This obviously is not only a problem of taking or not taking drugs but a socioeconomic status of the population. During WWII the Britons had a huge incidence of ulcers. Balck South Africans moving to large town had an incerased rate of ulcers- stress and new way of life.
Political changes, unemployement, poor nutrition, alcohol consumption, smoking, surely are associated factors in the genesis of the mega-ulcer disease in your practice as is probably Helicobacter.
I believe there are nowdays 2 types of DU's- the one associated with Helicobacter and the one associated with non-steroidal anti-inf drugs (NSAID).
Now, in the poor risk-sick case (APACHE II >10) I would do only omentopexy-starting the patient on acid-reducing and anti-bacterial regimen postop.
In a good risk case depends on the patient: a "nice" chap for example - well insured, non NSAID and reliable- I would do only an omentopexy and erradicate the bacteria postop. Unemployed, non-insured, non-reliable, diffcult to follow up or on NSAID -I would add a HSV to cure the ulcer (in 90%).
Gastic ulcer- here the Helicobater issue is less definitive; large gastric perforations on the lesser curvature are best managed with Bil I gastrectomy.
Basically the choice of the procedure depends on the ULCER (type, size), the PATIENT (his condition) the PERITONEAL CAVITY (established peritonitis versus contamination only) and the SURGEON (is he from Chile or Brazil) (JOKE).
BTW: can we send our residents for an elective? -they may learn how to operatively manage complicated peptic ulcer disease.