PEPTİK ÜLSER PERFORASYONLARINDA TEDAVİ SEÇENEKLERİMİZ

Öz

Peptik ülser tedavisindeki gelişmeler sayesinde elektif ülser operasyonlarının sayısı azalırken, özellikle non-steroid ağrı kesiciler, siklooksijenaz inhibitörleri, selektif serotonin geri alım inhibitörleri ve steroidler gibi ilaçların kullanımının yaygınlaşması nedeniyle acil komplikasyonlara bağlı operasyonların sayısında ise azalma olmamıştır. Postoperatif asit baskılayıcı tedaviler sayesinde son yıllarda definitif ülser cerrahisine gereksinim azalmıştır. Biz de bu çalışmamızda peptik ülser perforasyonları konusunda kliniğimizin deneyimlerini yeni yaklaşımlar ışığında irdelemeyi amaçladık. İzmir Bozyaka Eğitim ve Araştırma Hastanesi 2. Genel Cerrahi Kliniği’nde son 5 yılda peptik ülser perforasyonları nedeniyle opere edilen 61 hastanın dosyaları retrospektif olarak incelendi. Hastaların 9’u %14,7 kadın, 52’si %85,2 erkekti ve yaş ortalaması 49,6 idi. Preoperatif tanı, 47 %77 hastada akciğer grafisinde diyafragma altında serbest hava görülmesi ile, 8 hastada %13,1 ise abdominal tomografide intraperitoneal serbest hava görülmesi ile konuldu. 6 hastada ise %9,8 tanı intraoperatif olarak konuldu. Perforasyonların 37’si %60,7 bulbusta, 18’i %29,5 prepilorik alanda, 2’si %3,3 mide küçük kurvaturda, 1’i %1,6 mide korpusta ve 1’i %1,6 duodenum 2. kıtada lokalizeydi. Ülser cerrahisi öyküsü olan 2 %3,3 hastada da gastroenterostomi hattında perforasyon saptandı. Hastaların 50’sine %82 primer tamir+omentoplasti, 4’üne %6,6 omental yama ile tamir, 2’sine %3,3 sadece primer tamir, 3’üne %4,9 subtotal gastrektomi ve Roux en Y anastomoz, 2’sine %3,3 antrektomi ve Billroth-II prosüdürleri uygulandı. Mortalite saptanmazken morbidite olarak 8 %13,1 hastada postoperatif yara yeri enfeksiyonu gelişti. Peptik ülser perforasyonlarında non-operatif tedaviden geniş rezeksiyonlara kadar pek çok tedavi seçeneği mevcuttur. Bu seçeneklerden hangisini tercih edeceğimiz hastaların genel durumuna ve perforasyonların çeşidine göre değişmektedir. Erken tanı ve doğru müdahalenin yapılması morbidite ve mortalite riskini azaltmak açısından önemlidir

Anahtar Kelimeler

• peptik ülser,perforasyon,cerrahi

OUR TREATMENT ALTERNATIVES FOR PERFORATED PEPTIC ULCER DISEASE

Abstract

Even though elective operation number has been decreasing for perforated peptic ulcer disease, increasing use of non-steroidal anti-inflammatory pain killer drugs, cyclooxygenase inhibitors, selective serotonin uptake inhibitors and steroids prevented likewise decrease in peptic ulcer disease complication related emergency operation frequency. The need for definitive ulcer surgery had decreased owing to postoperative acid suppressive therapies. We tried to examine the experience of our peptic ulcer perforation with the light of new approaches. The files of 61 patients which operated for peptic ulcer perforation were examined retrospectively during the last five years in İzmir Bozyaka Education and Research Hospital. There were 9 %14.7 female, 52 85.2% male patients with the mean age of 49.6 . Preoperative diagnosis was established with the air under the diaphragm on chest x-ray in 47 77% patients whereas intraperitonealfree air on abdominal computed tomography was the diagnostic finding in 8 13.1% patients. Six patients 9.8% have had the definitive diagnosis intraoperatively. The number of perforation sites were 37 60.7% for bulbus; 18 29.5% for prepyloric area; 2 3.3% for lesser curvature; 1 1.6% for corpus and 1 1.6% for duodenum 2nd portion. There were 2 3.3% patient with ulcer surgery in past medical history in whom perforation detected at gastroenterostomy site. 50 82% patients underwent primary repair and omentoplasty; 4 6.6% mending with omental patch; 2 3.3% only primary suturing; 3 4.9% subtotal gastrectomy and Roux & Y anastomosis and 2 3.3% antrectomy and Billroth II procedure were applied. There was no mortality observed whereas 8 13.1% surgical site infection had developed as morbidity. There is a wide range of treatment alternatives for peptic ulcer perforation starting from nonoperative observation to wide excisions. The choice of treatment depends on the patient’s general condition and the type of perforation. It is important to establish early diagnosis and appropriate therapy in order to reduce the morbidity and mortality

Keywords

• Peptic ulcer,perforation,surgery

Kaynakça

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45. Yazının alınma tarihi: 07.03.2014 Kabül tarihi: 18.04.2014 Online basım: 24.04.2014