What are the criteria for gastric Graham patching in a patient with peptic ulcer disease?

Criteria for Gastric Graham Patching

Graham patch repair is indicated for perforated peptic ulcers smaller than 2 cm in hemodynamically stable patients, with primary suture closure and omental patch reinforcement as the standard approach. 1, 2

Size-Based Criteria

Small Perforations (<2 cm)

• Primary repair with omental patch is the recommended standard treatment for perforations under 2 cm 1, 2
• Perforations less than 1 cm are ideal candidates for laparoscopic Graham patch repair in stable patients 2
• Simple closure without omental patch may achieve comparable leak rates but is not routinely recommended 1
• The omental patch technique shows low postoperative leak rates even for perforations approaching 2 cm diameter 1

Large Perforations (≥2 cm)

• Graham patch is NOT appropriate for perforations 2 cm or larger—these require resection or alternative repair strategies 1
• Large gastric ulcers mandate resection with intraoperative frozen section to exclude malignancy (10-16% of gastric perforations are caused by carcinoma) 1, 2
• Large duodenal ulcers require consideration of resection, repair with pyloric exclusion, or external bile drainage 1

Patient Hemodynamic Status

Stable Patients

• Laparoscopic approach is preferred for stable patients with small perforations 2, 3
• Laparoscopic repair demonstrates shorter operative time, less postoperative pain, reduced chest complications, and shorter hospital stays compared to open repair 3
• Immediate surgical exploration is mandatory even in stable patients presenting with peritonitis 2

Unstable Patients

• Damage control surgery with open abdomen approach should replace definitive Graham patch repair in hemodynamically unstable patients 2
• Patients in septic shock with severe physiological derangement require abbreviated procedures focused on contamination control 1
• Avoid complex definitive procedures in patients with severe sepsis 2

Anatomic Location Considerations

Gastric Ulcers

• Gastric location is easier to treat than duodenal location 1
• Mandatory biopsy of all gastric perforations during repair to exclude malignancy 2
• Graham patch is appropriate for small benign gastric ulcers without suspicion of malignancy 1, 2

Duodenal Ulcers

• Juxtapyloric duodenal ulcers are ideal candidates for Graham patch 3
• Non-juxtapyloric gastric ulcers or perforations larger than 10 mm should be converted from laparoscopic to open approach 3
• Proximity to common bile duct and ampulla of Vater must be assessed—may require intraoperative cholangiography 1

Technical Considerations

Tissue Quality

• Omental patch is particularly valuable for large ulcers with friable edges to prevent sutures from cutting through 1
• Friable tissue edges increase the risk of suture failure with simple closure alone 1

Operative Time

• Simple closure without omental patch requires less operative time and advanced laparoscopic skills 1
• However, the omental patch remains standard due to theoretical reinforcement benefits despite longer operative time 1

Exclusion Criteria

Absolute Contraindications

• History of upper abdominal surgery (relative contraindication for laparoscopic approach) 3
• Concomitant evidence of bleeding from the ulcer 3
• Gastric outlet obstruction 3
• Clinically sealed-off perforations without peritonitis or sepsis (these can be managed non-operatively) 3

Situations Requiring Alternative Approaches

• Perforations ≥2 cm require resection rather than patch repair 1
• Suspicion of malignancy mandates resection with frozen section 1, 2
• Giant ulcers with severe tissue inflammation in patients with severe septic shock may require duodenostomy as last resort 1

Common Pitfalls to Avoid

• Failure to obtain biopsies during repair of gastric perforations, potentially missing malignancy 2
• Attempting Graham patch on perforations ≥2 cm, which have leak rates up to 12% 1
• Performing complex resections in hemodynamically unstable patients instead of damage control 2
• Underestimating severity of peritonitis, which may require more aggressive surgical approach 2
• Converting to open surgery unnecessarily for small perforations in stable patients when laparoscopic expertise is available 3