Perforated peptic ulcer: a deliberative approach

Between 1966 and 1987, 116 patients with 119 episodes of perforation were admitted to Box Hill Hospital into one surgical unit, and 91 patients with 92 episodes were admitted into the other, with patients being admitted in alternate weeks. In the former unit, in order to avoid surgery in those patients whose ulcers had sealed spontaneously, a deliberative approach was followed according to a strict protocol--involving a deliberate time delay in surgical decision-making. In the latter unit, a more conventional approach was adopted, and patients in that unit are used as a retrospective comparison. In the first unit, of 115 episodes which followed the protocol, six were unresuscitable, 15 needed immediate surgery and 94 followed a delayed approach. Of that 94, 12 needed surgery at 4-6 h, and a further eight needed later surgery. Seventy-four (68% of 'operable' patients) did not require corrective surgery at all, for their episode of perforation. The operable mortality rate was lower (6% compared with 13%), the bedstay was shorter, the prolonged bedstay rate was lower, and the morbidity was no worse, than those patients treated more conventionally in the second unit.