Remaining indications for vagotomy with drainage or antrectomy in duodenal ulcer.

Proximal gastric vagotomy (PGV) consists of denervation of the body and fundus of the stomach, the antral nerve supply being left intact. It has a low operative morbidity and mortality and there are few postvagotomy side effects. However, the recurrent ulcer rate may be higher than with other operations for duodenal ulcer. Nevertheless it is usually easier to treat post-PGV recurrence than the complications of other gastric acid lowering operations. This study defines those patients in whom we have not performed a PGV. Of 110 operations for duodenal ulcer since 1980, 70 were PGVs while 40 consisted of truncal or selective vagotomy combined either with a drainage procedure or antrectomy. It is our practice not to perform a PGV in those patients with prepyloric ulcers, pyloric stenosis, bleeding or perforated ulcers and recurrent ulcers.     

Immediate definitive surgery for perforated duodenal ulcers: a prospective controlled trial.

A prospective, randomized, double-blind trial was conducted in 101 patients to evaluate the safety and benefits of immediate definitive surgery for perforated duodenal ulcers. These patients, who were judged by predefined criteria to be medically fit and to have perforations in chronic ulcers, were randomized to undergo simple closure (35 patients), truncal vagotomy and drainage (VD) (32 patients), or proximal gastric vagotomy with closure (PGV) (34 patients). Patients were followed with endoscopic assessment for up to 39 months. There was no mortality and only a few minor postoperative complications. At 39 months follow-up, the cumulative rates of recurrence were 63.3%, 11.8% and 3.8% after closure, VD, and PGV, respectively (p less than 0.001). With the exception of the one recurrence after PGV, all relapses were symptomatic, and eight of these 18 required reoperation. Relapse rates and Visick scores between VD and PGV were significantly different. Both safe as well as effective, immediate, nonresective, definitive operation is indicated for good-risk patients who have perforations in chronic duodenal ulcers.     

Do perforated duodenal ulcers need an acid-decreasing surgical procedure now that omeprazole is available?

If a chronic duodenal ulcer perforates, the choice of operation will depend on the patient's condition. Preoperative shock, concurrent medical diseases, severe generalized peritonitis, or the presence of an intra-abdominal abscess are contraindications to a definitive ulcer operation; hence, simple closure or omental patch closure is performed. Omeprazole can then be used to heal the ulcer in the early postoperative period, with long-term H2-blocker therapy to follow. The patient without a contraindication to a definitive operation should have a proximal gastric vagotomy in addition to an omental patch closure of the perforation. The addition of this procedure does not change the operative mortality rate in properly selected patients, does not cause the gastrointestinal sequelae associated with truncal vagotomy and pyloroplasty or resection, and has a low rate of recurrent ulcer in experienced hands. The presence of a synchronous posterior "kissing" duodenal ulcer would prompt some to choose a vagotomy and pyloroplasty in preference to a proximal gastric vagotomy. The appropriate operation to perform after perforation of an acute duodenal ulcer in a patient with any of the contraindications listed above is simple closure or omental patch closure. In the stable nonseptic patient, the choice is not as clear. Boey and associates noted cumulative recurrent ulcer rates of 37% and 31% at 3 years in separate studies in which omental patch closure was used for perforated acute duodenal ulcers. This may reflect the asymptomatic nature of chronic duodenal ulcers in some patients prior to perforation, the failure of the surgeon to recognize the extent of periduodenal scarring at operation, or differences in the length of postperforation follow-up in series reporting perforations of acute or chronic ulcers. Jordan has suggested that all stable patients with perforated duodenal ulcers should undergo a proximal gastric vagotomy in addition to omental patch closure. In his hands, the addition of proximal gastric vagotomy has an operative mortality rate of 0 to 1%, a recurrent ulcer rate of 3% to 5%, and no adverse postoperative sequelae. He has noted that "this operation gives protection from further ulcer disease to those who need it and will produce no harm to the unidentifiable patients that might not have benefited from definitive surgery." Boey and Wong suggested that omental patch closure is indicated for "acute ulcers associated with drug ingestion or acute stress" in addition to those that occur in patients who are considered to be poor risk, while proximal gastric vagotomy should be added in the remaining patients with perforations of acute ulcers.(ABSTRACT TRUNCATED AT 400 WORDS)     

Emergency operations for gastric and duodenal ulcers in high risk patients.

