, muscle spasm, a quiet abdomen by auscultation, leukocytosis and x-ray evidence of free air in the peritoneal cavity. The most commonly used anesthetic was spinal and with it the patient mortality was lower (12 per cent) than that of general (21 per cent) and the combination of general and spinal (42 per cent). The abdomen was opened in many ways and the transverse incision was virtually abandoned after 1938. The right upper rectus incision became the popular choice followed closely by the right upper paramedian. Both of these incisions gave adequate exposure. The ulcer perforation was found to be gastric in 45.5 per cent, duodenal in 39.5 per cent and pyloric in 15 per cent of the patients. The lowest mortality rate was noted with the pyloric perforations and the highest with the duodenal perforations. (Table VI.) Three perforated malignant lesions were found and those patients died following closure of the perforation. During the series the more complicated procedures, such as multiple layer closure of the perforation and posterior gastro-enterostomy, were discarded for the simple, single layer closure and the omental graft because of a mounting mortality rate and more frequent complications. Suprapubic drainage has not been used for eight years and of the three deaths complicated by mechanical intestinal obstruction suprapubic drainage was present in each case. Post-operative therapy now consists of gastric siphonage for at least twelve to forty-eight hours, sips of water twelve hours postoperatively, adequate parenteral feedings with vitamins and amino acid preparations, chemotherapeutic and antibiotic agents prophylactically to combat and prevent peritonitis, wound infections and the pneumonities.