非手术与手术治疗穿孔性十二指肠溃疡的比较

Nonoperative treatment versus operative for perforated duodenal ulcer

目的 :比较非手术与手术治疗穿孔性十二指肠溃疡的疗效。方法 :对我院 1995年 1月至 1999年 12月期间 ,所收治的 2 5 4例穿孔性十二指肠溃疡病人的临床资料进行回顾分析。结果 :非手术治 5 8例 ,1例出现腹腔脓肿 ,无一例再穿孔和死亡 ,3个月后溃疡愈合率为 92 .5 % ;手术治疗 186例 ,其中 10 2例行穿孔修补术 ,无一例出现腹腔脓肿 ,1例出现幽门梗阻需再行胃大切术 ,3个月后溃疡愈合 94 .1% ,与非手术治疗无明显差异 ,另外 84例行胃大部分切除术 ,出现残端漏 2例 ,腹腔脓肿 1例。结论 :急性十二指肠溃疡穿孔能自行闭合 ,以非手术治疗史合理和安全 ,通过使用抗生素、质子泵抑制剂或H2 受体阻止剂联合药物治疗 ,溃疡是可治愈的。不能自行闭合的急性穿孔 ,选择单纯修补可降低手术并发症 ,术后配合内科治疗也可达到溃疡治愈目的。慢性十二指肠溃疡穿孔 ,往往伴有溃疡周围疤痕多、胼胝状溃疡、幽门梗阻、病史长、症状严重反复发作等因素 ,即使穿孔超过 12h ,仍可以选择“溃疡确定性外科”治疗。

Objective: Nonoperative effect versus operative for perforated duodenal ulcer. Methods: A retrospective study of 254 cases with perforated duodenal ulcer between January 1995 and December 1999 in our hospital was made. Results: Patients were treated nonoperatively in 58 of 254 cases, an intra-abdominal abscess developed in 1 case, reperforation and death didn't occur, the cure rate of 58 cares was 92.5% after 3 months;patients were treated operatively in 186 of 254 cases, operative closure was performed in 102 cases, an intra-abdominal abscess didn't develop,pylorochesis developed in 1 of 102 cases, and subtotal gastrectomy was performed for him, the cure rate of 102 cases was 94.1% after 3 months ;the other 84 cases were treated by subtotal gastrectomy, duodenal stump fistula developed in 2 of 84 cases, an intra-abdominal abscess developed in1 of 84 cases. Conclusions: Acute perforated duodenal ulcer can be self-sealing spontaneously, and it was safe and reasonable to be treated nonoperatively, patients with perforated duodenal ulcer would recover by treatment of a combination of antibiotics and a proton-pump inhibitor or histamine 2 blocker, if acute perforated duodenal ulcer couldn't be self-sealing spontaneously, patients whom were treated with medical therapy after operative closure would recover, and complication reduced. Patients with chronic perforated duodenal ulcer had factors of a large scaring around the ulcer, or callus ulcer, or pylorochesis, or a long history of ulcer,or a serious repeatly symptom etc, an ulcer-definitive operation should be performed although over 12 hours.