Surgical treatment of complicated duodenal ulcers: Controlled trials

Indications for surgery of duodenal ulcer (DU) have changed radically becau se of the efficacy of H-2-antagonists, endoscopic procedures, and eradicati on of Helicobacter pylorus. The aim of this study was to analyze the curren t literature to determine if definitive surgery is still relevant for compl icated DU (bleeding, perforation, gastric outlet obstruction). Two studies have compared early to late surgery in terms of bleeding. One recommended e arly surgery (significant reduction in mortality) in the elderly, but no st atistically significant difference was found when analyzed with "intention to treat." In the other, mortality with early surgery was five times higher than with expectant therapy (when it was possible). Two studies comparing different surgical techniques for bleeding favored the radical procedure, O f at least 15 studies comparing endoscopic treatments, however, none has co mpared endoscopic therapy to surgical intervention for bleeding DU, One tri al, comparing nonoperative to surgical treatment for perforation, found sim ilar rates of morbidity, intraabdominal abscess, and mortality; but the hos pital stay was longer (p < 0.001). Nonoperative treatment failed more often (p < 0.05) in patients over age 70. In three trials, postoperative morbidi ty (excepting wound sepsis in one) was not significantly increased by defin itive surgery, with less ulcer recurrence (p < 0.05) compared with simple c losure. Laparoscopy (versus laparotomy) was shown to take longer (p < 0.001 ) but required less postoperative analgesics (p < 0.03); there were no stat istically significant differences as concerns the duration of nasogastric a spiration, intravenous drips, hospital stay, time to resume normal diet, Vi sual Analogous Scale pain scores for the first 24 hours after surgery, morb idity, reoperation rate, or mortality, Of 48 laparoscopic patients, 11 (Uk) underwent conversion to open surgery. Three surgical techniques [highly se lective vagotomy (HSU) + gastrojejunostomy (group i), HSV + Jaboulay gastro duodenostomy (group 2), or selective vagotomy (group 3) + antrectomy) for g astric outlet obstruction (GOO)] showed that although postoperative results were similar (except wound sepsis in one trial), long-term Visick scores w ere significantly (p < 0.01) better in group 1 than in group 2, but not in group 3, Further studies are needed to determine the exact prevalence of He licobacter pylori in complicated DU and to compare (1) definitive to minima l surgery (stop the bleeding or close the perforation) combined with antise cretory drugs and eradication of H. pylori; (2) surgery to endoscopic treat ment combined with eradication of H. pylori; and (3) for GOO, surgery to ba lloon dilatation combined with eradication of H. pylori.