Omental (Graham) Patch

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Omental patching began in 1937, when Roscoe Reid Graham of Toronto reported 51 cases of perforated peptic ulcer successfully treated with an omental patch. ^[1]  In Graham’s initial cases, he concluded that routine gastroenterostomy was unnecessary, the omental patch being more than sufficient for closure of the duodenal perforation. More than 70 years since its initial description, this technique is still extremely useful in selected patients with perforated duodenal ulcers.

The goal of an operative procedure for perforated duodenal ulcers is to provide durable repair of the injury with appropriate source control and limitation of parietal cell acid production. Control over gastric acidity has been traditionally gained by means of vagotomy and drainage or parietal cell vagotomy. However, since the introduction of proton pump inhibitors (PPIs), chemical vagotomy has decreased the rate of surgical vagotomy because of the high efficiency of PPIs in preventing acid production with relative ease.

The discovery that most ulcers can be treated by eradication of Helicobacter pylori has further fueled the move toward minimalist damage-control omental patching in this setting. The modern operative approach to a perforated duodenal ulcer can include omental patching alone with postoperative use of PPIs and eradication of H pylori, as indicated, or it can include an omental patch with surgical control of gastric acid by means of vagotomy and drainage, parietal cell vagotomy, or antrectomy. ^[2] The choice of operation is dictated by the following:

The omental patch alone is indicated in the following circumstances:

Addition of parietal cell vagotomy or vagotomy and drainage can be performed in a certain population of patients, as delineated below. Nevertheless, most patients respond well to postoperative treatment of H pylori and chemical vagotomy with PPIs; mortality, morbidity, and ulcer recurrence with omental patch repair have all been shown to be extremely low. ^{[3, 4]}

Many speculate that the balance will shift further away from definitive antiacid surgical intervention in the future; fewer and fewer vagotomies are being performed, and the newest surgical trainees therefore have less experience in performing these procedures than did the previous surgical generation. Whether the demonstration that long-term PPI use is associated with an increased incidence of hip fractures in the elderly skews this balance in the opposite direction remains to be seen.

Omental patch repair has also been incorporated in the management of perforated gastric ulcers. Perforated prepyloric or pyloric ulcers are amenable to closure with omental patch with minimal tension because of the close proximity of the injury. Gastric ulcers in atypical (more proximal) locations or with features suggestive of malignancy should not be patched but should be wedge-resected unless biopsy and other measures can assure that they are benign. The conservative approach of omental patch repair seems attractive, especially when extensive inflammatory reaction of the pylorus and duodenum is observed, the patient’s hemodynamic status is poor, and rapid control of the septic source is required.

Gastric outlet obstruction is a recognized postoperative complication of patched pyloric or prepyloric ulcers, with a frequency of about 15%. ^[5]  If the ulcer is large and the patient is stable, this complication can be prevented by excision of the ulcer and incorporation of the repair into a Heineke-Mikulicz pyloroplasty. Another indication for this type of repair is in duodenal defects larger than 1 cm to allow prevention of stricture and subsequent obstruction. In clinically stable patients, distal gastrectomy or antrectomy and vagotomy are more aggressive but more definitive surgical options.

Relative indications for adding surgical acid control to an omental patch are as follows:

Preoperative resuscitation

Improving outcome in high-risk surgical patients such as those with a perforated viscus is a fundamental augmentation to surgical treatment for source control. The importance of preoperative resuscitation was underlined by Shoemaker in a study demonstrating improved mortality and morbidity in high-risk surgical patients with supranormal hemodynamic and oxygen transport variables. ^[6]

The Surviving Sepsis Campaign has delineated key steps in the resuscitation of patients in sepsis or septic shock. ^[7]  The clinical improvement noticed with adequate preoperative resuscitation is derived from the concept of optimization of the circulation and augmentation of oxygen delivery to peripheral tissues by an adequate preload that would result in a high stroke volume.

