Long-Term Results Of Simple Closure Of Perforated Duodenal Ulcer In The Era Of Proton Pump Inhibitor And Anti-H.Pylori Therapy

摘要

Background:A simple closure of duodenal ulcer perforation followed by proton pump inhibitor therapy and treatment for Helicobacter pylori is the standard treatment at many centres, but the literature is silent on long-term results.Objective: This study was conducted to determine the long-term results of a duodenal ulcer perforation treated by a simple closure, proton pump inhibitors and an anti-Helicobacter pylori treatment. Methods:A prospective study involving 50 patients of perforated duodenal ulcer treated with simple closure, proton pump inhibitors and triple regime for Helicobacter pylori was undertaken.An annual follow-up was conducted and patients were graded according to modified Viscik’s grading.Results:Out of 50 patients, 47 got complete follow-up evaluations for 12 to 15 years (mean follow-up period 12 years). Excellent and good results were obtained in 78.72% patients. Seven patients (14.89%) had moderate symptoms easily controlled by medication and only 3 (6.38%) patients were on constant medication and needed definitive surgery.Conclusion:Perforated duodenal ulcer treated with simple closure along with proton pump inhibitors and anti-Helicobacter pylori treatment is not associated with a high rate of recurrence in long-term follow-ups and the cumulative relapse rate increases with an increase in the follow-up period. Introduction Prior to the use of H2 blockers, simple closure of perforated duodenal ulcer was associated with recurring ulcer symptoms in 40 to 80% of patients and about 40 to 60% required subsequent definitive operation.1, 2 The efficacy of simple closure of perforated peptic ulcers has been compared with definitive surgery in several randomized trials.2 Ulcer recurrence has been reported to occur in 61% and 6% of cases following simple closure and definitive surgical treatment, respectively.3 This high recurrence rate after simple closure of the ulcer has been the basis of argument in favour of the addition of some definitive surgical procedure.4 However, there is an obvious return from definitive anti-ulcer surgery to simple closure of the perforation followed by anti-secretory and antibacterial medication in recent years.5, 1, 6 Simple closure followed by H.pylori eradication may become the optimum treatment for the majority of cases of duodenal ulcer perforation.1 On the other hand, with the advent of potent acid-suppressing agents, more patients are treated with simple patch repair and maintained on long-term acid suppressing drugs, although the effectiveness of this strategy in the long-term has been insufficiently studied.4 It therefore seemed appropriate to review the long-term results of duodenal ulcer patients treated with simple closure followed by PPI and anti-H.pylori treatment in this hospital. Hence, a follow-up study was conducted to document the recurrence of subsequent ulcer symptoms, and in the light of these findings, to reassess our operative strategy in these patients. Materials And Methods Study type and setting: A prospective study was conducted on 50 cases of duodenal ulcer perforation treated by simple closure along with proton pump inhibitors (PPI) and anti-H.pylori treatment during 1993-1997 in the Department of Surgery, Krishna Hospital and Medical Research Center, Karad, Maharashtra, India. These cases were followed for a period of 12 to 15 years.The study was approved by the Ethics Committee of Krishna Hospital and Medical Research Center, Karad, and informed patient consent was obtained. Inclusion and Exclusion criteria: All patients of perforated duodenal ulcer treated by simple closure along with PPI and anti-H.pylori treatment were considered for sampling. Patients treated conservatively, with definitive surgery, or those patients with sealed perforations at the time of laparotomy were excluded from the study. Simple random sampling was employed to select the 50 cases for the study and SPSS software v1.0 was used to facilitate statistical analysis.Every attempt wa