Surgical Management For Gastric Ulcer Perforation

Surgical Management for Gastric Ulcer
Perforation
Surf
Denny Septarendra
Digestive Surgeon Soetomo Hospital
Surgical Management for Gastric
Perforation
 There’s a hole in my bucket..how should I mend it?

 Just patch it!
 Moshe Schein
 “ Every doctor, faced with a perforated ulcer of
the stomach or intestine, must consider opening
the abdomen, sewing up the hole, and averting a
possible or actual inflammation by careful of yhe
abdominal cavity “ ( Johan Mikulicz, 1850-1905)
Current Indication for Surgical
Intervention
 1. Bleeding  Most Common Complication 
100 per 100.000 population
 2. Perforation  11 per 100.000 population 
highest rate of mortality
 3. Obstruction  scarring of prepyloric and
duodenal ulcers
 4. Failed Medical therapy  PPIs
 5. Risk of Malignancy  large gastric ulcers
Modified Johnson Classification
Type Location Acid secretion

I Lesser Curvature Low
II Body of Stomach and duodenum High
III Prepyloric (2-3 cm of pylorus) High
IV High on Lesser Curve, near GEJ Low
V Anywhere, induced by medication Low
Gastric Perforation
 Smoking and NSAIDs  etiologic factors for

ulcer perforation  particularly older woman
 The outcome of patients depends on:
 1. Time Delay to presentation and treatment
 2. Site of perforation  gastric perforation
poorer prognosis
 3.Patient’s age elderly  worse outcome
 4. Presence of hypotension (systolic <100) 
Worse outcome
Gastric Perforation
 perforation was most common at the

duodenal bulb (62%), pyloric region (20%),
and the gastric body (18%)
Gastric Perforation
 Perforated gastric ulcer have a higher rate of
reperforation and complications
 Conservative therapy in situations where the
source is gastric perforation, is not
recommended.
 H. pylori infection  70–90% of duodenal
ulcers and 30–60% of gastric ulcers 
antibiotic therapy is very effective at
eradication.
Surgical Management
 It is important to quickly diagnose a

perforated peptic ulcer.
 The prognosis is improved if treatment is
provided within 6 hours of perforation.
 Delay in treatment beyond 12 hours  an
increase in both morbidity and mortality
Surgical Management
 A prospective study of patients 

perforations >48 hours, pre-operative shock,
and concurrent medical illness were
associated with an increase in mortality.
The goals of Surgical
procedures
 1. Permit ulcer healing
 2. Prevent or treat ulcer complication
 3. Address underlying ulcer etiology
 4. Minimize postoperative digestive
consequence
 “ No single therapy Procedure satisfies all

these objectives “
Emergency Surgery for Complicated
Peptic Ulcer Disease
 1. Deal with the complication that
necessitated surgical intervention
 2. Reduce the risk of future ulcer recurrence
 3. Perform a safe, quick and effective
operation
 4. Minimize long-term effects on the GI tract
 5. Establish the H.Pylori status of the patient
 The therapeutic goal in a perforated peptic
ulcer is to repair the hole in the GI tract and
treat peritoneal contamination.
 Operative intervention is almost always
indicated in the treatment of perforated
peptic ulcers.
 Emergency surgery for a perforated peptic
ulcer has a 6–30% risk of mortality
 The choice of operation will depend on the
site of perforation found at exploration and
Sistemic condition.
 The most common technique  patch repair
with an omental pedicle  Graham patch or
omentopexy
 In this technique the ulcer is not closed ->
pedicle of vascularized omentum is sutured
over the perforation site with multiple
interrupted sutures
 Can be performed by a laparoscopic or open
approach  ulcers over 10 mm in size appear
to increase the risk of conversion to open
surgery.
 There were no significant differences
between the groups receiving an open or
laparoscopic repair in terms of mortality,
incidence of reoperation, or in the
identification of post-operative intra-
abdominal fluid collections
 Vagotomy and pyloroplasty is the easiest
operation to perform, but has an 10–15%
ulcer recurrence rate.
 Vagotomy with antrectomy  ulcer
recurrence rate is very low.
 The disadvantages are that the operative
mortality is higher than either of the other
procedures
 The choice of definitive operation should
depend on the experience of the surgeon.
 In the absence of significant experience with
ulcer surgery, vagotomy and pyloroplasty or
not performing definitive surgery in the
emergent setting  not recommended
 Malignancy 4–14% of gastric perforations 
biopsy or excision of the ulcer  important
Omentoplasty or Omental patch ?
Necessary or not?
 Cellan-Jones 1929 after excision of friable
edges, the application of purse string sutures
and on top an omental graft
 Problem Narrowing of the duodenum
 To Avoid that Suggested omentoplasty
without primary closing of the defect
 “ Do not stitch the perforation but plug it with
viable omentum and patch a perforation ulcer
if you can, if you cannot, then you must
resect” ( Mosche Schein)
Is an Omentoplasty is Sufficient or is a
Definitive ulcer operation required
 1. Is the performance of an operation

