ACUTE PERFORATED DUODENAL ULCER

VERNE G. BURDEN, M.D.

Attending Surgeon, St. Joseph’s and Fitzgerald-5lercy 1 hospitals

PHILADELPHIA,

T HE ever present threat of perforation is a deadIy menace to the patient who has a duodena1 uIcer. The incidence

of perforation is not known but it seems to have geographic variations. It is more frequent in EngIand than in this country. A chronic duodena1 uIcer may be present for eight or ten years and suddenly per- forate or perforation may be the first and only symptom. As yet, there is no expIana- tion for this unusual behavior. There is very little assurance in the prevention of perforation by medica treatment. How- ever, perforation of a duodenal ulcer is extremefy rare after gastroenterostomy because the original uIcer aImost invariably heals.

Acute perforation of a duodenal ulcer necessitates an immediate operation. There are no recognized reasons for deIay. The obvious surgical procedure is closure of the perforation. Whether this shouId be supplemented by gastroenterostomy is a question on which there are different opinions. Statistics do not afford the answer. The figures for surgical mortality vary and depend on many factors; the one most commonly stressed is the interval of time between perforation and operation. CuItures of the peritonea1 fluid in the earIy hours after perforation usuaIIy are sterile - probabIy the resuIt of the action of hydro- chloric acid in the stomach. Later the cuI- tures often show pathogenic bacteria and there is evidence of peritonitis. The nature of the contents of the stomach may or may not have a bearing on the viruIence of the peritoneal process. Patients with duodena1 ulcer usuaIIy have an abundance of free hydrochIoric acid in the stomach but there is no available information as to the Iength of time required for ingested fluid

PENNSYLVANIA

to be rendered free of bacteria by the action of the acid; or, for that matter, if it ever becomes steriIe. It may be assumed that after a mea1 has been completeI) acted upon by the stomach the resultant mixture is sterile, but sureIy it is not un- common for food stuff to Ieave the stom- ach and enter the duodenum before the above process is complete.

Casting theory and speculation aside, it stands as a fact, as in many other sur- gical conditions, the earlier the operation the lower the mortaIity. Without surgical heIp, these patients usually die of peri- tonitis, which is also the most common cause of death after operation. The opera- tive procedure may be accused of con- tributory negIigence if a duodenal fistula or a subphrenic abscess occurs. No patient with acute perforation of a duodenal ulcer, regardless of delay or degree of peritonitis, should be denied the chance which onl) operation can offer. Surgery is subject to a multitude of human diversities. No two “cases” are aIike. The mortalit? of an operation in a thousand reported cases may be 3 per cent but for the patient who dies it is IOO per cent. A competent sur-

geon may encounter a series of fatalities

because of uncontrollable circumstances

and a tyro may have a number, large or

small, of the same type of case without a

death. After all, is it not true that the

surgeon when confronted by a problem in

the individual patient is by duty bound

to do the right thing at the right trme and

Jet statistics fa11 where they may? To do

this requires, of course, training and experi-

ence, and that which is more important,

observant and thoughtful consideration of

pathologic states and physiologic changes.

61

62 American Journsl of Surgery Burden-Perforated UIcer

The mortahty of operation in acute perforation, before tweIve hours, shouId be under IO per cent; after that interva1 it rapidIy increases. Peritonitis is the most frequent cause of death even in those pa- tients who succumb after an earIy opera- tion. The peritonea1 fluid is not always steriIe in the first four or five hours after perforation and it is not aIways true that earIy operation means recovery. Death may be the resuIt of subphrenic abscess and puImonary compIications.

Is it not an obvious fact that a11 duo- dena uIcers are potential cases of perfora- tion? It is impossibIe to separate into cIinica1 groups uIcers which wiI1 bIeed, uIcers which wiI1 perforate, uIcers which wiI1 cicatrize and stenose, and those which wiI1 run a smooth uneventfu1 proIonged course. There is no basis in fact for the assertion that bIeeding uIcers do not per- forate. The natura1 history of duodena1 ulcer is characterized by ahernate hearing and reactivation. UsuaIIy these phases correspond with cIinicaI symptoms. UIcers which have no tendency to heaI do not show scar tissue. It is rare for the surgeon to expose a chronic duodena1 uIcer with- out evidence of scar tissue. An exception is duodenitis in which a definite uIcer is absent. In the picture of an acute perfora- tion of the duodenum there is usuaIIy very IittIe if any evidence of scar tissue to indi- cate the presence of chronic uIceration. I have no positive conviction that onIy acute uIcers perforate but in my experi- ence the findings at operation and the frequent absence of uIcer symptoms prior to perforation strongIy suggest it. In not a few cases of duodena1 ulcer the First symptom is either from perforation or hemorrhage. It is significant of an acute process that some patients experience a short preperforative period of one to three weeks in which the symptoms of uIcer are intense and constant and the usua1 methods of reIief as by antacid pow- ders and diet are of no avai1. In these patients perforation seems to be inevitabIe, but usuahy one is unabIe to foreteI1 this

