Management of Perforated Duodenal Ulcer
Initial Assessment and Management
- Patients presenting with rigid abdominal pain and free air on direct graphy require immediate surgical intervention, as every hour of delay from admission to surgery is associated with a 2.4% decreased probability of survival 1
- Operative treatment is strongly recommended for patients with significant pneumoperitoneum, extraluminal contrast extravasation, or signs of peritonitis 3
Surgical Approach Selection
- For hemodynamically stable patients with perforated duodenal ulcer, a laparoscopic approach is suggested 4
- Open approach should be considered for patients with hemodynamic instability, severe sepsis, or when laparoscopic expertise is unavailable 4
Primary Repair with Omentopexy
- For duodenal ulcers smaller than 2 cm, primary repair with omentopexy is the standard treatment 5
Management Based on Perforation Size
- For perforations between 1-2 cm, primary repair with omentopexy remains the standard approach 4
- For large perforations (≥2 cm), more complex procedures may be required based on the location of the perforation 6
Alternative Procedures for Complex Cases
- For large duodenal perforations (>2 cm) or those close to the ampulla of Vater, more complex procedures may be necessary 6
- Several different procedures such as jejunal serosal patch, Roux en-Y duodenojejunostomy, or pyloric exclusion may be considered for large defects when primary repair is not feasible 6
Special Considerations
- The proximity of the perforation to the common bile duct and ampulla of Vater must be thoroughly investigated 6
- Intraoperative cholangiography may be necessary to verify common bile duct anatomy in complex cases 6