With routine endoscopy, histamine antagonists, proximal gastric vagotomy (PGV) and declining prevalence of duodenal ulcers, morbidity and mortality of ulcer surgery should have declined. Two hundred thirty-four ulcer operations performed since 1976 were compared with 778 between 1961 and 1971. The hospital mortality rate has increased from 2.7 to 14.5%. Increased mortality was related to a doubling of the rate of emergency operations over age 50 and to a 94% decline in elective operations under 50. Mortality was increased by the need for emergency operations and more by concurrent diseases than by old age. Few operations could have been avoided by earlier elective surgery. Most perforations and hemorrhages occurred from previously unsuspected ulcers, many in patients being treated for other advanced or terminal diseases. Although most deaths occurred in this group, 42% survived. Such patients should be expeditiously offered the definitive operations most appropriate to the locations of their ulcers. Since 1976 among 200 survivors, 20 ulcers have recurred. Most recurred after PGV was tried for pyloric and prepyloric ulcers (8 of 16 recurred) and after previously untreated perforated ulcers were simply closed (4 of 11 recurred). The authors so far have one recurrence after 43 PGVs for duodenal ulcers. These recurrences confirm the need for vagotomy in perforated duodenal ulcer and for resection of ulcers proximal to the duodenum.     

Eradication of Helicobacter pylori prevents recurrence of ulcer after simple closure of duodenal ulcer perforation: randomized controlled trial

OBJECTIVE: In this randomized trial, the authors sought to determine whether eradication of Helicobacter pylori could reduce the risk of ulcer recurrence after simple closure of perforated duodenal ulcer. BACKGROUND DATA: Immediate acid-reduction surgery has been strongly advocated for perforated duodenal ulcers because of the high incidence of ulcer relapse after simple patch repair. Although H. pylori eradication is now the standard treatment of uncomplicated and bleeding peptic ulcers, its role in perforation remains controversial. Recently a high prevalence of H. pylori infection has been reported in patients with perforations of duodenal ulcer. It is unclear whether eradication of the bacterium confers prolonged ulcer remission after simple repair and hence obviates the need for an immediate definitive operation. METHODS: Of 129 patients with perforated duodenal ulcers, 104 (81%) were shown to be infected by H. pylori. Ninety-nine H. pylori-positive patients were randomized to receive either a course of quadruple anti-helicobacter therapy or a 4-week course of omeprazole alone. Follow-up endoscopy was performed 8 weeks, 16 weeks (if the ulcer did not heal at 8 weeks), and 1 year after hospital discharge for surveillance of ulcer healing and determination of H. pylori status. The endpoints were initial ulcer healing and ulcer relapse rate after 1 year. RESULTS: Fifty-one patients were assigned to the anti-Helicobacter therapy and 48 to omeprazole alone. Nine patients did not undergo the first follow-up endoscopy. Of the 90 patients who did undergo follow-up endoscopy, 43 of the 44 patients in the anti-Helicobacter group and 8 of the 46 in the omeprazole alone group had H. pylori eradicated; initial ulcer healing rates were similar in the two groups (82% vs. 87%). After 1 year, ulcer relapse was significantly less common in patients treated with anti-Helicobacter therapy than in those who received omeprazole alone (4.8% vs. 38.1%). CONCLUSIONS: Eradication of H. pylori prevents ulcer recurrence in patients with H. pylori-associated perforated duodenal ulcers. Immediate acid-reduction surgery in the presence of generalized peritonitis is unnecessary.     

Perforated duodenal ulcer managed by proximal gastric vagotomy and suture plication.

Twenty-one patients with acute perforated duodenal ulcer were managed by proximal gastric vagotomy without drainage and simple closure of the perforation reinforced with an omental patch. There was no operative mortality. No recurrent duodenal ulcers have developed. All patients have achieved a good to excellent clinical result from their operation. Dumping, diarrhea, and reflux gastritis have not developed. Follow-up studies extend to three and one-half years. Proximal gastric vagotomy with simple closure is safe, effective management for the patient with an acute perforated duodenal ulcer. This operation is a satisfactory compromise between simple closure alone which does not protect against recurrent ulcer and definitive ulcer operations which may subject patients who would not have further ulcer symptoms to the unnecessary risk of increased mortality, morbidity, and postgastrectomy disorders.     

Proximal gastric vagotomy, truncal vagotomy with drainage, and truncal vagotomy with antrectomy for chronic duodenal ulcer. A prospective, randomized controlled trial.

