What is the recommended method for gastric closure in a perforated peptic ulcer?

Recommended Method for Gastric Closure in Perforated Peptic Ulcer

For perforations less than 2 cm in hemodynamically stable patients, perform simple closure with omental patch reinforcement via laparoscopic approach; for larger perforations or unstable patients, tailor your approach based on ulcer location and patient physiology, avoiding complex resections in septic patients. 1, 2

Surgical Approach Based on Perforation Size

Small Perforations (<2 cm)

• Primary suture with omental patch is the standard treatment for small perforated ulcers. 1, 2
• Simple closure alone (without omental patch) achieves comparable outcomes to omental patch repair in terms of leak rates and surgical outcomes, though the patch may provide additional security when tissue edges are friable. 1, 2
• The omental patch technique takes longer operative time than simple closure for perforations smaller than 12 mm, but this difference is clinically acceptable in stable patients. 2

Large Perforations (≥2 cm)

• A tailored approach based on ulcer location is mandatory rather than routine omental patching. 2
• For large gastric ulcers, resection with intraoperative frozen section examination is preferred due to 10-16% malignancy risk. 2
• For large duodenal ulcers, consider alternative procedures such as jejunal serosal patch, Roux-en-Y duodenojejunostomy, or pyloric exclusion when primary repair is not feasible. 3
• Leak rates up to 12% have been reported from attempted closure with omental patch in large ulcers. 1

Patient Hemodynamic Status Determines Technique

Hemodynamically Stable Patients

• Laparoscopic approach is preferred for stable patients with perforations less than 1 cm. 2
• Primary suture with omental patch reinforcement via minimally invasive surgery provides improved outcomes compared with open techniques. 4
• Conversion to open surgery occurs in 27% for fibrin glue repair and 15% for laparoscopic suture repair, primarily when perforation ≥1 cm or failure to locate the perforation site. 2

Hemodynamically Unstable Patients

• Damage control surgery with abbreviated procedures is recommended for patients in septic shock with severe physiological derangement. 1, 2
• Avoid complex definitive resectional approaches (such as Whipple procedure) in patients with peritonitis due to high physiological impact and risk of postoperative complications. 1
• After copious abdominal irrigation, temporary abdominal closure can be placed if mandatory factors dictate open abdomen management. 1
• Anastomoses should be avoided in the presence of hypotension or hemodynamic instability, especially if the patient requires vasopressors. 1

Critical Anatomic Considerations

Gastric Ulcer Perforations

• Mandatory biopsy of all gastric perforations must be obtained to exclude malignancy, as 10-16% may be caused by gastric carcinoma. 2
• Large gastric ulcers (>2 cm) should undergo resection rather than patch repair. 2
• Gastrectomy can be performed safely even in high-risk cases and should be considered where there is well-documented chronicity or when the nature of the ulcer precludes safe simple closure. 5

Duodenal Ulcer Perforations

• For duodenal ulcers in the first portion, primary repair with omentopexy is standard. 3
• The proximity of the perforation to the common bile duct and ampulla of Vater must be thoroughly investigated. 3, 6
• Intraoperative cholangiography may be necessary to verify common bile duct anatomy in complex cases involving perforations near the ampullary area. 3, 6
• For giant ulcers with severe tissue inflammation when duodenal mobilization is not possible and the patient is in severe septic shock, duodenostomy over a Petzer tube should be used only as a last resort. 1

Timing of Surgical Intervention

• Surgery must be performed as soon as possible, as each hour of surgical delay beyond hospital admission is associated with an adjusted 2.4% decreased probability of survival over the first 24 hours. 2, 3
• Perforation-to-surgery interval longer than 36 hours is significantly associated with increased postoperative mortality. 2
• Surgery should not be delayed for extensive preoperative optimization, particularly in patients with delayed presentation and those older than 70 years. 2

Common Pitfalls to Avoid

• Never omit biopsy of gastric perforations regardless of size or appearance, as this may miss malignancy in 10-16% of cases. 2
• Do not routinely apply omental patch for very small perforations (<12 mm) as it increases operative time without improving outcomes, though it remains standard for perforations up to 2 cm. 2
• Avoid attempting definitive resection in unstable patients with severe sepsis; focus on controlling contamination and stabilizing physiology first. 1, 2
• Do not underestimate the severity of peritonitis, which may require more aggressive surgical approach than initially anticipated. 2, 3
• Patients with Boey scores of 2-3 may not be suitable candidates for laparoscopic approach and should be considered for open surgery. 2