Operations for peptic ulcer disease: Paradigm lost

Over the past several decades, the pharmacologic and endoscopic treatment o f peptic ulcer disease (PUD) has dramatically improved. To determine the ef fects of these and other changes on the operative management of PUD, we rev iewed our surgical experience with gastroduodenal ulcers over the past 20 y ears. A computerized surgical database was used to analyze the frequencies of all operations for PUD performed in two training hospitals during four c onsecutive 5-year intervals be inning in 1980. Operative rates for both int ractable and complicated PUD were compared with those for other general sur gical procedures and operations for gastric malignancy. In the first 5-year period (1980 to 1984), a yearly average of 70 upper gastrointestinal opera tions were performed. This experience included 36 operations for intractabi lity, 15 for hemorrhage, 12 for perforation, and seven for obstruction. Dur ing die same time span, 13 resections were performed annually for gastric m alignancy. By the most recent 5-year interval (1994 to 1999), the total num ber of upper gastrointestinal operations had declined by 80% (14 cases), al though the number of operations for gastric cancer had changed only slightl y. Operations decreased most markedly for patients with intractability, but the prevalence of operations for bleeding, obstruction, and perforation wa s also decreased. We conclude that improved pharmacologic and endoscopic ap proaches have progressively curtailed the use of operative therapy for PUD. Elective surgery is now rarely indicated, and emergency operations are muc h less common. This changed paradigm poses new challenges for training and suggests different approaches for practice.