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PubMed2002

Spontaneous free perforation of the small intestine in Crohn's disease.

Spontaneous free perforation of the small intestine is a rare but often dramatic event in the clinical course of Crohn's disease. Fifteen new cases of spontaneous free perforation of the small intestine--nine female patients and six male patients--were discovered in a series of 1000 consecutively evaluated patients with Crohn's disease seen during a period spanning 20 years, for an estimated frequency of 1.5%. Spontaneous free perforation was the presenting clinical feature of Crohn's disease in nine (60%) of the newly discovered cases. Most perforations were located in the ileum rather than in the jejunum, and there were no duodenal free perforations. One patient with extensive intestinal disease presented with concomitant free perforations of the jejunum and ileum, while a second patient had two free ileal perforations that developed independently, separated by about six years. No perforations were the result of a superimposed malignant process, ie, adenocarcinoma or lymphoma. There have been no mortalities, and the subsequent clinical course of these patients has been limited to a minority requiring corticosteroid or immunosuppressive medications, or further surgical resections.

Adolescent↗
PubMed1988

Emergency laparotomy for spontaneous intestinal and colonic perforations in cancer patients receiving corticosteroids and chemotherapy.

Thirty patients with lymphoma (12), leukemia (two), myeloma (one), or metastatic solid tumors (15) were explored for 31 episodes of spontaneous intestinal perforation during an 11-year period at Memorial Sloan-Kettering Cancer Center. Twenty-three patients (76.6%) were receiving corticosteroids alone or in combination with chemotherapy and seven patients (23.4%) were receiving chemotherapy alone at the time of perforation. Fourteen perforations (45%) occurred in the small intestine and 17 perforations (55%) occurred in the colon. Malignancy was histologically demonstrated at the site of perforation in 16 patients (52%). Twenty major postoperative complications occurred in 15 patients (50%) and the operative mortality rate was 53%. Factors such as age, sex, duration or type of symptoms, site of perforation, malignancy at the site of perforation, peripheral leukocyte count, and serum albumin and total protein levels were not significantly related to patient survival. Early diagnosis and aggressive surgical intervention is essential to improve survival following intestinal perforation in this high-risk population.

Adrenal Cortex Hormones↗
PubMed1989

The value of CT in detecting bowel perforation in children after blunt abdominal trauma.

In this era of conservative management for most infants and children with blunt abdominal trauma, there is a concern that the diagnosis of bowel perforation may be missed or delayed. To determine the sensitivity of CT in the detection of perforated viscus in this population, we reviewed the CT examinations of 547 consecutive children who had had blunt abdominal trauma. Of six patients (1%) with documented bowel perforation, four (67%) had free intraperitoneal air detected preoperatively by CT. The remaining two cases had secondary signs of bowel thickening and unexplained peritoneal fluid. Free intraperitoneal air was not a specific indicator for bowel perforation. Of nine patients in whom CT studies showed pneumoperitoneum, only four (44%) had a ruptured bowel. The remaining five patients had pneumoperitoneum from sources other than bowel perforation including pneumomediastinum, bladder perforation, and previous peritoneal lavage. This experience shows that the CT finding of pneumoperitoneum is useful, although not specific for the detection of bowel perforation in children with blunt abdominal trauma. When free air is not present, secondary signs of bowel wall thickening and unexplained peritoneal fluid suggest a bowel perforation.

Abdominal Injuries↗
PubMed1993

Esophageal perforation: CT findings.

OBJECTIVE: Esophageal perforation is a life-threatening condition that can be quickly diagnosed on the basis of findings on contrast esophagograms when the typical signs and symptoms of vomiting, chest pain, and subcutaneous emphysema occur. If the clinical features are atypical, CT may be performed early in the clinical course. Thus, recognition of the CT findings of esophageal perforation is important. MATERIALS AND METHODS: We reviewed the CT scans of 12 patients with esophageal perforation. The site of perforation was the cervical esophagus in three and the thoracic esophagus in nine. The causes of the perforations were neoplastic (four patients), idiopathic (three patients), iatrogenic (three patients), and traumatic (two patients). RESULTS: CT abnormalities included esophageal thickening in nine patients, periesophageal fluid in 11 patients, extraluminal air in 11, and pleural effusion in nine. The site of the perforation was visible on the CT scan in two patients. In four patients (33%), CT findings were the first indication of esophageal perforation. CONCLUSION: For patients who have atypical signs and symptoms, CT scans optimally define the extraluminal manifestations of esophageal perforation. Extraesophageal air is the most useful finding. The CT findings may be the first indication of the diagnosis.

