Is duodenal ulcer perforation best treated with vagotomy and pyloroplasty?

From 1967 to 1980, 65 patients underwent vagotomy and pyloroplasty for treatment of an acute perforated duodenal ulcer at the University of Oklahoma Health Sciences Center. Their age ranged from 15 to 82 years, with a mean age of 49.6 years. All vagotomies were truncal and pyloroplasties were of the Heineke-Mikulicz variety. The condition of each patient was classified as acute or chronic depending on the duration of symptoms before perforation. The postoperative complication rate and perioperative mortality were higher in the group of patients whose symptoms had been present less than 3 months before perforation. Patients who underwent vagotomy and pyloroplasty more than 24 hours after the onset of symptoms had a higher mortality compared with those who were operated on less than 24 hours from the onset of symptoms. We mainly attributed the perioperative death rate of 11 percent to advanced patient age and associated cardiopulmonary disease. There was no significant difference in the rate of postoperative complications in patients over 60 years of age compared with those under 40 years; hence, age alone does not preclude definitive treatment, such as vagotomy and pyloroplasty. The degree of contamination found at operation did not correlate with a poor postoperative course. There was no significant increase in the mortality in the group with gross contamination. Of the patients available for long-term follow-up, 85 percent remained free of symptoms. These results compare favorably with reports for the elective treatment of duodenal ulcer with vagotomy and pyloroplasty. We conclude that vagotomy and pyloroplasty is acceptable, safe, and ideal for patients with acute perforated duodenal ulcers, except when significant cardiopulmonary disease exists or when the duration of perforation is more than 24 hours.