duodenal ulcer perforation is still a common complication of chronic peptic ulcer disease . despite the wide spread use of anti - secretory and h. pylori eradication therapy
most of the literature pertaining to the situation in the developed world , showed that the disease is largely confined to the elderly patients taking ulcerogenic medications.[15 ] the situation in the developed nations is summed up by johnson :  the surgeon s major role in the management of peptic ulcer disease will be the performance of life - saving emergency operations in the elderly unfit patient .  in contrast to the developing world , the patients are younger and have a long life - time of potentially useful activity ahead of them[18 ] as anti - secretory and anti - h .
pylori eradication drugs are been freely used , we had expected an improvement in this disease condition .
hence , we set out in this review to look at the prevalence , pattern of presentation , risk factors and management outcome in the study environment and we also set out to look at the management pattern if sufficient for a semi - urban area in a developing world .
this review was conducted at the federal medical centre ido - ekiti , southwest nigeria .
the case records of all patients with clinically established diagnosis of pdus , managed in this center from january 2004 to december 2011 were reviewed .
the diagnostic protocol for every patient at presentation included : the clinical findings , abdominal ultrasound , and chest x - rays which in some cases gave further credence to the diagnosis .
full blood count , urea and electrolytes , creatinine , and urinalysis results were documented .
the patients were optimized for surgery with intravenous fluids , antibiotics , and urethral catheterization .
clinical and intra - operative findings , treatment outcome and follow - ups were all evaluated .
none of the patients had a prior diagnosis of their ulcer by an upper gastro - intestinal endoscopy ( ugie ) before presentation .
although , 20 ( 66.6% ) of them had peptic ulcer symptoms with , inadequate or no medical treatment .
the remainder , 10 ( 33.3% ) presented for the first time with perforation , with no prior treatment for peptic ulcer disease .
the notable risk factor was the free abuse of herbal concoction ( admixture of local gin , spices , roots and bitters ) for body pains .
fifteen patients took alcohol and only two took non - steroidal anti - inflammatory drugs [ table 1 ] .
a good proportion of the patients 76.6% were referred to us from private health institutions , while the rest came to our center from their homes .
after adequate resuscitation , all the 30 patients had emergency surgery of simple closure of their perforations , re - enforced with an omental patch and thorough peritoneal larvage .
most of the 26 managed patients had a favorable outcome ; were discharged home and followed - up at the clinic for 4 - 6 weeks but later lost to follow - up .
pdu is still a major complication of chronic peptic ulcer disease seen quite often in the study center , as well as other centers of the world as a frequent cause of acute abdomen .
although experience from some parts of nigeria showed that gastric outlet obstruction has overtaken pdu in incidence , it is still frequently seen in many centers in nigeria , as well as many centers in the developed world.[17 ] this study has also highlighted that the perforation affected mostly the younger age group ( in their 3 -6 decade ) [ table 2 ] , which is in keeping with studies in many centers in the developing world.[111 ] much has been written about non - operative management of pdu in the western world . since the early works of croft et al . , there has been considerable interests in the non - operative management of pdus . in a randomized trial comparing surgical and non - surgical therapy , for pdu
, they showed a mortality rate of 5% in each group and no difference in morbidity .
, have also shown that non - operative therapy could be effective in selected patients .
they showed that as much as 81% of their patients were treated conservatively , but 43% later had surgery .
some writers have claimed that virtually all patients with pdu , could be managed conservatively .
however , conservative management has not been accepted by many workers ; whereas , most surgeons have difficulty in understanding how a patient who has wide spread peritonitis with food debris widely distributed throughout the abdominal cavity can improve without operation .
undoubtedly , there are patients with small leaks , from a perforation and with relatively mild peritoneal contamination who may be managed conservatively ; these are in a minority .
we did not consider this treatment option because of the delay in presentation , 2 - 7 days as well as the socio - economic implications of long hospitalization .
all patients were operated as soon as they were resuscitated and optimized for surgery . in the pre h. pylori era , in the developed world , it has been shown that only 30% of patients with pdu treated with simple closure and thorough peritoneal larvage had good long - term result . in the present era , ( h. pylori era ) , studies have shown , that operation may achieve long - term satisfactory results , only when h. pylori infections , present in 50 - 70% of patients with pdu is totally eliminated .
