Smaller ulcers (1-3 cm) can be repaired with a Graham patch. Primary closure of small ulcers (< 1 cm) before patching may be considered. However, some concern exists over decreased adherence of the omentum on serosa versus mucosa.
Larger ulcers (> 3 cm) can be repaired with a jejunal serosal repair (Thal patch) to decrease the risk of recurrent leakage. A drain should be placed.
After patch repair, pyloric exclusion with gastrojejunostomy (Billroth II or Roux-en-Y) should be considered to assist with healing of larger ulcers. A jejunostomy tube should also be placed at the time of operation.
Thorough abdominal lavage should be performed at the completion.
Posterior ulcer perforation:
Resection of the ulcer segment should be performed as feasible with caution given to the ampulla of Vater if the ulcer occurs past the first segment of the duodenum.
Antrectomy is performed with Billroth I/II or Roux-en-Y reconstruction. Tension may limit the use of Billroth I reconstruction.
A nasogastric tube and drains are necessary. H pylori treatment is warranted if applicable.
Scar tissue and inflammation may make both the mobilization of the duodenum (adherent to posterior tissues such as the pancreas) and closure (duodenal stump leak) an issue.
If Billroth I is not possible, there are several techniques for difficult duodenal stump closure (Nissen-Bsteh) that attempt to reinforce the closure.
Educational aid only. Verify every dose, indication, and guideline against current institutional protocol. This is not a substitute for clinical judgment.
