What is the treatment for gastric perforations due to ulcers?

Treatment of Gastric Perforations Due to Ulcers

For hemodynamically stable patients with gastric perforation <1 cm, perform laparoscopic primary suture repair with omental patch reinforcement, and always obtain biopsies to exclude malignancy. 1, 2

Initial Assessment and Immediate Management

• Immediate surgical exploration is mandatory in unstable patients presenting with peritonitis—do not delay for additional imaging or workup 1, 2
• Assess hemodynamic stability first, as this determines your entire surgical approach 1, 2
• Every hour of delay from admission to surgery decreases survival probability by 2.4% 3

Surgical Approach Based on Patient Stability

Hemodynamically Stable Patients:

• Laparoscopic approach is preferred for perforations <1 cm 1, 2
• Perform primary suture repair with omental patch reinforcement as the standard treatment 1, 2
• Biopsies are mandatory—10-16% of gastric perforations are caused by gastric carcinoma 1, 2
• Simple closure without omental patch may be considered in selected cases, as studies show similar leak rates and outcomes, though omental patch remains the guideline-recommended standard 1

Hemodynamically Unstable Patients:

• Consider damage control surgery and open abdomen approach 1, 2
• Focus on controlling contamination and stabilizing the patient—avoid complex definitive procedures 2
• Do not attempt resections in patients with severe sepsis 2

Management Based on Perforation Size

Small Perforations (<1 cm):

• Primary suture with omental patch is the standard 1, 2
• Laparoscopic approach is safe and effective, with median operating time of 50 minutes 4
• Running suture technique (Lahodny suture) is simple, safe, and does not require intra-corporal knotting 4

Large Perforations (≥2 cm):

• Tailored approach based on ulcer location is necessary 1, 2
• For large gastric ulcers with suspicion of malignancy: perform resection with intraoperative frozen section examination 1, 2
• Gastric resection and reconstruction should be the surgical choice for perforated gastric ulcers >2 cm 1
• For large duodenal ulcers: consider resection or repair with pyloric exclusion/external bile drainage 1, 2

Critical Pitfalls to Avoid

• Failure to obtain biopsies during repair—this is the most common error, as 10-16% of gastric perforations harbor malignancy 1, 2
• Attempting complex resections in hemodynamically unstable patients 2, 3
• Underestimating the severity of peritonitis, which may require more aggressive surgical approach 2, 3
• Delaying surgery for additional workup in patients with clear peritonitis 3

Special Considerations in Post-Bariatric Surgery Patients

• In patients with previous bariatric surgery and perforated marginal ulcer, laparoscopic primary repair with omental patch remains the recommended approach 1
• Assess all anastomoses, the remnant stomach, and excluded duodenum 1
• If gastro-gastric fistula is found, consider omental or jejunal interposition if safe and time permits 1
• Assess the jejuno-jejunostomy for stenosis, as gastric remnant perforation may be secondary to back pressure from bowel obstruction 1

Postoperative Management

• Place nasogastric tube for proximal gastric decompression 5
• External drainage near the repair site to control potential leaks 5
• Initiate proton pump inhibitor therapy (omeprazole 40 mg once daily for 4-8 weeks for gastric ulcers) 6
• Eradicate H. pylori if present to reduce ulcer recurrence risk 6
• Monitor for increased drain output, fever, leukocytosis, and abdominal pain to detect duodenal fistula 5
• Avoid NSAIDs, smoking, and other ulcerogenic factors 1, 5