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CATASTROPHES OF PEPTIC ULCER
E. L. ELIASON, M.D. AND WALTER W. EBELING, M.D.
PHILADELPHIA
T HE impetus to make this review was gained by a desire to evamate the relative occurrence and mortahty of
the two uIcer catastrophes, hemorrhage and perforation. AI1 cases of duodena1 and gastric ulcer recorded for the past ten years on SurgicaI Division c and the Medical CIinic at the HospitaI of the University of PennsyIvania, and at the PhiIadeIphia Genera1 HospitaI were tabuIated. As the study progressed, many interesting facts appeared, whose vaIidity and expIanation have been aided by a review of the data on perforated uIcers presented by sixty-seven different writers, a11 of whom have reported a series of perforated peptic ulcers.
ACUTE HEMORRHAGE
Frequency of Acute Hemorrhage. Hema- temesis or meIena was recorded in 107 of 546 duodena1 uIcers, or 19.5 per cent, and in 36 of 92* gastric uIcers, or 39. I per cent. The degree of exsanguination and the acuteness of the hemorrhage was diffrcuIt to evaIuate. Those cases which presented frank hemat- emesis or tarry stooIs were accepted. Those cases whose stooIs showed occuIt bIood during routine study for uIcer, without a history of either hematemesis or tarry stooIs, were discarded.
Mortality in Acute Hemorrhage. One death was recorded in 107 cases presenting acute hemorrhage from duodena1 uIcers. This patient died a few hours after admis- sion, despite three bIood transfusions. At autopsy, the uIcer was found to be of the large caIIoused type, with erosion into the side of a Iarge vesse1 running across its floor.
* IIemorrhage data on 91 additional gastric uIcers were not available.
Three deaths were recorded in 36 cases presenting acute hemorrhage from gastric uIcers.
With 4 deaths in 143 bleeding ulcers, the non-operative mortaIity wouId be about 2.7 per cent for this series.
Behrend” has recorded 2 deaths from bIeeding uIcers, and advised early surgery, in fact, after twenty-four to forty-eight hours of preparation.
Rogers’O reported 2 cases of hematemesis in uIcers under medica treatment going on to death, and advised surgica1 intervention.
Soper in 1931 caIIed attention to the use of the retention catheter in the treat- ment of hematemesis. He stated that BaIfour,3 Bevan, and Lahey47 a.dvised against immediate operation in these cases, but reserved intervention Iater for recur- rent bIeeding.
In detai1 our treatment for acute hemor- rhage from a gastric or duodena1 uIcer is as foIIows: Bed rest, the position, depend- ing on the blood pressure and puIse rate, either flat or modified TrendeIenburg. Morphine is reguIarIy administered unless the respiratory rate faIIs beIow 16 per min- ute. A Jutte tube is passed through the nose on into the mid-portion of the stom- ach. The Jutte tube is aIIowed to drain into a cIear bottIe suspended from the side of the bed, and its patency is maintained by gentIe flushing with warm saIt soIution (20 c.c.) at hourIy intervaIs. The pa.tient is permitted nothing by mouth.
Fluids are administered, either in the form of physioIogica1 saIt soIution b,y hypo- dermocIysis, tap water or saIt soIution by proctocIysis, or preferably, physiologica salt soIution, to which has been added enough dextrose to make 5 or IO per cent dextrose soIution, by venocIysis. The
63
64 American Journal of Sul-yery Eliason & Ebehng-Peptic UIcer APRIL. 1934
patient’s bIood is immediately typed and one or more donors crossed, these to be used onIy shouId hemorrhage progress to a critica state. It is our contention that many of these patients wiII stop bIeeding when their bIood pressures faI1 sufficientIy to permit coIIapse of the bIeeding vesse1. The cIosure of the open vesse1 may be hastened by coIIapse of the stomach by means of the Jutte tube.
AI1 bIeeding uIcers on Service c were treated conservativeIy without operation during the acute hemorrhagic phase. When hemorrhage had ceased (no melena) and the bIood picture (Hgb and R.B.c.) had been restored (normaIIy or by transfusion) to at Ieast 50 per cent, then decision was made for continuation of medica treat- ment or in favor of surgery.
Where the mortaIity from gastric or duodena1 hemorrhage under these con- servative measures, as in our cases, does not even approach that from surgery in uIcer in the absence of hemorrhage, one couId hardIy advise earIy surgica1 inter- vention for acute hemorrhage.
ACUTE PERFORATION
Frequency of Perforation. Seven hun- dred and twenty-nine peptic uIcers were recorded from the three sources noted, of which 546 were duodena1 and 183 gastric. Sixty (I I .o per cent) of the duodena1 and 14 (7.6 per cent) of the gastric uIcers were perforated.
Peek’j4 in 1931 commented on the fre- quency of gastric and duodena1 uIcers. In 60,000 autopsies in BaItimore and New York, uIcers were found in 4.4 per cent of the cases.
Mayo and Reed52 stated that duodena1 uIcers were three times more frequent than gastric. The frequency of perforation was recorded variousIy between 12 and 28 per cent. PIatou65 quoted severa writers in whose cases the frequency of perforation ranged between 6.6 per cent and 28.5 per cent. The recorded cases at Ieast sup- port the Iower incidence of perforation.
Recurrent Perforation and Multiple Per- forations. No cases of recurrent perfora- tion were recorded in this series of 74 cases. Pearse63 in 1932 examined 4813 case reports and found 33 instances of recurrent perforation, a ratio of 1 in 145 cases, or 0.69 per cent. The tota number of perfora- tions was seventy-five. As many as three consecutive (recurrent) perforations have been observed by Skemp and Skemp,77 EhrIick,26 Thurston,88 and ButIer.16 In but seven of the papers reviewed were recurrent perforations recorded; the cases totaIIed 655, with reperforations in 15 or an incidence of about 2 per cent. Berg7 beIieved that many of the so-caIIed “re- currences” were probably due to previousIy unrecognized muItipIe Iesions.
No instances of muItipIe perforations were observed in the recorded series. Masson and SimonjO in 1927 reviewed the Iiterature from 1876 to that date and found 32 authentic cases of muItipIe perforations in gastric uIcers, to which they added one case of their own. Druryz5 has since recorded such a case.
Age-Sex Distribution (Table I). The majority of perforations occurred between the twenty-first and fiftieth years. The youngest patient observed in these 74 cases was eighteen years of age, and suf- fered a duodena1 uIcer perforation, whiIe the oIdest patient was seventy-one years, Iikewise having a perforated duodena1 uIcer.
Perforated uIcers have been reported in infants and the aged. Stern, Nessa and Perkins5 reported a perforated gastric uIcer in an infant of two days who was operated on twenty-four hours after per- foration, and died from genera1 peritonitis. Somerford,81 Harrison,38 and WiIsongg have separateIy reported perforated duodena1 uIcers in a chiId of fourteen days, a female chiId of fifty-eight days, and a femaIe chiId of eighteen months, respectiveIy.
Montgomery57 reported a case of per- forated peptic uIcer in a man of seventy- five years, who was operated upon seven hours after the perforation. There was no
evidence of maiignancy, his convalescence was uneventful and subsequent health good.
\1cara.
These reports are of course unusua1. In the aged one must suspect the per- foration of a gastric carcinoma. One or two authors, whose data have been tabu- lated, incIuded a few perforated car- cinomata in their series of perforated ulcers. These cases couId not be separated and were too few to be of consequence. IncidentaIIy, the very first perforative catastrophe personaIIx observed was in a case of carcinoma of the stomach.
The age distribution for our cases was quite in agreement with those observed by other writers.
Sex. There was but one femaIe patient, presenting a duodenal uIcer perforation, in this entire series of 74 cases. The ratio of male to femaIe perforations in 2630 uIcers was 31 to I. Not a11 of the papers reviewed, however, recorded sex.
Evans’” (EngIand) presented a series of 67 perforated uIcers, and Meyer and Bramsj” (United States) presented a series of 62 perforated uIcers, a11 in maIe patients. Semb’” (Norway) presented I 35 perforated ulcers in maIe and 31 in female patients,
a ratio of 4 to 1. Stewart and Barber*‘j and PattersonG’ (United States) had 36 perforated ulcers, with a ratio of male to femaIe patients, of 5 to I.
The majority of the perforated ulcers in the femaIe patients were of the gastric type. Of 57 perforated ulcers in the female patients, al1 those cases recorded bj Dunbar,‘l Dansey,“’ and Enoch and Har- ries,zs 37 were gastric uIcer perforations, or about 65 per cent. Corvese”” mereIy observed this fact. In the male patients by far the majority of the perforations occurred in duodena1 uIcers, while qastric perforations were more infrequent.
