Peritonitis manejada por laparoscopia como método terapéutico eficaz / Peritonitis treated by laparoscopy as an effective treatment

La peritonitis es una de las principales complicaciones de las urgencias abdominales. La laparoscopia sirve tanto para el manejo diagnóstico y terapéutico del abdomen agudo; en manos expertas la morbimortalidad de este método es mínima. Objetivo: El objetivo es comprobar la eficacia de la laparoscopia en pacientes con peritonitis secundaria realizando una sola cirugía sin necesidad de reintervenciones, asegurando el menor daño de la pared abdominal, evitando la laparotomía. Materiales y métodos: Estudio retrospectivo, se incluyeron pacientes con diagnostico final de peritonitis y manejados con técnica laparoscópica, abarcando un periodo de mayo del 2011 a julio del 2016, ingresados a la Clínica Nuestra Señora de Fátima, Pasto, Colombia. Resultados: La muestra fueron 67 pacientes. Los resultados indican una edad promedio de 45 años, edad máxima 94 y mínima 17 años, ± de 20,6; predomina el sexo Femenino en un 55,2% (n=37); siendo el 73,1% (n=49) del área urbana. El tiempo de evolución promedio de la patología fue de 4 días. No hubo casos de mortalidad en la población objeto de estudio. Conclusión: La técnica laparoscópica, el lavado exhaustivo de la cavidad abdominal, la inserción del dren mixto y el tratamiento adecuado de antibiótico, se constituye en una técnica segura en el paciente ya que evito reintervenciones quirúrgicas, riesgo de infecciones, ausencia de íleo paralitico y sangrado, evitando así la laparostomía y el defecto gigante de la pared abdominal.

Peritonitis is one of the main complications of abdominal emergencies. Laparoscopy serves both for the diagnostic and therapeutic management of the acute abdomen; in expert hands the morbimortality of this method is minimal. Objective: The objective is to verify the efficacy of laparoscopy in patients with secondary peritonitis performing a single surgery without the need for reinterventions, ensuring the least damage of the abdominal wall, avoiding laparotomy. Material and methods: Retrospective study included patients with final diagnosis of peritonitis and managed with laparoscopic technique, covering a period from May 2011 to July 2016, admitted to Clínica Nuestra Señora de Fátima, Pasto, Colombia. Results: The sample was 67 patients. The results indicate an average age of 45 years, maximum age 94 and minimum 17 years, ± 20.6; female sex predominates in 55.2% (n = 37); being 73.1% (n = 49) of the urban area. The mean evolution time of the disease was 4 days. There were no cases of mortality in the study population. Conclusion: The laparoscopic technique, thorough cleaning of the abdominal cavity, insertion of the mixed drainage and adequate antibiotic treatment, constitutes a safe technique in the patient since it prevents surgical reinterventions, risk of infections, absence of paralytic ileus and bleeding, thus avoiding laparostomy and the giant defect of the abdominal wall.

Complicações gastrintestinais em usuários de cocaína/crack: revisão da literatura / Gastrointestinal complications among users of cocaine / crack-a literature review

O consumo de cocaína/crack atinge todos os extratos sociais e grande parcela da população, principalmente os jovens. Esse abuso leva à ampla gama de complicações sistêmicas. No trato gastrintestinal, pode se expressar por manifestações como perfuração gastroduodenal aguda, colite isquêmica, infarto, isquemia intestinal e, raramente, hemorragia maciça. Seu mecanismo fisiopatológico parece ser o vasoespasmo ou vasoconstrição, que pode levar à isquemia, inclusive com necrose transmural. É importante a atenção e vigilância para o abuso de cocaína/crack ao deparar com paciente com dor abdominal inexplicável. (AU)

Cocaine/crack have being consumed by a large portion of the population especially by youth and reaching all social levels. This abuse leads to a wide range of systemic complications. In the gastrointestinal tract, the drug can lead to manifestations such as acute gastroduodenal perforation, ischemic colitis, infarction, intestinal ischemia and, rarely, massive hemorrhage. The most accepted pathophysiological mechanism is vasospasm or vasoconstriction which can lead to ischemia, including transmural necrosis. It is important that physicians to be aware and search recent history of abuse of crack / cocaine when faced with a patient with unexplained abdominal pain. (AU)

A Case of Subcapsular Liver Abscess Secondary to Perforating Ulcer of Gastric Cancer / 대한소화기학회지

Intrahepatic abscess is an unusual complication of peptic ulcer disease. We present a case of gastric cancer in which the ulcer penetrated into the left lobe of liver with subsequent abscess and fistula formation. Esophagogastroduodenoscopy confirmed ulcers and a fistula opening in the antrum. Abdominal computed tomogram showed a subcapsular liver abscess adjacent to the gastric antrum. Subtotal gastrectomy with curettage of the fistulous tract was performed. The final diagnosis was the signet ring cell gastric carcinoma complicating subcapsular liver abscess. To our knowledge, this is the first reported case in Korea.