Adolescent↗
PubMed2004

[Iatrogenic perforations of the esophagus and hypopharynx--5 year experience at the Center for Esophageal Surgery].

Iatrogenic perforations of the esophagus and hypopharynx are important problem, due to diagnostic difficulties, controversies about adequate treatment, and high morbidity and mortality rate. Incidence of iatrogenic perforations is from 50 to 75% of all perforations. In the period from April 1999. to April 2004, 15 patients with iatrogenic perforation of the esophagus and hypopharynx were treated at the Department of esophageal surgery, First University Surgical Hospital in Belgrade. In majority of patients iatrogenic perforation occured during endoscopic interventional procedure (endoscopic removal of ingested foreign body--10 pts, endotracheal intubation--2 pts, intraoperative iatrogenic perforation--2 pts, pneumatic dilatation--1 pt). Surgical treatment was performed in 12 (80%) pts and 3 (20%) pts were treated conservatively. Surgical approach was cervicoabdominal, thoracoabdominal and cervicothoracoabdominal in 9.1 and 2 pts, respectively. Among 12 operated pts, primary repair of the esophagus was performed in 5 pts, and esophageal resection or exclusion in 7 pts. Overall mortality rate was 13.3% (2 pts), in surgical group 8.3% (1 pt) and in conservatively treated group 33.3% (1 pt). Iatrogenic perforations of the esophagus and hypopharynx are diagnostic and therapeutic problem. Awareness of the possibility of esophageal perforation during instrumental manipulations and early diagnosis is essential for successful, individually adapted, and in most cases surgical, treatment.

Adult↗
PubMed2004

[Endoscopic perforations of colon and rectum].

Although fiberoptic examination of the colon is nowdays considered to be safe procedure, endoscopic perforation remains rare, but serious and potentially life threatening complication. General incidence od diagnostic and interventional perforations of colon ranges, according to the literature between 0.1-0.9%, or for diagnostic procedure about 0.17%, and for interventional 0.41%, with general mortality rate of 0.006%. In spite of the general trend for diminishing this occdurence, it is necessary to compare various experiences in order to achieve an algorrhithm of early diagnostic and the way of the surgical management of this particular kind of perforation. The aim of this work is to present the experience in 1995-2004 period, upon 7 (0.12%) cases of surgically treated perforations of colon after 5,680 performed diagnostic colonoscopies. In all 7 cases the reason for perforation was not basically pathologiocal process. 4 cases of perforations were recognized immediately, and they were managed by direct suture of the perforation. In 3 cases diagnosis was late from 1 to 3 days, and two-step operative procedure was performed in septic condition. Subjective and clinical signs of perforations were not always unifrom, but in all 7 cases there were clear X-ray signs of free intraabdominal air. Surgical treatment was successfull, and without deaths. In the algorrhithm of surgical diagnostic and procedure, the same principles and criteria used for civilian injuries of colon are to be used.

Aged↗
PubMed2006

First myringotomy with insertion of a modified Goode T-Tube: changing the perforation paradigm.

BACKGROUND: Goode T-Tubes (Medtronic Xomed, Inc) have a bad reputation because of their residual tympanic perforation rate. However, these long-term tubes are mostly used in patients with chronic middle ear problems. On the other hand, "safer," short-term tubes may need to be reinserted in up to 20% of children. OBJECTIVE: To demonstrate that modified Goode T-Tubes inserted at the first myringotomy in normal children leave a perforation rate comparable to the rate reported in the literature for short-term tubes and may be extracted safely in the outpatient clinic when eustachian tube function is thought to be adequate. METHOD: This prospective study followed 58 children (100 ears) who had their modified Goode T-Tubes electively removed in the clinic, from October 2003 to November 2004. RESULTS: We found only one persistent perforation at the third follow-up (mean time 5.2 months). The tubes had been in place for an average of 2.9 years. The perforation healing rate was inversely related to intubation duration. Adenotonsillectomy seemed to favourably influence the speed of healing. The perforations healed faster when tubes were inserted for chronic middle ear effusion compared with recurrent acute otitis media. Age, gender, and the site of intubation were not related to persistent perforation. All of the tubes spontaneously extruded (13) healed without perforation. CONCLUSION: Modified Goode T-Tubes inserted at the first myringotomy and electively extracted allow for a longer middle ear ventilation period and have a perforation rate comparable to that of short-term tubes.

