A randomized trial of nonoperative treatment for perforated peptic ulcer

Trevor J. Crofts, Kenneth G. M. Park, Robert J. C. Steele, Sydney S. C. Chung, Arthur K. C. Li

    Research output: Contribution to journalArticle

    184 Citations (Scopus)

    Abstract

    To determine whether surgery could be avoided in some patients with perforated peptic ulcer, we conducted a prospective randomized trial comparing the outcome of nonoperative treatment with that of emergency surgery in patients with a clinical diagnosis of perforated peptic ulcer. Of the 83 patients entered in the study over a 13-month period, 40 were randomly assigned to conservative treatment, which consisted of resuscitation with intravenous fluids, institution of nasogastric suction, and intravenous administration of antibiotics (cefuroxime, ampicillin, and metronidazole) and ranitidine. Eleven of these patients (28 percent) had no clinical improvement after 12 hours and required an operation. Two of the 11 had a perforated gastric carcinoma, and 1 had a perforated sigmoid carcinoma. The other 43 patients were assigned to immediate laparotomy and repair of the perforation. One of these patients was found to have a perforated gastric carcinoma. The overall mortality rates in the two groups were similar (two deaths in each, 5 percent), and did not differ significantly in the morbidity (infection, cardiac failure, or renal failure) rates (40 percent in the surgical group and 50 percent in the nonsurgical group). The hospital stay was 35 percent longer in the group treated conservatively. Patients over 70 years old were less likely to respond to conservative treatment than younger patients (P less than 0.05). We conclude that in patients with perforated peptic ulcer, an initial period of nonoperative treatment with careful observation may be safely allowed except in patients over 70 years old, and that the use of such an observation period can obviate the need for emergency surgery in more than 70 percent of patients.
    Original languageEnglish
    Pages (from-to)970-3
    Number of pages4
    JournalNew England Journal of Medicine
    Volume320
    Issue number15
    DOIs
    Publication statusPublished - 1989

    Fingerprint

    Peptic Ulcer
    Therapeutics
    Carcinoma
    Stomach
    Observation
    Cefuroxime
    Ranitidine
    Emergency Treatment
    Metronidazole
    Suction
    Sigmoid Colon
    Ampicillin
    Resuscitation
    Intravenous Administration
    Laparotomy
    Renal Insufficiency
    Length of Stay
    Emergencies
    Heart Failure
    Anti-Bacterial Agents

    Keywords

    • Age Factors
    • Anti-Bacterial Agents
    • Drug Therapy, Combination
    • Female
    • Humans
    • Length of Stay
    • Male
    • Middle Aged
    • Peptic Ulcer Perforation
    • Prospective Studies
    • Random Allocation
    • Ranitidine
    • Suction

    Cite this

    Crofts, Trevor J. ; Park, Kenneth G. M. ; Steele, Robert J. C. ; Chung, Sydney S. C. ; Li, Arthur K. C. . / A randomized trial of nonoperative treatment for perforated peptic ulcer. In: New England Journal of Medicine. 1989 ; Vol. 320, No. 15. pp. 970-3.
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    abstract = "To determine whether surgery could be avoided in some patients with perforated peptic ulcer, we conducted a prospective randomized trial comparing the outcome of nonoperative treatment with that of emergency surgery in patients with a clinical diagnosis of perforated peptic ulcer. Of the 83 patients entered in the study over a 13-month period, 40 were randomly assigned to conservative treatment, which consisted of resuscitation with intravenous fluids, institution of nasogastric suction, and intravenous administration of antibiotics (cefuroxime, ampicillin, and metronidazole) and ranitidine. Eleven of these patients (28 percent) had no clinical improvement after 12 hours and required an operation. Two of the 11 had a perforated gastric carcinoma, and 1 had a perforated sigmoid carcinoma. The other 43 patients were assigned to immediate laparotomy and repair of the perforation. One of these patients was found to have a perforated gastric carcinoma. The overall mortality rates in the two groups were similar (two deaths in each, 5 percent), and did not differ significantly in the morbidity (infection, cardiac failure, or renal failure) rates (40 percent in the surgical group and 50 percent in the nonsurgical group). The hospital stay was 35 percent longer in the group treated conservatively. Patients over 70 years old were less likely to respond to conservative treatment than younger patients (P less than 0.05). We conclude that in patients with perforated peptic ulcer, an initial period of nonoperative treatment with careful observation may be safely allowed except in patients over 70 years old, and that the use of such an observation period can obviate the need for emergency surgery in more than 70 percent of patients.",
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    A randomized trial of nonoperative treatment for perforated peptic ulcer. / Crofts, Trevor J.; Park, Kenneth G. M.; Steele, Robert J. C. ; Chung, Sydney S. C. ; Li, Arthur K. C. .

