ABSTRACT

CORRESPONDING AUTHOR:
Dr. Rajanna B,
Associate Professor & HOD,
Department of General Surgery,
Hassan Institute of Medical Sciences, Hassan.
Email: drrajannab@gmail.com

ABSTRACT: BACKGROUND: Duodenal ulcer is a very common disease in the southern part of India and complication like perforation is still common and surgical intervention is considered the treatment of choice.⁽¹⁾ METHODS: A prospective study consisting of 70 patients of duodenal perforation presenting as acute abdomen to the casualty department of Victoria hospital and Bowring & Lady Curzon Hospital, Bangalore, between October 2009 to Aug 2011. RESULTS: In our study, presentation of duodenal perforation is common in males (91.4%) between 3^rd to 6^th decades. The incidence of the duodenal perforation is more in those consume spicy food, living in rural areas (59%) and with ‘0’ positive blood group (51%). Most of our patients presented after 48 hours and major post-operative complications observed in these patients (50%). CONCLUSION: Live omental patch closure with technical modifications is still the better operation in perforated duodenal ulcer and definitive procedure are reserved when suitable conditions are present.⁽²⁾ Mortality rate in perforated duodenal ulcer is less when compared to other acute abdominal conditions and is directly related to duration of clinical symptoms, age, severity of dehydration, and peritoneal cavity contamination.

KEYWORDS: Duodenal ulcer, perforation, peritonitis, omentoplasty, trancal vagotony, pyloroplasty.

INTRODUCTION: Duodenal ulcers (DU) may occur in any age group but are most common in the young and middle-aged (20 to 45 years). They appear in men more often than women. About 95% of duodenal ulcers are situated within 2 cm of the pylorus, in the duodenal bulb (cap).^{(1, 3)} Duodenal ulcer is a very common disease in the southern part of India, even though the incidence is decreasing, the complication like perforation is still common and surgical intervention is considered the treatment of choice. In the earlier years the main treatment of duodenal ulcer was primarily surgical, but now it’s out of vogue due to advent of effective medical line of treatment.^{(3, 4)}

It is estimated that roughly 1.3% of population above the age of 20 years have had some degree of peptic ulcer activity during any annual period. Duodenal perforation is one of the dreaded complications that is known to occur in 15% of all recognized duodenal ulcer cases. Perforation of DU is one of the most serious and life threatening complication of peptic ulcer.⁽⁴⁾

Perforation of duodenal ulcer leads to contamination of peritoneal cavity with duodenal and gastric secretions which may initiate catastrophic cascade of events which until stopped in its track can be detrimental to the life of the patient.⁽⁵⁾ Perforation can occur in about 20% of patient without any relevant preceding symptoms. Thus perforation of duodenal ulcer has become a pestilence that threatens to cripple the economic and social life of significant section of society if attended to and surgical intervention is treatment of choice.

Simple suturing of perforation still remains the most commonly employed method for management of perforated Duodenal Ulcer.

Radical treatment of perforated Duodenal Ulcer by antrectomy and truncal vagotomy is justified in the hands of experienced surgeon. pyloroplasty with Vagotomy has been carried out successfully in emergency situation.^(6,7) Omental closure is indicated for perforation in poor risk cases and for acute ulcer associated with drug ingestion or acute stress. Only in fit patients with acute ulcer perforation; when an experienced surgeon is available, pyloroplasty with Vagotomy or Highly Selective Vagotomy is undertaken as an ideal operation.^(7,8)

It progresses in definitive manner leading to death due to peritonitis. Mortality increases with delay in operation and mortality rate almost approached zero if operated within 6hrs., from 6-12 hrs the rate is 5-10% and 12-24hrs it is a 25%or higher and in the course of 3^rd day or after the surgery is seldom successful. Hence the role of either general Practitioners in identifying the disease and immediate referral to a major surgical center is very important.⁽⁴⁾

AIMS AND OBJECTIVES: To study the prevalence, predisposing factors outcome of surgical treatment and prognosis of perforation duodenal ulcer and its age, sex, incidence & regional distribution.

