A logical solution to the perforated ulcer controversy.

Until recently, the Graham patch was the undisputed method of management for a perforated duodenal ulcer. Results of our experience with 186 patients treated at Wayne State University Affiliated Hospitals from 1970 through 1978 dispute this concept and suggest that a definitive operation is the procedure of choice. One hundred and thirty-seven of the patients were treated with an omental patch, and 47 underwent a definitive operation; 114 of the patients were available for an 18 month follow-up study. It was found that previous ulcer symptoms were not an accurate predictor of the need for a subsequent definitive operation and that mortality was determined by the age and condition of the patient at the time of operation rather than by the choice of operation itself. It is recommended that the perforation itself is an indication for a definitive operation unless the patient is in a state of shock at the time of operation. Vagotomy and pyloroplasty have proved to be safe, reliable, definitive operations in this situation.