Mortality Among Perforated Peptic Ulcer Patients After Selective Management of the Stratified High Risk Cases

Peptic ulcer disease has afflicted humans with its dreaded complications since antiquity. Treatment was suboptimal until a few decades ago when the pathophysiology of the disease was unraveled. The discovery of Helicobacter pylori and the introduction of proton pump inhibitors has virtually eliminated surgery (at least in the ‘‘developed world’’) as the primary treatment modality and reduced its role to salvage intervention for complicated disease. One such complication is perforation, a clinical condition that results in three components mandating a rationale for treatment: the ulcer itself, the perforation, and the resulting peritonitis. The magnitude of surgery has been swinging back and forth, from a bare minimum of damage control to definitive procedures. Peptic ulcer itself is a curable infectious disease treated by antibiotics and proton pump inhibitors or H2 blockers [1]. Perforation only obligates the surgeon to eliminate the peritoneal contamination when the ulcer fails to seal spontaneously. Self-sealing of a perforation has long been recognized [2]. One study had shown that half of perforated duodenal ulcers are self-sealed by the time the patients are admitted to the hospital [3], a process that is known to be remarkably secure. Re-leak is rare, and the rate of intraabdominal abscess is only 3% [3]. The development of effective medical therapy and the self-sealing comprise the cornerstone of nonoperative management of perforation, a strategy that is contraindicated for free perforation, which leads to chemical peritonitis and eventually bacterial contamination and sepsis. In the study under discussion, Rahman et al. from Bangladesh, report their vast experience in management of two groups of patients (A and B) with comparable demographics and pathology that were treated differently. In group A, managed conventionally, 43 of 479 patients (8.9%) died. After retrospective evaluation, a subgroup of 124 was considered at high risk, which encompassed 39 of the 43 deaths (90.6%). The selection criteria extracted from group A were used to select a subgroup of 84 high-risk patients from 785 patients in group B; 626 of the patients in this group were managed conventionally, whereas the highrisk patients were managed with peritoneal tube drainage. The change in treatment strategy decreased the overall mortality from 9.5% to 3.9% and the perioperative mortality from 8.9% to 4.1%. This is a large series with an impressive outcome, to say the least. However, there are some questions that call for answers: How many ulcers were duodenal, and how many were gastric? How many patients were denied surgery based on irreversible shock or on self-sealing? Was the diagnosis of self-sealing reached clinically or by contrast studies? Was the choice of the surgical procedures standardized? How long was the follow-up? Additionally, any retrospective data collection in an underprivileged health care facility with no computerized databases and registries must be eyed critically when it comes to authenticity and reliability. Others had previously shown that ‘‘lesser’’ procedures in high-risk patients, some based on APACHE II scores, with perforated peptic ulcers tolerate better lesser procedures [4, 5], and this study tends to confirm it. It advocates a minimal operative option for managing highrisk patients with free perforation, an option that many of us would consider dangerous. The attractiveness of the peritoneal tube drainage advocated by the authors stems S. Johna (&) Department of Surgery, Loma Linda University School of Medicine, Loma Linda, California 92350, USA e-mail: s.johna@verizon.net