The relative merits of proximal gastric vagotomy (PGV), truncal vagotomy with drainage (TV + D), and truncal vagotomy with antrectomy (TV + A) in the treatment of chronic duodenal ulcer were evaluated and compared in 152 patients in a prospective, randomized and controlled clinical trial. One death occurred after TV + A, resulting in an operative mortality of 2% after gastrectomy and 0.7% for the entire series. After one to six years, stomal and duodenal ulcers proven by endoscopy occurred in eight patients after PGV (16%) and in six patients after TV + D (11.8%); the difference was not statistically significant (p greater than 0.5). One additional patient developed a gastric ulcer nine months after PGV. There was so far no ulcer recurrence after TV + A. Majority (13 patients) of the recurrent ulcers were discovered within three years after surgery. Patients after PGV experienced significantly less unwanted side effects than those after either TV + D or TV + A; particularly, dumping, epigastric fullness, and diarrhea. When the functional status was graded according to a modified Visick system that excluded ulcer recurrence, significantly more PGV patients were placed in the near-perfect grade (82.1%) than TV + A patients (58%). Patients after TV + D fared better than patients after TV + A; but the differences were not significant. However, when ulcer recurrence was included in the functional assessment, the advantage of PGV was lost.     

Simple suture with or without proximal gastric vagotomy for perforated duodenal ulcer

To assess the results of proximal gastric vagotomy (PGV) in the definitive treatment of perforated duodenal ulcers, a prospective study was carried out comparing PGV in association with omental patch suture (PGV + S) with the simple omental patch suture procedure (S). The PGV + S series consisted of 38 consecutive patients with perforated duodenal ulcer and the S series consisted of 38 survivors of a similar series of 41 consecutive patients. Surgical mortality was zero in the PGV + S series. The patients were followed up for 1 to 7 years. No cases of dumping or diarrhoea were observed. Thirty-three patients in the PGV + S series (87 per cent) were classified as Visick grade I and only two (5 per cent) as Visick grade IV. In contrast, 11 patients (29 per cent) were Visick grade I and 22 (58 per cent) were Visick grade IV in the S series. Recurrent ulcer was detected endoscopically in 58 per cent of the patients who had been treated with simple suture and in only 5 per cent after suture plus PGV. PGV is a safe operation with a negligible morbidity rate and with a significant rate of effective control of ulcer disease. Depending on the general condition of the patient and on the surgeon's skill, it appears preferable to treat not only the acute perforation but also the ulcer disease by PGV.     

Effect of Helicobacter pylori eradication on the ulcer recurrence rate after simple closure of perforated duodenal ulcer: retrospective and prospective randomized controlled studies

BACKGROUND: The possible advantage of eradication of Helicobacter pylori in patients with perforated duodenal ulcer is unknown. This study was planned to assess the prevalence of H. pylori after simple closure of a perforated duodenal ulcer and to study the effect of H. pylori eradication on ulcer persistence and recurrence. METHODS: Some 202 patients were followed prospectively for 2 years after simple closure of a perforated duodenal ulcer (prospective group). A second group of 60 patients was reviewed 5 years or more after perforation closure (retrospective group). The prevalence of H. pylori in patients with perforated duodenal ulcer was compared with that in controls. Patients in the prospective group were randomized to receive either ranitidine alone or quadruple therapy (ranitidine, colloidal bismuth subcitrate, metronidazole and tetracycline) after operation. The incidence of H. pylori infection after the two treatments and the association with residual or recurrent ulcer were studied. In the retrospective group long-term ulcer recurrence was correlated with H. pylori status. RESULTS: The prevalence of H. pylori in patients with perforated duodenal ulcer was not significantly different from that in controls. At every interval of follow-up in the prospective group and in the retrospective group the H. pylori infection rate was significantly higher in patients who had recurrent or residual ulcers. CONCLUSION: Eradication of H. pylori after simple closure of a perforated duodenal ulcer should reduce the incidence of residual and recurrent ulcers.     

Perforated pyloroduodenal ulcers. Long-term results with omental patch closure and parietal cell vagotomy.

