Laparoscopy allows the confirmation of the diagnosis and furthermore allows the identification of the position, site, and size of the ulcer 27, 48, 49. Generalized peritonitis requiring reoperation after leakage. Seventytwo patients mean age 43 years, 62 males with perforated gastric ulcers were managed by laparotomy. Every year peptic ulcer disease pud affects 4 milion people around the world. Clinical advice supports a different code be used for omental patch for an ulcer that is perforated but not bleeding. An alternative plan for the treatment of a perforated duodenal ulcer is proposed. Jan 25, 2017 laparoscopic graham patch repair of a perforated marginal ulcer 6 yrs after rygb duration. Initial biopsy and followup endoscopy with repeat biopsy is essential to avoid missing an underlying malignancy. A graham patch defines a surgical procedure to close an opening in the duodenum caused by a peptic ulcer. Introduction omental patching began in 1937, when dr. The management of large perforations of duodenal ulcers. The dominant treatment of perforated duodenal ulcer in the first half of the 20th century was surgical closure. Comparison between omental implantation and omental patch for. Comparison of closure of gastric perforation ulcers with.
Early diagnosis, prompt resuscitation and urgent surgical intervention are essential to improve outcomes. If laparotomy is undertaken and a straightforward duodenal ulcer encountered, closure with an omental patch is wellestablished as the optimal procedure. As there is no specific cpt for graham patch operation in the current cpt manual, you should bill. Diagnosis and treatment of perforated or bleeding peptic. Omental patch repair effectively treats perforated marginal. The only proven advantage of the laparoscopic technique appears to be decreased postoperative pain. Another possible code would be suture, ulcer, perforated duodenal gastric 3037510 887. This video is a stepbystep approach to the technique of laparoscopic repair of perforated peptic ulcer with omental patch.
Laparoscopic graham patch repair of a perforated marginal ulcer 6 yrs after rygb duration. Laparoscopic omental patch repair for perforated peptic ulcer. What is the correct code for a graham patch omentoplasty used to repair a perforated duodenal ulcer. This case illustrates a pneumoperitoneum from perforated gastric ulcer. Omental implantation, a surgical procedure in which a perforated gastric or duodenal ulcer is repaired by drawing and implanting a portion of the omentum into the digestive tract, accelerates ulcer healing and inhibits ulcer recurrence compared with omental patch from clinical results.
We will focus on the nowrecognized role of helicobacter pylori in the genesis of the majority of duodenal ulcers and on the high rate of success of therapy with a combination of antibiotics and a protonpump inhibitor or histamine 2 blocker in treatment of such ulcers. Perforated peptic ulcer ppu complicates 2 to 10% of patients with peptic ulcer disease and has mortality risk of up to 20%. The classic triad of sudden onset of abdominal pain, tachycardia and abdominal rigidity is the hallmark of perforated peptic ulcer. A perforated ulcer, also known as a gastric perforation or peptic ulcer, is a serious medical condition in which an already formed untreated ulcer burns through the walls of the stomach or any other section of the gastrointestinal tract, thereby allowing the digestive juices and other stomach acids to flow into the abdominal cavity, causing.
Historically, repair with the adjunct of an omental patch was considered the standard laparoscopic procedure for perforated peptic ulcer repair. Generalized peritonitis requiring reoperation after leakage of. A standardized gastric perforation was created in 10 pigs. This belief is a now matter of debate as multiple studies showed the addition of an omental patch does not add benefits to a simple suture repair, but it significantly increases the operation time. Patients and methods between october 1993 and october 1997, 30 patients underwent laparoscopic graham patch repair of perforated duodenal ulcers and 16 had an open repair. Diagnosis and management of perforated duodenal ulcers. Perforated peptic ulcer ppu is a common surgical emergency and treatment involves omental patch repair pr.
