Surgical management of bleeding chronic peptic ulcer. A 10-year prospective study.

Analysis of experience with chronic bleeding peptic ulcer in 504 patients, admitted from 1960 to 1971, shows a hospital mortality of 12%. This retrospective review suggested that early endoscopic diagnosis, adequate resuscitation and a policy of early selective surgery was necessary if mortality was to be reduced. With this policy, there were 37 deaths in 633 patients admitted during the period of prospective study from 1972 to 1982 (5.8%). There were 25 deaths after emergency surgery in 206 patients, 56% of postoperative deaths were related to technical factors and 44% to nontechnical complications. Comparison with the retrospective study from 1961 to 1970 showed, matching in terms of incidence of shock, sex distribution and number of patients over 60 years of age. During this period, 142 emergency operations were performed, with 25 postoperative deaths, an operative mortality of 17.6%. Thirty-five deaths occurred in conservatively treated patients (9.5%) compared with 12 deaths in conservatively treated patients from 1972 to 1982 (2.6%). Within the period of prospective study, there was a significant reduction in mortality from 8%, for the first 5 years, to 3.9% for the second 5 years of study. These two periods matched except for a significant increase in the proportion of patients 60 years and over. This was mainly due to a rise in incidence of aged patients with gastric ulcer. Also noted was a decrease in mortality in patients 60 years and over which reached significance, and a significant decrease in the number of deaths in shocked patients. A significant fall in technically related postoperative complications was noted, from 44 (11 causing death) to 12 (three causing death) during the second 5 years of prospective study. There were 444 patients admitted with bleeding duodenal ulcer with 20 deaths in hospital (4.5%), and 17 deaths in 189 patients admitted with bleeding gastric ulcer, a mortality of 9%. No single factor could be isolated as the reason for the improved results. Possibly the most significant reason is the application of a defined policy in a special unit where staff became familiar with all aspects of the problem of bleeding chronic peptic ulceration.