Operative Repair of Perforated Duodenal Ulcer
A 31-year-old man undergoes emergency laparotomy after 12 hours of severe epigastric pain, a rigid abdomen and free subdiaphragmatic air. At operation there is a 5 mm perforation on the anterior wall of the first part of the duodenum with generalized peritoneal soiling. He is hemodynamically stable. Which of the following is the most appropriate operative management?
- A.Highly selective vagotomy and pyloroplasty
- B.Distal gastrectomy with reconstruction
- C.Simple closure with omental patchCorrect
- D.Truncal vagotomy and pyloroplasty
Explanation
The operative priority in a perforated duodenal ulcer with peritoneal contamination is rapid, safe source control, not definitive acid-reducing surgery. Simple suture closure buttressed with a vascularized tongue of omentum, the Graham or modified Graham patch, is the gold standard for a small anterior duodenal perforation. The omentum provides a well perfused biological seal that tolerates the friable, inflamed duodenal tissue better than sutures alone. The procedure is quick, can be performed laparoscopically or open, and is combined with thorough peritoneal lavage and drainage. Because potent acid suppression with proton pump inhibitors and eradication of Helicobacter pylori now cure the underlying ulcer diathesis medically, the historical acid-reducing operations have essentially disappeared from emergency practice. Truncal vagotomy with pyloroplasty and highly selective vagotomy add operative time, denervation side effects such as diarrhea and dumping, and anastomotic risk in a contaminated field for no added benefit. Distal gastrectomy is a major resection reserved for a giant perforation, a perforated gastric ulcer suspicious for malignancy, or a perforation not amenable to patch closure. Postoperatively the patient should be tested and treated for Helicobacter pylori and started on a proton pump inhibitor.
Why each option
- A.
- Highly selective vagotomy is technically demanding and time-consuming, and is inappropriate in a contaminated peritoneal cavity when medical therapy controls acid effectively.
- B.
- Distal gastrectomy is an unnecessarily extensive, high-risk resection for a small anterior duodenal perforation and is reserved for giant or malignant-appearing perforations.
- C.
- Correct. Simple closure reinforced with an omental patch achieves rapid source control with minimal operative trauma and is the standard of care.
- D.
- Truncal vagotomy with pyloroplasty is a definitive acid-reducing procedure that adds time and morbidity and is obsolete in the emergency setting given modern acid suppression.
Reference: Schwartz's Principles of Surgery, 11th ed., 2019, chapter on Stomach
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