catastrophe. MedicaI treatment does not prevent, and I seriousIy doubt that it even reduces the incidence of perforation. There are authentic records of patients who have suffered a perforation whiIe confined to bed under hospita1 treatment. One of my patients had an acute perfora- tion within a few minutes after a barium mea1 for an x-ray examination of his stomach.

The effect of injury or strain of the abdomina1 waII as a cause of rupture of an uIcer has received occasiona comment. One of my patients, a structura1 iron worker, had an acute perforation of a duodena1 uIcer whiIe he was hording a rivetting hammer against his abdomen. Of course, this may have been a coinci- dence and not cause and effect. However, there are many instances on record in which perforation fohowed so cIose upon muscuIar effort associated with Iifting, cranking a motor and in some cases direct bIows to the abdomen, that an etioIogic relationship may not be unIikeIy. I suspect that the genera1 concept of the process of perforation of a duodena1 uIcer is a progres- sive erosion through the coats of the duo- dena waII unti1 the protective covering on the peritonea1 side becomes so thin that, Iike the bIowout of a worn automo- biIe tire, sudden expIosive rupture occurs. Anyone who has given some thought to the appearance of a duodena1 perforation at the operating tabIe knows the utter faIIacy of the above theory. The picture of the perforation is nearIy aIways the same. It is not a tear nor is it a bIowout. There is nothing about it to suggest physica force from without or from within. It is aIways a cIean-cut rounded hoIe. A qui- escent or heaIed ulcer does not perforate nor rupture. The evidence indicates that acute perforation occurs 0nIy in an acute ulcer or in a chronic one which has under- gone acute exacerbation. The actuaI per- foration is the resuIt of an active uIcerative process which usually is rather rapid from start to finish because one rareIy sees pro- tective adhesions.

NE\\ SERIES VOL. LXIII. No. I Burden-Perforated Ulcer

The recognition of an acute perforation of a duodena1 uIcer is so easy that it is diffIcuJt to explain the Iong delay which often occurs before operation. UnIike the symptoms of acute appendicitis those of perforated uIcer are dramatic and faith- fully characteristic. I saw a patient within a few minutes after his uIcer perforated. He had severe upper abdomina1 pain and IocaIized tenderness but rigidity of the muscIes had not yet appeared. There was not the slightest indication of shock and the pulse and temperature were normal. At operation, Iess than two hours Iater, there was an opening about I cm. in diameter in the duodenum from which biIe-stained fluid was pouring into the free peritonea1 cavity. Within a short time after perforation the pain becomes agonizingly severe; it is constant and without remission. At the same time there develops a rigidity of the abdominal muscles, more pronounced in the upper part, which is board-like and serves to splint and to immobiJize the entire abcIomen. In no other condition is there rigidity such as this; it is the most charac- teristic physical finding. The patient re- mains flat on his back and is afraid to change from this position. Vomiting is not common. Grunting respiration is a charac- teristic symptom. A fJat x-ray plate of the abcJomen for detection of an air bubble uncier the diaphragm is said to be of diag- nostic importance. It has been my expert- ence in the surgical diagnosis of acute abdominal conditions that the more Iabors- tory aids are brought into use the more likely. it is for confusion to repIace cIear thinkmg and the patient becomes the loser as the result of indecision and delay. There is one forgivable error in the diagnosis of perforated uIcer_-acute perforative ap- pendicitis. After the lapse of a few hours the fluid from the perforation foJIows a natura1 drainage path as pointed out 6) Moynihan years ago, down the outer side of the right coJon, over the region of the appendix and into the peIvis. In such cases, usuaJJy late, there is tenderness and rigidit) over the area of the appendix and often a

tender peIvic mass by rectal palpation. FortunateIy, these findings usuaIIy call for immediate operation. Once the abdomen is opened, the character of the peritoneai fluid noted and the appendix examined, the observant surgeon wiI1 readily recognize the situation and act accordingI?.; thereb! no harm has come to the patient.