Child, Preschool↗
PubMed1995

Epidermal growth factor and basic fibroblast growth factor are induced in guinea-pig tympanic membrane following traumatic perforation.

Epidermal growth factor (EGF) and basic fibroblast growth factor (bFGF or FGF-2) have been shown to enhance the healing of traumatic tympanic membrane (TM) perforations. The action of EGF and bFGF in the TM repair process remains unknown. This study was designed to determine the expression of EGF and bFGF in normal and injured TM by immunohistochemistry. EGF was detected in normal TM mainly in the annulus tympani area. After a perforation in the TM posterior/superior quadrant, EGF was detected around the perforated area in polynuclear cells, in pericytes and in basal epithelial cells. EGF was also detected in the antero/superior quadrant in basal epithelial cells and pericytes. The peak of EGF detection was observed 3 days after the perforation. bFGF was not detected in normal TM, but it was expressed 3 days after a traumatic perforation mainly in the perforated area in pericytes and in polynuclear cells. This study suggests that EGF and bFGF are involved in the control of TM acute perforation repair. These findings help to explain the accelerated healing of TM perforations that are seen after application of FGF or EGF, and suggest that antibodies against these growth factors would retard the healing process.

Animals↗
PubMed1997

Peptic ulcer perforation before and after the introduction of H2-receptor blockers and proton pump inhibitors.

BACKGROUND: The aim of this retrospective study was to compare patients treated for perforated peptic ulcer before and after the introduction of the H2-receptor antagonists and proton pump inhibitors (PPI) with regard to their medical history, clinical features, methods of diagnosis and treatment, complications, and mortality. METHODS AND RESULTS: During the study period 1974 to 1992 we found a significant reduction in the incidence of peptic ulcer perforation (P < 0.001). Patients admitted during the later period of the study were older and more seriously ill. The incidence of perforation among men decreased, but that among women was stable, thus changing the sex ratio towards a female preponderance at the end of the study period. After the introduction of PPI the relative number of gastric perforations decreased compared with the number of perforations in the duodenum. A relatively higher proportion of patients with gastric perforations was taking acetylsalicylic acid or non-steroid, anti-inflammatory drugs at the time of admission compared with patients with duodenal perforation. Simple suture of the perforation was the operative procedure used in 80% of the patients. CONCLUSIONS: Even though patients were increasingly older and more ill, neither the mortality nor the rate of postoperative complications changed during the study period.

Age Factors↗
PubMed1999

Wound management in perforated appendicitis.

Open wound management after perforated appendicitis was common practice but, recently, primary closure has been advocated to reduce costs and morbidity. Hospital records from 319 adults who underwent appendectomy from 1993 to 1996 were reviewed to identify surgical wound infections (SWIs) and examine risk factors. Information about age, length of stay (LOS), operative time, white blood cell count, and antibiotic administration were obtained. Perforation was either noted at operation or identified microscopically by the pathologist. If primary wound closure was performed, patients with acute appendicitis and perforation had a 4-fold higher readmission rate, a 5-fold increase in SWI, and twice the LOS compared with patients with acute appendicitis without perforation. Patients with grossly perforated acute appendicitis had no difference in LOS if the wound was treated open or closed primarily. No patient with microscopic perforation and primary wound closure developed SWI. Primary wound closure after acute appendicitis was safe in the absence of clinical perforation. In the presence of clinical appendiceal perforation the wound should be left open.

Acute Disease↗
PubMed1999

[The single-stage surgery of perforated colon carcinoma. Our experience of 46 cases].

