What is the management of a gastric perforation?

Management of Gastric Perforation

Immediate Management Based on Hemodynamic Status

For hemodynamically unstable patients with gastric perforation and peritonitis, perform immediate surgical exploration without delay, and strongly consider damage control surgery with open abdomen technique. 1

For hemodynamically stable patients with perforations <1 cm, perform laparoscopic primary suture repair with omental patch reinforcement, which is associated with decreased operative time, blood loss, and length of hospital stay. 1

Initial Resuscitation and Diagnostic Approach

• Initiate aggressive fluid resuscitation with isotonic intravenous fluids and correct electrolyte imbalances immediately while preparing for intervention 2
• Start broad-spectrum antibiotics covering gram-negative, gram-positive, and anaerobic organisms 1, 2
• Keep patient NPO and place nasogastric tube for gastric decompression 1, 3
• Obtain urgent surgical consultation even if endoscopic repair is technically feasible 1
• Perform CT imaging to confirm diagnosis and assess extent of contamination, as it is more sensitive than plain radiographs for detecting free air 2

Surgical Management Algorithm

For Stable Patients with Small Perforations (<2 cm):

• Laparoscopic approach is preferred for perforations <1 cm with primary suture repair and omental patch reinforcement 1
• Endoscopic closure may be attempted for perforations <2 cm using through-the-scope clips (TTSCs) or over-the-scope clips (OTSCs) 1
• For perforations >2 cm, use endoscopic suturing or combination of TTSCs and endoloop 1
• Always obtain biopsies of the perforated ulceration to exclude malignancy, as 8.8% of perforated gastric ulcers harbor underlying carcinoma 1, 4

For Unstable Patients or Large Perforations:

• Proceed directly to open surgical exploration without delay in hemodynamically unstable patients 1
• Consider damage control surgery with abbreviated laparotomy and open abdomen technique for patients with severe peritonitis, septic shock, or extensive contamination 1
• Plan re-laparotomies every 36-48 hours until the abdomen is free of ongoing peritonitis 2
• For large perforations requiring resection, distal gastrectomy may be necessary, though this carries higher mortality (0-50%) compared to simple closure 4, 5

Special Considerations

Post-Bariatric Surgery Patients:

• Assess all anastomoses, the remnant stomach, and excluded duodenum during exploration 1
• If perforation is in the gastric remnant, manage with primary suture and omental patch or stapled resection 1
• Consider gastrostomy tube placement proximal to the perforation site if significant postoperative ileus is anticipated due to peritonitis 1, 3, 2
• Explore the jejuno-jejunostomy for stenosis or gastric remnant for gastro-gastric fistula if diffuse peritonitis is present 1, 2

Endoscopy-Related Perforations:

• Most ESD-related perforations (97.3%) can be managed successfully with immediate endoscopic clip closure 6
• Conservative management with fasting, IV antibiotics, and proton pump inhibitors is successful for clinically suspected perforations without visible defects 6, 7
• Use carbon dioxide insufflation for all endoscopic procedures to minimize complications if perforation occurs 1

Postoperative Management

• Confirm absence of ongoing leak with water-soluble upper GI series before initiating oral intake 1
• Maintain NPO status with nasogastric decompression until bowel function returns 1, 3
• Continue broad-spectrum antibiotics and adjust based on culture results 2
• Serial clinical and imaging monitoring every 3-6 hours in the immediate postoperative period 2
• Administer subcutaneous heparin for thromboembolism prophylaxis 3
• Implement opioid-sparing analgesia strategies to minimize postoperative ileus 3

Critical Pitfalls to Avoid

• Never delay surgical consultation even when endoscopic repair appears successful, as clinical deterioration can occur 1
• Do not miss underlying malignancy: Always obtain biopsies and arrange follow-up endoscopy with repeat biopsy, as initial biopsy can be falsely negative 1, 4
• Avoid fluid overloading as it worsens intestinal edema and prolongs ileus 3
• Do not attempt primary gastrectomy in unstable patients with severe contamination—use damage control principles instead 1, 5