Dr Liang and colleagues contend that a significant percentage of patients presenting with perforated ulcer are best managed nonoperatively if a water-soluble contrast study is normal. With the exception of the very rare nonimmunocompromised patient presenting with free air and minimal if any physical findings on examination, I would disagree.
Before embarking on a nontraditional pathway, cautious scrutiny of past experience and the surgical literature is mandatory. I offer 2 examples. Dr Liang notes that Wangensteen1 reported the “success” of nonoperative management. However, 4 of 9 patients in his study had no free air on roentgen examination, questioning the diagnosis. Of the remaining 5 patients, 2 developed subphrenic abscess and 1 patient died of peritonitis 14 days after admission. The definition of success is clearly in the eyes of the beholder. Wangensteen himself concludes that “there can be no debate about the early (presenting) case. Closure of the perforation should be done immediately.”
Behrman SW. Management of Complicated Peptic Ulcer Disease—Reply. Arch Surg. 2005;140(9):915. doi:10.1001/archsurg.140.9.915