Analysis of risk factors cotnributing to releak in duodenal ulcer perforation: experience of surgical closure by Graham's patch

Free perforation of peptic ulcer into the general peritoneal cavity is a catastrophic event. Although laparoscopic approach has been successfully used for its management, primary closure of the perforation using an omental patch [Grahm's patch] is the immediate alterative. This study was planned to analyse risk factors, which could predict releak following Grahm's patch closure. This study was carried out for five years from April 2003 to March 2008, at department of surgery Muhammad Medical College Mirpurkhas. All patients undergoing surgery for perforated duodenal ulcer were included in the study. 53 patients underwent Grahm's Patch Closure. 6 patients developed releakage post operatively. Therefore two groups were made. Patients with releak were kept in case group [n=6] and the patients with no leak [n=47] were included in control group. In this study all patients were assessed for age, pulse rate, systolic blood pressure, hemoglobin and serum Protein / albumin, total leukocyte count [TLC] on arrival, delay in arrival since sign and symptom [probable] of perforation and size of perforation on operation were also documented. Age greater than 50 years [p=0.05], pulse greater than 110/min [p=0.22], systolic blood pressure less then 90mmHg [p=0.02l], hemoglobin less than 10gm% [p=0.25], serum albumin less than 2.5gm% [p=0.018], delay in arrival for more then 36 hour [p=0.00017], and size of proportion greater then 5mm in it maximum dimension were identified as risk factor for releak. Delay in arrival was the single most significant factor influencing mortality rate after omental patch closure of perforated duodenal ulcer

Ten-years comparative study after surgical treatment of perforated peptic ulcer according to ulcer relapse between H. Pylori positive, after eradication, and negative patients / Estudo comparativo quanto à recidiva ulcerosa do tratamento cirúrgico de úlcera péptica perfurada entre pacientes H. Pylori positivos, após erradicação, e negativos

BACKGROUND: The surgical treatment for perforated peptic ulcer is still a matter of discussion. The surgeons, for many years, made their options between acid-reducing procedures with some morbi-mortality and simpler procedures like closure of the perforation. But, in these cases, were faced with a high chance of ulcer relapse. Since the proved link between peptic ulcer and gastroduodenal infection caused by H. pylori, a recommendation for a change in their attitudes going back to simpler procedures with eradication of the bacteria was done.AIM: To analyse ulcer recurrence in patients treated with the same surgical procedure but belonging to two different groups: positive and negative to H. pilori.METHODS: A total of 144 patients were treated with simple closure of their perforated pre-pyloric, pyloric and duodenal ulcers. Thirty days after operation they were submitted to upper endoscopy and tested for the bacteria by urease and histopathological exams and divided into two groups according to the results of the tests: positive and negative. The positive ones were eradicated and, together with the negative group, were followed through six months interval endoscopies and detection tests looking for ulcer relapses and reinfection in the eradicated group. The positive group consisted of 25 patients, with two patients considered non eradicable according to the treatment protocol. They were followed for an average period of 38,21 months.RESULTS: Relapse was detected in four patients (17,39%), half of them (8,69%) were reinfected. The negative group consisted of 26 patients, with a median follow-up of 38,28 months and eight (30,76%) relapses were detected. There was no statistical significant difference due probably to the high dropout of patients.CONCLUSION: Simple suture with H. pilori eradication is the gold standard for the positive group, leaving the question of acid-reducing procedures open for the negative ones.