OccasionaIJy, one will see a patient ten or twe1T.e hours after the onset of sudden and severe upper abdominai pain. At present he is sitting in a chair and he is able to walk about the room. The pulse and temperature are normal. The onI\- com- pJaint is epigastric soreness. Palpation of the abdomen detects board-like rigidity which is confined to the right upper quad- rant and firm pressure elicits deep tender- ness. It is difficult to convince him that he should submit to operation. Exploration reveaJs a perforated duodenal ulcer which has become JooseIy seaIed to the under- surface of the liver. The attachment is so insecure that it lets go with the slightest manipuJation and it is a great satisfaction to the surgeon that he is at once prepared to prevent an inevitable disaster. The above circumstances occurred in :I patient upon whom I operated eighteen hours after perforation. He recovered prompt I y after closure of the perforation and a posterior gastroenterostomy, and has re- mained entirely we11 to date now eight years after operation.

The method of anesthesia is of great importance but it has been consistently ignored or unrecognized in discussions of the subject. Th e anesthetist often has dificulty in maintaining a smooth anes- thesia with gas or ether, and in such instances postoperative pulmonar! com- pJications seem to be more frequent. Of greater importance is the aImost constant difficulty in obtaining reIaxation of the abdominal muscJes so that it becomes necessary for the surgeon to fight his N-ny through guarded muscJes and the can- tankerous annoyance of protruding ab- dominal contents. Under these conditions the handling of a grave surgical lesion

64 American Journal of Surgery Burden-Perforated Ulcer

which requires impeccabIe technic may be an extremeIy diffrcuh task. Is it not possi- bIe that the above situation, not aIways conducive to tranquiIIity of mind and procedure, has had something to do with the oft repeated admonition that these patients are desperateIy iI1, that onIy emergency treatment, nameIy, cIosure of the perforation is justified and that gastro- enterostomy subjects the patient to undue proIongation of the operation? CompIete reIaxation can be obtained with spinal anesthesia which I have used in these cases for sixteen years. Under its inffuence the fieId of operation is quiet, there is Iess traumatism to peritonea1 surfaces; accurate technic is favored; the surgica1 procedure can be carried out in an unhurried manner and an additiona fifteen minutes for a gastroenterostomy does not increase the operative risk. A patient with a perforated duodena1 uIcer, other things being equa1, stands as good a chance for recovery after forty-five minutes on the operating tabIe as another simiIar patient who has been there onIy thirty minutes. Operations many times are proIonged by cIumsy operating, unnecessary maneuvers, needIess handIing of tissues and faiIure to compIete one technica detai1 before moving on to the next. In my experience spina anesthesia has been more satisfactory than any other method and equaIIy safe.

The preoperative diagnosis usuaIIy is correct and the incision properIy pIaced. When through error of diagnosis (appendi- citis) the incision has been made in the right Iower quadrant the true state of affairs is soon reveaIed. Remove the ap- pendix and cIose the incision; then make a separate incision in the right upper quad- rant. OccasionaIIy, it may be wise to use the Iower incision for the insertion of a drain. When the peritoneum is opened, the diagnosis is confirmed by the appearance of biIe-stained ffuid which contains ffakes of pIastic exudate and often smaI1 bits of food debris. In many instances gas bubbles are seen. The fluid shouId be mopped up with Iarge moist gauze sponges or removed

by suction. The stomach is then puIIed downward and to the patient’s right, handed to an assistant who hoIds it with a dry sponge and turns it toward the patient’s Ieft. By this maneuver the site of perforation in the duodenum is freeIy exposed and the parts are under perfect contro1 for cIosure of the perforation. Moist gauze pads should be judiciousIy pIaced to prevent further soiIing of the peritoneum. During these manipuIations one must be exceedingIy carefu1 to prevent the free fluid from gaining access to the space between the uppersurface of the Iiver and the diaphragm. This region is diffrcuIt to cIeanse properIy and methods for drain- ing it are inadequate. The danger, of course, is the deveIopment of a subphrenic abscess. It is remarkabIe how quickIy pIastic exudate forms after a perforation of a duodena1 uIcer; it is not uncommon to find the perforated part of the duodenum IooseIy adherent to the undersurface of the right Iobe of the Iiver. Leakage from the opening rareIy is compIeteIy checked but usuaIIy materiaIIy Iessened, so that the spreading of peritonitis is temporariIy haIted and IocaIized. I have never seen the great omentum taking part in seaIing over the perforation. In many instances, on the other hand, it is not uncommon to expose a perforation which is as free as a Ieak in a rainspout and pouring forth fluid containing particIes of undigested food which may be infested with bacteria. It is obvious that the interva1 of time between perforation and operation in the first instance is comparativeIy unimportant whiIe in the latter it becomes the chief determining factor in prognosis. Such factors, and they are rareIy mentioned, have a profound effect upon statistics and on the patient.

