Correspondence

Perforated Duodenal Ulcer

N Engl J Med 1997; 337:1013October 2, 1997

Article

To the Editor:

Molmenti (May 22 issue)1 presented an Image in Clinical Medicine showing a perforated duodenal ulcer. The surgeon closed the ulcer with several stitches but subsequently performed a vagotomy. Vagotomy was once the standard surgical treatment as prophylaxis against recurrence of the ulcer. We now know that infection with Helicobacter pylori is the main cause of duodenal ulcers.2 If this infection is cured, ulcers and their complications rarely recur.3 A very small percentage of duodenal ulcers are caused by aspirin or nonsteroidal antiinflammatory drugs, and these can be managed safely by stopping treatment with these drugs or, if this is impossible, adding misoprostol or acid-reducing drugs. Because antibiotics can cure duodenal ulcer disease, a surgeon operating on an ulcer complication should ligate the bleeding or patch the perforation but should not perform a prophylactic vagotomy.4,5

In my teaching hospital, the professor of medicine always threatened to cut off a finger of every resident who had not performed a digital rectal examination. Although I have no recollection of any of my colleagues going through life with fewer than 10 fingers, his oft-repeated threat taught us never to forget this part of the physical examination. It is time to threaten our surgical colleagues that we will cut off one of their fingers if they dare to put a knife in the precious vagus nerve. Apparently, they must be taught that ulcer disease is managed medically and that vagotomy is no longer appropriate.

Wink A. de Boer, M.D.
Sint Anna Hospital, NL-5340 BE Oss, the Netherlands

5 References

1. 1

   Molmenti EP. Perforated duodenal ulcer. N Engl J Med 1997;336:1499-1499
   Full Text | Web of Science | Medline

2. 2

   Walsh JH, Peterson WL. The treatment of Helicobacter pylori infection in the management of peptic ulcer disease. N Engl J Med 1995;333:984-991
   Full Text | Web of Science | Medline

3. 3

   Hopkins RJ, Girardi LS, Turney EA. Relationship between Helicobacter pylori eradication and reduced duodenal and gastric ulcer recurrence: a review. Gastroenterology 1996;110:1244-1252
   CrossRef | Web of Science | Medline

4. 4

   Sebastian M, Chandran VP, Elashall YI, Sim AJ. Helicobacter pylori infection in perforated peptic ulcer disease. Br J Surg 1995;82:360-362
   CrossRef | Web of Science | Medline

5. 5

   Witte CL. Is vagotomy and gastrectomy still justified for gastroduodenal ulcer? J Clin Gastroenterol 1995;20:2-3
   CrossRef | Web of Science | Medline

Author/Editor Response

The author replies:

To the Editor: Dr. de Boer states that “antibiotics can cure duodenal ulcer disease” and threatens any surgeon who “dare[s] to put a knife in the precious vagus nerve.” Not everybody, however, is quite so dogmatic.

In a recent review in the Journal, Walsh and Peterson point out that “despite the fact that H. pylori is necessary for the development of peptic ulcers in most patients, it is far from sufficient.”1 Others have observed that H. pylori had a limited role in causing disease in surgical patients, and suggested that an “adequate acid reduction procedure will still be the main objective of surgical treatment and prevention of . . . ulcer recurrence.” 2 Still others corroborate our observations that omental-patch closure combined with parietal-cell vagotomy is an excellent approach to the treatment of patients with perforated pyloroduodenal ulcers.3 It not only allows the resolution of an emergency but simultaneously provides protection for patients who would have required additional surgical interventions for continued ulcer disease. The most recent textbooks of medicine and surgery assert that vagotomy is an acceptable treatment for perforated duodenal ulcers.4,5

Ernesto P. Molmenti, M.D.
University of Pittsburgh, Pittsburgh, PA 15213

5 References

1. 1

   Walsh JH, Peterson WL. The treatment of Helicobacter pylori infection in the management of peptic ulcer disease. N Engl J Med 1995;333:984-991
   Full Text | Web of Science | Medline

2. 2

   Lee WJ, Wu MS, Chen CN, Yuan RH, Lin JT, Chang KJ. Seroprevalence of Helicobacter pylori in patients with surgical peptic ulcer. Arch Surg 1997;132:430-433
   Web of Science | Medline

3. 3

   Jordan PH Jr, Thornby J. Perforated pyloroduodenal ulcers: long-term results with omental patch closure and parietal cell vagotomy. Ann Surg 1995;221:479-486
   CrossRef | Web of Science | Medline

4. 4

   Kelley WN, ed. Textbook of internal medicine. 3rd ed. Philadelphia: Lippincott–Raven, 1997:700.
   

5. 5

   Sabiston DC Jr, ed. Textbook of surgery: the biological basis of modern surgical practice. 15th ed. Philadelphia: W.B. Saunders, 1997:860.