Omental (Graham) Patch

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 80 years after 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:

• Pathology responsible for the perforation
• Patient’s premorbid health status
• Patient’s perioperative hemodynamic status
• Degree of contamination of the peritoneum that has been found

The omental patch alone is indicated in the following circumstances:

• Generalized peritonitis
• Hemodynamic instability with shock
• Perforation for more than 24 hours
• Perforation clearly associated with the use of nonsteroidal anti-inflammatory drugs (NSAIDs)
• Patient has not had significant symptoms for 3 months before the procedure

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]

It is possible 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 will skew the balance in the opposite direction remains to be seen.

Omental patch repair has also been incorporated in the management of perforated gastric ulcers.[5] 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%.[6]  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:

• Hemodynamic stability (localized peritonitis and minimal spillage of gastroduodenal contents)
• Short duration of preoperative acute symptoms (< 12-24 hr)
• Failure of medical therapy
• Noncompliance with medical therapy
• Need for postoperative NSAIDs
• H pylori negative testing
• Chronic history of peptic ulcer

Omental patching with purse-string endosuture closure has been proposed as a potential means of closing large iatrogenic defects after endoscopic full-thickness resection (EFTR) of gastric gastrointestinal stromal tumors (GISTs).[7, 8]

Procedural planning

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.[9]

The Surviving Sepsis Campaign delineated key steps in the resuscitation of patients in sepsis or septic shock.[10]  The clinical improvement noticed with adequate preoperative resuscitation was 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 as compared with therapy directed by central venous pressure (CVP) measurements. Therefore, commonly used parameters for goal-directed therapy in septic patients are CVP, 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 whether drains are placed or not, 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 reasonably be 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 (GI) 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, 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.[11]

In a systematic review and meta-analysis (29 studies; N = 5311) comparing the outcomes of open (n = 3624) and laparoscopic (n = 1687) omental patch repair for perforated peptic ulcer, Chan et al found that the laparoscopic approach was associated with lower mortality, decreased overall morbidity, shorter length of stay, less intraoperative blood loss, and reduced postoperative pain as compared with the open approach.[12]  

Resuscitation of the patient plays a crucial role in the management of a patient with perforated duodenal ulcer. An increase in preload with reduction of the afterload and improvement of stroke output is ideal. This also allows the patient to compensate for the reduction in preload engendered by positive-pressure ventilation during and often after surgery.

Resuscitation is usually facilitated by using a central venous catheter to measure central venous pressure (CVP). This allows the surgeon to resuscitate the patient more aggressively toward a prechosen CVP goal.

Monitoring of urine output and lactic acid also provides important insights into the preoperative resuscitation of a hemodynamically labile patient.

Consideration should be given to placement of an arterial catheter for hemodynamic monitoring and prompt arterial blood gas measurements based upon the degree of shock present. This can be established preoperatively during fluid resuscitation or by the anesthesia team after induction to allow timely surgical intervention. Resuscitation should be expeditious because a delay in operation is associated with increased morbidity and mortality.

Preoperative decompression of the stomach using a nasogastric tube limits further spillage of gastrointestinal (GI) secretions into the peritoneum during the resuscitation period.

Broad-spectrum antibiotic coverage is initiated preoperatively and continued postoperatively for a duration dependent on the patient’s clinical status and the degree of intra-abdominal spillage.

General anesthesia is used for either open or laparoscopic omental patch repair of perforated duodenal ulcer.

After the patient is placed in supine position on the operating table, the abdomen is prepared and draped in a standard fashion. Transverse epigastric or subcostal incisions have been described; however, an upper midline incision is generally the preferred route for entry into the peritoneal cavity in this setting. In addition to providing good surgical exposure, an upper midline incision also permits extension inferiorly if a perforated ulcer is not found and the remainder of the bowel is to be inspected or manipulated.

Suctioning of gastrointestinal (GI) spillage and of any fibrinous exudates is quickly performed, and attention is turned to inspection of the duodenum and visualization of the perforation. The perforation can be usually found on the anterior wall of the duodenum, in proximity to the duodenal bulb. If the perforation is not apparent, mobilization of the duodenum along with inspection of the stomach and jejunum should be carried out next.

Once the bowel perforation is identified, sponges can be used to flank the duodenum to prevent further spillage of gastroduodenal contents. Materials commonly used for repair are nonabsorbable sutures (eg, silk) or monofilament absorbable sutures (eg, polydioxanone). The suture can be either a 2-0 or 3-0 on a small half-circle swaged needle.

