What are the surgical options for a patient with a perforation at the gastric fundus, possibly with a history of peptic ulcer disease?

Surgical Options for Gastric Fundus Perforation

For a perforation at the gastric fundus, perform laparoscopic simple closure with or without omental patch reinforcement as the primary surgical approach, reserving gastric resection for large perforations (≥2 cm) with friable edges or when malignancy is suspected. 1, 2

Primary Surgical Approach: Laparoscopic Repair

Laparoscopic simple closure is the preferred initial technique for most gastric fundus perforations, offering superior outcomes compared to open surgery with reduced postoperative complications and shorter recovery times. 1, 3

Simple Closure Technique

• Direct suture repair (single or double layer) is appropriate for small perforations (<2 cm) with healthy tissue edges 1
• No routine need for omental patch in straightforward cases, as simple closure achieves similar outcomes with shorter operative time 1
• Laparoscopic approach is strongly preferred over open surgery when expertise is available, demonstrating improved morbidity and mortality outcomes 3

When to Add Omental Patch

• Consider omental patch reinforcement for perforations with friable or edematous edges to prevent suture line failure 1, 3
• Large ulcers approaching 2 cm may benefit from patch reinforcement, though this requires advanced laparoscopic skills 1
• Omental patch may be most useful when tissue quality is poor and primary closure alone carries high risk of leak 3

Resectional Surgery: When Simple Repair is Inadequate

Gastric resection becomes necessary when the perforation characteristics make simple repair unsafe or when underlying pathology requires definitive treatment. 1, 2

Indications for Distal Gastrectomy

• Large perforations ≥2 cm with extensive tissue loss or severe inflammation that precludes safe primary closure 1, 2
• Suspected malignancy based on ulcer appearance, as 10-16% of gastric perforations are caused by gastric carcinoma requiring resection with frozen section examination 1, 2
• Gastric corpus or antral location near the pylorus where resection and reconstruction are technically feasible 2
• Refractory bleeding from the perforation site that cannot be controlled by local measures 2

Technical Considerations for Resection

• Hemodynamic stability is essential before proceeding with resection, as this is a more extensive procedure than simple repair 2
• Standard distal gastrectomy removes approximately two-thirds of the stomach with D1 lymphadenectomy for benign disease 2
• Higher mortality risk compared to simple repair, particularly in elderly or unstable patients, necessitates careful patient selection 2

Special Considerations for Fundal Location

The gastric fundus location is generally easier to repair than duodenal perforations, as the stomach wall is more amenable to suturing and resection without risk to adjacent structures like the bile duct or pancreas. 1

• Gastric resection and reconstruction can be performed safely for fundal perforations when indicated, unlike proximal duodenal perforations where anatomy is more constrained 1
• Adequate mobilization of the fundus may be necessary to achieve tension-free closure 4

Damage Control Surgery

In hemodynamically unstable patients or those with severe peritonitis, consider damage control principles rather than definitive repair. 1

• Temporary measures may include simple closure with planned reoperation if the patient cannot tolerate prolonged surgery 1
• Damage control is reserved for patients in extremis where physiologic derangement precludes definitive repair 1

Critical Pitfalls to Avoid

• Do not delay surgery for extensive preoperative optimization, as every hour of delay decreases survival probability by 2.4% 2
• Do not attempt simple closure on large perforations (≥2 cm) with friable tissue, as leak rates up to 12% are reported with this approach 1
• Do not miss occult malignancy in gastric perforations—maintain high suspicion and obtain frozen section if ulcer appears atypical 1, 2
• Recognize that leak after repair occurs in 12-17% of cases, requiring readiness for reintervention with endoscopic, radiologic, or surgical approaches 3

Essential Postoperative Management

• All patients require H. pylori testing and treatment if positive, as this is the most important intervention for preventing recurrence 5
• Continue proton pump inhibitor therapy postoperatively to promote healing 5
• Strictly avoid NSAIDs, which are etiologic in 36% of peptic ulcer cases and associated with increased mortality 5