Tsugawa K, Koyanagi N, Hashizume M, Tomikawa M, Akahoshi K, Ayukawa K, Wada H, Tanoue K, Sugimachi K
Department of Surgery and Sciences, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
Hepatogastroenterology. 2001 Jan-Feb;48(37):156-62.
BACKGROUND/AIMS: Gastroduodenal ulcer is a very common illness in Japan. As the number of elderly persons in Japan increases the same as in Europe and America, the number of such patients requiring a gastroduodenal emergency operation has also increased. Regarding the complications of peptic ulcer, a perforation remains the most important fatal complication. The aim of this study is to investigate the operative risk factors and the long-term recurrence rates and to define the optimal surgical procedures in emergency situations in elderly patients.
From April 1988 through March 1997, 130 patients over 70 years of age with a perforated gastroduodenal ulcer (a duodenal ulcer perforation in 50 patients and a gastric ulcer perforation in 80 patients) were operated on in an emergency situation in our clinic. We investigated the following items; medical illness, preoperative risk factor, optimal surgical procedure, postoperative organ failure and the cumulative recurrence-free rates after surgical treatment.
A significant correlation with mortality was observed in patients with established comorbidity in the following organs: lung (P = 0.03), heart (P = 0.02), kidney (P = 0.04), and diabetes (P = 0.03). The highest postoperative mortality rate was recorded in patients who underwent a simple closure of a duodenal ulcer perforation (4 patients; 26.7%), while the lowest postoperative mortality rate was recorded in patients who underwent a simple closure and vagotomy of a duodenal ulcer perforation (3 patients; 12.5%). In gastric ulcers, the mortality rate in patients with a gastrectomy was significantly higher than in patients with a simple closure. The practical application of the three risk factors (preoperative shock, delay to surgery over 24 hours, and medical illness) was shown by the progressive rise in the mortality rate with the increasing number of risk factors. Based on the 5 postoperative years after treating a perforated duodenal ulcer, the cumulative recurrence rate after a simple closure (63.6%) was significantly higher than that after a simple closure and vagotomy (38.1%) (n = 0.02) or after gastrectomy (0%) (P < 0.001). At 5 years postoperatively, the cumulative recurrence rate after a simple closure (41.2%) was significantly higher than that after a gastrectomy (15.9%) (P < 0.01).
In conclusion, in an emergency situation, elderly patients are in a highly unfavorable prognostic condition due to their advanced age, and comorbidity, which thus leads to poorer results, not only worldwide, but also in Japan. Based on our findings, in duodenal ulcer cases, a simple closure and vagotomy is recommended because of its low mortality and minimal stress, except for cases with a giant perforation measuring over 20 mm in diameter at the perforation hole or with severe duodenal stenosis. In stomach ulcer cases, a gastrectomy may be recommended because of its low recurrence rate.
背景/目的：胃十二指肠溃疡在日本是一种非常常见的疾病。随着日本老年人数量与欧美国家一样增加，需要进行胃十二指肠急诊手术的此类患者数量也有所增加。关于消化性溃疡的并发症，穿孔仍然是最重要的致命并发症。本研究的目的是调查手术风险因素和长期复发率，并确定老年患者在紧急情况下的最佳手术方法。
从1988年4月至1997年3月，130例70岁以上胃十二指肠溃疡穿孔患者（十二指肠溃疡穿孔50例，胃溃疡穿孔80例）在我们诊所接受了急诊手术。我们调查了以下项目：内科疾病、术前风险因素、最佳手术方法、术后器官衰竭以及手术治疗后的累积无复发率。
在以下器官患有合并症的患者中观察到与死亡率有显著相关性：肺（P = 0.03）、心脏（P = 0.02）、肾脏（P = 0.04）和糖尿病（P = 0.03）。十二指肠溃疡穿孔单纯缝合患者的术后死亡率最高（4例；26.7%），而十二指肠溃疡穿孔单纯缝合加迷走神经切断术患者的术后死亡率最低（3例；12.5%）。在胃溃疡患者中，胃切除术患者的死亡率显著高于单纯缝合患者。三个风险因素（术前休克、手术延迟超过24小时和内科疾病）的实际应用表现为随着风险因素数量的增加死亡率逐渐上升。基于十二指肠溃疡穿孔治疗后的5年随访，单纯缝合后的累积复发率（63.6%）显著高于单纯缝合加迷走神经切断术（38.1%）（n = 0.02）或胃切除术后（0%）（P < 0.001）。术后5年，单纯缝合后的累积复发率（41.2%）显著高于胃切除术后（15.9%）（P < 0.01）。
总之，在紧急情况下，老年患者由于年龄较大和合并症，预后状况非常不利，这不仅在全球范围内，而且在日本都导致了较差的结果。根据我们的研究结果，在十二指肠溃疡病例中，除了穿孔孔直径超过20毫米的巨大穿孔或严重十二指肠狭窄的病例外，建议采用单纯缝合加迷走神经切断术，因为其死亡率低且应激最小。在胃溃疡病例中，由于其复发率低，可能建议进行胃切除术。