In the original description of the technique, the full-thickness bites were placed approximately 0.5 cm away from the edges of the perforation from one margin to the other. A theoretical hazard with the full-thickness bites is passing the needle through the posterior duodenal wall. Commonly, three or four sutures are placed perpendicularly between the edges of the perforation and are laid out on each side of the duodenum (see the image below).

A patch of omentum is brought without tension and positioned over the perforation, and the sutures are successively tied from the superior to the inferior aspect across the omental patch to anchor the omental graft in place (see the images below)

An important feature of a sturdy repair is reliant on the tying technique. The applied tension to the sutures should be strong enough to stabilize the omentum in place but loose enough to preserve the omental blood supply. Strangulation of the omental patch from increased tension on the knots is associated with failure of the repair and continued postoperative leakage. In the classical repair, the sutures are not passed through the omentum but only tied around it. Another variation is to use seromuscular sutures rather than full-thickness bites on the duodenum.

After surgical repair has been accomplished, some surgeons perform a leak test to allow detection of technical errors. This can be accomplished either with endoscopic insufflation of air or with instillation of methylene blue proximal to the perforation and manual distal compression of the duodenum. Other surgeons, however, argue that this step is unnecessary, because the repair need not initially be completely occlusive against hydrostatic pressure. These surgeons argue that the goal of the repair is to secure the omentum across the perforation, allowing it subsequently to adhere to the inflamed serosa and thereby seal the perforation.

The peritoneal cavity is then irrigated with 10 L of warm saline solution to remove further contamination. Particular care is taken to irrigate the suprahepatic and infrahepatic recesses, the lesser sac, the paracolic gutters, and the pelvis.

Optionally, drainage of the areas close to the perforation can be attempted if a concern about possible leakage from the ulceration exists. For this purpose, a Jackson-Pratt drain is sometimes placed in the paraduodenal area or infrahepatic space. The purported advantages of such drainage include the early detection of a postoperative leak and provision of controlled drainage using the closed suction drain if a leak does occur. However, drainage should be selective because routine placement of drains has been found to be associated with significant morbidity and infection with no changes in incidence of postoperative intra-abdominal abscesses.[13]

The abdomen is then closed in the usual fashion with continuous or interrupted sutures of polypropylene or polydioxanone. If substantial edema of the bowel causes tension on the fascial edges upon attempted closure, then the abdomen may be managed open by means of various techniques, including vacuum-assisted closure, the Wittmann patch, and a number of other options.

A variant of the classical technique that is used by some surgeons is the modified omental patch. After sutures are placed between the edges of the perforation in a standard fashion, they are tied in an attempt to close the wall defect. Without cutting of the sutures, a segment of omentum is then brought on top of the closed perforation and tied knots, and the same sutures are used to tie down the omental patch over the already approximated perforation.

Opponents of this modified technique express concern regarding the seal obtained from the omentum when suture knots are interposed between the duodenal serosa and the omental patch. Furthermore, the apposition of omentum is not as broad as with the original omental patch. To date, however, the literature has not provided definitive conclusions regarding the differences in morbidity or mortality associated with each of these techniques.

Another variant of the standard technique is the use of seromuscular (Lembert) suture placement instead of full-thickness bites. This is accomplished without entry into the duodenal lumen, and these sutures theoretically have a lower risk of passing the needle through the posterior wall, minimizing the risk of obstruction. Seromuscular sutures are generally used during laparoscopic repair of perforated duodenal ulcers.

Another variant, used when the omentum is not available (because of previous surgery, necrosis, or unfavorable anatomy), is the Thal patch, in which a loop of jejunum is used to patch the perforation (see the image below). In this case, seromuscular sutures are used to attach the serosal side of a loop of jejunum across the ulcer defect.