RACIONAL: O tratamento cirúrgico da úlcera péptica perfurada é assunto discutível. Os cirurgiões, por muitos anos, fizeram suas opções entre procedimentos de redução ácida, somente fechamento da perfuração - porém com maior chance de recidiva ulcerosa. Desde a comprovada vinculação da úlcera péptica e suas complicações à infecção gastroduodenal causada pelo Helicobacter pylori, houve recomendação para mudança na atitude dos cirurgiões na volta à operação mais simples com erradicação da bactéria.OBJETIVO: Analisar a recidiva ulcerosa em pacientes com úlcera perfurada H. pylori positiva que foram submetidos à simples sutura da lesão e omentopexia com erradicação da bactéria e compará-la com H. pylori negativo submetido ao mesmo tratamento cirúrgico.MÉTODOS: Cento e quatorze pacientes com úlceras pré-pilóricas, pilóricas e duodenais perfuradas foram atendidos com fechamento simples. Trinta dias após a operação submeteram-se à endoscopia digestiva alta com biópsias para testes da urease e histopatológicos. Foram divididos em dois grupos de acordo com o resultado dos testes: positivo e negativo.Os positivos foram erradicados e, junto com o grupo negativo, foram seguidos com endoscopias semestrais e testes de detecção para H. pylori procurando por recidiva ulcerosa e reinfecção no grupo erradicado.RESULTADOS: O grupo positivo foi formado por 25 pacientes, dos quais dois foram considerados não erradicáveis segundo os critérios do protocolo. Os demais foram seguidos por período médio de 38,21 meses e detectadas recidivas em quatro pacientes (17,39%), metade deles (8,69%) foram reinfectados. O grupo negativo foi formado por 26 pacientes, seguido por período médio de 38,28 meses e oito (30,76%) apresentaram recidiva ulcerosa. Não foi evidenciada diferença estatisticamente significativa entre os grupos...

Perforated Peptic Ulcer Disease at Kenyatta National Hospital; Nairobi

Background: Published reports on perforated peptic ulcers indicate increasing rates for the elderly; those chronically ill and females. Our local observations are at variance. This study analysed patients treated for peptic ulcer perforations at the Kenyatta National Hospital between January 2005 and December 2006. Methods: Clinical charts for patients admitted and treated for perforated peptic ulcer disease were reviewed. Data sought included patient demographic data; clinical presentation; and time from onset of symptoms to treatment; operative findings and treatment mplications. The determinants of post-operative complications were evaluated using univariate analysis. Results: Forty four patients with perforated ulcers were admitted and treated over a two year study period. Twenty eight were analyzed (retrieval rate 63.6). Males (86.2) and those 35 years of age and younger (57.1) predominated. Alcohol; smoking and prior use of non steroidal anti inflammatory drugs were respectively documented in 39.3; 39.3and 10.7of patients. The complication rate was 25. Four patients died. The factors significantly related to complications was treatment delay (p=0.007) and acute perforation (0.027) Conclusion: Perforated peptic ulcer disease is a disease of young males. Efforts to reduce delay in presentation in this population may reduce the complications

Effect of Candida infection on outcome in patients with perforation peritonitis.

Perforation peritonitis is treated with surgery and antibiotics. This study was conducted to identify bacterial and fungal microorganisms responsible for peritonitis in patients with hollow viscus perforation and to examine the influence of these microorganisms on the outcome. A prospective study was conducted from May 2005 to September 2006 involving 84 consecutive patients with spontaneous gastrointestinal perforation peritonitis, who were referred for surgery. Peritoneal fluid was analyzed by microbial culture and biochemical tests for bacteria and fungi. The Jabalpur Prognostic Score was calculated. Forty-two of the 84 patients had positive peritoneal fluid cultures. Escherichia coli was the most common bacterium (n=26) and Candida (n=13) the most common fungus isolated. Bacterial isolates were largely sensitive to amikacin while all the Candida isolates were sensitive to fluconazole. Mortality was significantly higher in patients with positive peritoneal cultures (15/42) compared with those with negative peritoneal cultures (0/42, p<0.001), and in patients with mixed bacterial and fungal-positive cultures (10/13) compared with those with isolated bacterial cultures (5/29, p<0.001). Using the Jabalpur Prognostic Score, positive fungal cultures were found to be associated with a significantly higher than expected mortality. Patients with gastrointestinal perforations and positive peritoneal cultures have a poor prognosis, which is significantly worsened by the association of positive fungal cultures. Early recognition and treatment of fungal infection is advisable.

