The therapeutic strategies in performing emergency surgery for gastroduodenal ulcer perforation in 130 patients over 70 years of age

Background/Aims: Gastroduodenal ulcer is a very common illness in Japan. As the number of elderly persons in Japan increases the same as in Europe and America, the number of such patients requiring a gastroduodenal emergency operation has also increased. Regarding the complications of peptic ulcer, a perforation remains the most important fatal complication. The aim of thi s study is to investigate the operative risk factors and the long-term recu rrence rates and to define the optimal surgical procedures in emergency sit uations in elderly patients. Methodology: From April 1988 through March 1997, 130 patients over 70 years of age with a perforated gastroduodenal ulcer (a duodenal ulcer perforatio n in 50 patients and a gastric ulcer perforation in 80 patients) were opera ted on in an emergency situation in our clinic. We investigated the followi ng items; medical illness, preoperative risk factor, optimal surgical proce dure, postoperative organ failure and the cumulative recurrence-free rates after surgical treatment. Results: A significant correlation with mortality was observed in patients with established comorbidity in the following organs: lung (P=0.03), heart (P=0.02), kidney (P=0.04), and diabetes (P=0.03). The highest postoperative mortality rate was recorded in patients who underwent a simple closure of a duodenal ulcer perforation (4 patients; 26.7%), while the lowest postoper ative mortality rate was recorded in patients who underwent a simple closur e and vagotomy of a duodenal ulcer perforation (3 patients; 12.5%). In gast ric ulcers, the mortality rate in patients with a gastrectomy was significa ntly higher than in patients with a simple closure. The practical applicati on of the three risk factors (preoperative shock, delay to surgery over 24 hours, and medical illness) was shown by the progressive rise in the mortal ity rate with the increasing number of risk factors. Based on the 5 postope rative years after treating a perforated duodenal ulcer, the cumulative rec urrence rate after a simple closure (63.6%) was significantly higher than t hat after a simple closure and vagotomy (38.1%) (n=0.02) or after gastrecto my (0%) (P<0.001). At 5 years post;operatively, the cumulative recurrence r ate after a simple closure (41.2%) was significantly higher than that: afte r a gastrectomy (15.9%) (P<0.01). Conclusions: In conclusion, in an emergency situation, elderly patients are in a highly unfavorable prognostic condition due to their advanced age, an d comorbidity, which thus leads to poorer results, not only worldwide, but also in Japan. Based on our findings, in duodenal ulcer cases, a simple clo sure and vagotomy is recommended because of its low mortality and minimal s tress, except for cases with a giant perforation measuring over 20mm in dia meter at the perforation hole or with severe duodenal stenosis. In stomach ulcer cases, a gastrectomy may be recommended because of its low recurrence rate.