Surgical Treatment of Complicated Duodenal Ulcers: Controlled Trials

Abstract

Indications for surgery of duodenal ulcer (DU) have changed radically because of the efficacy of H(2)-antagonists, endoscopic procedures, and eradication of Helicobacter pylorus. The aim of this study was to analyze the current literature to determine if definitive surgery is still relevant for complicated DU (bleeding, perforation, gastric outlet obstruction). Two studies have compared early to late surgery in terms of bleeding. One recommended early surgery (significant reduction in mortality) in the elderly, but no statistically significant difference was found when analyzed with "intention to treat." In the other, mortality with early surgery was five times higher than with expectant therapy (when it was possible). Two studies comparing different surgical techniques for bleeding favored the radical procedure. Of at least 15 studies comparing endoscopic treatments, however, none has compared endoscopic therapy to surgical intervention for bleeding DU. One trial, comparing nonoperative to surgical treatment for perforation, found similar rates of morbidity, intraabdominal abscess, and mortality; but the hospital stay was longer (p < 0.001). Nonoperative treatment failed more often (p < 0.05) in patients over age 70. In three trials, postoperative morbidity (excepting wound sepsis in one) was not significantly increased by definitive surgery, with less ulcer recurrence (p < 0.05) compared with simple closure. Laparoscopy (versus laparotomy) was shown to take longer (p < 0.001) but required less postoperative analgesics (p < 0.03); there were no statistically significant differences as concerns the duration of nasogastric aspiration, intravenous drips, hospital stay, time to resume normal diet, Visual Analogous Scale pain scores for the first 24 hours after surgery, morbidity, reoperation rate, or mortality. Of 48 laparoscopic patients, 11 (23%) underwent conversion to open surgery. Three surgical techniques [highly selective vagotomy (HSU) + gastrojejunostomy (group 1), HSV + Jaboulay gastroduodenostomy (group 2), or selective vagotomy (group 3) + antrectomy) for gastric outlet obstruction (GOO)] showed that although postoperative results were similar (except wound sepsis in one trial), long-term Visick scores were significantly (p < 0.01) better in group 1 than in group 2, but not in group 3. Further studies are needed to determine the exact prevalence of Helicobacter pylori in complicated DU and to compare (1) definitive to minimal surgery (stop the bleeding or close the perforation) combined with antisecretory drugs and eradication of H. pylori; (2) surgery to endoscopic treatment combined with eradication of H. pylori; and (3) for GOO, surgery to balloon dilatation combined with eradication of H. pylori.

The Perforation-Operation time Interval; an Important Mortality Indicator in Peptic Ulcer Perforation

“…As soon as the diagnosis is made, resuscitative measures like nasogastric tube aspiration, fluid resuscitation, PPI administration and antimicrobial therapy should be started. In our study, under general anaesthesia, laparatomies were done with simple closures of the perforations by using vicryl 2-0, omental patches were fixed around the perforations, thorough claim that the prognosis is not related to the surgical procedure itself [11,12].The present study showed that the risk of mortality and morbidity was statistically significant when the patient was submitted to surgery with a perforation time which was later than 24 hours , which was in agreement with the reports in the literature, which emphasized on the importance of early surgical interventions in improving the outcomes [13]. The increase in the therapeutic delay was mainly due to a delayed access to the hospital, since the patients were treated immediately after their admissions .It has been shown that the therapeutic delay increases the mortality rate [14].…”

The electrophysiological characteristics of the motor activity of the gastrointestinal tract following selective proximal vagotomy in the patients presenting with ulcerative pyloroduodenal stenosis

“…Для электрофизиологической оценки состоя ния МЭФ желудка и кишечника использовали ме тод ПЭГЭГ, которую выполняли аппаратом ГастросканГЭМ по стандартной методике [11,16].…”

“…Пациен тов, подлежащих оперативному лечению, наиболее часто объединяют в группу субкомпенсированного ПДС, что приводит к существенному различию при водимых разными авторами результатов его хирур гического лечения [1,3,5,6,8,11].…”

Fatores preditivos do tratamento operatório na úlcera péptica hemorrágica

“…Contudo, sabe-se que a instabilidade hemodinâmica e anemia são fatores relacionados a complicações e maior letalidade nos doentes operados por úlcera péptica hemorrágica [10][11][12] . Portanto, postergar a indicação de uma operação pode determinar pior prognóstico.…”

“…Outras variáveis também são analisadas para a indicação precisa do tratamento operatório, como idade, local e características endoscópicas das úlceras, histó-ria prévia de utilização de fármacos antiinflamatórios não esteróides, doença péptica crô-nica, tipo sangüíneo e volume de concentrados de hemácias transfundido 9 . Esta variedade de fatores muitas vezes torna difícil a decisão quanto à melhor forma de tratamento.Contudo, sabe-se que a instabilidade hemodinâmica e anemia são fatores relacionados a complicações e maior letalidade nos doentes operados por úlcera péptica hemorrágica [10][11][12] . Portanto, postergar a indicação de uma operação pode determinar pior prognóstico.…”