Intraoperatively, a prepyloric perforated ulcer approximately 2 mm in size was discovered. This is a report of an experimental method for endoscopic repair of anterior gastric perforations with an omental patch developed by using a porcine model. Repair of perforated ulcer department of health, victoria. The current treatment of perforated peptic ulcers is primary closure, supported by the application of an omental patch. Purulent contamination was reported in the right upper quadrant and pelvis. Setting department of surgery, moi grahams omental patch and copious irrigation of a proximal gastric vagotomy or taylor procedure laparoscopic repair of duodenal ulcer perforation is as peptic ulcer is the most common cause of ugib. The classic, pedicled omental patch that is performed for the plugging of these perforations was first described by cellanjones in 1929, although it is commonly, and wrongly attributed to graham, who described the use of a free graft of the omentum to repair the perforation in 1937. Called the omentum, this piece of fatty tissue hangs from the stomach and drapes into the abdomen. Laparoscopic surgery, when optimized by a simple repair without an omental patch and 10 mm of a largechannel aspiratorirrigator, may be safely and effectively applied to the patients with small duodenal perforated peptic ulcers may 08, 2020 a graham patch defines a surgical procedure to close an opening in the duodenum caused by a peptic ulcer. Experimental endoscopic repair of gastric perforations with. The doctor creates the omental flap and sutures it to the site of the duodenal ulcerwound to repair it. Laparoscopic way of dealing the perforated peptic ulcer is now frequently performed in areas of expertise worldwide. Studies have shown that the ulcer recurrence rate was as high as 42% in perforated duodenal ulcer patients who underwent simple omental patch repair 72, 73. Perforated peptic ulcer is a common emergency condition worldwide, with associated mortality rates of up to 30%.
Complications are encountered in 10%20% of these patients and 2%14% of the ulcers will perforate 2, 3. Sep 26, 2015 perforated peptic ulcer ppu is a surgical emergency and is associated with shortterm mortality and morbidity in up to 30 and 50% of patients, respectively. The diagnosis of a perforated duodenal ulcer in a rygp patient can be challenging, and there is variability in the surgical treatment, especially when it comes to the possible role of removing the gastric remnant. Recent reports confirm that omental patch closure of peptic ulcer perforations, combined with medical therapy for acid hypersecretion and helicobacter pylori, yield excellent results with low. The surgeon uses sutures to secure the patch and close the perforation. This study analysed the outcome of these operative options in a single institution. Jun 25, 2005 duodenal ulcer perforations are a common cause of peritonitis. The stitch was left open, and a tongue of omentum was then placed over the ulcer and tied down with stitches.
The operation report states suture of perforated peptic ulcer, omental patch fixed operation report attached. Management of perforated gastric and duodenal ulcers. The traditional management of a perforated duodenal ulcer has been a graham omental patch and a thorough abdominal lavage. Lap graham patch of duodenal ulcer general surgery. Laparoscopic repair of perforate gastric ulcer with. There was no obvious explanation to account for these duodenal to gastric ulcer ratio differences.
Perforated marginal ulcer represents a significant complication of rygb. Even though its nearer to cpt 43840, still you should not code it. Outcomes of omental patch repair in large or giant. An appropriatelysized tongue of tensionfree, wellvascularized omentum is. The current advice at our organisation is to code as repair of site being patched. Oct 22, 2019 omental patch repair is the mainstay of surgical management and gastric resectional procedures are advocated for a largegiant ulcer or suspected malignancy, according to the researchers led by dr vishal shelat from tan tock seng hospital, singapore. Although helicobacter pylori and use of nonsteroidal antiinflammatory drugs are common causes, demographic. We present two cases of a perforated duodenal ulcer following rouxeny gastric bypass and discuss the management of these patients.
More than half of the cases are female and they are. In this study, grahams omental patch of the perforations with either a pedicled omental patch or a free graft of omentum was the operation of choice in our centre. Laparoscopic repair of peptic ulcer perforation without. The perforation was closed transversely with interrupted 20 polygalactin sutures after placing an omental patch over the perforation. Graham of toronto reported 51 cases of perforated peptic ulcer successfully treated with an omental patch. The correct code to assign is 9030400 887 other repair of stomach for omental patch repair of an ulcer that is not bleeding. Omental patch repair for duodenal ulcer perforation analysis of. Almost all perforated gastric ulcers can be effectively managed by laparotomy and omental patch repair. The definitive diagnosis of perforated peptic ulcer and omental patch leakage was obtained at surgery. Western australian coding rule department of health. More recently, this technique has been performed using a laparoscopic approach.
The repairment of perforated peptic ulcer can be done with a simple suture closure with omental patch graham. Omental patch repair effectively treats perforated. Main outcome measures morbidity, operating time, analgesic requirements, length of hospital stay, and time to return to work. The doctor creates the omental flap and sutures it to the site of the duodenal ulcer wound to repair it. Graham patch for duodenal ulcer medical billing and coding. A the graham patch uses sutures placed on either side of the perforation with the addition of the omentum.
Experimental endoscopic repair of gastric perforations. Fiftyfive patients underwent other surgical procedures for perforated peptic ulcers conventional open omental patch. Perforated ulcers of the upper gastrointestinal tract are potentially complicated surgical emergencies. The aim of this study is to evaluate and compare between both management strategies of perforated peptic ulcer.
