Omental patch repair of large perforated peptic ulcers ≥25 mm is associated with higher leak rate
Background and Aim: Omental patch repair is the present gold-standard technique for patients with perforated peptic ulcers (PPUs). Data are lacking regarding the safe ulcer size for omental patch repair leak (OPL). We analyze our experience in managing PPU to identify an ulcer size cut-off for predicting OPL.
Methods: Patients who had undergone omental patch repair for PPU between Jan 2004 and Apr 2016 were included. Demographic data, the American Society of Anesthesiologists score, ulcer size, operative approach, post-operative complications, and length of stay were recorded. OPL, intraabdominal collection, repeat surgery, and 30-day mortality were recorded. The relationship between ulcer size, pre-operative characteristics, and OPL were investigated with univariate and multivariate logistic regression. Receiver operating characteristic curve analysis derived the ulcer size cut-off to predict OPL. In addition, we analyzed if ulcer size predicted mortality or malignancy.
Results: Six hundred and ninety patients with a mean age of 55.1 years (range 16-94) were managed for PPU during the study period. Free air on X-ray was evident in 417 (60.4%) patients. Mean ulcer size was 7.8 mm (range 1-50). OPL occurred in 15 patients (2.2%) and 30-day mortality was 7.4% (n=51). Multivariate analysis found ulcer size increase of 10 mm (OR 3.30, 95% CI 1.81-6.02, P<0.001) predicted increased risk of OPL. At 25 mm cut-off, sensitivity was 26.7%, specificity was 97.2%, positive likelihood ratio was 9.47, and negative likelihood ratio was 0.76 for OPL.
Conclusion: Ulcer size increase in 10 mm increases leak rate by 3.3 times. Ulcer size ≥25 mm predicts OPL.
Relevance for Patients: Increased risk of OPL for ≥25 mm warrants need for close post-operative monitoring and lowers threshold for investigations in event of clinical deterioration. Decision for omental patch repair versus gastrectomy however should not be based on ulcer size alone.
[1] Lau W, Leow C. History of Perforated Duodenal and Gastric Ulcers. World J Surg 1997;21:890-6.
[2] Cellan-Jones C. ARapid Method of Treatment in Perforated Duodenal Ulcer. Br Med J 1929;1:1076-7.
[3] George R, Smith I. Long-Term Results After Omental Patch Repair in Patients with Perforated Duodenal Ulcers: A 5-to 10-Year Follow-Up Study. Can J Surg 1991;34:447-9.
[4] Arora BK, Arora R, Arora A. Modified Graham’s Repair for Peptic Ulcer Perforation: Reassessment Study. Int Surg J 2017;4:1667-71.
[5] Bertleff MJ, Lange JF. Perforated Peptic Ulcer Disease: AReview of History and Treatment. Dig Surg 2010;27:161-9.
[6] Lau JY, Sung J, Hill C, Henderson C, Howden CW, Metz DC. Systematic Review of the Epidemiology of Complicated Peptic Ulcer Disease: Incidence, Recurrence, Risk Factors and Mortality. Digestion 2011;84:102-13.
[7] Maghsoudi H, Ghaffari A. Generalized Peritonitis Requiring Re-Operation after Leakage of Omental Patch Repair of Perforated Peptic Ulcer. Saudi J Gastroenterol 2011;17:124.
[8] Kumar K, Pai D, Srinivasan K, Jagdish S, Ananthakrishnan N. Factors Contributing to Releak after Surgical Closure of Perforated Duodenal Ulcer by Graham’s Patch. Trop Gastroenterol 2002;23:190-2.
[9] Chung KT, Shelat VG. Perforated Peptic Ulcer-an Update. World J Gastrointest Surg 2017;9:1-12.
[10] Seow J, Lim Y, Shelat V. Low Serum Albumin May Predict the Need for Gastric Resection in Patients with Perforated Peptic Ulcer. Eur J Trauma Emerg Surg 2017;43:293-8.
[11] Anbalakan K, Chua D, Pandya GJ, Shelat VG. Five Year Experience in Management of Perforated Peptic Ulcer and Validation of Common Mortality Risk Prediction Modelsare Existing Models Sufficient? A Retrospective Cohort Study. Int J Surg 2015;14:38-44.
[12] Shelat VG, Ahmed S, Chia CL, Cheah YL. Strict Selection Criteria during Surgical Training Ensures Good Outcomes in Laparoscopic Omental Patch Repair (LOPR) for Perforated Peptic Ulcer (PPU). Int Surg 2015;100:370-5.
[13] Hansson LE, Nyrén O, Hsing AW, Bergström R, Josefsson S, Chow WH, et al. The Risk of Stomach Cancer in Patients with Gastric or Duodenal Ulcer Disease. N Engl J Med 1996;335:242-9.
[14] Ng EK, Lam Y, Sung JJ, Yung MY, To KF, Chan AC, et al. Eradication of Helicobacter pylori prevents Recurrence of Ulcer after Simple Closure of Duodenal Ulcer Perforation: Randomized Controlled Trial. Ann Surg 2000;231:153-8.
[15] Nomura A, Stemmermann GN, Chyou PH, Perez-Perez GI, Blaser MJ. Helicobacter pylori Infection and the Risk for Duodenal and Gastric Ulceration. Ann Intern Med 1994;120:977-81.
[16] Prabhu V, Shivani A. An Overview of History, Pathogenesis and Treatment of Perforated Peptic Ulcer Disease with Evaluation of Prognostic Scoring in Adults. Ann Med Health Sci Res 2014;4:22-9.
[17] Lewis JD, Bilker WB, Brensinger C, Farrar JT, Strom BL. Hospitalization and Mortality Rates from Peptic Ulcer Disease and GI Bleeding in the 1990s: Relationship to Sales of Nonsteroidal Anti-Inflammatory Drugs and Acid Suppression Medications. Am J Gastroenterol 2002;97:2540-9.