indicated?
 2. Is an omental “Plication” sufficient or is
definitive ulcer operation?
 3. Is the patient stable enough to undergo a
definitive ulcer operation?
 4. Which definitive ulcer operation is
indicated?
 5. Laparoscopic or Laparotomy
Omentum: A unique organ of
exceptional Versality
 Protect the peritoneal cavity Collections of
macrophages
 Limits the spread of infection “The policeman of the
abdomen”
 Potent Lymphatic absorb enormous of oedeme fluids
 Highly vascular organ  promote the Growth of blood
vessels
 Source of Growth factors, neurotransmitter,
Neurotrophic factors and inflammatory mediators
 Contains omnipotent stem cells  can differentiate into
a variety of cell types
 Alagumuthu M, Das B et al. The omentum: a unique organ of exceptional versatility
Indian Journal of Surgery 2006; 68(3): 136-141
Re-leak following omentoplasty
 The rate leak reported 2-7,6%

 1. Age>60 years
 2. Pulse rate >110/minute
 3. Blood pressure <90 mmhg
 4. Hb , 10 g/dl
 5. Serum albumin < 2,5 g/dl
 6. Total lymphocyte count < 1800 cells/mm3
 7. Size of operation > 5mm
Irigation of the Peritoneal cavity
 Some Surgeons  Doubt the usefulness of

Irrigation  but Nothing has been found in
the literature supporting this theory
 Irrigation  One of the most Important parts
of surgery  6-10 liters even up to 30 litres of
warm saline are recommended
Drainage or not?
 Still controversial
 80% no need
 Drain Will not reduce the incidence of
intraabdominal fluid collections or abcesses
(Schein.M)
 10% can become infected and intestinal
obstruction
 Often left it as a sentinel
Surgical Reconstruction
 Both Billroth reconstruction  lead to bile

reflux  5-35%
 To avoid that  Roux-en-Y reconstruction
(Roux 1897)
 Roux-en-Y reconstruction  plaqued with a
Roux stasis syndrome
 Braun variaton Billroth (1893)  lower
incidence of Bile reflux  some authors
recommend this as standard reconstruction.
 Others promote “uncut” Roux-en-Y
Braun anastomosis vc Roux-en-Y
 Clinical StudyBillroth II with Braun

Enteroenterostomy Is a Good Alternative
Reconstruction to Roux-en-Y
Gastrojejunostomy in Laparoscopic Distal
Gastrectomy
 Long-Hai Cui, Sang-Yong Son, Ho-Jung Shin, Cheulsu Byun,
Hoon Hur, Sang-Uk Han, and Yong Kwan Cho
 Gastroenterology Research and Practice Volume 2017 (2017), Article ID

1803851, 6 pageshttps://doi.org/10.1155/2017/1803851
 BII Braun anastomosis successfully diverted a
substantial amount of bile from the remnant
stomach, this method may be a good
alternative to RY reconstruction in preventing
bile reflux.
Complication of Ulcer Operations
 1. Early Satiety
 2.postvagotomy syndrome  diare  30%
 3. Dumping Syndrome  20%
 4. Alkaline Reflux gastritis  10%
 5. Afferent and Efferent loop syndrome 
Mechanical obstr of the limb kinking,
anastomosis narrowing, or adhesion
 6. Roux stasis syndrome
 7. Recurrent Ulceration
 8. Anastomosis leaks
Conclusion
 Gastric ulcer perforation is common problem

 To Choose the best operation, the surgeon
must consider charateristics on the ulcer
(location, Chronicity, type of complication),
the likely etiology, the patient age and the
operation
 The morbidity of ulcer disease id replaced by
the morbidity of the operation .

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Surgical Management for Gastric Ulcer

 There’s a hole in my bucket..how should I mend it?

Type Location Acid secretion

 Smoking and NSAIDs  etiologic factors for

 perforation was most common at the

 It is important to quickly diagnose a

 A prospective study of patients 

 “ No single therapy Procedure satisfies all

 1. Is the performance of an operation

 The rate leak reported 2-7,6%

 Some Surgeons  Doubt the usefulness of

 Both Billroth reconstruction  lead to bile

 Clinical StudyBillroth II with Braun

 Gastroenterology Research and Practice Volume 2017 (2017), Article ID

 Gastric ulcer perforation is common problem

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