What are the criteria for a patient to be considered for gastric omental patching for a perforation?

Criteria for Gastric Omental Patching

For perforated peptic ulcers smaller than 2 cm, primary repair with or without omental patch is appropriate, though the omental patch does not provide additional benefit over simple closure alone in most cases. 1

Perforation Size-Based Criteria

Small Perforations (<2 cm)

• Omental patch repair is NOT routinely necessary for perforations smaller than 2 cm, as multiple studies demonstrate comparable leakage rates and surgical outcomes between simple closure and omental patch repair 1
• Simple closure takes significantly less operative time than omentopexy for perforations smaller than 12 mm 1
• However, omental patch may be considered for ulcers with friable edges to reduce risk of sutures cutting through tissue 1

Large Perforations (≥2 cm)

• A tailored approach based on ulcer location is required rather than routine omental patching 1
• For large gastric ulcers: resection with frozen section examination is preferred due to 10-16% malignancy risk 1, 2
• For large duodenal ulcers: consider resection or repair with pyloric exclusion/external bile drainage 1
• Perforations ≥25 mm have significantly higher leak rates (3.3-fold increase per 10 mm increase in size) and warrant close postoperative monitoring 3

Patient Hemodynamic Status Criteria

Hemodynamically Stable Patients

• Laparoscopic approach is preferred for perforations less than 1 cm 2
• Primary suture with omental patch reinforcement can be performed safely 2, 4
• Mean operative time approximately 64 minutes with acceptable morbidity 4

Hemodynamically Unstable Patients

• Damage control surgery should be employed rather than definitive repair 1, 2
• Avoid complex resectional procedures (e.g., Whipple) in patients with severe sepsis and peritonitis 1
• Focus on controlling contamination and stabilizing physiology 1

Anatomic Location Criteria

Gastric Ulcers

• Mandatory biopsy of all gastric perforations to exclude malignancy (10-16% are caused by gastric carcinoma) 1, 2
• Gastric location is easier to treat than duodenal location 1
• Large gastric ulcers (>2 cm) should undergo resection rather than patch repair 1

Duodenal Ulcers

• Perforations in first portion of duodenum can be managed with omental patch 1
• Large duodenal perforations (>20 mm) benefit from omental plugging rather than simple omentopexy, with significantly lower leak rates and mortality 5
• Proximity to ampulla of Vater requires intraoperative cholangiography consideration 1

Special Population Criteria

Post-Bariatric Surgery Patients

• Perforated marginal ulcers after Roux-en-Y gastric bypass are effectively treated with omental patch repair (laparoscopic or open) 2, 6
• Omental patch repair has shorter operative time (101 vs 138 minutes), less blood loss (70 vs 250 mL), and shorter hospital stay (5.6 vs 11.0 days) compared to anastomotic revision 6
• 44% of these patients have identifiable risk factors (NSAIDs, steroids, smoking) 6

Technical Considerations

Conversion Criteria

• Main reasons for conversion to open surgery: perforation ≥1 cm and failure to locate perforation site 1
• Conversion rates: 27% for fibrin glue repair, 15% for laparoscopic suture repair 1

High-Risk Exclusion Criteria

• Patients with Boey scores of 2-3 may not be suitable candidates for laparoscopic approach 1
• Severe tissue inflammation preventing duodenal mobilization requires alternative approaches 1

Common Pitfalls to Avoid

• Do not routinely apply omental patch for small perforations (<2 cm) as it increases operative time without improving outcomes 1
• Never omit biopsy of gastric perforations regardless of size or appearance 1, 2
• Do not attempt definitive resection in unstable patients with severe sepsis 1, 2
• Recognize that perforations ≥25 mm require heightened postoperative surveillance due to 3.3-fold increased leak risk per 10 mm size increase 3