Previous Ulcer History (Table II). Many interesting facts may be added to the perforated uIcer history provided one takes the troubIe to interrogate the patient during his con\raIescence. Oftimes a nega- tive history wiI1 prove to be positive. Singer and Rosii” empIoyed this method to provide the positive histor!- of previous
Dururion oJ prerious history
Under 6 months From 6 mo. to I yr. From I to 2 gr?,. From z to j yrs 0 “CT j years..
free perforation in 30 cases of perigastric abscess of uIcer origin. They were suc- cessfu1 in 29 cases. However, for diagnostic purposes at least, the surgeon has only the previous history to reIy upon.
66 American Journal of Surgery EIiason & Ebeling-Peptic UIcer APRIL, 1934
There was a tota absence of previous uIcer history in 12 of 67 patients, or about 18 per cent. These patients became aware of the presence of their uIcer onIy by perforation. In 1346 perforated uIcers, whose reporters recorded this information, 181 or I 3.4 per cent were said to be without a history suggestive of peptic uIcer. In none (our own cases incIuded) was there a mention of postoperative or convaIescent history-taking.
Character of Previous Ulcer History. The typica uIcer history: pain, food ease or aIkaIi reIief, hunger, and pain; or food, pain and then aIkaIi reIief, was re- corded in 30 of 55 of these patients, or 54.5 per cent. Symptoms suggestive of interference with the exit of the stomach, distention. and gaseous eructation, or vomiting, were recorded in Ig of 56 pa- tients or 34 per cent for the former, and in 25 of 58 patients or 43 per cent for the Iatter. WhiIe it has been stated that perforation rareIy occurs in a fourth-stage (stenosing) uIcer, it wouId appear to have occurred with more than the usua1 fre- quency in this series.
Hemorrhage in the Per&rated Ulcers. The statements that “perforated uIcers rareIy bIeed” and “ bIeeding uIcers rareIy perforate” deserve quaI&ation. Berg’ be- Iieved that when the two catastrophes occurred simuItaneousIy, often two uIcers were present, one bIeeding, the other perforating. When one observes that most of the perforating uIcers were situated on the anterior surface of the duodenum and pyIoru’s, and that many of the bIeeding uIcers are on the posterior waI1 of those structures, this becomes Iess difflcuIt to comprehend. MuItipIe uIcers are not in- frequentIy seen at operation for duodena1 uIcer or gastric uIcer, when neither per- foration nor hemorrhage has occurred.
Frank hematemesis was recorded in the past histories of g of 54 patients, whiIe meIena (tarry stooIs) was observed in g of 51 patients.
In 240 perforated uIcers reported by Raven 67 GiImour and Saint 34 > , and Semb,74
the history of previous hemorrhage was observed 24 times.
Hematemesis at the time of actua1 perforation was observed in 4 cases of our series.
Medical Treatment and the Occurrence of Perforation. It has been commonIy stated that in any patient suffering from duodena1 uIcer, who has had and is receiving adequate medica treatment, the uIcer wiI1 not perforate. BIackford and Baker9 most recentIy expIoited this view. Most of their cases of perforated uIcers had not had a diagnosis of peptic uIcer prior to perforation.
Twenty-seven of 56 of our patients with perforated gastric and duodena1 uIcers had medica treatment for peptic uIcer. One patient had a perforation whiIe on medica treatment in the wards of the hospita1. Hinton reported 6 perforations in his series of 139 perforated uIcers, while under medica care. Thirty-six per cent of his patients had previous medica treat- ment. Fifty per cent of IOO cases of perforated ulcer reported by Brown12 had previous medica treatment.
MoynihaIYg pointed out that perforation was a preventabIe compIication, provided medica treatment did not permit progres- sion of uIceration. Not Iess than one- quarter of the cases of perforation were heraIded by an increase in the severity of the recurring pain and suspicion shouId have been aroused as to the imminence of danger. It wouId appear that the faiIure to recognize the fact that medica treat- ment was inadequate, or persistence in medica treatment despite its faiIure, were responsibIe for a goodIy portion of these catastrophes.
Time of Ulcer Perforations. The time of perforation was we11 distributed through- out the year. Four were observed in the month of January, 7 in February, 4 in March, 5 in April, 6 in May, and 5 in June. The majority, however, occurred in the Iatter haIf of the year, with 8 in JuIy, 7 in August, 4 in September, 7 in both October and November, and IO in
NEW SCHIES VOL. XXIV, No. I Eliason & Ebeling-Peptic UIcer Amcricnn Journal of Surgrl-y 67
December. The month of JuIy boasted 5 of the 14 gastric uIcer perforations.
foration. Fewer stiI1 were mereIy prostrated by the “shock” of the catastrophe.
Forty of 60 cases, or 66.6 per cent of the uIcers, perforated whiIe the individuaIs were awake. In but 6 cases did the perfora- tion occur shortIy after the taking of food, and in I I cases, the patients were at physica labor.
TABLE 111
HISTORY OF PERFORATION
CorIette18 has recentIy showed that the mechanism of uIcer perforation operated rather strictIy under Boyle’s Law; further, that the contractions of the muscuIar waIIs of the stomach wouId increase the hydro- static pressure within the organ without increasing the genera1 intra-abdomina1 pressure, and if the difference in pressure passed the bursting strain of the uIcer, perforation wouId occur. He believed that the effect of actua1 pressure of the gastric content, accidents or coIIisions, and faIIs from a height, as possibIe causes of per- foration, were reIativeIy unimportant; fur- ther, that increased intra-abdomina1 pres- sure couId not cause an uIcer to perforate.
Pain announcing perforation. / Location
General abdomen.. Epigastrium.. Mid. abdomen.. .I Right. abdomen. Lower abdomen., _. Left abdomen.
59 ) 21 135.5 13 5 38.4 $9 , 29 149.1 ‘3 6 146.1 59 3 i.0’ 59 3 5.0 ‘3 I 49 z 3.3’ ~ 7.6
59 1 1.6 13 I 7.6
Pain reference Right shoulder ............ Both shoulders ............ InterscapuIar. ............. Back .................. ...1 Right lower quadrant ...... Lower abdomen ............
3 I
I
2,.
2 I.... I
Symptoms and Signs ofPerforation (Table III). The pain which announced the perforated uIcer was IocaIized to the epigastrium or genera1 abdomen in 61, or 83 per cent, of 72 cases in whose his- tories these points were recorded. In 9 cases, the pain reference was to the back (shouIder and interscapuIar areas inchrded).
Character of pain
, (1-~ .: : ~~.._ _~ __
Severe, violent, terrific ex- crucisting. agonizing sharp, knife-like, unbearable or pro-’
f ound... _. _. 5- 4’ 82.4 IZ IO 83.3 CoIlicky.. Dull.. _. .; :;
7 11.2 3 5.2 IZ 2 16.6
Immediate efert of pain Fixed, paralyzed or doubled-
up..................... 16 26.6 14 Collapsed, fainted. pros-
strated, “shocked”. .I :: ~ 4 i 6.0~ r4
1 (28.5
r ~ 7. I
*Number of cases or histories in which these ptints wcrr recorded.
In character, the pain was of the vioIentIy severe type in 57, or 81 per cent, of 69 patients for whom this information was recorded; the remaining 12 patients observed a coIIicky or dulI pain.
There appears to be some difference in opinion as to whether the pain which announces the perforation of an uIcer is due to the rupture of the ulcer or to the sudden chemica1 peritonitis. Gregoire35 conchided the Iatter expIanation to be the most tenabIe.
One quarter of the patients (17 of 67) who suffered a perforation were fairIy comfortabIe when first observed. The remainder, and by far the majority, bore an agonized expression indicative of the severity of their discomfort. Whether those who were comfortabIe had morphine prior to admission or not, was undetermined.
Vomiting was recorded in 18 cases at the time of perforation. Four had hematemesis.
The immediate effect of the perforation in 20, or 27 per cent, of the 74 patients in whose histories this point was recorded, was fixation, in whatever position the individua1 occupied immediateIy upon per-
Genera1 abdomina1 tenderness (TabIe IV) and rigidity were observed in prac- ticaIIy a11 of those uIcers, which at opera- tion showed free fluid in the peritonea1 cavity. LocaIized and marked tenderness in the epigastrium or right upper quadrant caIIed attention to the stomach or duo- denum in many instances. Peristalsis was
68 Ammican Journal of Surgery EIiason & EbeIing--Peptic UIcer APHIL, ,934
totaIIy absent in the majority, though present in a few.