BACKGROUND: 46 cases of perforated colonic neoplasm (4.6% of the entire series): 11 (24%) of the right colon, 35 (76%) of the left colon; 19 males (41%) and 27 females (59%); mean age 67 years old, range 32-92 years. pTNM: stage II, 1 case (2%); stage III: 27 cases (59%); stage IV, 18 cases (39%). The aim of this study was to resolve the perforation and to treat the neoplasm in a single operation. METHODS: The various types of perforation included: 35/46 = 76% perforations in situ; 6/47 = 13% recent perforations upstream; and 5/46 = 11% at a distance from the neoplasia. The following types of peritonitis were observed: purulent localised 10/46 = 22%, purulent generalised 12/46 = 26%, fecaloid 18/46 = 39%, fecal 6/46 = 13%. In 24 cases/46 = 52% the perforation had occurred in an occluded colon. The preoperative finding of pneumoperitoneum in 12/46 = 26% indicated generalised fecaloid-fecal peritonitis. Surgery commenced by suturing the perforation followed wherever possible by standard colectomy: on the right in all 11 cases = 100%, on the left in 15/35 = 43%; only in the event of prohibitive local or in particular general conditions was Hartmann's segmentary colectomy used in 10 cases/35 = 29%, or a definitive preternatural anus in 10/35 = 29%. The following aspects are essential in this single-stage surgery: the emergency nature of the operation; massive dose antibiotic treatment limited to the pre- and perioperative stages and above all peritoneal cleansing using accurate, methodical, repeated and abundant lavage with 8-10-20 or more litres of polysaline isotonic solution at 37 degrees C, but only used 500 ml at a time. This lavage is essential to reduce bacterial load contributes to the rapid hydroelectrolytic re-equilibrium in severe conditions of peritonitis. When necessary, colonic preparation was carried out using direct colostomic perioperative lavage. The peritonisation of the retroperitoneum with the omentum is important, as is the protection of the anastomosis using omental wrapping and active lavage and aspiration of the colorectal anastomosis, even using the 3-way tube, in a transanal trans- or subanastomotic position. Total parenteral feeding is useful and almost indispensable for 6-8 days. RESULTS: Postoperative morbidity was negligible and mortality occurred in 14/46 cases = 30%, of whom 13/32 = 41% were over 60 and 1/14 = 7% under 60; if the cases are divided into two periods, pre-Gullino tube (1974-84) mortality was 8/22 = 36% and with Gullino's tube (1985-95) it was 6/24 = 25%; postoperative stay was 18 days in the first period and only 11 days in the second. The 11 cases at stage IV who survived the operation all died following the spread of neoplasms within 2-30 months, mean 10 months; the over-5-year survival rate for the only case at stage II and the 19 at stage III was 38% (Kaplan-Meier). CONCLUSIONS: By using this courageous single-stage surgery and operating patients at such a severe stage, both the immediate and long-term results appear to be more than satisfactory. It is important to underline, however, that not all neoplastic perforations appeared to be caused by endoluminal hypertension-ischemia; in those cases with non-occluded colon, about half might have been the consequence of biological problems of immune hyperreactivity of a rejection reaction type (Arthus, Snarelli-Shwartzman phenomenon and similar).

Adult↗
PubMed1999

[Perioperative mortality for perforated duodenal and gastric ulcer--analysis of 226 patients].

Between 1988 and 1997 in 226 patients (169 males--75.2% and 57 females--24.8%) surgical treatment was performed due to duodenal ulcer perforation (205 cases--90.7%) or gastric ulcer perforation (21 cases--9.3%, including 3 cases of perforated gastric cancer). Mean age was 51.5 years (19-94 years). In perforated duodenal ulcer the main procedure was truncal vagotomy with pyloroplasty performed in 95.6%, and simple ulcer suture in 4.4%. In perforated gastric ulcer the main procedure was Billroth I (Rydygier) stomach resection performed in 76.18%, and simple ulcer suture in 23.82%. A group of patients who died in perioperative period (29 cases--12.8%) was selected and compared to a group of others regarding age, sex, smoking, alcohol abuse, time elapsing between first symptoms and surgical treatment, use of NSAIDs, location and size of perforation hole, type of surgical procedures. On that basis 4 risk factors of disease in perioperative period due to perforated ulcer surgery were appointed: 1. Age--mean age of patients who died was 67 years (vs. 48.9 years among successfully treated), perioperative mortality in patients over 60 years old was 35.4%, and in patients over 70 years old was 50%). 2. Presence of three or more coexisting diseases--54.54% risk of disease (vs. 2.5% in patients with less than three or without coexisting diseases). 3. Delay in surgical treatment over 24 hours--48.15% of diseases vs. 7.04% in patients undergoing surgery within the first 24 hours following perforation. 4. Septic shock--80% of diseases.

Aged↗
PubMed1999

Computed tomography scanning for the diagnosis of perforated appendicitis.

