A Clinical Study of Duodenal Perforations

 

Article By:

R. P. Raut Dessai

S. K. Parashar

A.M.P. Dharwadkar

 

This Paper was read at the XXV (Silver Jubilee) Annual Conference of the International College of Surgeons Indian Section held at Panaji, Goa on September 29 – October 1, 1979

 

This article has been reproduced from the April 1980 Issue, Vol. 44, No. 8, “The Clinician”. Permission has been obtained from Dr. A.M.P. Dharwadkar for reprint of this article.

 

“We have no responsibility to such patients but to save their lives. Any procedure…… which aims to do more than this can quite justifiably be called meddle-some surgery. We have no responsibility during surgery to carry out any procedure designed to cure the patient of his original duodenal ulcer.”

 

Introduction :

Time has changed much since Roscoe Graham published his results of 51 cases of perforated duodenal ulcers treated by suture plication (Graham’s procedure).[1] A better understanding of the pathophysiology involved in the process, improved operative techniques and materials, and improvements in anaesthesia have helped the present day surgeons to carry out more definitive procedures with relative impunity. We are presenting our experience in the management of perforation of duodenal ulcers treated at the Panaji hospital of Goa Medical College.

 

Materials and Methods:

From January 1975 to July 1979, a total of 65 cases  of  duodenal  perforations  were admitted. Of these, 56 were male and 9 were female. It was noted that duodenal ulcer perforations were more common in the 4th and 5th decades. The youngest patient was 21 years and the oldest was 75 years (Table 1).

TC- Oct 2016 - 025 - Age groups of all cases of duodenal ulcer

 

CLINICAL PRESENTATION:

Pain was the commonest symptom, present in all 65 cases, but typical pain was present in only 56 of the 65 cases. It is said that vomiting is absent in cases of perforation. However, we observed that a substantial number of our cases (38.36%) had vomiting. Other features are shown in Table 2.

 

TC- Oct 2016 - 026 - Clinical presentation of the 65 cases of duodenal ulcer

* Out of 65 cases that presented with pain as a symptom

 

RADIOLOGICAL FINDINGS:

A plain X-Ray of abdomen in erect posture was the single most important diagnostic investigation. It was done in 53 cases and gas was demonstrated in 42 cases (79.24%) X-Ray can be misleading as in eight of our patients with perforation, gas was not demonstrated Table 3.

TC- Oct 2016 - 027 - Radiological findings of 65 cases of duodenal ulcer

 

TREATMENT:

A total of 62 out of 65 cases were treated surgically. In one patient the medical condition was too bad to withstand any surgical procedure and in the remaining two cases the diagnosis was made only postmortem. The types of surgical procedure done are shown in Table 4.

TC- Oct 2016 - 028 - Surgical treatment in 62 cases

* out of 15 cases with primary procedure

 

Fifteen cases were treated by a definitive procedure. The main criteria adopted for selection of cases for a primary procedure were a good to fair general condition, minimal peritoneal soilage and presence of peristalsis. Duration of perforation and age of patient had no bearing on selection.

 

Results (Table 5):

Post-operatively there were nine deaths amongst the 44 cases treated by suture-plication (20.46%) whereas in the group treated by a definitive procedure there was one death due to lung abcess (6.67%). This however does not suggest that definitive procedures reduce mortality since most of the cases that were selected for a primary procedure were unfit to undergo definitive procedures and some of them were quite severe. The minimum period of follow-up was 4 months and maximum was 4 years.

Of the 35 cases that survived after only suture plication, 18 continued to have ulcer symptoms. Of these patients, three had to be re-operated (6.87%). The remaining fifteen patients (34.09%) are continuing on medical treatment. Only 5 cases (11.36%) treated by simple plication reported being completely symptom free. Twelve cases who did not come for follow-up however replied to us complaining that they continued to have ulcer symptoms but were unable to continue medical treatment because of the heavy cost and could not come for repeat surgery as it would interfere with their daily earning schedule.

In the group of 15 patients treated by a definitive procedure there was only one post-operative death due to lung abscess; Seven patients (46.67%) reported being completely symptom free and another seven (46.67%) did not come for follow-up.

TC- Oct 2016 - 029 - Follow-up results based on type of surgery performed

 

Discussion:

Comparative studies between simple plication and definitive procedures for perforated duodenal ulcers have been done at many medical centers and more and more surgeons are now favouring a definitive surgical procedure.[2-7]

Playforth and MacMohan[8] are of the opinion that there are serious limitations to the use of simple suture plication in the treatment of perforated duodenal ulcer[6] because it fails to check the ulcerogenic process and therefore, exposes the patients to the definite risk of further serious ulcer complication. In fact, they suggest  that a  lower  operative mortality might result from the addition of a definitive procedure in those patients who are able to accept the extra operating time and where necessary surgical expertise is available.

Our experience shows that 50% of patients treated by suture plication alone come back with ulcer symptoms and have to remain on medical treatment or undergo definitive surgery, and most of them cannot afford a long term medical treatment.

None of our patients in whom definitive procedure was done reported with ulcer symptoms. Considering the cost of long term medical treatment or a second operation, we feel that a definitive surgical procedure should be carried out wherever possible.

 

Conclusion :

We have presented 65 cases of perforated duodenal ulcers, 62 of which were treated by surgery. 44 patients were treated by suture plication alone and in 15 patients a definitive procedure was done. Operative and post-operative mortality was low (1 death in 15) when a definitive procedure was done.

Fifty percent of patients who were treated by simple suture plication alone came back with ulcer symptoms but none amongst those that were treated by a definitive procedure. By doing a definitive procedure, the heavy cost of long term medical treatment or a second operation can be avoided. We therefore recommend that a definitive surgical procedure should be added to simple closure whenever indicated.

 

Acknowledgements :

We thank the Dean of Goa Medical College for allowing us to publish this paper.

 

TC- Oct 2016 - 030 - Writers Art pg 28

 

References:

  1. Graham RR. (1937). Quoted by Playforth and Mc Mahon, 1978.
  2. Griffin GE, Organ CH. The natural history of the perforated duodenal ulcer treated by suture plication. Ann Surg. 1976;183:382.
  3. Herbert (1969). Quoted by Steiger and Cooperman 1976.
  4. Jordan GL Jr. Debakey ME, Duncan JM Jr. Surgical management of perforated peptic ulcer. Ann Surg. 1974; 179:628.
  5. McEwan AJ, Milligan GF (1978) Quoted by Steiger and Cooperman, 1976
  6. Reimers J. (1967) Quoted by Steigers and Cooperman 1976
  7. Wangensteen SL, Wray RC, Golden GT. Perforated duodenal ulcers. Amer. J. Surg. 1972:123:538.
  8. Playforth, MJ, McMahon MJ. The indications for simple closure of perforated duodenal ulcer. Brit J. Surg. 1978;65:99
  9. Steiger E. Cooperman AM. Considerations in the management of perforated peptic ulcers. Surg Clin. N. Amer. 1976;56:1395.