Free perforation of a duodenal ulcer presents a characteristic picture at the operating tabIe. InvariabIy there is a round pyunched out opening 3 to 8 mm. in diameter and about 2 to 4 cm. distal from the pyIorus on the antero-superior surface of the duodenum. For a distance of 2 or

NEW SERIES VOL. LXIII, No. I Burden-Perforated UIcer

3 cm. around the opening the duodenum shows the grey paIIor of inflammatory edema; its waII is much thicker than nor- ma1 and has lost its pIiabIe, supple quality. Because of these IocaI tissue changes sutures easily tear out. InfoIding of the perforation is almost impossibIe and secure accurate cIosure as we would deem a necessity for an opening elsewhere in the bowel cannot be accomplished.

With the duodenum adequateIy exposed and the perforation visuaIized, it is cIosed by three or four through-and-through cot- ton sutures which are pIaced Iongitudinally or transversely depending upon the ease of cIosure. Several pieces of nearby mesenteric fat or omental tabs are incIuded by a third knot in the above sutures, thereby making the cIosure more secure against leakage. No effort is made to infold the perforated area and onIy one layer of sutures is used. Only enough IS done to cIose theopening be- cause too much suturing is IikeIy to favor leakage and to weaken the closure. After the perforation is exposed and before the closure is made, it is my practice to clean out by the use of Iarge moist sponges and suctron all accessible free fluid. Large moist gauze pads are then pIaced around the area of perforation, a pad in the sub- hepatic space, another pad between the undersurface of the liver and the duodenum which serves to prevent contaminated fluid gaining access to the space between the liver and diaphragm, and another moist sponge is placed just above the duodenum. I believe that the proper dis- position of gauze in operations for per- forated duodenal ulcer is second in im- portance 0nIy to a simiIar precautionary measure in cases of acute perforated appendicitis. Too often, fata peritonitis is man-made. A posterior short-loop gas- troenterostomy is now made. My reasons for doing a posterior gastroenterostomy are based on the folIowing persona1 con- victions. A duodenal uIcer is a local mani- festation of disturbed physiology of the stomach; acute perforation of the uIcer is a complication and not a cure of the

disease. CIosure of the perforation alone may save the patient’s Iife but he is left in a state of potentia1 danger of another perforation. The high rate of recurrence of duodenal ulcer after local excision cer- tainly does not support the theory that perforation cures the ulcer. On the other hand, the rate of recurrence of ulcer in the duodenum fohowing gastroenterostoml is very low. At least two-thirds of the pa- tients who have had a simple closure of an acute perforation experience symptoms indicative of recurrence of the ulcer. Does the addition of gastroenterostomy increase the operative risk? I believe that the opera- tion in competent hands actualIy is a safety measure so far as the immediate condition is concerned. Certainlv the additional fifteen minutes does not increase the risk, so that, the only factor of danger would be some technical error in the operation itseIf. The performance of gastroenter- ostomy affords definite protection to the recently sutured opening in the duodenum. Under the best conditions this closure is not secure. The resumption of traffic over the weakened and partially devitalized area immediately after suture and the added physiologic distention resulting from forceful ejection of contents from the stomach make the margin of safety verv narrow from the standpoint of leakage. In cases of death from peritonitis or from subdiaphragmatic abscess after simple clo- sure of a perforated ulcer, is it not prob- abIe that leakage at the suture line of closure has been at fault? The necessity of a gastroenterostomy- should not depend upon any apparent narrowing of the lumen of the duodenum incident to closure of the perforation. After the inAammatory edema has subsided and heaIing has occurred it wiI1 be found, as it usually is at subsequent operations, that the duodenal lumen is entirely adequate. I believe that the making of a gastroenterostomv will pre- vent or lessen the dangers described in the preceding remarks. I have known of several instances in which duodenal tis- tulas followed simpIe closure of’ a perforn-