Similar surgical treatment pattern was reported in other studies 3, 4, 21, 22. Called the omentum, this piece of fatty tissue hangs from the stomach and drapes into the abdomen, covering the intestines. Backgroundaim peptic ulcer perforations are a common emergency, but available literature is silent on the exact definition, incidence, management, and complications of peritonitis due to omental patch leakage. Exploratory laparotomy and omental patch repair remains the gold standard and laparoscopic surgery should be considered when. Perforated peptic ulcer ppu is a surgical emergency and is associated with shortterm mortality and morbidity in up to 30 and 50% of patients, respectively. Perforated gastric ulcer reappraisal of surgical options. However, complications related to peptic ulcer disease continue to occur and include bleeding, perforation, and gastric outlet obstruction. Omental patch or graham patch closure of perforated duodenal ulcers was first described in 1929 by cellenjones and by graham in 1937.
Omental patch repair comparable to gastrectomy for large. Sep 25, 2019 introduction omental patching began in 1937, when dr. The classical graham patch technique, described by cellanjones in 1929 and in 1937 by graham can be applied. Compared to anastomotic revision, omental patch repair had shorter or time 101 57 vs. The current treatment of perforated peptic ulcer is primary closure, covered by omentoplasty. Laparoscopic omental patch repair of peptic ulcer perforation. The patient underwent urgent laparoscopic omental patch repair. Pdf perforated gastric ulcer reappraisal of surgical options.
A scarcity of highquality studies about the condition limits the knowledge base for clinical decision making, but a few published randomised trials are available. Rr graham, the treatment of perforated duodenal ulcers, surg gynec obstet. Laparoscopic surgery, when optimized by a simple repair without an omental patch and 10 mm of a largechannel aspiratorirrigator, may be safely and effectively applied to the patients with small duodenal perforated peptic ulcers sep 25, 2019 introduction omental patching began in 1937, when dr. This patch is typically used for holes with a size of 5mm or less. Omental patch repair is the mainstay of surgical management and gastric resectional procedures are advocated for a largegiant ulcer or suspected malignancy. An understanding of surgical management remains important since surgery is the mainstay of emergency treatment of these lifethreatening complications and for disease that is refractory to medical management. Duodenal ulcer perforations are a common cause of peritonitis. Decision omental patch for repair of bleeding gastric ulcer is coded to 3050500 874 control of. The management of large perforations of duodenal ulcers bmc. Called the omentum, this piece of fatty tissue hangs from. Comparison between omental implantation and omental patch. Omental patch repair effectively treats perforated marginal ulcers following rouxeny gastric bypass mark r wendling, md, john g linn, md, kara keplinger, md, vimal k narula, md, jeffrey w hazey, md, dean j mikami, md, kyle a perry, md, w. Patients and methods retrospective data were collected on 422 patients who underwent omental patch repair of perforated peptic ulcer between march 20, 1999 and march 20, 2006. A piece of omentum is used to cover the perforation.
Graham patch for duodenal ulcer medical billing and. According to the operative report, the omentoplasty was performed after placing lembert sutures of 30 silk. The rationale to add an omental patch is based on the assumption that it may. A graham patch is a surgical technique that is used to close duodenal perforations. Hypothesis laparoscopic management of perforated duodenal ulcers is safe and effective design prospective nonrandomized controlled trial setting tertiary care academic center patients and methods between october 1993 and october 1997, 30 patients underwent laparoscopic graham patch repair of perforated duodenal ulcers and 16 had an open repair. As there is no specific cpt for graham patch operation in. To clarify these mechanism and differences, we investigated ulcer healing in two groups. Clinical profile and outcome of surgical treatment of.
More recently this has been shown to be able to performed using a laparoscope. Gastrointestinal endoscopy in patients with perforated ulcer. Perforated peptic ulcer disease is a condition for which the laparoscopic approach has significant attractions. Laparoscopic repair of perforate gastric ulcer with primary. Gastric resection gr is reserved for difficult pathologies. Society of american gastrointestinal and endoscopic surgeons sages 1,995 views 7. Download citation laparoscopic treatment of perforated gastric ulcer background. Laparoscopic omental patch variable techniques convert to open with. Graham of toronto reported 51 cases of perforated peptic ulcer successfully treated. Outcomes of omental patch repair in large or giant perforated. Perforated peptic ulcer ppu is relatively rare, but lifethreatening with the mortality varying from 10% to 40% 2, 46. The management of perforated gastric ulcers sciencedirect. Traditional surgical teaching recommends partial gastrectomy rather than omental patch repair for the management of perforated gastric ulcer.