TABLE Iv PHYSICAL SIGNS
SIT. -- ” erlng ....................
No discomfort ............... No record ................... Abdominal signs (free fluid
group). ................... /
General tenderness and rigidity Tenderness most marked in
Right upper quadrant. Epigastrium. Right lower quadrant.. Left upper quadrant.. ~
Peristalsis mesent in. I Hepatic dullness diminished in
. . . . . 9 3 (of 4 obser- vations)
Abdominal signs (subawe. walled-off or “forme Jruste” group).. .I 13
General tenderness and rigidit.y Tenderness and rigidity I 3
in R.U.Q... 3 in R. side. _. I
39 (z subacute; 16 (9 subacute: 5 (2 subacute:
4, Duodenal Physicat signs
not recorded in z
45
9 6 3
in R.L.Q . _. __. I Epigastric tend. and rigidity. I B&w & to Ieft of umbilicus. I Below umbilicus,, ........... I No localizing signs. .......... 1 Peristalsis present in. ........ 12
1
2
2
0
In those uIcers characterized by IocaI abscess formation, waIIed-off, subacute or forme fruste type of perforation, the physica signs usuaIIy pointed to the upper abdomen as the source of troubIe. PeristaI- sis was present in most of these cases.
The Ieucocytic response varied greatIy, but in 31 cases ranged from a norma IeveI of 7500 to as high as I 7,500 white bIood ceIIs per cubic miIIimeter. Seven cases had counts beIow this IeveI, whiIe 18
presented white counts above this, up to 32,500 white blood ceIIs per cubic milli- meter. On the basis that the peritonea1 reaction wouId be measured in degree by the Ieucocytic response, it was found that 20 patients, or 52 per cent, out of 38 with counts beIow 17,500, succumbed; whiIe 12, or 66 per cent, of 18 whose counts were above I 7,500, recovered. ObviousIy, too few observations of this nature are recorded.
Shock. It is rather doubtfu1 whether true surgica1 shock ever occurs as an
immediate resuIt of uIcer perforation. It wouId appear that those cases admitted many hours after perforation were diag- nosed shoclz on the basis of a faiIing circuIation, due to peritonitis. Brown12 stated that shock was present in 66 per cent of his cases. Johnston4” recorded the presence of shock in 8 per cent. Watson,g2
CoIp, l7 and WiIIiams and WaIsh98 believed shock to be present occasionaIIy. It is possibIe that the term shock has been applied rather IooseIy.
In the anaIysis of the 74 perforated uIcers, the temperature, p&e and respira- tory rates, and bIood pressure readings were seIected as being partiaIIy dependable criteria for the determination of surgical shock. The Iowest temperature recorded was 96°F. and the highest 103.3’~. The maximum pulse rate was 142 per minute. Thirty-eight patients had puIse rates above IOO per minute. The maximum respiratory rate was 60 per minute and but 30 had respiratory rates above 28. In 46 patients in whom blood pressure readings were avaiIabIe, but 4 had systoIic pressures beIow IOO mm. Hg.
Those patients whose condition most nearIy approached that of shock are listed below. Their condition would fail to war- rant this diagnosis.
CASE I. BIood pressure g8/74. T. g8”, P.
125, R. 60. CriticaIIy ilI. Hands and feet coId. Operated on eighteen hours after perforation. Died.
Case II. Blood pressure g4/7o. T. g6.4”,
P. 82, R. 48. III. Vomited bIood. Operated on fifty-five hours after perforation. Died.
Case III. BIood pressure go/6a. T. 98.4’.
P. I IO, R. 28. Fe11 to the ground when perfora- tion occurred. Felt faint and was said to have been shocked. Operated on five hours after perforation. Recovered.
Case IV. BIood pressure go/65. T. g8”, P. 94,
R. 24. Moribund and moaning on admission. Operated on twenty-seven hours after perfora- tion. Died.
Seven patients presented temperatures on admission of 97%. or beIow. Of these, but 2 recovered, and these two were operated upon within one and one-half
NOW Swum VOL. XXIV, No. I Eliason & Ebeling-Peptic Ulcer American Journal oFSurgery 69
an d seven hours from the time of perfora- tion. Moynihansg pointed out that the term prostration was better suited to this immediate post-perforative condition.
Diagnosis (Table v). The preoperative diagnosis was correct in 62 cases, or 82 per cent. The commonest singIe source of
TABLE v
PREOPERATIVE DIAGNOSIS
Duodenal Ulcers : Gastric Ulcers
_~ ~~~~^ ~~.. ~ ~~...~~ Correct in .! $1 or 85.0 Correct in 2 or
per cent 14.2 per cent Appendicits 3 or 9.8 Perforated ulcer 9
per cent or 64.2 per cent Cholecystitis. I 78.4 per cent Intestinal obst. due to I Appendicitis 3 or
hernia PyIoric carcinoma. I
2 I .4 per cent I
Incidental finding at operation for hernia. I
error was acute appendicitis. This error was not uncommon with other writers, and some went so far as to advocate a right McBurney incision before explora- tion of the upper abdomen. The fact that occasionaIIy a perforated ulcer wiI1 cause the initia1 and referred pain in the right Iower quadrant, following which Iocalizing symptoms and signs to that area are in evidence, Ieads to this error. FortunateIy it is not a serious error, for the McBurney incision Iends itseIf niceIy to the insertion of the pelvic drain, and consumes but little time.
In one case, that of a waILed-off abscess folIowing perforation, the diagnosis of pyIoric carcinoma was entertained. This error is not an uncommon one in those patients presenting marked deformation of the pyIorus and interference with the emptying of the stomach. The carefuI history wiII often eIicit the various uIcer phases, Ieading up to this stenotic fourth- stage uIcer. It is our practice to suspect a chronic ulcer as being responsibIe for the stenosis in a11 patients presenting evi- dences of pyIoric obstruction. UntiI proved otherwise, and that when possible at the operating tabIe, do we accept a diagnosis
of carcinoma. X-ray Diagnosis oj Perforated Discus.
In 1927 CortIe and SpaIdinglg concIuded that the x-ray through the demonstration of pneumoperitoneum was of more vaIue in the diagnosis of a perforated uIcer than the usuaIIy unsuccessfu1 search for dimin- ished Iiver duIIness.
Vaughan and Singergo presented a series of 72 bon&de perforated uIcers, in 63 of which abdomina1 x-ray had been per- formed. Fifty-four, or 85.7 per cent, of these showed free air within the peri- toneum. In I I examinations recorded on our 74 cases, but 4 showed air under the diaphragm in the semi-erect or erect posture. MattingIyS1 found air present in 8 of 13 examinations. WoIfson and Graylo found air in 4 of 13 examinations.
Free intraperitonea1 air has been demon- strated as earIy as ten minutes after perforation, by Geier.32 In two of our cases examined, with positive results, the perforations had occurred ninety-six and 144 hours prior to examination.
The roentgenoIogica1 examination of the patient suspected of a perforated uIcer becomes most vaIuabIe in those patients presenting an unusuai picture, and where the diagnosis is in doubt. Where, in the acute surgical abdomen, the decision rests between an upper or Iower abdomina1 expIoration, the demonstration of free air wiI1 definiteIy terminate the issue. However, where one’s decision is to perform the upper abdomina1 exploration, despite the possibIe absence of air under the diaphragm, there is IittIe need of sub- jecting the patient to further investigation.
LittIe time need be consumed in the roentgenoIogicaI study provided one has the cooperation of the roentgenoIog;ist and adequate x-ray equipment.
Location of the Perforated Ulcers. In 37, or 80.4 per cent, the perforated duo- denal uIcers were Iocated on the anterior surface of the first portion of the duo- denum. Seven, or 15.2 per cent, were situated on the anterior surface of the second portion, whiIe 2, or 4.3 per cent,
70 American Journal of Surgery Eliason & EbeIing-Peptic Ulcer APRIL, ,934
Drainage alone.. . . . 8 Oversewed with drainage 22 Oversew, gastroent. with
drainage.. . . . . . . . 14 Pylorectomy. gastroduo-
denost. with drain. . . I Jejunost. with drainage.. . I
-
Total drainage cases.. . 46
Oversewed, no drainage. I 0VW.W. gastro-ent. no
drainage.. . . . . . . . . 8 -
Total non-drainage cases 9
were found on the posterior waI1. In 12,
the situation was not recorded. In 7, or haIf of the perforated gastric
uIcers, the Iocation was on the anterior surface of the pylorus; 5, or 35.7 per cent, were situated on the Iesser curvature, anteriorIy near the pyIorus; and 2, or 14.2 per cent, were situated on the pos- terior surface of the stomach.
