Ng E K, Lam Y H, Sung J J, Yung M Y, To K F, Chan A C, Lee D W, Law B K, Lau J Y, Ling T K, Lau W Y, Chung S C
Department of Surgery, The Chinese University of Hong Kong, Hong Kong.
Ann Surg. 2000 Feb;231(2):153-8. doi: 10.1097/00000658-200002000-00001.
In this randomized trial, the authors sought to determine whether eradication of Helicobacter pylori could reduce the risk of ulcer recurrence after simple closure of perforated duodenal ulcer.
Immediate acid-reduction surgery has been strongly advocated for perforated duodenal ulcers because of the high incidence of ulcer relapse after simple patch repair. Although H. pylori eradication is now the standard treatment of uncomplicated and bleeding peptic ulcers, its role in perforation remains controversial. Recently a high prevalence of H. pylori infection has been reported in patients with perforations of duodenal ulcer. It is unclear whether eradication of the bacterium confers prolonged ulcer remission after simple repair and hence obviates the need for an immediate definitive operation.
Of 129 patients with perforated duodenal ulcers, 104 (81%) were shown to be infected by H. pylori. Ninety-nine H. pylori-positive patients were randomized to receive either a course of quadruple anti-helicobacter therapy or a 4-week course of omeprazole alone. Follow-up endoscopy was performed 8 weeks, 16 weeks (if the ulcer did not heal at 8 weeks), and 1 year after hospital discharge for surveillance of ulcer healing and determination of H. pylori status. The endpoints were initial ulcer healing and ulcer relapse rate after 1 year.
Fifty-one patients were assigned to the anti-Helicobacter therapy and 48 to omeprazole alone. Nine patients did not undergo the first follow-up endoscopy. Of the 90 patients who did undergo follow-up endoscopy, 43 of the 44 patients in the anti-Helicobacter group and 8 of the 46 in the omeprazole alone group had H. pylori eradicated; initial ulcer healing rates were similar in the two groups (82% vs. 87%). After 1 year, ulcer relapse was significantly less common in patients treated with anti-Helicobacter therapy than in those who received omeprazole alone (4.8% vs. 38.1%).
Eradication of H. pylori prevents ulcer recurrence in patients with H. pylori-associated perforated duodenal ulcers. Immediate acid-reduction surgery in the presence of generalized peritonitis is unnecessary.
在这项随机试验中，作者试图确定根除幽门螺杆菌是否能降低十二指肠溃疡穿孔单纯缝合术后溃疡复发的风险。
由于单纯修补术后溃疡复发率高，一直强烈主张对十二指肠溃疡穿孔患者立即进行减酸手术。虽然幽门螺杆菌根除现在是无并发症和出血性消化性溃疡的标准治疗方法，但其在穿孔中的作用仍存在争议。最近有报道称十二指肠溃疡穿孔患者中幽门螺杆菌感染率很高。目前尚不清楚根除该细菌是否能在单纯修补术后延长溃疡缓解期，从而避免立即进行确定性手术的必要性。
在129例十二指肠溃疡穿孔患者中，104例（81%）被证实感染幽门螺杆菌。99例幽门螺杆菌阳性患者被随机分为接受四联抗幽门螺杆菌治疗疗程或仅接受4周奥美拉唑治疗。出院后8周、16周（如果溃疡在8周未愈合）和1年进行随访内镜检查，以监测溃疡愈合情况并确定幽门螺杆菌状态。终点指标为初始溃疡愈合情况和1年后溃疡复发率。
51例患者被分配接受抗幽门螺杆菌治疗，48例仅接受奥美拉唑治疗。9例患者未接受首次随访内镜检查。在接受随访内镜检查的90例患者中，抗幽门螺杆菌组44例中的43例和仅接受奥美拉唑组46例中的8例幽门螺杆菌被根除；两组初始溃疡愈合率相似（82%对87%）。1年后，接受抗幽门螺杆菌治疗的患者溃疡复发明显少于仅接受奥美拉唑治疗的患者（4.8%对38.1%）。
根除幽门螺杆菌可预防幽门螺杆菌相关十二指肠溃疡穿孔患者的溃疡复发。在存在弥漫性腹膜炎时无需立即进行减酸手术。