MATERIALS AND METHODS: SOURCE: A prospective study consisting of 70 patients of duodenal perforation presenting as acute abdomen to the casualty department of Victoria hospital and Bowring & Lady Curzon Hospital, Bangalore, between October 2009 to Aug 2011.

METHODS OF COLLECTION OF PATIENTS AND DATA: DU perforation patients who are presented early <12hrs, with minimal contamination of peritoneal cavity, good general condition are considered for definitive procedure.

In all other DU perforation patients live omental patch closures done. All patients will undergo routine investigation, X ray erect abdomen before the procedure.

Data will be collected by meticulous history taking, careful clinical examination, appropriative radiological studies, operative finding and follow up of patients. The collected data will be analyzed with respect to the presentation by the patient’s, age, sex incidence, etiological factors, morbidity and mortality.

INCLUSION CRITERIA: Patient above 18 years, who are willing to give informed consent and presenting with features of hollow viscous perforation clinically, radiologically, and duodenal perforation confirmed during intraoperative period.

EXCLUSION CRITERIA:

• Pediatric age group (<18yrs).
• Patients with traumatic duodenal perforation.
• Patients with hollow viscous perforation other than DU perforation.
• Patients who are hemodynamically unstable even after resuscitation.

RESULTS: The data will be analyzed using chi square test. In the present series age of the patients varied from <20 to>70 years. Median age of presentation is 41.50years, which is quite similar to age incidence in other authors.

Age distribution of duodenal perforation in other Studies:

Sex and regional distribution: The following table and chart show sex and region distribution which shows male predominance. Among the region majority are from rural area.

Blood group distribution: The following table and chart shows that duodenal perforation is most common among blood group O patients.

PREDISPOSING FACTORS: The following table shows number of patients with predisposing factors.

PRESENTATION OF PATIENTS: The following table shows the duration with which patients presented with pain abdomen. According to the table majority (62%) presented within 2 days.

Association of duration of presentation of symptoms and, mean hospital stay:

                Above table shows that as the number of days of symptoms increases the mean hospital stay as well as mortality increases. However the mean hospital stay is not only influenced by disease itself but also by cultural practices such as distance from hospital etc.

Association of age and post-operative complications:

It is observed that, for the age group 41-60 years the proportion of post-operative complication is significantly higher compared to any other age groups(p<0.05). It is also observed that as the age is increased, major complications (including death) were increased.

Association of time since onset of pain and post-operative complication:

The risk of complication increases with the increase in time since onset of symptoms. This table & graph shows that there is increase in rate of complication when the presentation is more than 2 days (p <0.05). 62% of patients presented to our hospital within 48hrs (2days).

Association of Dehydration of the patients with the post-operative complication:

Chi-square – 26.60 Degree of freedom – 3P value 0.00000714 (<0.005).

The above table and chart shows that 71% of our patients either presented with no dehydration or mild dehydration. Complications noted in these 2 groups were significantly lower than those presenting with either moderate or severe dehydration (p-<0.005). as the severity of dehydration increases risk of post-operative complication also increases.

Association of operative procedure with post-operative complications:

Chi-square – 1.85, Degree of freedom – 2 p value- 0.1376.

According to the above table and chart, there is significantly increased complications noted in simple closure of perforation with live omental patch compared to truncalvagatomy with pyloroplasty(p->0.005). However in many other studies the opposite is true i.e., complications are more with definitive procedure. These observations are probably due to the criteria for selection of patients, sample sizes in each group are different.

Association of size of perforation with the post-operative complication:

The above table and graph shows 74% of patients with duodenal perforation have the size of <1 cm. There is increased rate of complication with increase in size of perforation, in our study it is>0.5cm.

