What is the most appropriate post‑operative advice for a patient after surgical repair of a perforated peptic ulcer with an omental patch?

Post-Operative Management After Omental Patch Repair for Perforated Peptic Ulcer

The most appropriate advice is to avoid NSAIDs, as they represent one of the strongest independent risk factors for peptic ulcer perforation and mortality, followed by H. pylori testing and eradication therapy if positive. 1, 2, 3

Primary Post-Operative Recommendations

NSAID Avoidance (Most Critical)

Complete and permanent discontinuation of all NSAIDs is non-negotiable and represents the single most effective preventive measure after perforated peptic ulcer repair. 1, 2, 3

• A systematic review of 29,782 patients demonstrated that NSAID use is independently associated with increased mortality in perforated peptic ulcer patients 1, 3
• NSAIDs directly affect gastric mucosal acid secretion and represent a primary etiologic factor for peptic ulcer disease alongside H. pylori infection 1, 3
• Patients with prior peptic ulcer disease who use NSAIDs have a greater than 10-fold increased risk for developing a GI bleed 3

H. pylori Testing and Eradication (Essential Secondary Measure)

All patients must undergo H. pylori testing if not already performed, with immediate eradication therapy if positive. 1, 2, 3

• H. pylori infection is present in approximately 65-70% of perforated peptic ulcer cases, though rates vary from study to study 4
• Recurrent ulcer disease after perforation mainly occurs in patients with persistent H. pylori infection 4
• Eradication therapy prevents or significantly decreases ulcer recurrence and re-perforation after simple closure 4, 5
• Triple therapy should be initiated during the immediate postoperative period 2

Additional Risk Factor Modifications

Mandatory smoking cessation and steroid minimization are required to reduce recurrence risk. 1, 2, 3

• Smoking is a key etiologic factor for peptic ulcer disease affecting gastric acid secretion 1, 3
• Corticosteroids are associated with increased mortality risk and perforation; avoid or minimize when clinically feasible 1, 2, 3
• Reduce dietary salt intake as an adjunctive strategy, though its impact is modest compared to NSAIDs 1, 3

Why "Maintain a Healthy Diet" Alone is Insufficient

While dietary modifications have a role, they are far less impactful than NSAID avoidance and H. pylori eradication:

• Dietary salt reduction affects gastric acid secretion but has modest impact compared to the dominant effect of NSAIDs 3
• No specific dietary restrictions beyond salt reduction are emphasized in major guidelines 1, 2, 3
• The primary etiologic factors are NSAIDs, H. pylori, steroids, and smoking—not diet 1, 3

Clinical Algorithm for Post-Operative Counseling

Step 1: Immediately counsel on permanent NSAID discontinuation (including over-the-counter products) 1, 2, 3

Step 2: Arrange H. pylori testing if not performed preoperatively; initiate triple therapy if positive 1, 2, 4

Step 3: Mandate smoking cessation and minimize/discontinue steroids when possible 1, 2, 3

Step 4: Advise dietary salt reduction as adjunctive measure 1, 3

Common Pitfalls to Avoid

• Do not allow patients to resume NSAIDs "occasionally" or "as needed"—even intermittent use dramatically increases perforation risk 1, 3
• Do not delay H. pylori testing—eradication therapy should begin in the immediate postoperative period 2, 4
• Do not overlook over-the-counter NSAIDs—patients often don't recognize ibuprofen, naproxen, or aspirin as problematic 3
• Do not assume H. pylori-negative patients don't need follow-up—these patients may require evaluation for Zollinger-Ellison syndrome or have NSAID-related disease 5

Special Considerations

• Patients with history of bariatric surgery require assessment for gastro-gastric fistula, as this increases marginal ulcer recurrence risk 2
• No routine physical activity restrictions are necessary after successful omental patch repair 1, 2
• The only remaining indication for elective definitive surgical treatment is intractable recurrent symptoms despite adequate medical treatment in H. pylori-negative patients (e.g., those requiring ongoing NSAIDs for other conditions) 4