World J. Surg. 20, 574 –577, 1996 WORLD Journal of SURGERY © 1996 by the Socie ´te ´ Internationale de Chirurgie Acute Surgical Treatment of Complicated Peptic Ulcers with Special Reference to the Elderly Orhan Bulut, M.D., Christian Rasmussen, M.D., Anders Fischer, M.D., D.M.Sc. Department of Gastrointestinal Surgery, Gentofte Hospital, University of Copenhagen, DK-2900 Hellerup, Denmark Abstract. The results of 136 consecutive patients treated surgically for the acute complications of peptic ulcers between 1990 and 1993 are reviewed. All patients required emergency operation. Among 136 patients, 91 had perforations, 42 hemorrhage, and 3 a penetrated peptic ulcer. The median age was 77 years; 65% were women; and 83% were more than 60 years old. Concurrent disease requiring medical treatment were present in 92 patients; 79 patients (58%) were currently or recently taking antiinflam- matory drugs at the time of admission; 66% of the patients had duodenal ulcer. Only 46 patients (34%) had no postoperative complications; pneumonia, arrhythmia, bleeding, and septic complications were the most frequent. The overall mortality was 30%. Sepsis and multiple organ failure was the leading cause of death in most of the patients. It was concluded that elderly individuals using two or more antiinflammatory drugs should be considered potential peptic ulcer patients and should be treated prophylactically with ulcer-healing drugs. Surgical intervention in uncomplicated peptic ulcer disease has decreased considerably since the introduction of H 2 -receptor antagonists and proton pump inhibitors. In contrast, several studies have shown that the number of acute surgical procedures performed in patients with complicated peptic ulcer has remained unchanged [1, 2]. Recent findings suggest that increased usage of nonsteroidal antiinflammatory drugs (NSAIDs) or other antiin- flammatory drugs among old people have contributed to a signif- icant increase in the number of hospital admissions for compli- cated peptic ulcer [3, 4]. This study was undertaken to evaluate the results of acute surgical treatment in old people with complicated peptic ulcer and to identify risk factors. Patients and Methods This study includes a series of 136 consecutive patients treated surgically for complicated benign peptic ulcers between 1990 and 1993 at our institution. During the same period, only 25 elective peptic ulcer operations were performed. Our data were obtained retrospectively from patients’ records. This series consists of patients operated on for perforation, massive bleeding, or penetration. All diagnoses were confirmed at laparotomy. The operative indication for perforation was based on one of the following findings: free air demonstrated on an upright chest film or a lateral decubitus film (n = 69) or physical examination alone (n = 17). In five patients perforations were diagnosed during laparotomy, upper gastrointestinal radiography, or computed tomography (CT) scan. Bleeding peptic ulcer was diagnosed endoscopically in all cases. Operation was performed on patients not responding to medical and endoscopic manage- ment or if they required administration of at least 6 units of packed red blood cells for a short observation period. Angiogra- phy or a technetium scan was used in two patients. Penetrating peptic ulcer was diagnosed clinically (n = 1) or by endoscopy (n = 2). Postoperative mortality was defined as death during the hospital admission. Ninety-one (67%) patients had a perforation, 42 (31%) patients were bleeding, and 3 (2%) had a penetrating ulcer (Table 1). Results Patients undergoing surgery were predominantly elderly, with a median age of 77. Eighty-nine patients (65%) were women with a median age of 78.5 years (lower quartile 67 years, upper quartile 85.5 years), and 47 patients (35%) were men with a median age of 71 years (lower quartile 60 years, upper quartile 80 years). A history of peptic ulcer was present in 52 of 136 patients (38%). At the time of admission only 8 (6%) were on specific medical therapy for peptic ulcer: 79 (58%) of the patients were given one or more antiinflammatory drugs (NSAIDs, aspirin, or corticosteroids) at the time of admission. Aspirin was used most frequently. Fifteen of the patients had had recent fractures and were treated with NSAIDs (Table 2). No malignancy was found in this series. Most of the ulcers (90 of 136, or 66%) were located in the duodenum or the pyloric channel (29 of 136, or 21%). Perforated ulcers were most commonly located in the pylorus or duodenum, and bleeding ulcers were in the duodenum. All three penetrating ulcers were in the duodenum. Seven gastric ulcers were perforated, and seven were bleeding (Table 3). No additional disease was observed in 44 patients. Concurrent disease requiring medical treatment were present in 92 patients (68%). Most of the patients had concomitant cardiovascular disease, pulmonary disease, or malignancy (Table 4). Simple closure including a Graham patch, closure alone, or closure combined with an omental patch were the most common procedures for treating perforation (86 of 91). Two patients Correspondence to: O. Bulut, M.D.