Association of size of perforation with the general condition of the patients:

This table shows that the size of the perforation is related to the general condition of the patient and as the size of the perforation increases rate of morbidity and mortality increases.

                The above table shows that, live omental patch closure for perforated duodenal ulcer is safer and can be performed in all sizes of perforation. Truncal vagatomy with pyloroplasty which is the definitive surgery in duodenal ulcer perforation can only be performed with increase in size of perforation and there is no contamination in peritoneal cavity.

                Above table shows that all the cases of truncal vagatomy with pyloroplasty were performed when the general condition of the patient is good with little or no peritoneal contamination to minimize post op complication.

Chi-square – 3.27 Degree of freedom – 2 p value- 0.194.

                The above table shows that delay in taking the patients for surgery has significant direct relationship with complications. However the time for taking the patient for surgery also depends on general condition of the patient on presentation, availability of operation theatre, many other factors related to relatives.

 In our study, we followed the patients at 2 intervals; first at 6 weeks and late follow up at 6 months. 84% of patients had uneventful follow up. 20% of our patients had persistent pain at wound site at 6 weeks none of them had pain at 6 months 3 (4%) of our patients had wound discharge. Among these patients 1 patient presented with 4days pain abdomen, 1 with 5 days pain abdomen and 1 with 6 days pain abdomen. Complications are directly related to duration of symptoms. 2 (3%) of patients developed recurrence of pain at epigastrium which was managed conservatively with anti H. pylori regime. 3(4%) of our patients had incisional hernia which was managed by mesh repair. There were 4 deaths in our study, all of them died in the immediate post-operative period.

DISCUSSION: Duodenal Ulcer perforation is one of the commonest acute abdominal emergencies presenting to the Victoria hospital and Bowring and lady Curzon hospital between Oct 2009 to Aug 2011. Peak age of incidence in our study population is 41.5 years which implies that majority of people developing duodenal ulcer perforation belong to productive period of life (pg no.75). Now-a-days, there is an increased incidence of DU perforation seen in aged individuals and these are the population at risk for morbidity and mortality.^{(4, 9)}

It is more common in low socio-economic status people with rural and urban slum males are being affected commonly. In our study more than half of our patients were of blood group ‘O’ positive. Predisposing factor for Duodenal Ulcer in our study was consumption of spicy food (63%) followed by alcohol consumption (50%) and smoking (13%) 11% had prior history of drug intake. i.e., NSAID’s (15% in others²⁰) 20% had prior H/o peptic ulcer. In those patients with peptic ulcer it varied from 1-2 years, 34% of our patients had no habits.^(10,11)

Most patients presented with sudden onset of acute pain abdomen in epigastrium initially, later became generalized with variable duration. General condition of the patient was stable at the time of admission in those patients who came within 48 hours and in those who were referred form other hospitals or general practitioners.

In our study 71.43% of patients had either no signs of dehydration or mild dehydration. All patients presented with pain abdomen, vomiting was present in 98% of patients and abdominal distension in 92% of patients. All had generalized guarding, rigidity and diffuse tenderness with obliteration of liver dullness.

All cases showed gas under diaphragm in one or both the domes of diaphragm with ground glass appearance. Most of our patient’s routine investigations were within normal limit except for few, among the patients who showed abnormality, electrolyte imbalance was the most common finding followed by elevated RFT. Diagnostic peritoneal tap was positive in all cases. It was bilious and in few cases pus was aspirated.⁽¹²⁾

Closure of the perforation was done by live omental patch closure in 80% of patients. It is safer and most common procedure performed in emergency situation. However definitive procedure like truncal vagotomy and pyloroplasty (20%in our study) can also be done safely provided there are definitive indications are present or general condition of the patient is good, there is no gross contamination of peritoneal cavity and the patient is young.

