What is the recommended surgical procedure for a patient with perforated peptic ulcer disease (PPUD)?

Surgical Procedure for Perforated Peptic Ulcer Disease (PPUD)

Primary Recommendation

For stable patients with perforated peptic ulcer, perform laparoscopic simple closure with omental patch reinforcement; for unstable patients, proceed immediately with open surgery and damage control principles. 1, 2

Surgical Approach Selection Algorithm

Hemodynamic Status Assessment

Stable Patients:

• Laparoscopic approach is preferred for hemodynamically stable patients with perforations, offering reduced postoperative complications and shorter recovery times compared to open surgery 1, 2
• Laparoscopic repair is particularly recommended for perforations less than 1 cm 2
• Conversion to open surgery occurs in approximately 15-27% of cases, primarily due to perforation ≥1 cm or inability to locate the perforation site 2

Unstable Patients:

• Open surgery is mandatory in hemodynamically unstable patients or those with severe peritonitis 1, 2
• Apply damage control surgery principles rather than attempting definitive repair 2, 3
• Focus on controlling contamination and stabilizing physiology, avoiding complex resectional procedures in patients with severe sepsis 2

Surgical Technique Based on Perforation Size

Small Perforations (<2 cm):

• Primary suture with omental patch reinforcement is the standard treatment 2, 4
• Simple closure without omental patch may be considered in selected cases, as studies demonstrate comparable leakage rates and surgical outcomes, with significantly shorter operative time 2
• Omental patch is most useful when ulcer edges are friable to prevent sutures from cutting through tissue 2, 4

Large Perforations (≥2 cm):

• Tailored approach based on ulcer location is required 2
• For large gastric ulcers with suspicion of malignancy, perform resection with intraoperative frozen section examination, as 10-16% of gastric perforations are caused by gastric carcinoma 2, 3
• For large duodenal ulcers, consider resection or repair with pyloric exclusion/external bile drainage 2
• Leak rates up to 12-17% are reported with simple closure of large perforations with friable tissue 3, 4

Critical Intraoperative Steps

Mandatory Biopsy Protocol

• Always obtain biopsies of gastric perforations to exclude malignancy, regardless of size or appearance, as 10-16% harbor gastric carcinoma 2, 3
• This step must never be omitted even in emergency settings 2

Bleeding Control (When Applicable)

• For bleeding duodenal ulcers requiring surgery, perform suture ligature of the bleeding vessel via duodenotomy with ligation of the gastroduodenal artery 5
• Bleeding gastric ulcers should be resected if possible 6

Timing of Surgery

Surgery must be performed as soon as possible, especially in patients with delayed presentation and those older than 70 years 1

• Each hour of surgical delay beyond hospital admission is associated with an adjusted 2.4% decreased probability of survival over the first 24 hours 1, 3
• Perforation-to-surgery interval longer than 36 hours is significantly associated with increased postoperative mortality 1
• Do not delay surgery for extensive preoperative optimization 3

Common Pitfalls to Avoid

• Never attempt complex definitive procedures (like resection with reconstruction) in hemodynamically unstable patients with severe sepsis 2
• Do not routinely apply omental patch for small perforations (<2 cm) as it increases operative time without improving outcomes 2
• Never omit biopsy of gastric perforations regardless of appearance, as this risks missing occult malignancy 2, 3
• Do not attempt simple closure on large perforations (≥2 cm) with friable tissue, as leak rates are unacceptably high 3
• Avoid laparoscopic approach in patients with Boey scores of 2-3, as they may not be suitable candidates 2

Special Populations

Patients with Previous Bariatric Surgery:

• Laparoscopic primary repair with omental patch remains the recommended approach for perforated marginal ulcers 2
• Evaluate for associated conditions including gastro-gastric fistula and jejuno-jejunostomy stenosis 2
• For perforated remnant stomach after gastric bypass, consider primary suture with omental patch or stapled resection 2

Postoperative Management Essentials

• All patients require H. pylori testing and treatment if positive, as this is the most important intervention for preventing recurrence 3, 7
• Continue proton pump inhibitor therapy postoperatively to promote healing 3, 7
• Strictly avoid NSAIDs postoperatively, as they are etiologic factors in 36% of peptic ulcer cases and strongly associated with mortality 3, 7
• Recommend smoking cessation, as smoking is a key etiologic factor for peptic ulcer disease 2