Surgical Management of Perforated Peptic Ulcer Disease
Indications for Surgery
Operative treatment is strongly recommended for patients with perforated peptic ulcer who have significant pneumoperitoneum, extraluminal contrast extravasation on imaging, or clinical signs of peritonitis. 1
Surgery should be performed as soon as possible after diagnosis, particularly in patients with delayed presentation (>24 hours) and those older than 70 years, as each hour of surgical delay beyond hospital admission is associated with a 2.4% decreased probability of survival. 1
Non-operative management may be considered only in highly selected cases: patients who are hemodynamically stable, without signs of generalized peritonitis, and with contained perforation confirmed on CT imaging without contrast leak. 2, 3
Surgical Approach: Open vs Laparoscopic
For hemodynamically stable patients, laparoscopic repair is the preferred approach, offering reduced postoperative pain, fewer wound infections, and comparable mortality to open surgery. 1
A laparoscopic approach should be pursued when appropriate surgical skills and equipment are available. 1
Open surgery is mandatory for hemodynamically unstable patients due to the adverse effects of pneumoperitoneum (increased systemic vascular resistance, decreased cardiac output, hypercarbia) which can worsen cardiovascular compromise. 1
Open surgery is also recommended when laparoscopic expertise is unavailable or when conversion is necessary due to technical difficulties. 1
Recent evidence shows that primary laparoscopic repair can be successfully completed without conversion in the majority of cases, with acceptable morbidity and mortality rates. 4
Surgical Technique
Small Perforations (<2 cm)
Simple closure with omental patch (Graham patch) is the standard procedure for small perforations. 5, 3
This can be performed via either open or laparoscopic technique depending on patient stability and surgeon expertise. 5
The perforation is closed with interrupted sutures, and viable omentum is used to buttress the repair. 5
Large Perforations (≥2 cm)
For large perforations with friable tissue edges, omental patch closure without primary suture closure may be most appropriate. 3
In cases of giant ulcers where primary closure is not feasible, consider gastric resection or exclusion procedures. 5
Gastric ulcer perforations should be biopsied or resected when possible to exclude malignancy, whereas duodenal ulcers typically require only closure. 6
Additional Procedures
Definitive ulcer surgery (vagotomy, antrectomy) to reduce gastric acid secretion is no longer justified in the acute setting of perforation. 7
Thorough peritoneal lavage and drainage should be performed regardless of approach. 1
Management of Failed Repairs
Leak after repair occurs in 12-17% of cases and represents a critical complication with high morbidity and mortality. 3
Initial management options include expectant management with drainage, radiologic intervention, endoscopic intervention, or repeat surgery depending on patient stability and extent of leak. 3
Complete healing may take considerable time, and aggressive supportive care is essential. 3
Antimicrobial Therapy
Empiric antibiotic therapy covering gram-negative and anaerobic organisms should be initiated immediately in all patients with perforated peptic ulcer. 1
- The duration of antibiotics should be tailored to the clinical scenario but typically continues for several days postoperatively. 1
Critical Prognostic Factors
Key predictors of poor outcome include:
- Age >70 years 1
- Shock on admission 1
- Preoperative metabolic acidosis 1
- ASA score >III 4
- Boey Score of 3 (shock on admission, major medical illness, prolonged perforation >24 hours) 4
- Surgical delay >24-36 hours 1
These high-risk patients require aggressive resuscitation, expedited surgery, and intensive postoperative monitoring as mortality can reach 30% despite optimal management. 3