[Hemorrhagic duodenal ulcer: which procedure should be performed?].

The authors reviewed the emergency treatment of 64 duodenal ulcers operated during the haemorrhagic period in order to evaluate the results of an approach adapted to the site of the ulcer and to the lesions observed. Twenty-four ulcers were situated in the post-bulbar region (37.5%) and need to be considered separately as their anatomical situation and the frequently callous and burrowing nature raise difficult problems in the diagnosis and surgical approach. Conservative treatment (vagotomy, pyloroplasty, direct suture) was possible in 75% of cases. Sixteen gastrectomies (25%) were necessary because of the severity of the duodenal disease with a significantly higher rate in the case of post-bulbar ulcers. The overall postoperative mortality was 25%; it was due to a surgical cause in one half of cases. The surgical morbidity was dominated by recurrent haemorrhages (11%) with 85% mortality. The authors believe that suture vagotomy, which is the basic treatment for bulbar ulcers, also constitutes treatment of choice in the post-bulbar variety when the duodenum appears to be suturable after haemostasis. In the opposite case, duodenal resection is necessary and should extend beyond the ulcer crater. In every case, identification of the common bile duct and the papilla constitutes an essential precaution.