OBJECTIVE: The authors evaluated parietal cell vagotomy and omental patch closure as treatment for perforated pyloroduodenal ulcers. BACKGROUND DATA: Since the beginning of the century, there has been a difference of opinion as to whether perforated pyloroduodenal ulcers are best managed with nonoperative treatment, simple closure, or definitive treatment, i.e., a procedure that handles the emergency problem and simultaneously provides protection against further ulcer disease. The criticism of using definitive treatment at the time of perforation has been that some patients who might not have recurrent ulcer, if a definitive operation was not performed, would be at risk of adverse postoperative sequelae, including death. Parietal cell vagotomy as treatment of intractable duodenal ulcer disease was shown to be almost without complications. The objective of this study was to determine if the operation was equally applicable to perforated pyloroduodenal ulcers. METHODS: A group of 107 selected patients with perforated pyloroduodenal ulcers underwent definitive treatment by omental patch closure and parietal cell vagotomy. The patients were evaluated prospectively on an annual basis up to 21 years. Gastric analyses were performed on each visit for which the patient gave his/her consent. Patients suspected of a recurrent ulcer were examined endoscopically for verification. RESULTS: There was one death (0.9%). Ninety-three patients were observed for follow-up for 2 to 21 years. The recurrent ulcer rate by life table analysis was 7.4%. The reoperative rate was 1.9%. Postoperative gastric sequelae were insignificant. All but four patients were graded Visick I or II at the time of their last evaluation. CONCLUSION: This study confirms that the combination of parietal cell vagotomy and omental patch closure is an excellent choice for treatment of patients with perforated pyloroduodenal ulcers, who, by virtue of their age, fitness, and status of the peritoneal cavity are candidates for definitive surgery. Virtually none of the morbidity that occurs with other forms of definitive treatment is inflicted on patients who might never have needed a definitive operation if simple closure was performed. At the same time, it provides definitive therapy for the larger number of patients who subsequently would have required a second operation for continued ulcer disease if simple closure alone was performed. Whether this operation is performed at the time of perforation should depend on the presence or absence of risk factors, rather than whether the ulcer is acute or chronic.     

Emergency management of perforated peptic ulcers in the elderly patient

The results of selective operative treatment for perforated peptic ulcers in 93 elderly patients 60 years of age or older have been found to be similar to those in a large group of patients of all ages with selective operative treatment for perforated peptic ulcers (1,127 patients). Elderly patients with previous symptoms of acid-peptic disease who do not have serious associated diseases that increase the risk of operation or generalized peritonitis or localized abscesses in the peritoneal cavity can undergo definitive ulcer procedures for perforated peptic ulcers with satisfactory morbidity and low mortality rates. Simple closure or omental patch closure is performed when such contraindications to a definitive operation are present and can be expected to have a greater mortality for this reason. Gastrectomy for a perforated gastric ulcer and truncal vagotomy and hemigastrectomy for a perforated duodenal ulcer offer the best long-term results for elderly patients who are fit to undergo definitive operation.     

Perforated Peptic Ulcer Treated by Simple Closure and Helicobacter Pylori Eradication

Simple closure followed by Helicobacter pylori (Hp) eradication has become the most used procedure in perforated ulcer treatment. However, its efficacy and safety are still to be determined. To assess recurrence and re-perforation rates, and as a secondary objective, to analyze Hp infection rates in perforated ulcer patients and controls, we conducted a prospective study. Ninety-two consecutive patients (ages: 19–96 years) were operated on between 1996 and 2002, and treated by simple closure followed by Hp eradication and NSAID avoidance. The data were prospectively collected in a database. Hp infection was diagnosed in 68 patients (73.9%). Thirty-four patients (37%) consumed nonsteroidal anti-inflammatory drugs (NSAIDs), and 23 (25%) had both Hp infection and NSAID antecedents. The perforation was gastric in 4 cases and pre-pyloric, pyloric or duodenal in 88. There were postoperative complications in 24 patients (26%) and 4 patients died (4.3%). Hp eradication was shown in 46 patients. There was clinical ulcer recurrence in 4 (4.3%); in 3 of them recurrence manifested as re-perforation, all in gastric locations. Overall relapse and re-perforation 1-year crude rates were 6.1% and 4.1%, respectively. Crude rates for non-gastric ulcer recurrence were 0 at 1 year and 2.6% at 2 years and for non-gastric ulcer re-perforation rates were 0 at 1 and 2 years. This therapeutic strategy is associated with a low rate of recurrence and no re-perforations in case of duodenal, pyloric, or pre-pyloric perforated ulcers, but it is not acceptable for perforated gastric ulcers.     