Laparoscopic omental patch closure of perforated duodenal ulcer has become increasingly common as the field of minimally invasive surgery has grown. Initial reports demonstrated little difference between laparoscopy and laparotomy for omental patching; however, subsequent reports suggested that selected patients approached laparoscopically exhibit shorter length of stay (LOS), less postoperative pain, and earlier return to daily activities.[14, 15, 16, 17, 18, 19, 20, 21]  A 2020 study by Coe et al found no differences between open and laparoscopic omental patch repair of perforated peptic ulcer with respect to 90-day mortality, median LOS, or readmission to critical care.[22]

Patient selection plays an important role in the success of laparoscopic omental patching. Delayed (>24 hr) presentation, hemodynamic instability, high acute physiology, and chronic health evaluation scores are each associated with significantly increased likelihood of postoperative leak, and laparotomy is therefore indicated in such patients.[23]

In addition, skill in laparoscopic technique is also required for such procedures. Some surgeons perform intraoperative esophagogastroduodenoscopy (EGD) to aid in identification of the perforation and stabilization of the omental patch until laparoscopic suturing can be performed.[24] The need for intraoperative EGD is dictated by the experience of the laparoscopic surgeon and the difficulty of the case.

At present, both open and laparoscopic approaches to omentopexy are within the standard of care, depending on the experience of the surgeon and the condition of the patient. Laparoscopic omental patch repair appears to be safe and effective as treament for perforated peptic ulcer in children as well as in adults.[25]

Resuscitation

After the procedure, the resuscitation that began in the early preoperative phase is continued with the use of crystalloid solutions. The goals of resuscitation focus on urinary output, lactic acid levels, mean arterial pressure (MAP), and central venous pressure (CVP) parameters. Vasopressors may sometimes also be required, depending on the patient’s hemodynamic status and response to resuscitative intervention.

Nutrition

Many patients requiring this type of repair were malnourished before their perforation, and others become malnourished during a prolonged postoperative septic and catabolic state. Attention to nutrition is therefore important. Healing of the duodenal perforation or operative incision must be augmented by improved nutritional status in the early postoperative period.

Oral feeding is likely to be delayed because of the need for the ileus to resolve and the omental patch to heal. Some patients may benefit from intraoperative placement of a jejunostomy feeding tube. This is especially worth considering in elderly or debilitated patients who are expected to have a prolonged hospitalization and deprivation of oral nutrition.

The disadvantages associated with adjunctive surgical jejunostomy feeding tubes include prolongation of the operative case, as well as the complications of jejunostomy, including leaks, obstruction, and internal herniation. Many patients requiring an omental patch are initially hemodynamically unstable, and an approach with minimal intraoperative time under general anesthesia is often preferred.

An alternative to jejunostomy feeding is intraoperative or postoperative placement of a double-lumen gastrojejunal tube to allow simultaneous decompression of the stomach and delivery of enteric nutrients distally to the omental patch repair. Parenteral nutrition is sometimes alternatively used, but as a rule, enteral nutrition distal to the perforation is preferable if possible.

Antimicrobial therapy

Duodenal perforation with localized or generalized peritonitis and spillage of enteric contents in hemodynamically unstable patients found in sepsis or septic shock is considered a complicated intra-abdominal infection. The 2010 guidelines from the Infectious Diseases Society of America (IDSA) and the Surgical Infection Society (SIS) stated that antimicrobial therapy should be continued postoperatively for 24 hours when the perforation has been surgically closed in the first 12 hours.[26]

If resolution of clinical signs of infection, including normalization of white blood cell count and temperature, does not occur after 24 hours postoperatively, antimicrobials can be continued for 4-7 days. Either a combination of a beta-lactam with a beta-lactamase inhibitor (eg, amoxicillin-clavulanate) or a carbapenem (eg, ertapenem or imipenem) is preferred. (See Antibiotic Therapy for Peritonitis.)

Some authors have suggested that in patients with positive peritoneal fungal cultures or an elevated Mannheim Peritonitis Index score, antifungal therapy could also be of benefit[27] ; however, this suggestion has been controversial. A study by Barmparas et al found that empiric antifungal therapy did not significantly reduce the incidence of organ-space infection in the setting of surgical treatment of perforated peptic ulcer and was therefore unnecessary in that setting.[28]  

In cases where there is evidence of persistent or recurrent infection after 4-7 days of therapy, the presence of abscesses or missed intraoperative injuries is certainly a possibility. At the same time, other sources of infection, like urinary or respiratory tract, catheters, and lines, should be investigated after intra-abdominal insults are ruled out.

H pylori eradication should also be considered. Some surgeons may opt for empiric postoperative eradication with antisecretory medications and antibiotics once the patient is tolerating an oral diet, whereas others choose to test for H pylori and then treat only patients who test positive for H pylori. Eradication significantly decreases morbidity, mortality, and ulcer recurrence in patients with perforations associated with H pylori.[3, 4] (See Helicobacter Pylori Infection.)