Perforation occurs most frequentjy in those duodena1 or gastric uIcers occupying the region of the pyIoric sphincter on the anterior surface. CorvesezO found about go per cent of his perforated uIcers within x to 1% inches of the pyIoric sphincter. Some few frankIy admitted that because of the acute inflammatory edema about the site of perforation, they were unabIe to definiteIy pIace the Iocation of the perforation to one side or the other of the sphincter. Others considered the distinc- tion between the two unnecessary, at Ieast, so far as their surgery was concerned.
Operative Procedures (Table VI). Thirty of these perforated ulcers were simpIy
TABLE VI
OPERATIVE PROCEDURES
Procedure
6 I
I
I
- -
22 (47 per II cent)
0 2
3 I - -
3 (33.3 Per 3 cent)
I -
6 (54.5 per cellt)
0
cIosed, with drainage of the peritonea1 cavity. Three were simpIy cIosed, without drainage, a tota of simpIe cIosures in 33, or 47 per cent. The uIcers were cauterized in many, prior to cIosure. Gastroenteros- tomy was added to simpIe cIosure in 15 cases which were drained, and to g without
drainage, a tota of 24 gastroenterostomies, or 34 per cent.
Drainage aIone was performed IO times, where the condition of the patient, the presence of a IocaIized abscess, or faiIure to find the perforation made this procedure a necessity. Two patients were subjected to aIternative procedures, with fata resuIts.
In those uIcers in which simpIe cIosure or simpIe cIosure pIus gastroenterostomy was performed, drainage was instituted in 82 per cent. The drains were usuaIIy pIaced under the right diaphragm, in Morison’s pouch, to protrude through a stab wound in the flank, and through a suprapubic wound into the peIvis. Not a11 of these sites were drained in each instance.
Thirty-five patients were operated upon by one surgeon (28 per cent mortaIity) whiIe twenty-three different surgeons ac- counted for the baIance. In three instances where the patients succumbed on the tabIe, no definite operative procedure had been compIeted. One patient refused operation, and in another, where the perforation was incidentaIIy recognized during herniorrhaphy, the uIcer was not found.
Mortality (Table VII). The gross mor- taIity for these 74 perforated uIcers was
TABLE VII
MORTALITY STATISTICS
PERFORATED ULCERS
Duodenal Gastric
--
Cases lDied~6~~ Cases iDiedl&
Total mortality.. . . . . 60 2.8 46.6 14 6 42.8 Operative mortality.. . . 58 28 48.2 14 6 42.8
Operative mortality in free fluid group.. . . . . . . 46 21 47.8 IZ 5 41.6
Operative mortality in wall- ed-off group.. . . . . I= 6 50.0 z I 50.0
45.9 per cent. The operative mortaIity was 47.2 per cent. HaIf of those patients operated upon after their perforation had resuIted in a Iocalized abscess or inffam- matory mass, succumbed. The mortality in those patients operated upon, and in
NEW SERIES VOL. XXIV, No. I Eliason & EbeIing-Peptic Ulcer American Journal ot Surzvry ,I
whom there was free fluid within the abdominal cavity, was 46.5 per cent.
The average operative mortaIity for individua1 series of perforated uIcers pub- Iished from this country (TabIe VIII)
TABLE VIII
PERFOKATED ULCER SERIES COLLECTED FROM THE
LITERATURE OF THE UNITED STATES
__~ ___ - Williams-Tsnker-
sky’+‘. Greensboro, N. C. I921 7 3 28.5 WinsJowI~. . , B&more, Md. I921 29 I5 51.7 Hepburn’Q.. . Boston, Mass. 192.2 8 0 0 Stewart-Barb&@. N. Y. City I922 12 0 0
Guthri#. . . . Sayre, Pa. I923 42 7 16.6
Noehren”D. . ./ Buffalo, N. Y. 1924 6 McCreerys3.. _. N. Y. City I924 24 x0 Stanglsa.. . St. Cloud. Minn. I925 8 2 35.0 Holbrook”?. Mankato. Minn. BurnsIs. ,’ Cuero, Texas
I926 IO I IO.0 1926 6 0 0
Johnston, L. B.‘b. Cincinnati, 0. 1926 35 I3 37,I ZartmanI02. . . Columbus, 0. I926 6 3 50.0 Pollock6@. . Temple, Texas Igz6 I5 3 30.0 Meyer-Brams6~. Chicago, III. Igz6 62 18 29.0 McGlannan-Bon-
1928! 80 34 42.5 11929 15 /I930
0, 0 110, ZI 19.1
I930 Ij4, 20 rz.9 I930 ~$8; 4629.1
1930 80 22,27.5
gardt”“. . . . Baltimore, Md. I927 28 932.1 Brenner’o. N. Y. City I927 27 I 3.7 Hayter3P. ,’ Roanoke, Va. I927 9 34.0 Stenbuck*“. N. Y. City I927 2 27 30.6 Hinton’ N. Y. City Igz8 Iz I 8.3 Gibsonas N. Y. City IgzR ‘23 23 18.6
Fobesa”. . . N. Y. City 1928 I3 5 38.5 Morrison58. . Boston, Mass. ‘929 50 g 18.0 Olson-Cable6’. Minneapolis, Minx Igzg 46 16 34.7 Snodgrass”. Flint. Mich. ‘929 I4 642.8 Brownl*. Philadelphia, Pa. I929 100 33 33.3 Wolfson-Gr~y’oI..’ Brooklyn. N. Y. I929 27 2 7.3 Dineen . . N. Y. City 1929 I42 31 21.8 ColpI;. _. _. N. Y. City 1929: 20 2.IO.O PIatou”5.. Brooklyn, N. Y. ,Igzg 60 9 15.0 Patterson62. Cuthbert, Ga. ,929 I2 0 0 Robitshek”. Minneapolis. Minn. Ig3ol 53 I3 24.5 Hamme@‘. Albuquerque, N. M. Ig3o IO 660.0 Blackford-Bakers Seattle, Wash. I93I 21 3 14.2 Hinton”‘. N. Y. City I931 IO0 20 20.0 Weinstein-MC- Long Island City,
Hugh*l.. _. N. Y. 1931 50 20 40.0 Mattingly51 New Orleans, La. HorsleyQ.. ~ Richmond, Va.
I931 91 I3 14.2
1931 8 I12.5 Taylora’. _. .’ Ellensberg, Wash. Ig3I I2 o o Askew’. .! Atlanta. Ga. I9jI 55 I7 30.9 Schulte’r.. Newark, N. J. I93I I64 58,35.3 Whit@ N. Y. City I93I 79 I7ZI.5 Carves@ _. Providence, R. I. I932 106 3331.1 Johnston, W. M.461 Akron, 0. I932 52 16 30.7 EIiason-Ebeling
Smith”. England Schmidt’l.. Sweden Wad&. ........... Scotland Brown, K. P.“. ... Scotland
T urn&Q. .......... England W’II I an96 ........... England W’II I a1106 ........... England M&s% England EvamP ........... i England Ball4 .............. i England Ball”. ..... ...... ,’ England Dunbar*&. .......... Scotlnnd Danseyzl.. ........ I Australia Soderlund”. ....... Sweden Moynihanhg ........ England Jirasek-Perskey*’ Cheko-Slovakia Rogers”. .......... England Watson=. ......... England Bryce’“. ........... England WiIliams-Walsh08 England
ER aven67 ........... England neck-Harries% England
Searby’ .......... Australia Searby’“, ...... Australia Semb’4 .......... Norwav Gilmour-Saint’d.. .’ EnglnnTl
Total _!
mortaIity for our series of 74 cases wouId appear to merit further consideration. Likewise, the difference in mortahty be- tween the quoted statistics from our own country and those of foreign sources deserve some thought.
TABLE x
RELATION OF DELAYED OPERATION TO MORTALITY
(AppIicabIe to perforated ulcers presenting free fluid in peritoneum)
(nuthors). Philndelphia. Pa. I933 72 34 47.2 -I-
Totnl,...,,,.. .._......_... ..,,I I I
I940 5o425,gav.
