Do perforated duodenal ulcers need an acid-decreasing surgical procedure now that omeprazole is available?

Abstract

If a chronic duodenal ulcer perforates, the choice of operation will depend on the patient's condition. Preoperative shock, concurrent medical diseases, severe generalized peritonitis, or the presence of an intra-abdominal abscess are contraindications to a definitive ulcer operation; hence, simple closure or omental patch closure is performed. Omeprazole can then be used to heal the ulcer in the early postoperative period, with long-term H2-blocker therapy to follow. The patient without a contraindication to a definitive operation should have a proximal gastric vagotomy in addition to an omental patch closure of the perforation. The addition of this procedure does not change the operative mortality rate in properly selected patients, does not cause the gastrointestinal sequelae associated with truncal vagotomy and pyloroplasty or resection, and has a low rate of recurrent ulcer in experienced hands. The presence of a synchronous posterior "kissing" duodenal ulcer would prompt some to choose a vagotomy and pyloroplasty in preference to a proximal gastric vagotomy. The appropriate operation to perform after perforation of an acute duodenal ulcer in a patient with any of the contraindications listed above is simple closure or omental patch closure. In the stable nonseptic patient, the choice is not as clear. Boey and associates noted cumulative recurrent ulcer rates of 37% and 31% at 3 years in separate studies in which omental patch closure was used for perforated acute duodenal ulcers. This may reflect the asymptomatic nature of chronic duodenal ulcers in some patients prior to perforation, the failure of the surgeon to recognize the extent of periduodenal scarring at operation, or differences in the length of postperforation follow-up in series reporting perforations of acute or chronic ulcers. Jordan has suggested that all stable patients with perforated duodenal ulcers should undergo a proximal gastric vagotomy in addition to omental patch closure. In his hands, the addition of proximal gastric vagotomy has an operative mortality rate of 0 to 1%, a recurrent ulcer rate of 3% to 5%, and no adverse postoperative sequelae. He has noted that "this operation gives protection from further ulcer disease to those who need it and will produce no harm to the unidentifiable patients that might not have benefited from definitive surgery." Boey and Wong suggested that omental patch closure is indicated for "acute ulcers associated with drug ingestion or acute stress" in addition to those that occur in patients who are considered to be poor risk, while proximal gastric vagotomy should be added in the remaining patients with perforations of acute ulcers.(ABSTRACT TRUNCATED AT 400 WORDS)