Jordan P H, Thornby J
Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.
Ann Surg. 1995 May;221(5):479-86; discussion 486-8. doi: 10.1097/00000658-199505000-00005.
The authors evaluated parietal cell vagotomy and omental patch closure as treatment for perforated pyloroduodenal ulcers.
Since the beginning of the century, there has been a difference of opinion as to whether perforated pyloroduodenal ulcers are best managed with nonoperative treatment, simple closure, or definitive treatment, i.e., a procedure that handles the emergency problem and simultaneously provides protection against further ulcer disease. The criticism of using definitive treatment at the time of perforation has been that some patients who might not have recurrent ulcer, if a definitive operation was not performed, would be at risk of adverse postoperative sequelae, including death. Parietal cell vagotomy as treatment of intractable duodenal ulcer disease was shown to be almost without complications. The objective of this study was to determine if the operation was equally applicable to perforated pyloroduodenal ulcers.
A group of 107 selected patients with perforated pyloroduodenal ulcers underwent definitive treatment by omental patch closure and parietal cell vagotomy. The patients were evaluated prospectively on an annual basis up to 21 years. Gastric analyses were performed on each visit for which the patient gave his/her consent. Patients suspected of a recurrent ulcer were examined endoscopically for verification.
There was one death (0.9%). Ninety-three patients were observed for follow-up for 2 to 21 years. The recurrent ulcer rate by life table analysis was 7.4%. The reoperative rate was 1.9%. Postoperative gastric sequelae were insignificant. All but four patients were graded Visick I or II at the time of their last evaluation.
This study confirms that the combination of parietal cell vagotomy and omental patch closure is an excellent choice for treatment of patients with perforated pyloroduodenal ulcers, who, by virtue of their age, fitness, and status of the peritoneal cavity are candidates for definitive surgery. Virtually none of the morbidity that occurs with other forms of definitive treatment is inflicted on patients who might never have needed a definitive operation if simple closure was performed. At the same time, it provides definitive therapy for the larger number of patients who subsequently would have required a second operation for continued ulcer disease if simple closure alone was performed. Whether this operation is performed at the time of perforation should depend on the presence or absence of risk factors, rather than whether the ulcer is acute or chronic.
作者评估了壁细胞迷走神经切断术和网膜补片闭合术治疗幽门十二指肠溃疡穿孔的效果。
自本世纪初以来，对于幽门十二指肠溃疡穿孔是采用非手术治疗、单纯闭合术还是确定性治疗（即一种既能处理紧急问题又能预防进一步溃疡病的手术），一直存在意见分歧。对在穿孔时采用确定性治疗的批评是，一些如果不进行确定性手术可能不会复发溃疡的患者，会面临术后不良后遗症的风险，包括死亡。壁细胞迷走神经切断术作为治疗顽固性十二指肠溃疡病的方法，几乎没有并发症。本研究的目的是确定该手术是否同样适用于幽门十二指肠溃疡穿孔。
一组107例经选择的幽门十二指肠溃疡穿孔患者接受了网膜补片闭合术和壁细胞迷走神经切断术的确定性治疗。对患者进行前瞻性评估，每年评估一次，直至21年。每次患者同意时进行胃液分析。对疑似复发性溃疡的患者进行内镜检查以确诊。
有1例死亡（0.9%）。93例患者接受了2至21年的随访。通过生命表分析，复发性溃疡率为7.4%。再次手术率为1.9%。术后胃部后遗症不明显。除4例患者外，所有患者在最后一次评估时的Visick分级为I级或II级。
本研究证实，壁细胞迷走神经切断术和网膜补片闭合术联合应用是治疗幽门十二指肠溃疡穿孔患者的极佳选择，这些患者因其年龄、身体状况和腹腔情况而适合进行确定性手术。如果进行单纯闭合术，几乎不会给那些可能永远不需要确定性手术的患者带来其他形式确定性治疗所伴随的发病率。同时，对于大量如果仅进行单纯闭合术随后可能因溃疡病持续需要二次手术的患者，它提供了确定性治疗。该手术是否在穿孔时进行应取决于危险因素的存在与否，而不是溃疡是急性还是慢性。