Abordaje laparoscópico de la úlcera duodenal perforada / Laparoscopic approach to the perforated gastroduodenal ulcer

Presentamos nuestra experiencia con el abordaje laparoscópico en 7 pacientes consecutivos con diagnóstico clínico de úlcera gastroduodenal perforada. En todos los casos se utilizó la técnica de cierre simple a puntos separados más parches de epiplón, con lavado y drenaje peritoneal. Se convirtieron dos pacientes a cirugía abierta debido a úlceras posteriores. En los cincos pacientes completados por laparoscopia se obtuvo un tiempo quirúrgico de hospitalización promedio de 80 minutos (45`- 120`) y 5 días respectivamente (3 a 8 días). La morbilidad fue de una paciente la cual presentó descarga purulenta a través del drenaje abdominal que se resolvió por esta vía junto con la administración de antibióticos orales. No hubo mortalidad en la serie. Estos resultados muestran que esta técnica representa un excelente abordaje para la úlcera duodenal perforada y debería ser el método estándar de tratamiento en estos casos

Validade da amilasemia e da lipasemia no diagnóstico diferencial entre pancreatite aguda/crônica agudizada e outras causas de dor abdominal aguda / Validity of serum amylase and lipase for the differential diagnosis between acute/acutized chronic pancreatitis and other causes of acute abdominal pain

RACIONAL: Várias doenças abdominais podem cursar com aumento de amilasemia e lipasemia. OBJETIVO: Avaliar a validade da amilasemia e lipasemia para os diagnósticos diferenciais entre pancreatite aguda/pancreatite crônica agudizada, doenças das vias biliares, úlcera gastroduodenal perfurada e apendicite aguda. PACIENTES E MÉTODOS: Foram avaliados, prospectivamente, 38 pacientes com pancreatite aguda/pancreatite crônica agudizada, 35 com doenças das vias biliares, 17 com úlcera gastroduodenal perfurada e 44 com apendicite aguda, com idade média (desvio padrão) de 42,4 ± 17,7, 46,7 ± 18,3, 47,8 ± 12 e 33,7 ± 17,8 anos, respectivamente. A amilasemia e a lipasemia foram determinadas à admissão no pronto-socorro. RESULTADOS: Para o diagnóstico de pancreatite aguda/pancreatite crônica agudizada, quando o nível de corte da amilasemia variou entre o limite superior de referência e 5 vezes este limite, a sensibilidade diminuiu de 92 por cento para 74 por cento, a especificidade aumentou de 85 por cento para 99 por cento, o valor preditivo positivo aumentou de 71 por cento para 97 por cento e o valor preditivo negativo diminuiu de 96 por cento para 91 por cento. Para a lipasemia valores semelhantes foram obtidos para sensibilidade e valor preditivo negativo, mas a especificidade e o valor preditivo positivo foram mais baixos. Quando se considerou amilasemia ou lipasemia elevadas, houve pequeno aumento na sensibilidade e no valor preditivo negativo. CONCLUSÕES: Para o diagnóstico de pancreatite aguda/pancreatite crônica agudizada, 1) o melhor nível de corte para ambos os testes foi o de duas vezes o limite superior de referência; 2) as sensibilidades da amilasemia e da lipasemia foram semelhantes; 3) a especificidade e o valor preditivo positivo da amilasemia foram ligeiramente maiores do que as da lipasemia; 4) a sensibilidade, mas não a especificidade, aumentou quando pelo menos uma das enzimas estava elevada.

Experience of peptic ulcer perforation over a decade in a teaching hospital of southern Bangladesh.

OBJECTIVE: To determine disease characteristics, check the treatment status and compare outcome with other series. DESIGN AND SETTING: A retrospective study in a single unit of the Department of Surgery of Khulna Medical College Hospital, south west Bangladesh. PATIENTS AND METHODS: After diagnosis by clinical and radiological examination, 491 patients were treated during the period July 1992 to November 2002. Two options of treatment were carried out: simple closure and peritoneal lavage in 364 cases, and 127 patients managed by non-surgical methods. Main outcome measures: mortality and morbidities. RESULTS: Male:female ratio was 445:46, average age 43 years. Mortality in the surgical group was 6.8% and in the non-surgical group 0.02%. CONCLUSION: Perforated peptic ulcer is prevalent even after the wide use of H2 receptor antagonists. Strict case selection for surgical and non-surgical treatment has reduced mortality. These results support the case for non-operative treatment and for conservative surgery.