The optimal initial treatment for perforated appendicitis may be nonoperative. For this reason it is important to be able to reliably distinguish between acute and perforated appendicitis. CT scanning has been shown to be highly accurate for the diagnosis of appendicitis, but it has not been specifically evaluated for perforated appendicitis. Our objective was to evaluate CT for the diagnosis of perforated appendicitis. Our study population comprised 84 patients who underwent appendectomy between 1993 and 1997 and who had CT scanning performed preoperatively. Medical records were reviewed retrospectively. CT scans were reviewed in a blinded fashion. CT findings were correlated with pathologic and clinical factors. Sixteen patients with acute appendicitis, 59 patients with gangrenous or perforated appendicitis, and 9 patients with normal appendices or other diagnoses were evaluated. For patients with pathologic documentation of appendicitis, CT findings that independently predict perforation or gangrene included abscess (P<0.001), phlegmon (P<0.001), extraluminal gas (P = 0.01), and terminal ileal wall thickening (P = 0.03). CT findings of an abscess, extraluminal gas, or phlegmon have a sensitivity of 92 per cent, specificity of 88 per cent, positive predictive value of 96 per cent, and negative predictive value of 74 per cent for perforated or gangrenous appendicitis. We conclude that CT can reliably distinguish between acute and perforated appendicitis.

Acute Disease↗
PubMed2002

A new perspective in appendicitis: calculation of half time (T(1/2)) for perforation.

Appendicitis is generally a more serious disease in the elderly than in the young. In the former, perforation is seen commonly leading to the belief that the appendix perforates more readily and rapidly in the elderly. A competing view is that the appendix perforates relatively more frequently in the elderly than in the young. To distinguish between these two views we analyzed 126 cases of acute appendicitis stratified by age group. The time between onset of symptoms and perforation was calculated with a novel method that utilized the biological concept of T(1/2) for perforation. Our findings suggest that the rate of perforation in the elderly is not significantly different from that in the young but the frequency of perforation is higher in the elderly. We concluded that appendicitis carries a graver prognosis in the elderly because the frequency of appendiceal perforation is higher in the elderly.

Acute Disease↗
PubMed2003

Free perforation in Crohn's disease.

BACKGROUND: Free bowel perforation is one of the indications for emergency surgery in Crohn's disease. It is generally accepted that 1-3% of patients with Crohn's disease will present with a free perforation initially or eventually in their disease course. OBJECTIVES: To evaluate the incidence and treatment results of free perforation in patients with Crohn's disease and, based on our experience, to suggest recommendations. METHODS: Between 1987 and 1996, 160 patients with Crohn's disease were treated in our department and were followed for a mean period of 5 years. RESULTS: Of the 83 patients (52%) requiring surgical intervention, 13 (15.6%) were operated due to free perforation. The mean age of the perforated CD was 33 +/- 12 years and the mean duration of symptoms prior to surgery was 6 years. The location of the free perforation was the terminal ileum in 10 patients, the mid-ileum in 2 patients, and the left colon in 1 patient. Surgical treatment included 10 ileocecectomies, 2 segmental resections of small bowel, and resection of left colon with transverse colostomy and mucus fistula in one patient. There was no operative mortality. Postoperative hospital stay was 21 +/- 12 days (range 8-55 days). All patients were followed for 10-120 months (mean 58.0 +/- 36.7). Six patients (42%) required a second operation during the follow-up period. CONCLUSION: The incidence of free perforation in Crohn's disease in our experience was 15.6%. We raise the question whether surgery should be offered earlier to Crohn's disease patients in order to lower the incidence of free perforation.

Adolescent↗
PubMedDate not supplied

[Late intestinal perforations after alloplastic repair of postoperative eventrations].

Late intestinal perforation is the most rare and the most serious complication following the repair of abdominal parietal defects with alloplastic material. The authors have gathered in 7 years 6 cases of perforations which occurred between 1 and 10 years after using nonabsorbable synthetic mesh prostheses made of polyester (4 cases) and polypropylene (2 cases) as parietal substitution materials. The perforations were discovered either by the appearance of complete enteric fistulas after exploration of circumscribed parietal suppurations (3 cases) or during surgery of suppurations without external fistulas. All cases involved perforations of the small intestine and in only one case there was also a perforation of the transverse colon. In 4 cases, where eventration relapse co-existed, the polyester prostheses were found partially or totally detached from the abdominal wall. The treatment of enteric perforation consisted of 5 segmental enterectomies (one of those a double one) followed by anastomoses and one enteroraphy. The colic perforation was excised and sutured. The mesh was totally removed in 5 cases and partially removed in 1 case (around the perforation). The postoperative evolution was simple in only 3 cases. In the other 3 cases anastomotic fistulas occurred and one of them (with reduced leakage) was treated by nonoperative management. It did not close spontaneously even after 12 months. The other 2 cases required multiple reinterventions (enterectomies, ileostomies, ileocoloanastomosis). One of these patients has been lost away after 200 days of hospitalization and multiple reinterventions. In all cases, the closure of the abdominal wall was simplificad by cutaneous suture only whereas consecutive relapsed eventrations remain to be treated by subsequent reinterventions.