24-48 hours. _. , 48-96 hours.. After 96 hours
since rg21 was 23.9 per cent. The average Efect of Delay in Operation upon Mar- operative mortahty for individua1 series tality (Table x). The fact that deIayed of perforated uIcers pubIished from various operation for an acuteIy perforated uIcer foreign sources (TabIe IX) was 22.6 per increases the mortaIity percentage has cent. The average operative mortaIity Iong been appreciated. For those patients for the entire group of 3061 perforated presenting free ffuid within the peritoneal uIcers was 23.9 per cent. The rather high cavity, and operated upon within the
TABLE IX
PERFORATED ULCER SERIES COLLECTED kR.OM THE
FOREIGN LITERATURE:
I / I I :
Author Location
_~.___... -.-.
Y 3”
s.
48
Hrs
. or
Ove
r ,”
TA
BLE
x1
R
ELA
TIO
N
OF
D
ELA
YE
D
OPE
RA
TIO
N
TO
M
OR
TA
LIT
Y
-
II 24 H
rs.
or O
ver T
24 to
48
Hrs
.
- II o
to 1
2 H
rs.
I I 2
HY
S.
or O
ver
1) 1
2 t
o 24 H
rs.
II o
to 6
Hrs
. 610
12 H
rs. Per
C
en
kfor
i
35.
27
20
29.
17
32 7
28. .
21.
23.
-
he:
‘5 5
IO
-
30
Per
C
ent
Mor
t
Au
thor
1
I C
ases
1
i I
Bro
wn
*2.
. ,..
....
. .
Cor
vese
zO.
Din
een
zZ....:::::::
‘94
Mey
er-B
ram
s”“.
33
Joh
nst
on4G
. S
ten
bu
cks4
. ;;
Gib
son
a3.
McC
reer
ys3.
Sch
ult
e72.
. . .
M
cGla
nn
an-B
on-
gard
t@.
. I
I E
lias
on-E
bel
ing
U.
S.*
Tot
al..
167
__-
Bry
ce14..
75
Moy
nih
ansg
.
Sea
rby7
3.
53
Sea
rby’
3.
I z
Jir
asek
-Per
sky4
4.
12
Tu
rner
s9.
Giim
our-
Sai
nt3
4
Sem
br’
. .
WiIIa
ng”
.
Wad
e9 1
. B
row
n,
K.
P.lI,
__
- For
.*
Tot
aI.
152
_.~__
~
Su
mm
atio
n.
31 g
* U
. S
. U
nit
ed
Sta
tes.
F
or.
For
eign
.
- lie
-
.
. . 6 7 . I . - ‘4
-
9 9 A
. - 25
- 39
-
- Xec
. . 5 .
- 5
-
7 . 7
- I2
-
,
he!
rl -
Per
I)
ied
C
en,
Mor
r
IO
5
50
16
13
81
7
19
‘5 2
52 6
19
__
146
_
5
71
14
73
9
60
2 1
00
35
67
5
83
12
63
-__ 100
68
--
_-
IO
9
90
20
17
85
16
IO
62
81
22
27
__
127
-__ 5
8’
45.1
_-
158
57.:
)iel
- d I
-
I2
80
4
5
21
-
80
50
37 I 9
7o.
c 47
6
60
6
6
- 27
-
60
6
67.5
-
53
-
__~
__
__
I I
Per
h
ses
Die
d
Cen
t C
ases
M
ort .
____
- 54
14
28
71
14
20 .
52
13
25
IO
22
522
53
713
..
94
I2
I2
17
I 6
- L
- .-
.-
._
-
____
P
er
Cen
t C
ase:
ilo
rt .
. 14
25
50
. 6
12
‘4 8
27 3
4
~__
50
1’3
26
28
27 7
27
‘3
38
63 2 I
26
206
____
32.4
319
___
Per
X
ed
Cen
t M
wt
8 57
14
56
.
4
67
3
25
2
*4
3
60
12
44
2
67
3
75
_- 5’
45.’
-~ 14
50
15
55
I 14
9
33
2
15
7
18
14
22
0
0
0
0
- _-
t c
L.
5 I 5
7
9
-
- SL
- --
_-
-
3ie
l 6 7
.
0 0
- 13
-
4
5 0 2 . .
- II
24
--
)iec
23 I 7
- 3*
- d n
- -
__-_
_ P
er
Cen
t C
ases
1
Mar
t .
____
_
7
20
17
.
0 26
. 0 5
__-_
_-
7.7
48
5
52
9
28
0
14
‘7
21
7.2
115
I ~
..._
_I_
7.5
, 163
1 1 n -
6
a -
_
I I-
9;
16
18
.
16
I 6
33
II
33
. .
__-_
_~
502
g4
18.7
IO
__
__-_
_
I27
13
IO
27
‘43
27
16
. .
81
14
17
26
3.8
.
. 33
i24
. g8
8
8
51
6.5
112
I,8
. 45
511
. .
19
421
IO
IO
12 1
325
, 62
30
___
1’3
35.4
40
-
first twelve hours, I I out of 33 succumbed, or 33 per cent. AII, or 3 patients, operated upon between the tweIfth and twenty- fourth hour, of the free fluid group, suc- cumbed. Five, or 44 per cent, of I I uIcers operated upon between the twenty-fourth and forty-eighth hours folIowing perfora- tion, succumbed. After the forty-eighth hour following perforation, 7 of 9, or 78 per cent, of those with perforated ulcers operated upon, died.
The effect of deIay in operation has been more effectiveIy and accurateIy dem- onstrated by the coIIected data from 22
different writers (Table XI). The average twelve hour operative mortaIity was 14.9 per cent,. tweIve to twenty-four hour operative *mortaIity 35.5 per cent, and over twenty-four hours’ deIay in operation resulted in an average operative mortality of 57.6 per cent. Beyond the twenty-four hour period, the operative mortaIity per- centage appeared to IeveI off at about this constant IeveI.
It was possibIe to arrive at a six hour mortality and a six to tweIve hour mor- taIity for 3 19 cases. It was interesting to note that, as one wouId expect, those patients operated upon under six hours had an operative mortaIity of 7.5 per cent. Those patients operated upon between the sixth and twelfth hour foIIowing perfora- tion presented an operative mortality of 23.9 per cent. The second six-hour period was obviousIy responsible for the majority of the deaths in the first tweIve hours.
There was a definiteIy Iower mortaIity, hour-for-hour, in the coIIected foreign re- ports, as compared with those reports from the United States.
Searby of AustraIia reported the Iow- est tweIve-hour mortaIity for 26 consecu- tive cases, with but one death, or 3.8 per cent. McCreerys3 of New York re- ported one death in 17 cases, or about 6 per cent. Stenbucks4 of New York pre- sented a series of 27 cases operated upon within six hours, with no deaths.
Causes of Death Following Operations ,\or Perforated Ulcers (Table XII). Per-
itonitis was responsibre for 5o per cent of the deaths in 34 patients. PuImonary compIications ranked second, and were responsibIe for 1-1 per cent of the fataIi- ties. Other causes of death have been enumerated.
TABLE XII
CAUSES OF DEATH
Peritonitis. r7 or 60.7 per cent
PuImonary complic.. 4 or ~4.2 per cent
Cardiac faiIure.. i 2 Intestinal obstruct. I I Cow&ions (?) I TabIe deaths. ( 3 (Spinal anesth.,
1 shock, heart ; block)
-
3 Or 50.0 per (cent
1 or 16.6 per ‘cent
2
6
The causes of death in 672 cases (Table XIII) of the coIIected series have been analyzed. Genera1 peritonitis was respon- sibIe for 59.0 per cent. PuImonary com-
TABLE XILI
CAUSES OF DEATH IN 672 CASES or; PERFORATED
I'EPTIC ULCER
Per Cent Genera1 peritonitis. 398 50. General peritonitis + shock. 13 2.
General peritonitis + pneumonia. 1 Genera1 peritonitis + evisceration. _ Subdiaphragmatic abscess. 31 1.9 IntestinaI obstruction.. 8 Cardiac (sepsis?) 3 I 4.6 Shock (sepsis?), 29 4.3 Table (sepsis?). 6 Pulmonary complications. lo3 Ii.3
plications ranked second, with 15.3 per cent. Subdiaphragmatic and hepatic ab- scesses ranked third, with 4.9 per cent. Heart failure was responsibre for 4.6 per cent, and shock for 4.3 per cent. It is possibIe that these latter two factors, as well as the table deaths, wouId contrib- ute to the one great group, the septic abdomen, upon which they were primariIy dependent.