Cervical Epidural Abscess Secondary to Aorto-Duodenal Fistula: A Case Report

Although cervical epidural abscess is rare, it should be strongly suspected in any patient with unexplainable neck pain and fever, especially when the patient has a predisposing factor for this infectious process. The authors report a case of cervical epidural abscess in a 39-yr-old man with an aorto-duodenal fistula, which complicated the interposition of artificial graft for abdominal aortic aneurysm rupture, which had undertaken 40 months before. Timely detection and intervention rendered him a full neurological recovery. This extremely rare case is presented with a literature review.

Ulcera gastrica perfurada: doenca em ascensao em UTI neonatais? Particularidades neste periodo e relato de quatro casos / Perforated gastric ulcer: an ascending pathology in neonatal ICU?

A doenca peptica e pouco valorizada no periodo neonatal. Seu diagnostico e tratamento sao postergados ate que o neonatologista esteja frente a graves complicacoes, como perfuracao, hemorragia grave e morte. Este relato visa alertar sobre a presenca desta doenca no recem-nascido internado em UTI, salientando os possiveis fatores de risco para seu desenvolvimento e demonstrar sua importancia na etiologia das perfuracoes gastrointestinais deste periodo

Helicobacter pylori infection in patients with perforated duodenal ulcer.

AIM: Perforation is the commonest complication of duodenal ulcer. Helicobacter pylori is found in 95% patients with duodenal ulcer. However, there is paucity of reports on prevalence of H. pylori infection in patients with duodenal ulcer perforation. We, therefore compared the incidence of H. pylori infection in patients with duodenal ulcer perforation with the incidence in patients having complicated duodenal ulcers and non-ulcer dyspepsia. PATIENTS AND METHODS: The study was conducted on 45 patients (complicated duodenal ulcer 15, duodenal ulcer perforation 15, non-ulcer dyspepsia 15). Per-operative punch antral biopsies were taken in patients with duodenal ulcer perforation whereas endoscopic punch biopsies of antrum were taken in patients with non-ulcer dyspepsia. The criteria for H. pylori positivity was i) growth of H. pylori on culture, ii) combination of rapid urease test (RUT) and Giemsa staining, combination of RUT and Gram stain being positive for H. pylori. RESULTS: While 9 of 15 cases with complicated duodenal ulcer, 7 of 15 cases with non-ulcer dyspepsia were positive for H. pylori, none of the patients with duodenal ulcer perforation tested positive for H. pylori (p < 0.000). All patients with perforated duodenal ulcer had histological gastritis (H. pylori -ve). Fourteen of 15 patients (9 H. pylori +ve, 5 H. pylori -ve) with complicated duodenal ulcer and 9 of 15 patients (7 H. pylori +ve) with non-ulcer dyspepsia had histological gastritis. CONCLUSION: Patients with duodenal ulcer perforation do not have H. pylori infection. H. pylori negative patients of duodenal ulcer may have more predilection for perforation.

Incidencia y epidemiología de la ulcera péptica gastroduodenal perforada en el Hospital Regional Honorio Delgado de Arequipa (1960-1995)

La úlcera péptica gastroduodenal perforada es la segunda complicación ulcerosa más frecuente y la más grave, así como es la segunda gran causa de peritonitis difusa, luego de las de origen apendicular , es una complicación que predomina en el sexo masculino y que generalmente se agrupa en la tercera, cuarta y quinta décadas de la vida, y llega a ser una complicación excepcional en los extremos de la vida, el dolor constituye el síntoma principal acompañado de náuseas, vómito, defensa muscular, ausencia de matidez hepática y otros síntomas y signos menos frecuentes; el tratamiento es de emergencia y es quirúrgico. Se han encontrado 1878 pacientes que presentan úlcera péptica gastroduodenal en el Hospital Regional Honorio Delgado de Arequipa entre 1960 y 1995, encontrándose 40 pacientes que presentaron la patología de estudio, el cual representa una incidencia del 2 por ciento, con un 80 por ciento en sexo masculino y un 20 por ciento en el sexo femenino, predominando la úlcera perforada gástrica sobre la duodenal, presentando en la totalidad de los casos el dolor como signo característico. Se pudo observar que un 87 por ciento de los pacientes procedían de condiciones económicas de regular a baja y un 45 por ciento de los pacientes tenían gran predilección por el alcohol. Es importante también mencionar que se encontró una tasa de mortalidad de un 10 por ciento de los pacientes con predominancia en la mujeres.