66 Americnn Journal of Surgery Burden-Perforated Ulcer

tion aIthough I am not prepared to say that the comphcation wouId have been prevented by a gastroenterostomy. It is reasonabIy certain that for a varying length of time after cIosure of an acute perforation there is more or Iess physioIogic or anatomic obstruction to the emptying of the stomach. I have performed gastro- enterostomy in five patients for recurrence of duodena1 ulcer severa years after simple cIosure of an acute perforation. In these cases the duodenum and pyIorus were in- separabIy adherent to the undersurface of the right Iobe of the Iiver, thereby consti- tuting a mechanica fauIt as far as the func- tion of the pyIorus was concerned. Without attempting to separate the adhesions, a carefu1 inspection reveaIed inff ammatory changes with evidence of the presence of active duodena1 uIceration. Is it not prob- abIe that by seaIing the duodenum to the undersurface of the Iiver nature had done more than the surgeon to cIose the perfora- tion and to prevent a spreading peritonitis? At any rate the mechanica derangement of the pyIoric region of the stomach inci- dent to this condition even in the absence of active duodenal uIceration wouId be a sufficient reason for the making of a gastro- enterostomy. Then, too, it is possibIe for this mechanica derangement of the pyIorus actuaIIy to favor the recurrence of duo- dena uIceration. The patient with a duo- dena uIcer has a constitutiona disorder of the function of the stomach which wiI1 continue to form uIceration in the duo- denum regardIess of whether the uIcer is perforated or surgicaIIy excised. In a smaI1 percentage of cases, this constitutional defect favors the formation of an uIcer in the stoma of the anastomosis when the gastroenterostomy has faiIed in its primary purpose, nameIy, the control of excessive gastric acidity.

It is a we11 known fact that slow, pin- point perforation of a duodena1 uIcer rareIy gives rise to spreading peritonitis. The sIowness of the Ieakage permits ampIe time for the formation of protective adhesions to. nearby structures. UsuaIIy, these pa-

tients have had a duodena1 ulcer for years and then rather suddenIy the miId inter- mittent symptoms of uIcer are replaced b) constant IocaIized epigastric pain. It may be severe but it is never so acute as when free perforation has occurred. There is no board-Iike rigidity of the abdomen, only localized tenderness. Gastric retention and vomiting may be present. Does not this situation caI1 for urgent surgical relief? WouId it be sound surgica1 judgment to separate the adhesions which sea1 the perforation to the undersurface of the liver and then to cIose the perforation and Iet it go at that? I beIieve that nearIy every sur- geon would Ieave the IocaI condition strictIy aIone and consider the situation an idea1 indication for the making of a gastroenterostomy. If gastroenterostomy is indicated for this kind of perforation, why shouId it not be equaIIy appIicabIe in the case of acute free perforation? It seems to me that the onIy logical reason for the omission of gastroenterostomy in the case of acute perforation is the aIIeged risk incident to the prolongation of the opera- tion, especiaIIy in the presence of advanced peritonitis. The omission of gastroenter- ostomy may be justifiabIe on the grounds of expediency, but imperfect postoperative results are IikeIy to foIIow in 40 to 60 per cent of the patients. In this group there wiI1 be instances of second perforation and the majority wiI1 require gastroenter- ostomy because of the persistence of the symptoms of duodenal uIceration. These events wiI1 carry their own risks and mortaIity figures. After a11 is said and done, gastroenterostomy in spite of its fauIts, faiIures and misuses remains the most satisfactory method of treatment in properIy seIected cases of duodenal uIcer. This is true because it insures nature’s own contro1 of the vicarious acidity of hypersecretion which amounts to a con- stitutiona1 fauIt in the uIcer bearing pa- tient. This fauIt of gastric chemistry is part of the patient’s makeup and as such is intractabIe and persistent. To ignore this tenet in the treatment of a perforated

NFW SERIES VOI.. 1.X111. No. I Burden--Perforated Ulcer Americ:m .Iwrn:t! <,I Surrrrv 6$

duodena1 uIcer is to invite recurrence. The from the surrounding territory. Man) present state of deveIopment of surgical patients have died of peritonitis in spit.e technic demands in the case of the patient of drainage but I do not know of an) with perforation not only that his life be instance in which death from peritonitis saved by closure of the perforation but that has been attributed to the failure to insert his future be relieved of the anxiety and a drain. There are fewer indications for the iIl health incident to the lesion which suprapubic drain than there are for a drain originaIly laid him low. through the operative incision. A word of