Other causes of death have been enumerated.
74 American Journal of Surgery EIiason & EbeIing-Peptic UIcer APRIL, 1934
Anestbesia (Table XIV). Ether aIone, or modified by the administration of nitrous oxide and oxygen was empIoyed in the majority of instances. SpinaI anes- thesia was the onIy anesthetic charged with death.
TABLE XIV ANESTHESIA
Gastric Ulcers
Ether, open drop ...... 20 II 61.1 4 Gas with ether ........ 20 II 61.1 4 : Spinal ................ 10 3 42.8 3 I Local ................. 8 3 60.0 I I I
-
Two-no record. Spinal was the only anesthetic charged with B death.
Wound Complications. Ruptured or in- fected wounds occurred in 15 cases, I 3 from duodena1 perforations, and 2 from gastric uIcer perforation. Four of the former group succumbed. In none was the death attributed to these compIications.
The frequency of ruptured wounds and evisceration foIIowing operations for per- forated uIcer has resuIted in the common use of some non-absorbabIe sutures in the cIosure of the fascia1 pIanes (Iinea aIba or rectus sheath), and the protrusion of the drains through some incision other than the operative wound.
TABLE xv PULMONARY COMPLICATIONS
Duodenal Ulcers Gastric Ulcers I I Died Cases Died
PIeurisy.. . . 2 Bronchopneumonia.. IO 5 2 I AteIectasis. I I Lobar pneumonia. . 2 I PuImonary embolism I
-
I 6 (27.5 Charged with death
per cent) (of 58 op. cases)
in............... 4
Pulmonary Complications (TabEe xv), Bronchopneumonia contributed to the majority of the puImonary compIications. It is possibIe that many of these were
unrecognized ateIectases, or but the resuIt of genera1 sepsis. Pulmonary compIi+ tions were responsibIe for death in 5 cases.
Miscellaneous Complications. FistuIae occurred in 2 cases; cardiac faiIure in 4; subdiaphragmatic abscesses in 2; sub- hepatic and pancreatic abscess in I; peIvic abscesses in 2 ; parotitis in I ; phIebitis in I; and intestina1 obstruc- tion in I case. AI1 but 2 (cardiac faiIures) of these complications foIIowed operations for perforated duodena1 uIcers. MisceI- Ianeous compIications were charged with death in 4 cases.
Hospital Days. The average stay in the hospital for these patients with per- forated duodena1 uIcers, with recovery, was twenty-five days. The minimum was tweIve and the maximum seventy-seven days. The average stay for those with perforated gastric uIcers was thirty-one days, with a minimum of fourteen and a maximum of forty-six days. The two non- operative cases were not incIuded.
The usual postoperative day of death was about the third or fourth, at the end of the peritonea1 shock period described by Stenbuck.84 The maximum postopera- tive day of death was forty-eight, whiIe another patient died after the thirty- ninth day; however, these were the onIy two patients surviving eIeven days, within which period the majority of deaths occurred.
Follow-up data were rather Iimited. Information was onIy obtainabIe for those patients operated upon at the HospitaI of the University of PennsyIvania.
Of 12 patients in whom either packing and drainage, or simpIe oversewing had been performed, but one returned for a gastrojejunostomy. The remainder re- ported satisfactory anatomic, economic and functiona resuIts.
Seven patients in whom a posterior gastrojejunostomy had been added to simpIe cIosure, reported fuIIy satisfactory anatomic, economic and functiona resuIts.
These reports extended from three months to two years after operation. In
none of those patients in whom follow-up were pulmonary complications, subdia- information was avaiIabIe was there a phragmatic and hepatic abscesses (to second perforation. which one might add the pelvic abscesses),
FIG. I.
Comment. Certain salient points be- come apparent as one considers the data presented. In recapituIation they are as follows: (I) A reIativeIy high operative mortahty for this series of 74 perforated duodena1 and gastric uIcers, coIIected from two metroporitan hospitaIs, when compared to the average operative mor- tality for the coIIected reports from the United States and abroad.
(2) The higher average operative mor- taIity for the coIIected reports on per- forated duodena1 and gastric uIcers in the United States, as compared with the average operative mortaIity from the coI- Iected reports abroad.
(3) The higher average operative mor- taIity on a tweIve, tweIve to twenty-four and over twenty-four hour basis from the colIected reports in the United States compared to those abroad.
(4) The greatest singIe cause of death was peritonitis. FoIlowing in order
shock, heart faihrre, postoperative hemor- rhage and anesthesia.
Legitimate questions arise in the search for an expIanation of these facts. Does the collected average operative mortality for the United States, as presented, in any way approximate the truth? It is quite within reason to assume that only those surgeons who have some particuIar point to make, have troubIed to report their mortaIity resuIts in perforated uIcers. Many frankly stated that their reports covered consecutive perforations. The cit- ies from which these reports have arisen have been marked on the map of the United States (see Fig. I). Obviously, the mortaIity figures have been obtained from but a fraction of the avaiIabIe evi- dence on uIcer perforation. Those cases reported, with but rare exception, have come out of various university, teaching, and Iarger private cIinics. If the truth were known, the mortaIity figure for perforated
76 American Journal of Surgery Eliason & Ebehng-Peptic UIcer APRIL. r934
peptic uIcer in the United States wouId undoubtedIy exceed 25.9 per cent, by a wide margin.
Did the foreign writers operate upon tbeir patients earlier, on the whole, than we? Based on the avaiIabIe evidence in 761 perforated ulcers in the United States, 65.9 per cent were operated upon within tweIve hours, 14.7 per cent in from tweIve to twenty-four hours, and 19.4 per cent after twenty-four hours, foIIowing per- foration. For 1841 perforated uIcers from the foreign reports, 67.8 per cent were operated upon within tweIve hours, 25.4 per cent in from tweIve to twenty-four hours, and but 6.9 per cent after twenty- four hours, foIIowing perforation.
Despite the advantage provided in earlier surgery, the Iower mortaIity pre- sented by the coIIected foreign reports on the tweIve, tweIve to twenty-four and over twenty-four hourIy basis, must depend on other factors.
Stenbuck** has admirabIy summed up the various factors responsible for death from perforated gastric and duodena1 uIcers. In the first place, these may be roughly grouped under those points over which the surgeon or practitioner wouId appear to have some control, to wit: (I) duration of time between perforation and operation; (2) operative procedure; (3) drainage of the peritoneal cavity; (4) drainage of stomach; (5) seIection and preparation of patient for operation; (6) choice of anesthetic agent; (7) prevention of puImonary compIications, shock and hemorrhage. Secondarily, one may group those factors over which, for the present at Ieast, the surgeon or practitioner would appear to have no control whatsoever, to wit: (I) that immeasurabIe “something,” which we may best describe as the consti- tution of the patient; (2) time of perfora- tion (immediateIy after meaI), size of perforation, and extent of soihng of the peritonea1 cavity; (3) age of the patient, for it has been dehniteIy shown that as the age increases, the mortaIity rises; (4) presence of organic disease; (5) aI-
cohoIism, psychoses, etc. One must, perforce, Iimit himseIf to a
consideration of those factors over which there wouId appear to be possibIe contro1.
Delay in Operation. FuIIy 75 to go per cent of a11 patients suffering a per- forated uIcer have had symptoms of chronic uIcer suffmientIy suggestive to warrant some sort of medica treatment, sometime prior to the perforative catas- trophe. ApproximateIy 50 per cent of those patients suffering a perforated uIcer have had a diagnosis of a chronic peptic uIcer, and have received some sort of medica treatment. These patients shouId be made “perforation wise.” They shouId be fundamentaIIy aware of the fact that they are harboring a constant threat, and that deIayed surgery, when once perfora- tion occurs, may cost them their Iives.
Moynihan5g concluded :
The diagnosis of an abdominal caIamity requiring immediate surgica1 treatment is made when a sudden attack of prostrating and over- wheIming agony is associated with an obdurate, unyielding rigidity of the abdominal waII, which is everywhere excessiveIy tender and immobiIe. Shock in the strict surgica1 meaning is not present. If we wait for it, we are risking the patient’s Iife: for it is not an evidence of perforation, but of the peritonitis which is preventabIe, and shouId be prevented. We may not be able to say, when these signs aIone are present, that the catastrophe is certainIy in one viscus, or certainIy another. It matters IittIe where it is, a11 we need to know is that wherever it is, and whatever it is, it is irremedi- abIe except by surgery. We must reduce this matter to simpIe terms and that is the onIy method by which we can succeed. The saIva- tion of a human Iife is a greater thing than the estabIishment of a convincing irrefutabIe cIinica1 diagnosis.