Riscos em cirurgia gastroduodenal de emergência e urgência: morbidade e mortalidade: análise de 76 casos / Risk in emergencie gastroduodenal surgery: morbidadity and mortality: analisis of 76 cases

O autor apresenta 76 casos onde o risco cirúrgico é aumentado devido à urgência e emergência, como também às alteraçöes fisiopatológicas que daí decorrem. A mortalidade e morbidade säo elevadas nestes casos.

Perfuraçäo aguda de úlcera péptica / Acute perforation of peptic ulcer

A perfuraçäo é complicaçäo grave da úlcera péptica e continua freqüente, apesar dos avanços na terapêutica medicamentosa da doença péptica näo complicada. O quadro clínico, geralmente, é bem característico, com presença de peritonite e abdome em "tábua" e de pneumoperitônio. A estratificaçäo dos pacientes, baseada em critérios clínicos bem definidos, é importante para a seleçäo do tipo de tratamento. Os autores enfatizam a preferência pela cirurgia definitiva, visando a cura da doença péptica, sobre o fechamento da úlcera perfurada, desde que näo traga risco apreciável

Ulcera gastroduodenal perforada: procedimiento video-endoscópico / Perforated gastroduodenal ulcer: videolaparoscopic technique

El resultado del tratamiento de la úlcera gastroduodenal perforada mediante la aplicación del procedimiento videoendoscópico en 11 casos, fue sorprendentemente satisfactorio. El diagnóstico preoperatorio fue claro en 9 pacientes; en los dos restantes fue presuntivo de apendicitis aguda y colecistitis aguda. Se aplicó la técnica laparoscópica realizándose diagnóstico de úlcera perforada en cavidad libre en 10 casos y úlcera perforada y bloqueada en 1 paciente. En esta serie 10 pacientes presentaron úlcera duodenal perforada; el restante se trataba de una úlcera gástrica perforada. Todos presentaban peritonitis difusa generalizada. El tratamiento fue cierre simple con epiploplastia y lavado exhaustivo de toda la cavidad, drenándose la cavidad peritoneal en ocho de los once pacientes; no se colocaron puntos de sutura en la úlcera bloqueada. Todos los pacientes recibieron una asociación de cefalosporinas y aminoglucósidos, aspiración con SNG y la administración de bloqueantes H2. Todos los pacientes fueron operados sin conversiones y sin morbilidad ni mortalidad, que demostró ser válida la aplicación del procedimiento video-endoscópico en la úlcera gastroduodenal perforada

Manejo quirúrgico de urgencia en la úlcera gastroduodenal complicada / Urgent surgical treatment for complicated gastroduodenal ulcer

Objetivo: Conocer la incidencia de las complicaciones de la úlcera péptica y su tratamiento quirúrgico de urgencia. Diseño: Estudio retrospectivo, longitudinal observacional, de enero de 1990 a diciembre de 1992. Sede: Servicio de Cirugía General, del Hospital Juárez de México, D.F. Pacientes: Se analizaron 39 casos (0.13 por ciento) de un total de 28 800 ingresos, 27 masculinos y 12 femeninos, con edades entre 21 a 78 años (promedio 52.2 años). Resultados: Con antecedentes de etilismo y tabaquismo crónico 24 (61.5 por ciento), ingesta de antiinflamatorios tipo AINE siete (17.5 por ciento), hemorragia masiva cinco (12.8 por ciento) y perforación 34 (87.2 por ciento). Los síntomas mas importantes fueron dolor (61 por ciento) y sangrado masivo en 12.8 por ciento manifestado como hematemesis o melena. La endoscopia se realizó en seis pacientes, confirmando el diagnóstico clínico de perforación en un caso y hemorragia en cinco, placa simple de abdomen y telerradiografía de tórax se llevaron a cabo en 39 casos, las cuales fueron determinantes para apoyar el diagnóstico en el 76.9 por ciento de perforación libre. A 31 casos con perforación (79 por ciento) se les realizó como tratamiento quirúrgico parche de Graham, en dos casos vagotomía y piloroplastía y en uno gastrectomía. En dos casos con hemorragia masiva se practicó como tratamiento ulcerorrafia, a dos gastrectomía y a uno vagotomía, piloroplastia y ulcerorrafia. Fallecieron dos pacientes (5.1 por ciento) por hemorragia recidivante. Conclusión: La perforación es la complicación más frecuente de la úlcera péptica (87.2 por ciento). Su tratamiento quirúrgico de urgencia (parche de Graham) es fundamentalmente para preservarla vida del paciente dejando el tratamiento definitivo para casos muy seleccionados