[18] Matsuda M, Nishiyama M, Hanai T, Saeki S, Watanabe T. Laparoscopic Omental Patch Repair for Perforated Peptic Ulcer. Ann Surg 1995;221:236-40.
[19] Fischer DR, Nussbaum MS, Pritts TA, GilinskyNH, Weesner RE, Martin SP, et al. Use of Omeprazole in the Management of Giant Duodenal Ulcer: Results of a Prospective Study. Surgery 1999;126:643-9.
[20] Lee FY, Leung KL, Lai PB, Lau JW. Selection of Patients for Laparoscopic Repair of Perforated Peptic Ulcer. Br J Surg 2002;88:133-6.
[21] Tarasconi A, Coccolini F, Biffl WL, Tomasoni M, Ansaloni L, Picetti E, et al. Perforated and Bleeding Peptic Ulcer: WSES Guidelines. World J Emerg Surg 2020;15:3.
[22] Gupta S, Kaushik R, Sharma R, Attri A. The Management of Large Perforations of Duodenal Ulcers. BMC Surg 2005;5:15.
[23] Sharma D, Saxena A, Rahman H, Raina VK, Kapoor JP. ‘Free Omental Plug’: A Nostalgic Look at an Old and Dependable Technique for Giant Peptic Perforations. Dig Surg 2000;17:216-8.
[24] Simeone DM, Hassan A, Scheiman JM. Giant Peptic Ulcer: A Surgical or Medical Disease? Surgery 1999;126:474-8.
[25] Barragry TP, Blatchford J 3rd, Allen M. Giant Gastric Ulcers. A Review of 49 Cases. Ann Surg 1986;203:255-9.
[26] Chan KS, Wang YL, Chan XW, Shelat VG. Outcomes of Omental Patch Repair in Large or Giant Perforated Peptic Ulcer are Comparable to Gastrectomy. Eur J Trauma Emerg Surg 2021;47:1745-52.
[27] Deeks JJ, Altman DG. Diagnostic Tests 4: Likelihood Ratios. BMJ 2004;329:168-9.
[28] Hodnett RM, Gonzalez F, Lee WC, Nance FC, Deboisblanc R. The Need for Definitive Therapy in the Management of Perforated Gastric Ulcers. Review of 202 Cases. Ann Surg 1989;209:36-9.
[29] Roviello F, Rossi S, Marrelli D, de Manzoni G, PedrazzaniC, Morgagni P, et al. Perforated Gastric Carcinoma: A Report of 10 Cases and Review of the Literature. World J Surg Oncol 2006;4:19.
[30] Kotan C, Sumer A, Baser M, Kızıltan R, Carparlar MA. An Analysis of 13 Patients with Perforated Gastric Carcinoma: A Surgeon’s Nightmare? World J Emerg Surg 2008;3:17.
[31] Teng TZ, Sudharsan M, Yau JW, Tan W, Shelat VG. Helicobacter pylori knowledge and perception among multi-ethnic Asians. Helicobacter 2021;26:e12794.
[32] Boey J, Choi SK, Poon A, Alagaratnam TT. Risk Stratification in Perforated Duodenal Ulcers. A Prospective Validation of Predictive Factors. Ann Surg 1987;205:22-6.
[33] Boey J, Wong J, Ong GB. Bacteria and Septic Complications in Patients with Perforated Duodenal Ulcers. Am J Surg 1982;143:635-9.
[34] Boyd-Carson H, Doleman B, Cromwell D, Lockwood S, Williams JP, Tierney GM, et al. Delay in Source Control in Perforated Peptic Ulcer Leads to 6% Increased Risk of Death Per Hour: A Nationwide Cohort Study. World J Surg 2020;44:869-75.
[35] Svanes C, Lie RT, Svanes K, Lie SA, Søreide O. Adverse Effects of Delayed Treatment for Perforated Peptic Ulcer. Ann Surg 1994;220:168-75.
[36] Mohan R, Wei Lynn Goh S, Tan GW, Tan YP, Junnarkar SP, Huey CW, et al. Validation of Tokyo Guidelines 2007 and Tokyo Guidelines 2013/2018 Criteria for Acute Cholangitis and Predictors of in-Hospital Mortality. Visc Med 2021;37:434-42.
[37] Lee DJ, Ye M, Sun KH, Shelat VG, Koura A. Laparoscopic Versus Open Omental Patch Repair for Early Presentation of Perforated Peptic Ulcer: Matched Retrospective Cohort Study. Surg Res Pract 2016;2016:8605039.
[38] Zhou C, Wang W, Wang J, Zhang X, Zhang Q, Li B, et al. An Updated Meta-Analysis of Laparoscopic Versus Open Repair for Perforated Peptic Ulcer. Sci Rep 2015;5:13976.
[39] Cirocchi R, Soreide K, di Saverio S, Rossi E, Arezzo A, Zago M, et al. Meta-analysis of perioperative Outcomes of Acute Laparoscopic Versus Open Repair of Perforated Gastroduodenal Ulcers. J Trauma Acute Care Surg 2018;85:417-25.
[40] Lau WY, Leung KL, Kwong KH, Davey IC, Robertson C, Dawson JJ, et al. A Randomized Study Comparing Laparoscopic Versus Open Repair of Perforated Peptic Ulcer using Suture or Sutureless Technique. Ann Surg 1996;224:131-8.
[41] Kwan JR, Lim M, Ng F, Shelat V. Fungal Isolates in Peritoneal Fluid Culture do not Impact Peri-Operative Outcomes of Peptic Ulcer Perforation. Surg Infect 2019;20:619-24.