Chapter 15 Graham Patch Repair
INTRODUCTION
The surgical management of peptic ulcer disease (PUD) has changed dramatically since the 1970s primarily owing to the advancement of medical therapy. With the introduction and widespread use of histamine-2 (H2)–receptor blockers, proton pump inhibitors, and effective treatment of Helicobacter pylori (H. pylori), classic acid-reducing procedures are rarely performed.1 Despite these pharmacologic advances, however, the incidence of perforated duodenal ulcer has changed little. Therefore, a much larger proportion of surgery for PUD is emergent.2,3 In addition to presenting emergently, the typical patient with perforated PUD (PPUD) is 50 to 60 years of age4,5 with comorbid disease and limited physiologic reserve. Therefore, the general surgeon must be adept at identifying which of these patients require surgery and how to perform the necessary procedure(s) and must be familiar with the pitfalls associated with taking care of such patients. This chapter discusses repair of duodenal and juxtapyloric ulcers and excludes other more proximal or distal ulcers.
Perforated duodenal ulcer disease (DUD) is associated with a 2% to 10% mortality rate, with septicemia being the most common cause of death.6–8 Preoperative shock, perforation for greater than 24 hours prior to surgical intervention, and concurrent significant illness have consistently been shown to be predictive of mortality, and the presence of all three risk factors carries a near 100% mortality.7,9–11 Furthermore, some investigators have found that the amount and type of fluid in the abdomen and the patient’s preoperative nutritional status may also be predictive of mortality.8 Given that up to 50% of perforated ulcers seal by the time of operation,12 the challenge is to identify which patients require emergent operation to control the source of sepsis versus those patients that can be treated nonoperatively, thereby avoiding the additional morbidity of a laparotomy.
Omental patch or Graham patch closure of perforated duodenal ulcers was first described in 1929 by Cellen-Jones13 and by Graham in 1937.14 In its original description, a tongue of omentum is held in place over the perforation with suture. More recently, this technique has been performed using a laparoscopic approach. Although multiple reports have documented the safety of laparoscopic repair, no good studies demonstrate the superiority of this approach.10,15–20 Overall, these reports suggest that there is very little difference in outcome between patients undergoing laparoscopic or those having an open approach if the surgeon has advanced laparoscopic training and experience. The postoperative ileus, pain, wound infection rate, and hospital stay are very similar, and any differences noted may be due to bias in the trial design. As such, the decision to proceed laparoscopically should be made based on the surgeon’s experience and comfort with one modality versus the other.
Nonoperative treatment for PPUD can be instituted in very specific circumstances (Box 15-1) and includes antibiotics, treatment for H. pylori, and nasogastric decompression.12,16,21,22 A contrast study is essential to confirm that the perforation has sealed because the physical examination is unreliable for this determination. Assuming that the perforation has, in fact, sealed, this group of patients has an expected mortality rate of 35% to 50% owing to the delay in presentation or severity of comorbid illness(es).23 Of note, patients whose symptoms and physiologic status do not improve within 12 hours of the institution of nonoperative therapy require surgery.12
Box 15-1 Indications for Nonoperative Treatment
From Donovan AJ, Berne TV, Donovan JA. Perforated duodenal ulcer: an alternative therapeutic plan. Arch Surg 1998;133:1166–1171; Jamieson GG. Current status of indications for surgery in peptic ulcer disease. World J Surg 2000;24:256–258; Berne T, Donovan A. Nonoperative treatment of perforated duodenal ulcer. Arch Surg 1989;124:830–832; and Taylor H. Peptic ulcer perforation treated without operation. Lancet 1946;2:441–444.
KEY STEPS14,17,23
OPERATIVE PROCEDURE
Midline Incision
Injury to Visceral Organs
A standard laparotomy incision beginning just caudad to the xyphoid and ending several centimeters above the umbilicus is most often used. A transverse incision can also be used based on the patient’s previous surgical history or surgeon preference. Many, though not all, studies suggest that transverse incisions may be associated with a lower postoperative hernia rate.24–26 Complications related to midline incision and fascial closure are discussed separately in Section I, Chapter 5, Anesthesia for the Surgeon.
Trocar Insertion Injuries (Laparoscopic Approach)
Trocar placement varies based on surgeon preference and experience. One approach utilizes a Hassan trocar in the infraumbilical position, an 11-mm trocar in the left midclavicular line approximately just above the level of the umbilicus, and a 5-mm trocar in the right midclavicular line just above the umbilicus. Complications of trocar insertion are discussed separately in Section I, Chapter 7.
Exposure of the Area of Perforation and Irrigation of Surrounding Spaces
Opening of a Sealed Perforation
• Consequence
Placement of Sutures across the Perforation
Enlargement of the Perforation
• Consequence
• Repair
• Prevention
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