Mortality in perforated peptic ulcer patients after selective management of stratified poor risk cases.

INTRODUCTION

Perforated peptic ulcer disease continues to inflict high morbidity and mortality. Although patients can be stratified according to their surgical risk, optimal management has yet to be described. In this study we demonstrate a treatment option that improves the mortality among critically ill, poor risk patients with perforated peptic ulcer disease.

METHODS

In our study, two series were retrospectively reviewed: group A patients (n = 522) were treated in a single surgical unit at the Dhaka Medical College Hospital, Dhaka, Bangladesh during the 1980s. Among them, 124 patients were stratified as poor risk based on age, delayed presentation, peritoneal contamination, and coexisting medical problems. These criteria were the basis for selecting a group of poor risk patients (n = 84) for minimal surgical intervention (percutaneous peritoneal drainage) out of a larger group of patients, group B (n = 785) treated at Khulna Medical College Hospital during the 1990s.

RESULTS

In group A, 479 patients underwent conventional operative management with an operative mortality of 8.97%. Among the 43 deaths, 24 patients were >60 years of age (55.8%), 12 patients had delayed presentation (27.9%), and 7 patients were in shock or had multiple coexisting medical problems (16.2%). In group B, 626 underwent conventional operative management, with 26 deaths at a mortality rate of 4.15%. Altogether, 84 patients were stratified as poor risk and were managed with minimal surgical intervention (percutaneous peritoneal drainage) followed by conservative treatment. Three of these patients died with an operative mortality of 3.5%.

CONCLUSIONS

Minimal surgical intervention (percutaneous peritoneal drainage) can significantly lower the mortality rate among a selected group of critically ill, poor risk patients with perforated peptic ulcer disease.