Out of 14 cases who underwent pyloroplasty with truncal vagatomy, 3 underwent due to associated bleeding duodenal ulcer, 1 had second time duodenal perforation, in remaining 10 patients procedure was done as the general condition was good, there were no signs of dehydration, there was no gross contamination of peritoneal cavity or it was limited to the area around the perforation. Out of 14, 6 patients were young belonging to less than 30 years age group.

In our study, all the patients who underwent definitive procedure were presented with symptoms less than 24hrs duration and intra-operatively, found to be less or minimal peritoneal cavity contamination.

Among the post-operative complications, 15 were minor complications and 11 were major complications. Minor complications include post-operative wound discharge, serous or serosanguinous, wound pain. Out of 15, 2 patients underwent definitive procedure i.e, pyloroplasty with truncal vagatomy.11patients had major complications; 6 patients developed biliary leak which was managed conservatively, all patients recovered well. 1patient had burst abdomen which was managed by tension suturing; he recovered well. 4 patients died.

MC- most common.

Mortality rate in our study was 5%. Among 4 patients who died 2 people presented to the hospital after 6 days of onset of symptoms, 1 presented after 5 days and 1 presented after 4 days; time of presentation, general condition of patient, size of perforation and time gap for surgery were all related to post-operative complications and mortality. All 4 patients who died had severe dehydration and gross peritoneal cavity contamination.

Increasing size of perforation with the type of closure performed had significant relationship with postoperative complications. Duration of hospital stay was directly related to duration of symptoms, general condition of patient, and presence or absence of post-operative complications, though it is also influenced by distant stay where medical facilities are not available. Most of our patients will get discharged from the hospital only after removal of sutures.

Patients were followed up 2 times post operatively, 1 at 6 weeks and next at 6 months. At 6 weeks follow up 20% of patients had persistent pain at wound site which was not present at 6 months follow up. 3 of our patients had persistent wound discharge at 6 weeks but not present at 6 months.

At 6 months 2 patients had pain at epigastrium, upper GI endoscopy was done which showed antral hemorrhagic gastritis. They were managed with PPI’s.3 patients developed incisional hernia which was managed by mesh repair. 2 patients were lost to follow up.

Follow up period of 6 months was too short to assess recurrence of ulcer among the 2 different procedure performed. At least 2 years of follow up was recommended to assess the recurrence.

CONCLUSION: Duodenal Ulcer perforation is one of the commonest acute abdominal emergencies in our setup. Duodenal Ulcer perforation is common among male who are living in rural area or urban slums. It is common among people belonging to blood group ‘O’ positive.

Most common predisposing factor for duodenal ulcer in our study was, consumption of spicy food followed by alcohol and smoking. All our patients presented with signs and symptoms of generalized peritonitis with variable degree of dehydration.

Closure of the perforation was done by live omental patch in 80% of patients. It is safe and the most common procedure performed in an emergency situation. However definitive procedure like truncal vagotomy and pyloroplasty can also be done safely provided there are definitive indications, general condition of the patient is good, there is no gross contamination of peritoneal cavity and the patient is young.⁽¹⁹⁾

In our study among the 14 patients who underwent definitive procedure only 2 patients developed minor complications and no major complications. The results seems to be impressive, however there are many criteria with the selection of the patients.

Considering the time factor, lack of experience in the procedure(majority of emergency procedure were performed by residents or junior staffs) live omental patch closure with technical modifications is still the better operation in perforated duodenal ulcer and definitive procedure are reserved when suitable condition are present as mentioned above.

Postoperative complications are rare unlike ileal perforation. Complications include, mild wound infection, wound pain. Major complications which occurred in our study were biliary leak, wound dehiscence and incisional hernia.

Mortality rate in perforated duodenal ulcer is less when compared to other acute abdominal conditions and is directly related to duration of clinical symptoms, age, severity of dehydration, and peritoneal cavity contamination.

Follow up period was too short to assess recurrence of ulcer in both groups, at least 2 years of follow up is recommended to assess recurrence in other studies.

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