Hernia, Ventral↗
PubMedDate not supplied

Typhoid enteric perforation in north western Nigeria.

BACKGROUND: Typhoid perforation is the most important surgical complication of typhoid enteritis and is associated with high morbidity and mortality. AIMS AND OBJECTIVES: To determine the pattern and outcome of management of typhoid perforation in Aminu Kano University Teaching Hospital, Kano. METHOD: A retrospective Analysis of patients treated for typhoid perforation over a 6-year period. RESULTS: There were 47 patients: 35 males and 12 females, ratio 2.9 to 1. The patients were aged 4 years to 58 years (mean 18.9 years). Typhoid perforation occurred all the year round with a peak prevalence in September; Six (12.8%) patients perforated in the first week, 29 (61.7%) second week, and 12 (25.5%) third week, of illness. Single perforation was found in 91.5% of cases, and two to three perforations in 8.5%. Surgical treatment was by simple closure in 72.3%, wedge resection in 8.5%, ileal resection in 17.1% and right hemi-colectomy in 2.1%. Of the 41 survivors (87.2%), wound infection was the most common postoperative complication in 44.7% of cases. The mortality rate was 12.8% mostly due to overwhelming sepsis. CONCLUSION: Typhoid perforation requiring surgical intervention is still endemic in our subregion, and emphasis should be on preventive measures such as safe drinking water and appropriate sewage disposal, and typhoid vaccination.

Adolescent↗
PubMed2005

[Perforated stomach and duodenal ulcers at St Jósef's Hospital in Reykjavík up to 1948. 1950].

The St. Josephs Hospital in Reykjavík opened on the 1st of Sept. 1902. Until 1930 it was the main hospital of South Iceland. During the first 21 year period or until October 22nd 1923, not a single case of perforated peptic uncer seems to have been diagnosed nor treated in this hospital nor in any other hospital in the country. Neither is there any death from perforated pept. ulcer reported in the public health register of this period with only one exception in the year 1912. During the following 25 year period (1923-1948) 27 cases of an acute perforation and 8 cases of a subacute perforations (perf. larvata) of peptic ulcerations were admitted to and operated on in the St. Josephs Hospital and further 8 cases were given surgical treatment (reoperation) for the sequelae of an acute perforations that primarily had been operated on in other hospitals. There is thus a total of 42 cases as one of them is counted twice (in group 1 and 3).--In the first group there were two women, in the second group one woman and in the third group none.--The relation between the sexes thus being 39:3 for all three groups. Ulcers of the duodenum and pylorus were prevalent in all 3 groups (being 35 cases against 7 gastric ulcers). Two cases had perforated twice and 3 had perforated in the hospital. The treatment was surgical in all cases.--A simple closure of the ulcerperforation was made in 26 cases of the first group, but in one case a costal resection was done and no laparotomy. The immediate operative fatalities amongst those who underwent a laparotomy were 2 i. e. 7, 8 percent (or 7, 4 percent amongst all 27 cases). Eleven of the remaining 25 cases had to be reoperated on later because of the same disease or its complications (with one immediate fatality). Two more of them are dead, one from cancer of the stomach 5 years later (39 years old) and the other from a recurrent intestinal obstruction, the others (9) are still alive (1949) and are enjoying good health. Of the 14 not operated, 9 had a good or a fairly good result from the primary operation, 2 had a bad result and 2 have succumbed late on, one fram apoplexia, the other from an accident.--On couldn't be traced (foreigner). In the 2nd and 3rd group a G. E. anast. was done en 12 cases, an excision of the ulcer and G. E. anast., a gastrectomy and an exploratory laparatomy in one case each. In 14 cases the result has been good, bad in one case, they are all alive, with one exception, who died from cancer of the stomach five years later, at the age of 28. Approximately some 100 cases of an acute perforation of peptic ulceration are known to have had surgical treatment in all the hospitals of Iceland during this 25 year period (1923-1948). The immediate operative mortality as far as the author could trace amongst 87 of the cases does not seem to exceed 13 percent.

Duodenal Ulcer↗