    In: New England Journal of Medicine, Vol. 320, No. 15, 1989, p. 970-3.

    Research output: Contribution to journalArticle

    TY - JOUR

    T1 - A randomized trial of nonoperative treatment for perforated peptic ulcer

    AU - Crofts, Trevor J.

    AU - Park, Kenneth G. M.

    AU - Steele, Robert J. C.

    AU - Chung, Sydney S. C.

    AU - Li, Arthur K. C.

    PY - 1989

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    N2 - To determine whether surgery could be avoided in some patients with perforated peptic ulcer, we conducted a prospective randomized trial comparing the outcome of nonoperative treatment with that of emergency surgery in patients with a clinical diagnosis of perforated peptic ulcer. Of the 83 patients entered in the study over a 13-month period, 40 were randomly assigned to conservative treatment, which consisted of resuscitation with intravenous fluids, institution of nasogastric suction, and intravenous administration of antibiotics (cefuroxime, ampicillin, and metronidazole) and ranitidine. Eleven of these patients (28 percent) had no clinical improvement after 12 hours and required an operation. Two of the 11 had a perforated gastric carcinoma, and 1 had a perforated sigmoid carcinoma. The other 43 patients were assigned to immediate laparotomy and repair of the perforation. One of these patients was found to have a perforated gastric carcinoma. The overall mortality rates in the two groups were similar (two deaths in each, 5 percent), and did not differ significantly in the morbidity (infection, cardiac failure, or renal failure) rates (40 percent in the surgical group and 50 percent in the nonsurgical group). The hospital stay was 35 percent longer in the group treated conservatively. Patients over 70 years old were less likely to respond to conservative treatment than younger patients (P less than 0.05). We conclude that in patients with perforated peptic ulcer, an initial period of nonoperative treatment with careful observation may be safely allowed except in patients over 70 years old, and that the use of such an observation period can obviate the need for emergency surgery in more than 70 percent of patients.

    AB - To determine whether surgery could be avoided in some patients with perforated peptic ulcer, we conducted a prospective randomized trial comparing the outcome of nonoperative treatment with that of emergency surgery in patients with a clinical diagnosis of perforated peptic ulcer. Of the 83 patients entered in the study over a 13-month period, 40 were randomly assigned to conservative treatment, which consisted of resuscitation with intravenous fluids, institution of nasogastric suction, and intravenous administration of antibiotics (cefuroxime, ampicillin, and metronidazole) and ranitidine. Eleven of these patients (28 percent) had no clinical improvement after 12 hours and required an operation. Two of the 11 had a perforated gastric carcinoma, and 1 had a perforated sigmoid carcinoma. The other 43 patients were assigned to immediate laparotomy and repair of the perforation. One of these patients was found to have a perforated gastric carcinoma. The overall mortality rates in the two groups were similar (two deaths in each, 5 percent), and did not differ significantly in the morbidity (infection, cardiac failure, or renal failure) rates (40 percent in the surgical group and 50 percent in the nonsurgical group). The hospital stay was 35 percent longer in the group treated conservatively. Patients over 70 years old were less likely to respond to conservative treatment than younger patients (P less than 0.05). We conclude that in patients with perforated peptic ulcer, an initial period of nonoperative treatment with careful observation may be safely allowed except in patients over 70 years old, and that the use of such an observation period can obviate the need for emergency surgery in more than 70 percent of patients.

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    KW - Humans

    KW - Length of Stay

    KW - Male

    KW - Middle Aged

    KW - Peptic Ulcer Perforation

    KW - Prospective Studies

    KW - Random Allocation

    KW - Ranitidine

    KW - Suction

    U2 - 10.1056/NEJM198904133201504

    DO - 10.1056/NEJM198904133201504

    M3 - Article

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    SP - 970

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    ER -