Some of the physiologic parameters described in the original work in this area were derived via pulmonary artery catheters, which have been shown not to yield superior results in terms of mortality compared with therapy directed by central venous pressure measurements. Therefore, commonly used parameters for goal-directed therapy in septic patients are central venous pressure, lactic acid level, and central venous oxygen saturation. Urine output, blood pressure, and heart rate, though key indicators of hemodynamic instability, are less specific and reliable and therefore are insufficient to drive goal-directed therapy in many septic patients.

Closed suction drainage

The occlusive nature of the omental patch repair makes the addition of closed suction draining redundant. The patch is believed to adhere to the inflamed serosal layer of the bowel and thereby seal the perforation. Postoperative abscess rates are essentially the same with or without drains, and drains can themselves cause morbidity (eg, infection or erosion into visceral structures). Draining the free peritoneal cavity is generally believed to be impractical. However, if a walled-off abscess elsewhere in the abdomen accompanies the contamination derived from the perforated ulcer and this abscess cannot be broken up surgically, then a drain may be reasonably placed within the abscess cavity.

Surgical and chemical vagotomy in perforated ulcer disease

With the introduction of PPIs, chemical vagotomy largely supplanted surgical vagotomy, with good success rates. In patients who are not compliant with medical treatment, surgical vagotomy at the initial time or repair for perforated ulcer should be considered. However, as discussed in the text, the hemodynamic status of the patient is a major determinant of the extent of surgical intervention.

Omental patch for perforated gastric peptic ulcer

The option of omental patching of hollow viscus perforation is dependent on the location of the lesion and the microbial flora of the respective portion of the gastrointestinal tract. Prepyloric or pyloric ulcers are in close proximity to the omentum and therefore can be patched with minimal tension, whereas ulcerations on the more proximal curvatures of the stomach probably are not easily accessible with this method. At the same time, the acidic environment in the stomach and proximal duodenum with minimal growth and proliferation of the normal flora of gram positive cocci makes the repair amenable to simple patching, assuring a tight closure upon inflammatory cell recruitment.

Conversely, more proximal gastric ulcers are more likely to be malignant. Malignant perforated ulcers should not be patched, because they are unlikely to seal. Perforated malignant gastric ulcers should be at least wedge-resected if the patient is not stable enough to undergo a more classical cancer resection.

Omental patch repair does not correct the underlying process that causes perforation, and ulcers may recur. In a study of 94 patients with perforated foregut ulcers (53 gastric and 41 duodenal), of whom 77 (82%) were treated by omental patching alone, Smith et al documented a 12% rate of ulcer recurrence after omental patching and a 23% incidence of recurrent symptoms within 44 months. ^[8]

Graham R. The treatment of perforated duodenal ulcers. Surg Gynec Obstet. 1937. 64:235-238.

Chung KT, Shelat VG. Perforated peptic ulcer – an update. World J Gastrointest Surg. 2017 Jan 27. 9 (1):1-12. [Medline]. [Full Text].

Kate V, Ananthakrishnan N, Badrinath S. Effect of Helicobacter pylori eradication on the ulcer recurrence rate after simple closure of perforated duodenal ulcer: retrospective and prospective randomized controlled studies. Br J Surg. 2001 Aug. 88(8):1054-8. [Medline].

Ng EK, Lam YH, Sung JJ, Yung MY, To KF, Chan AC. Eradication of Helicobacter pylori prevents recurrence of ulcer after simple closure of duodenal ulcer perforation: randomized controlled trial. Ann Surg. 2000 Feb. 231(2):153-8. [Medline].

McGee GS, Sawyers JL. Perforated gastric ulcers. A plea for management by primary gastric resection. Arch Surg. 1987 May. 122(5):555-61. [Medline].

Shoemaker WC, Appel PL, Kram HB, Waxman K, Lee TS. Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. Chest. 1988 Dec. 94(6):1176-86. [Medline].

Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017 Mar. 43 (3):304-377. [Medline].

Smith D, Roeser M, Naranjo J, Carr JA. The natural history of perforated foregut ulcers after repair by omental patching or primary closure. Eur J Trauma Emerg Surg. 2017 Jul 29. [Medline].

Pai D, Sharma A, Kanungo R, Jagdish S, Gupta A. Role of abdominal drains in perforated duodenal ulcer patients: a prospective controlled study. Aust N Z J Surg. 1999 Mar. 69(3):210-3. [Medline].

Bergamaschi R, Mårvik R, Johnsen G, Thoresen JE, Ystgaard B, Myrvold HE. Open vs laparoscopic repair of perforated peptic ulcer. Surg Endosc. 1999 Jul. 13(7):679-82. [Medline].

Khoursheed M, Fuad M, Safar H, Dashti H, Behbehani A. Laparoscopic closure of perforated duodenal ulcer. Surg Endosc. 2000 Jan. 14(1):56-8. [Medline].

Siu WT, Leong HT, Law BK, Chau CH, Li AC, Fung KH, et al. Laparoscopic repair for perforated peptic ulcer: a randomized controlled trial. Ann Surg. 2002 Mar. 235(3):313-9. [Medline]. [Full Text].

Siow SL, Mahendran HA. Laparoscopic repair of perforated peptic ulcers: the sutured omental patch and focused sequential lavage technique. Surg Laparosc Endosc Percutan Tech. 2014 Apr. 24 (2):134-9. [Medline].

Wang YC, Hsieh CH, Lo HC, Su LT. Sutureless onlay omental patch for the laparoscopic repair of perforated peptic ulcers. World J Surg. 2014 Aug. 38 (8):1917-21. [Medline].

Sanabria A, Villegas MI, Morales Uribe CH. Laparoscopic repair for perforated peptic ulcer disease. Cochrane Database Syst Rev. 2013 Feb 28. 2:CD004778. [Medline].

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. [Medline]. [Full Text].

Lee FY, Leung KL, Lai PB, Lau JW. Selection of patients for laparoscopic repair of perforated peptic ulcer. Br J Surg. 2001 Jan. 88(1):133-6. [Medline].

Malkov IS, Zaynutdinov AM, Veliyev NA, Tagirov MR, Merrell RC. Laparoscopic and endoscopic management of perforated duodenal ulcers. J Am Coll Surg. 2004 Mar. 198(3):352-5. [Medline].

Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010 Jan 15. 50(2):133-64. [Medline].

Shan YS, Hsu HP, Hsieh YH, Sy ED, Lee JC, Lin PW. Significance of intraoperative peritoneal culture of fungus in perforated peptic ulcer. Br J Surg. 2003 Oct. 90(10):1215-9. [Medline].

Razvan C Opreanu, MD, MS Resident Physician in General Surgery, Department of Surgery, Michigan State University College of Human Medicine

Razvan C Opreanu, MD, MS is a member of the following medical societies: American College of Surgeons, American Society of Colon and Rectal Surgeons

Disclosure: Nothing to disclose.

Marc D Basson, MD, PhD, MBA, FACS Senior Associate Dean for Medicine and Research, Professor of Surgery, Pathology, and Biomedical Sciences, University of North Dakota School of Medicine and Health Sciences

Marc D Basson, MD, PhD, MBA, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Gastroenterological Association, Phi Beta Kappa, Sigma Xi

Disclosure: Nothing to disclose.

Julian E Losanoff, MD, MHA, MSS Professor of Surgery, University of Nevada-Las Vegas School of Medicine; Adjunct Professor of Surgery, Touro University College of Osteopathic Medicine; Chief of Surgery, VA Southern Nevada Healthcare System

Julian E Losanoff, MD, MHA, MSS is a member of the following medical societies: American College of Surgeons, Southern Medical Association

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Omental (Graham) Patch

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