however , all have agreed that it is sometimes difficult to determine the h. pylori status of patients having emergent operation for perforated d.u . in this study ,
none of the patients had an ugie done before presentation and surgery ; and in all of them , their h. pylori status was not known : although , 20 ( 66.6% ) of them were erratically treated at one time or the other for peptic ulcer disease symptoms .
all patients had simple closure of their perforation with omental patch reinforcement , thorough peritoneal larvage and h. pylori eradication therapy was instituted .
this is only palliative and is sufficient for the elderly patients in the developed world .
patients who have suffered one perforation may suffer another one if anti - secretory drugs are not maintained ; as it were , for life .
this life - long treatment is obviously not within the reach of an average patient in the developing world . in this study ,
most workers , from the developing world have also shown that pdu , affects mostly the younger age group.[18 ] all have attested to the fact that this group are not likely to be anti eradication drug compliant for life .
the costs of these drugs , re - infection by h. pylori organisms even after the eradication and dyspeptic symptoms after surgery,[18 ] shows that this palliative surgery ( omental patch ) is obviously not appropriate for a resource poor center , vis - a - vis for the developing world ; that a shift towards the free use of definitive ulcer surgery should be the goal .
dempsey summed it all ,  using the possible h. pylori infection eradication as an excuse not to do a definitive ulcer operation in any patient with perforated d - u is irrational .
 therefore the various surgical options that have been proposed by workers in the field include : 
 omental patch closure + highly selective vagotomyomental patch closure + bilateral truncal vagotomy ( btv)resectional surgery + truncal vagotomypyloroplasty + btv . 

dakubo et al . , writing from a west african sub - region had shown statistically that age greater than 60 years , alcohol intake and resectional surgery are key factors in predicting post - operative morbidity and mortality .
it stands therefore to reason that since the majority of the patients in the study center vis - a - vis developing world are below 60 years , they stand to benefit from a curative definitive ulcer surgery . pyloroplasty ( inco - operating the perforation ) and btv is quite safe and highly recommended because of its short operative time , simplicity and easily reproducible by all , even trainee surgeons .
omental patch closure + highly selective vagotomy omental patch closure + bilateral truncal vagotomy ( btv ) resectional surgery + truncal vagotomy pyloroplasty + btv .
pdu disease is still a frequent cause of acute abdomen in many centers of the developing world where it affects mostly the youths .
the relative high costs of triple regime therapy for h. pylori eradication , fear of re - perforation and easy loss to follow - up , call for an urgent re - appraisal of the present method of surgical treatment .
therefore , a more liberal role for wide spread definitive ulcer surgery is suggested for most of our young patients .
 introduction : perforated duodenal ulcer ( pdu ) is still seen frequently in the study center inspite of the free use of effective medical curative therapy . 
 we then set out to ascertain the pattern of presentation , peculiar risk factors in the study environment , re - evaluate our method of management , and to see if it is adequate for patients in a developing country.materials and methods : this is a retrospective study of patients admitted and managed for pdus , between january 2004 and december 2011 at the federal medical centre , idoekiti , southwest nigeria . 
 the records of patients were retrieved and demographic data relating to age , sex , symptoms , duration , diagnosis , intra - operative findings , and management outcome were extracted . 
 the results were analyzed.results:a total of 30 patients were admitted and operated during this period . 
 twenty - eight of them were males and two were females . 
 the mean age was 47 years and the male : female ratio was 14:1 . 
 the duration of symptoms before presentation ranged from 2 to 7 days . 
 none of the patients had a prior diagnosis of their ulcers , by an upper gastro intestinal endoscopy before presentation ; although most had dyspeptic symptoms , with inadequate or no medical treatment . 
 the notable peculiar risk factor was the abuse of local herbal concoction for body pains by all the patients . 
 seven patients smokes , 15 consumes alcohol , and only two take non - steroidal anti - inflammatory drugs for body pains . 
 most of the managed patients ; 26 were satisfactorily discharged home and later followed - up at the surgical out - patient department . 
 four mortality was recorded during the period of study.conclusion:pdu is still a major complication of chronic peptic ulcer disease . 
 simple omental patch and h. pylori eradication is no longer appropriate as a mode of treatment for the youths who are mostly affected in the center . 
 we therefore , suggest a more wide spread use of definitive ulcer surgery for most of our patients with no pre - operative risk factors . 
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