Bryce14 justIy stated, “It is to the genera1 practitioners who make the earIy diagnosis that any improvement shown in modern mortaIity figures is IargeIy due.”
There shouId be no deIay between the practitioner, the surgeon and the operating room.
NEW SERIES VOL. XXIV, No. I Ehason & Ebeling-Peptic Ulcer American Journal of Surge:-+ -7
Operative Procedure. Guthrie36 at- cIosure. They were of the opinion that the tempted to epitomize the consensus of Iow mortaIity figure fuIIy justified the opinion and practice concerning the proper use of simpIe suture as the routine treat- operative procedure for the perforated ment for acuteIy perforated uIcer. Searby peptic uIcer. Some few, whose opinions had a 6.1 per cent mortaIity in 33 persona1 were quoted, have pubhshed mortality cases, a11 of which were treated by simpIe data during the past ten years, and are closure; he concIuded that it was not noted herein. The discussion resoIved advisabIe to do more than cIose the itseIf about the advisabiIity of adding perforation at one operation. Smith7* had gastroenterostomy to simpIe cIosure, or a 12.1 per cent mortaIity in 41 consecutive being satisfied with simpIe cIosure, thus cases. AI1 but 2 were treated by simpIe Ieaving further surgery to a secondary cIosure; he advised postponement of gas- operation. troenterostomy until a Iater date.
WhiIe there remain stiI1 more radica1 procedures, too IittIe materiaI is as yet avaiIabIe to enter them into this discussion. Hinton, after performing tweIve pyIoro- pIasties, decided that the resuIts did not warrant their continuance. Lewisohn4* ad- vised against the performance of subtota1 gastrectomy in the presence of an exten- sive infection of the peritonea1 cavity.
The two schooIs stiI1 remain, those who routineIy perform simpIe cIosure of the perforation, and those who add gastroen- terostomy whenever the indication arises. There appears to be agreement on these points however: (I) The perforated peptic uIcer is aIways one of grave emergency, and one in which immediate prognosis must be guarded. (2) The major aim of whatever operative procedure is adopted, is to save life. (3) The minor aim is to relieve the patient, in so far as is possibIe, of ulcer recurrence and future catastro- phes; to cure him of peptic uIcer.
The foIIowing opinions are of interest. In each group, five or six of those surgeons whose operative mortaIity was the Iowest for that fieId, and who had reported over 25 perforated uIcers, were seIected.
Foreign Opinions. SoderIundEo (3. I per cent mortality in 32 cases) beIieved that in addition to simpIe cIosure of the perforation, some sort of drainage of the stomach was advantageous. In addition there was performed a gastrostomy after the method of WitzeI. GiImour and Saint34 had a 4.7 per cent mortaIity in 64 cases. AI1 cases except one were treated by simpIe
Opinion in the United States. Brenner’O (3.7 per cent mortaIity in 27 cases) favored simpIe cIosure, the end resuIts of which, for his series, were much better than those foIIowing gastroenterostomy. He warned about the 2 to 3 per cent chance of future gastrojejuna1 uIcer foI- Iowing gastroenterostomy. He beIieved that to state dogmaticaIIy that al1 cases treated by simpIe cIosure wouId resuIt in permanent cure, was as iIIogica1 as to insist upon a primary gastroenterostomy as a universa1 procedure. MattingIy51 (14.2 per cent mortaIity in 91 cases) performed gastroenterostomy in but one case. He advocated simpIe cIosure. He stated that he had yet to hnd where simpIe cIosure of the uIcer had caused marked encroachment upon the lumen. Four of his patients returned for gastro- enterostomy. PIatou 65 had a I 5 per cent mortaIity in 60 consecutive cases. Simple cIosures were performed in 44 cases with 8 deaths, 3 patients suffering reperfora- tion. Gastroenterostomy was added to simple cIosure in 15 cases, with one death. One patient was simpIy packed. Guthrie36 had a 16.6 per cent mortaIity in 42 cases. AI1 had simpIe cIosure with drainage. There were three secondary gastroen- terostomies. Guthrie concIuded his resume by pointing out that many surgeons of Iarge experience maintained that it was not wise to do gastroenterostomy at the time of cIosure in acuteIy perforated uIcer. Morrison58 had an 18 per cent mortaIity in 50 cases; a11 were operated on under
78 American Jourd of Surgery EIiason & EbeIing-Peptic UIcer APRIL, 1934
twenty-four hours; he beIieved that if the perforation was at or near the pyIorus, the puIse 120 or Iess, and the patient’s genera1 condition warranted, it was prefer- abIe to do a posterior gastrojejunostomy. Gibson33 had an 18.6 per cent mortaIity in 123 cases. SimpIe suture was performed in 109 cases, with but 17.4 per cent mortaIity. In 1923 Gibson3” reported 60 of these cases and concIuded at that time that the resuIts confirmed the beIief of the desirabihty of aiming simpIy to cIose the perforation, Ieaving the remote and probIematica1 after effects to be taken care of as the necessity arose. This opinion apparentIy was not aItered by this Iater study.
There remains very definite and worthy opinion that gastrojejunostomy added to simpIe cIosure does not affect the mortaIity if this procedure is carried out in seIected and earIy cases. The mortaIity resuIts on the basis of tweIve, tweIve to twenty-four and after twenty-four hour operations, foIIowing perforation, have been tabuIated (TabIe XVI). In but one or two instances,
TABLE XVI
MORTALITY FIGURES OF COLLECTED CASES
Simple Closure
Different 0-12 12-q zq. Hours Total series of
‘;
HOWS HOWS + Mortalify
the same 15 per cent qr per cent 65 per cent 40.3 per cent
eight Simple Closure witb Gastroenterostomy S”*geO** 21 per cent 26 per cent 6a per cent 49. per cent
4
those who advocated the performance of gastrojejunostomy in addition to simpIe cIosure have performed simpIe cIosure in by far the majority of their cases. Ob- viousIy too few cases have been studied in this manner to draw definite concIusions.
There has recentIy deveIoped a schoo1 whose major aim wouId appear to be better uItimate resuIts in a few, rather than a Iowered mortaIity. It wouId appear at Ieast from this discussion that the re- mote resuIt can aIways be improved in a Iive patient by a cIearIy indicated second- ary operation. ShouId, perchance, the foIIow-up resuIts be better in those patients who have had primary gastrojejunos- tomies, with due respect to immediate
operative mortaIity, one often faiIs to consider the fact that cured and Iiving cases may be added to the good resuIts by a secondary operation, carrying with it a mortaIity quoted variousIy between I to 4 per cent.
Bage? coIIected I 767 perforated uIcers from fifty hospitaIs in Sweden, operated upon by IOO surgeons during the period from 191 I to 1925. He concIuded that the poorer resuIts foIIowing simpIe suture compared with the combined operation of suture and gastroenterostomy were due undoubtedIy to the fact that the patients treated by suture alone were the worst operat’ive risks.
One must not forget that gastroen- terostomy foIIowing simpIe suture was usuaIIy performed in the seIected cases, and that it is possibIe, had the simpIe operation been continued in these, the mortaIity resuIts wouId have been much Iower.
Drainage of the Peritoneal Cavity. It is highIy probIematica1 whether the routine irrigation and drainage of the peritonea1 cavity wouId reduce the number of deaths due to genera1 peritonitis. The criteria for the institution of drainage rested in the one case on those perforations operated upon within the six hours foIIowing rup- ture of the uIcer, after which hour most of the cases were drained; and, upon the extent and quantity of the peritonea1 contamination or presence of infection. Irrigation was usuaIIy practiced onIy when there was much foreign materia1 within the peritonea1 cavity.