TABLE 1

1 I I 1 Duration 1 I ~ Age / Sex ~ of Per-

~ foration Closure of Per-

1 foration

I ,D. w. 33 RI *

z ID. B. 57 ~ h4 3 ‘J. K. 22 M

l& IE. L. 59 5 IJ. S. 32

~ RI hl

6 AS. F. 42 ~ hl 7 ~(3. B. 3” nl 8 K. B. 33 ~ RI

9 ,J. F. 34 hl 10 IG. B. 49 ~ hl II iM.A. 3” M 12 ‘T. B. h,l 13 IJ. F.

38 46 hl

14 J.W. I8 F 15 J. X. P. 47 hl 16 E. S. 19 hl 17 J. MC. A. 43 hl

18 R. hl. Al 19 ME. P.

33 24 hl

I * = yes. 0 = “0.

12

L

* 5 hrs. *

14 hrs. * 4 hrs. * 6 hrs. * 6 hrs. * 8 hrs. * 5 hrs. * 4 hrs. *

) 5; hrs. * 18 hrs. * 5 hrs. *

12 hrs. * 5 hrs. *

IO hrs. * 7 hrs. *

14 hrs. * 8 hrs. *

Gastro- enter-

ostorn>

* * :i;

* * * * * * * * * * * *

Spinal Spinal Spinal Spinal Spinal Spinal Spinal Spinal Spinal Spinal Spinal Spinal Spinal *

Ether Spinal

Spinal Spinal Spinal Spill:!1

The matter of drainage after operation warning should be said regarding the for acute perforation cannot be settled by pIacement of the drain when it is used. To statistical study, nor can rules of procedure place the end of the drain, whether it be be Iaid down. Usually the insertion of a drain does no harm, but that does not con-

of the cigarette type or a pIain rubber tube,

stitute a reason for using it. If one is down to and possibly in contact with the

uncertain about the security of the cIosure site of the closed perforation in the duo-

of the perforation and has not done a denum is a dangerous procedure because it favors or may actually incite leakage from

gastroenterostomy, the use of a drain may be a safety procedure. There is always

the suture line. I suspect in many cases in

peritoneal contamination in these cases which an apparent IaudabIe purpose has been served by the drain, so that the

but if one must use a drain on this basis, surgeon couId point with pride to his justi- where shouId it be pIaced? Bear in mind fiabIe practice, that if the truth were that a drain onIy serves to form a sealed- off outlet to which there are no tributaries

known there wouId have been no drainage or leakage if the drain had been omitted.

SUMMARY by erosion (acid) and not by rupture from increased pressure.

This report is based on a persona1 experi- The operation of choice shouId be ence with nineteen patients who were cIosure of the perforation and posterior operated upon for acute perforation of a gastroenterostomy. The closure is made duodena1 uIcer. CIosure of the perforation by three or four through-and-through cot- and posterior gastroenterostomy was done ton sutures re-enforced by severa nearby in al1 and in tweIve the appendix was fat tabs. Do not infold; do not use a removed. Drainage was used in onIy two purse-string suture. cases. There was one death. This patient Except in the presence of advanced peri- who was admitted in a state of shock five tonitis, gastroenterostomy is advisabIe hours after perforation and operated upon because (I) perforation does not cure the at once died twenty-four hours later. uIcer. Simple cIosure is foIIowed by recur- Th e youngest, and onIy female in the rence of uIcer in 40 to 60 per cent of the group, was a gir1 of eighteen years. This is patients and in others the stomach may not a seIected group but one which contains have motor diffIcuIty from fixation of the a11 cases of acute perforated duodena1 pyIorus to the undersurface of the liver. uIcer which have come under my care in Gastroenterostomy is the best safeguard the past fifteen years. against recurrence and motor dysfunction

Many perforated duodenal uIcers be- of the stomach. (2) It protects the sutured come seaIed temporariIy to the under- area of perforation against tension and surface of the Iiver, thereby preventing for Ieakage. (3) It does not increase the a time widespread contamination of the operative risk. peritoneum. When the appendix is readiIy accessible,

Acute perforation is the resuIt of an it shouId be removed. SpinaI anesthesia is acute uIcerative process in either a recent recommended except in the presence of or an oId uIcer. The perforation is caused shock. Drainage is rareIy indicated.

68 American Journal of Surgery Burden-Perforated UIcer