Management of Perforated Gastric Ulcer
Immediate surgical intervention is the standard of care for patients with perforated gastric ulcer, with laparoscopic primary suture repair and omental patch being the recommended first-line treatment for stable patients with perforations less than 1 cm. 1
Initial Assessment and Stabilization
- Immediate surgical exploration is mandatory in unstable patients presenting with peritonitis without delay 1
- Resuscitation with intravenous fluids, nasogastric suction, and administration of antibiotics should be initiated while preparing for surgery 2
- Hemodynamic stability assessment is crucial as it will determine the surgical approach 1
Surgical Management Based on Patient Status
For Hemodynamically Stable Patients:
- Laparoscopic approach is preferred for stable patients with perforations less than 1 cm 1
- Primary suture with omental patch reinforcement is recommended as the standard treatment 1
- Biopsies of the perforated ulceration must be taken to exclude malignancy (10-16% of gastric perforations may be caused by gastric carcinoma) 1
For Hemodynamically Unstable Patients:
- Damage control surgery and open abdomen approach should be considered 1
- Avoid complex definitive procedures (like Whipple) in patients with severe sepsis 1
- Focus on controlling contamination and stabilizing the patient 1
Management Based on Perforation Size
Small Perforations (<1 cm):
- Primary suture with omental patch is the standard treatment 1
- Simple closure without omental patch may be considered in selected cases as studies show similar outcomes 1
Large Perforations (≥2 cm):
- Tailored approach based on ulcer location is necessary 1
- For large gastric ulcers with suspicion of malignancy, resection with intraoperative frozen section examination is recommended 1
- For large duodenal ulcers, consider resection or repair with pyloric exclusion/external bile drainage 1
Special Considerations
- In patients with previous bariatric surgery and perforated marginal ulcer, laparoscopic primary repair with omental patch is still recommended 1
- If a gastro-gastric fistula is found during exploration, options include simple resection of the fistula or more complex procedures depending on the specific anatomy 1
- In case of perforated remnant stomach after gastric bypass, primary suture with omental patch or stapled resection should be considered 1
Postoperative Care
- Helicobacter pylori testing and eradication therapy if positive 3
- Proton pump inhibitor therapy 4
- Avoidance of NSAIDs, smoking, and other ulcerogenic factors 1
- Follow-up endoscopy with repeat biopsies is essential to exclude underlying malignancy 5
Common Pitfalls to Avoid
- Failure to obtain biopsies during repair, potentially missing malignancy 1, 5
- Attempting complex resections in hemodynamically unstable patients 1
- Overlooking associated conditions in patients with previous bariatric surgery (e.g., gastro-gastric fistula, jejuno-jejunostomy stenosis) 1
- Underestimating the severity of peritonitis, which may require more aggressive surgical approach 1