Attention has been caIIed to the frequent steriIity of cuItures of the gastric and duodena1 contents which have soiIed the peritonea1 cavity, foIIowing perforation of an uIcer. Loehr4g stated that go per cent of the cuItures folIowing duodena1 perfora- tions were steriIe, whiIe 82 per cent foI- Iowing gastric uIcer perforations were steriIe. BartIe and Harkins found but 3 of 26 specimens of gastric juices to be steriIe. Watsong2 quotes Dugeonz3 whose cuItures in 23 cases of perforated uIcers
EIiason & EbeIin.g-Peptic Ulcer American Journd ot Surgery 79
showed streptococci in 12, staphylococci in IO and steriIe cuItures in but 5. Bruett13 found that 26 per cent of I 12 cases pre- sented steriIe cuItures in from six to tweIve hours after perforation, while after the tweIfth hour but 7 per cent were steriIe. Breriner’O took cuItures in 14 cases, and up to twenty-six hours a11 were steriIe. MattingIyS1 reported 37 negative cuItures in 46 cases in which cuItures were taken. No one has troubled to report bow many of those patients in whom sterile cultures have been found, have subsequently died from general peritonitis. Gibson33 cuItured 43 cases, 65 per cent of which were steriIe, with a mortality of 14.8 per cent. Positive cultures were obtained in 13 with a mortaIity of 40 per cent. The cause of death in these patients was not recorded.
FIeming31 recorded subdiaphragmatic abscesses in 3 cases, in which upper abdominal drains were used. He noted records of 2 cases of perforation of the diaphragm where similar drains were used. Richardson6* (FIeming) observed a high mortality (25 per cent) from subdiaphragmatic abscesses in the ma- jority of which cases upper abdominal drainage had been used.
of puruIent drainage, and removed their drains reIativeIy early during convales- cence. None observed definite harmful effects from the insertion of drains, nor couId any mortaIity be definiteIy at- tributed to drainage.
Due to the common occurrence of ruptured wounds and wound infections foIIowing operations for the perforative catastrophe, practicaIIy a11 who observed this point were in agreement that the subdiaphragmatic and subhepatic drains shouId protrude from a stab wound in the right flank, and not through the operative wound.
One must observe that the term “upper abdomina1” is a broad one, and might we11 incIude the immediate area of uIcer perforation, the subhepatic area or supe- rior surface of the Iiver as weI1.
In the coIIected series, where sub- diaphragmatic, hepatic, subhepatic, and peIvic abscesses have been responsibIe for death, not one abscess couId be pinned directIy to the presence of a soft drain for that particuIar area in which the abscess occurred. Obviously, the reports couId have been more expIicit on this point. McGIannan and Bongardt5* who observed three deaths from subdiaphragmatic ab- scess where no drains had been used, added that drainage of the subdiaphragmatic area was now the routine.
Drainage of the Stomach. One of the most important arguments arising from the controversy between the advocates of simpIe cIosure and those favoring the addi- tion of gastrojejunostomy, was that the gastrojejunostomy provided ready drain- age of the stomach, and the tension on the suture Iine at the cIosure of the perforation was Iessened by this drainage, thus insuring healing of the perforative sight, with IittIe possibiIity of the occur- rence of duodena1 or gastric EIstuIae.
In this connection one must refer to the report by Bage? on the mortality resuIts of perforated uIcers in the Maria HospitaI in Stockholm. Lengthwise incision. of the uIcer, crosswise suture, irrigation of the abdomina1 cavity, gastrostomy and primary cIosure of the abdomen without drainage or tamponage, gave but I 1.3 per cent mortaIity in 78 cases. There were no deaths in 45 cases operated on under six hours. SoderIundso and Schmidt,71 whose cases were coIIected from the Maria Hos- pitaI, advocated the WitzeI gastrostomy for drainage of the stomach. WiIIiams and WaIshg7 used, in a simiIar way, a doubIe tube technique for gastrostomy.
On the basis of these reports, it wouId appear that there is a definite basi:s for the adequate drainage of the stomach im- mediateIy foIIowing simpIe closure of a perforated uIcer.
Many writers commented on the fre- With the advent of the Jutte tube, the quent observation of but a smaI1 amount immediate postoperative drainage of the
80 A merican Journal of Surgery EIiason & EbeIing-Peptic UIcer APRIL, 1934
stomach becomes a simpIe procedure, requiring neither a gastroenterostomy nor gastrostomy.
Selection and Preparation of the Patient for Operation. But few patients wouId appear to be in such condition as to make surgery an utter impossibiIity. Brown’2 went so far as to concIude that the diag- nosis of perforation was an indication for immediate operation regardIess of the patient’s condition. AbdominaI distention, the presence of free fluid within the peritoneum, coId and Iivid extremities, a Iowered body temperature, eIevated respiratory and puIse rates, bIood pressure beIow go mm. Hg systoIic, profound shock and toxemia, are but the signs of Iate peritonitis, and in such a patient surgery might justifiabIy be deferred. One couId not hope to benefit a moribund and puIseIess patient by the administration of an anesthetic and further insuIt to his tissues.
Singer75 and Wickbomg5 have reported cases of free perforation of peptic uIcers, that have recovered spontaneousIy. Sur- gery, then, may not be the onIy treatment.
In those patients in whom the term “hard hit” best describes their condition shortIy foIIowing the perforative catas- trophe, who have a somewhat eIevated puIse rate, tendency toward a Ieaky skin, and in whom some have been prone to make a diagnosis of “shock,” the pre- operative administration of intravenous medication wouId undoubtedIy make them more suitabIe surgica1 subjects. The deIay encountered in the administration of gIu- case in salt soIution or a bIood transfusion need not be so great as to further jeop- ardize their condition.
Selection of the Anesthetic. Where the circuIatory mechanism suffers such a se- vere bIow as is so frequently seen foIIowing the perforative catastrophe, one shouId not add insuIt to injury by the administra- tion of intraspina1 anesthesia, which in itseIf is known to produce vascuIar in- stabiIity, not infrequently resuIting in death.
Laboring under the deIusion that spina anesthesia wouId prove a boon in the reduction of postoperative puImonary com- pIications, which in perforated uIcer was second in cause of death, many proceeded to use spina anesthesia wherever possibIe. OnIy recentIy, on the basis of carefuIIy coIIected reports, has it become known that the morbidity from puImonary com- pIications under this anesthetic was greater than any other singIe anesthetic agent.
The use of spina anesthesia as a routine anesthetic for operations upon those pa- tients suffering a perforated uIcer is open to serious question.
There remain two agents which are known to give reIaxation sufficient to perform whatever surgery is necessary, ethyIene, and ether, the Iatter occasionaIIy being modified by the use of nitrous oxide and oxygen.
Prevention of Pulmonary Complications. As has aIready been indicated, the wise seIection of the anesthetic agent un- doubtedIy pIays some definite part. The routine use of carbon dioxide inhaIations in the production of hyperventiIation has not proved to be of benefit in Iarge series of patients so treated. There remain a few simpIe procedures which in the routine surgica1 patient have been proved to be of some concrete benefit.
The patient may be pIaced preferabIy in the semi-FowIer position. He shouId be turned from one side to another, at fre- quent (two hour) intervaIs. Breathing exercises, despite the pain occasioned at the operative site, shouId be insisted upon and encouraged. Deep breaths, in series, sIowIy inhaIed and rapidly exhaIed, re- peated at hourIy intervaIs, under the coaching of the nurse or physician, wiI1 undoubtedIy inffate the Iungs and force the mucus up into a position where a sIight cough wiI1 disIodge it. The effect of these simpIe procedures has been systematicaIIy reviewed by EIiason and McLaughIin.27
Prevention of Shock and Hemorrhage. Preoperative preparation of the patient, foIIowed by a rapid, but simpIe operation
YEW FERIFS Vor XXIV, No. I EIiason & Ebeling-Peptic UIcer Americnn Journal 01 Surp.cry 81
under the most innocuous anesthetic, and adequate postoperative intravenous (sugar- saIt or bIood transfusion) therapy may do much to decrease this factor.
Postoperative Hemorrhage. In but 4 patients of the coIIected series in whom simpIe closure was practiced, was post- operative hemorrhage charged with death. ObviousIy, the reports couId have been more expIicit on this point.
Conclusion
On the basis of this study, medica treatment wouId appear to offer the Iowest immediate mortaIity resuIts for those patients suffering acute and exsanguinating hemorrhage from a bIeeding gastric or
duodena1 uIcer. SimpIe cIosure, under ether or ethyIene
anesthesia; drainage of the peritonea1 cavity by subdiaphragmatic, subhepatic and peIvic drains, protruding through suitable stab wounds; cIosure of the oper- ative incision with non-absorbabIe materia1 in the fascia1 pIane; drainage of the stom- ach by means of the Jutte tube; selection of those patients fit for surgery or made so by timeIy preoperative therapy; adequate puImonary exercises; and adequate post- operative fluid, saIt, sugar and bIood administration, in those patients who ha.ve suffered an acute perforation of a gastric or duodena1 ulcer, wouId appear to offer the Iowest immediate mortaIity resuIts at the hands of the average surgeon.
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