Surgical therapy of ulcer disease. Early and late results of elective and emergency interventions]

Between 6/1974 and 12/1988 910 patients with peptic ulcer disease have been treated operatively. In 523 cases a resection, gastroenterostomy resp. ligation of a bleeding ulcer, in 160 cases with duodenal ulcers a vagotomy, and in 227 cases with perforated ulcers simple closure or primary resection have been performed. During this study the percentage of female patients rose from 32.0 to 39.7. There was also an increase of the mean age of the patients. Operative mortality rate was 7.3% for resection, GE resp. ligation of a bleeding vessel, 0.6% for vagotomies, and 16.3% for perforated ulcers. The fate of all patients was followed regularly. In patients operated before 1985--with a follow-up of 5-16 years--reoperations were necessary in 6.0% following resection, gastroenterostomy resp. ligation, in 7.7% following vagotomy, and in 21.3% following simple closure or primary resection of a perforated ulcer.     

Proximal gastric vagotomy versus selective vagotomy with antrectomy: results of a prospective, randomized clinical trial after four to twelve years

This prospective, randomized study of selective vagotomy with antrectomy (SVA) versus proximal gastric vagotomy (PGV) for patients with duodenal ulcer compares the incidence of recurrent duodenal ulcer and postoperative morbidity during a 4- to 12-year follow-up period. In 46 patients with SVA there were no recurrent ulcers, but 26% of these individuals had serious digestive problems that were not amenable to medical treatment. The 40 patients with PGV had eight recurrent ulcers (20%), but five of these were found in the first 15 patients (33%) compared with three in the 25 patients (12%) who had operations after the need for extensive periesophageal denervation was discovered in the mid-1970s. Most recurrent ulcers were amenable to medical treatment, but 5% of the patients who had PGV had postoperative dysphagia that required periodic bougienage. The data are consistent with several interpretations, depending on the bias of the individual. However, based upon the fact that recurrent ulcers could be managed nonoperatively after PGV versus the lack of effective treatments for postgastrectomy complaints after SVA, it is reasonable to consider wider use of PGV. There are reasons to believe that the variable ulcer recurrence rates after PGV can be explained by subtle differences in operative technique, including those based upon use of the Congo red test for completeness of vagotomy. Unlike SVA, PGV remains an operative procedure in evolution that requires further clinical investigation. At this time either operation can be applied if both the surgeon and the patient have a clear understanding of the possible effects.     

Indications for parietal cell vagotomy without drainage in gastrointestinal surgery.

Parietal cell vagotomy (PCV) was used for a variety of gastrointestinal conditions in 658 patients. Operative and late related deaths after PCV were 1.1% (3/273) in patients with intractable duodenal ulcers, 1.1% (1/91) in perforated ulcers, 0% (0/43) in Type I gastric ulcers, 0% (0/45) in pyloric and prepyloric ulcers, 3.2% (6/188) when combined with fundoplication, 8.7% (2/23) when combined with vascular surgery, and 4.2% (1/24) in ulcer patients with acute bleeding. The recurrent ulcer rate after PCV was 8.4% in patients operated on for duodenal ulcer, 6.4% for perforated ulcer, 5.3% for bleeding ulcers, 10% for Type I gastric ulcers, and 31% for pyloric and prepyloric ulcers. PCV was preferred to total gastrectomy in four patients in whom a gastrinoma could not be located. PCV was used in 188 patients with reflux esophagitis and in 12 patients with achalasia to facilitate fundoplication and placement of the myotomy, respectively. Based on the results of the study, PCV is contraindicated in patients with pyloric and prepyloric ulcers. PCV is not recommended when traumatic dilatation of the pylorus is required to overcome obstruction. PCV may have limited application in patients with bleeding ulcers and Type I gastric ulcers. In our experience PCV is not contraindicated in patients with ulcers resistant to H2 receptor antagonists. PCV may be contraindicated when acid hypersecretion exceeds an as-yet undetermined level. PCV is an ideal procedure for intractable duodenal ulcers and perforated ulcers.     

Risk factors in perforated peptic ulcer disease: comparison of a new score system with the Mannheim Peritonitis Index.

OBJECTIVE--To construct a score that would accurately predict outcome for patients with perforated peptic ulcers. DESIGN--Retrospective study. SETTING--University Hospital. SUBJECTS--173 patients who were operated on for perforated peptic duodenal ulcers over a 14 year period. MAIN OUTCOME MEASURES--Results of multivariate discriminant function analysis of derived set of clinical variables known to be associated with high mortality, and comparison with the Mannheim Peritonitis Index. RESULTS--Serious coexisting medical illness, acute renal failure, white cell count of more than 20 x 10(9)/l, and male sex were the most significant factors influencing mortality. The Hacettepe score for perforated peptic ulcer was established using these four variables. The sensitivity was 83%, the specificity 94%, and the overall predictive accuracy 93%. The corresponding figures for the Mannheim Peritonitis Index were 75%, 96%, and 94% respectively. CONCLUSION--The Hacettepe score is useful in predicting whether a patient will survive after perforation of a peptic duodenal ulcer.     

Proximal gastric vagotomy compared with vagotomy and antrectomy and selective gastric vagotomy and pyloroplasty.

A prospective, randomized study of proximal gastric vagotomy without drainage (PGV) was done in 174 adult men with chronic duodenal ulcer intractable to medical therapy. PGV was randomized against truncal vagotomy with antrectomy (TV + A) and against selective gastric vagotomy with Finney pyloroplasty (SGV + P). Postgastrectomy sequelae (dumping, diarrhea and reflux gastritis) were less after PGV. One patient after PGV developed a recurrent ulcer as did one patient after SGV + P. Two patients developed gastric ulcers after PGV. Good to excellent results (Visick I and II) were obtained in 96% of patients with PGV, 94% with TV + A and 86% with SGV + P. Follow-up studies were from six months to four years.     

Simple closure or vagotomy and pyloroplasty for the treatment of a perforated duodenal ulcer: comparison of results

BACKGROUND/AIMS: Treatment of the perforated duodenal ulcer continues to be a controversial subject. The purpose of our study was to compare the results of simple closure of perforated duodenal ulcer versus treatment by truncal vagotomy and pyloroplasty. METHODS: We present a prospective and randomized study of 207 patients who underwent surgical treatment due to perforated duodenal ulcer. In 117 patients the surgical treatment was simple closure and postsurgery medical treatment with proton pump inhibitors for 1 month, and in 90 patients vagotomy and pyloroplasty with no additional medical treatment. RESULTS: We applied the Visick scale in order to compare postsurgery results. The postoperative morbidity and mortality rates were the same with both techniques. Statistically, in both cases, no significant differences were found in postsurgery symptomatology. The different rates of recurrent ulcers and the reinterventions due to recurrent ulcers presented no significant statistical values. CONCLUSION: We conclude that simple closure remains the selected treatment in the majority of patients who present with a perforated duodenal ulcer. The operation is a simple and safe procedure.     

Long-term results after omental patch repair in patients with perforated duodenal ulcers: a 5- to 10-year follow-up study

Ninety-two patients with perforated duodenal ulcers were treated at two hospitals in St. John's. Five patients were managed conservatively, and the remainder received omental patch closure. All were prescribed histamine receptor antagonists. No patient had a definitive ulcer operation. Seventy-five patients were followed up for 5 to 10 years. Fourteen patients who had been taking ulcerogenic medications had a low recurrence rate (7%); the other 61 patients who had not been taking ulcerogenic medications had a high recurrence rate (77%). Use of an omental patch is effective treatment for perforated duodenal ulcers and provides long-term benefit for patients whose perforations are associated with ulcerogenic medications. Selected patients who have not been taking ulcerogenic medication are better treated by definitive ulcer surgery at the time of perforation.     

A prospective study of operative risk factors in perforated duodenal ulcers.

Operative risk factors for patients with perforated duodenal ulcers were examined prospectively in 213 operated patients. Nine hospital deaths (4.2%) resulted from respiratory failure, sepsis, and bleeding. Forty-five complications developed in 27 patients (12.7%). Concurrent medical illness, preoperative shock, and longstanding perforations (more than 48 hours) were significant features that increased mortality. Old age, gross peritoneal soiling, and the length of the ulcer history did not affect mortality in the absence of risk factors. No death attributable to either sepsis or abscess formation occurred when surgery was performed within two days of perforation. Bacterial contamination may not signify clinical peritonitis during this period. We conclude that simple closure of perforated ulcers is a more prudent choice when any risk factor is present, but that definitive surgery in good-risk patients merits further evaluations.