This document discusses management strategies for perforated giant duodenal ulcers and failed omental patching. Giant duodenal ulcers are defined as greater than 2cm in diameter involving a large portion of the duodenal bulb. Management options include omental plugging, jejunal serosal patching, duodenal exclusion with gastrojejunostomy, partial gastrectomy, and gastric disconnection. Surgical techniques for omental plugging and jejunal serosal patching are described in detail. Complications of different procedures and references are also provided. The goal is to determine the most appropriate repair method for these difficult cases.

1. Management of
perforated Giant Duodenal
Ulcer and patch failure
By Dr Mengistu Kassa
Assistant professor of General surgery
Debretabor university , Ethiopia

2. Giant Duodenal ulcer
• Defn: Full-thickness peptic ulcer that is 2 cm or
larger in diameter and usually involving a large
portion of the duodenal bulb.
• Comprise ∼1–2% of the perforated peptic ulcers
and 5% of peptic ulcers requiring surgical
intervention.
• Account for both high morbidity (20–70%) and
mortality (15–40%)

3. Perforated GDU
• Perforation of GDUs is considered particularly
hazardous because
1. Extensive duodenal tissue loss and
2. Surrounding tissue inflammation
This preclude simple closure with omental patch

4. Management
• Selection of the most appropriate technique for
repair of recurrent and giant duodenal perforation
have been the concern of many surgeons
• Management of the leaking omental patch is very
difficult. Although some leaks transform into
fistulas and will eventually close after prolonged
period of hyperalimentation

5. Management
• Options of management of perforated giant duodenal ulcer
and omental patch failure include
1.Omental plugging
2.Jejunal serosal patching
3.Duodenal (pyloric exclusion) and gastrojejunostomy
4.Partial gastrectomy (antrectomy)
5. Conversionof the perforation into pyloroplasty
6. Gastric disconnection (vagotomy, antrectomy, gastrostomy,
lateral duodenostomy, and feeding jejunostomy) restoring
intestinal continuity electively after 4 weeks

6. •Surgical techniques

7. • Fluid sacked out and perforation identified
• The tip of inserted nasogastric tube was taken out
to abdominal cavity via the perforation
• Then free edge of greater omentum was tied to tip
of nasogastric tube, and
• Anesthetist/assistant was asked to withdraw the
nasogastric tube, so that 5–6 cm of omentum went
inside stomach or duodenum;
Omental plugging

8. • Then edges of the
perforation were tied to
omental plug by 2-0
vicryl sutures.
• Wash the abdominal
cavity and leave drain in
the subhepatic space

9. Jejunal serosal patching
• Sack out of intraabdominal collections,
• Identify perforation site via gentle dissection of
adhesion, and then debride necrotic tissue and
debris .
• Then, moblize second part of duodenum
• Bring a loop of jejunum about 40–60 cm from the
ligament of Treitz above the transverse colon and
suture to defect in serosa-to serosa fashion via
interrupted 2-0 silk sutures about 2–3 cm away
from defect site.

10. • Perform diverting
jejunojejunostomy
20 cm distal to the
patch.
• Generous intra
abdominal lavage
with 9 littre of warm
saline and leave drain
in the subhepatic
space

11. Duodenal (pyloric exclusion) and
gastrojejunostomy
• There are two ways to close the pylorus :
•
• 1. Suture from within the stomach
•
• 2. Stapled closure

12. Steps of pyloric exclusion
• Create an gastrotomy
• Find the pyloric ring make an suturing with ‘O’
technique or interact suturing with absordable
• suture
• Construct gastrojejunostomy by bringing loop of
jejunum ∼12–15 cm from the ligament of Treitz
• Place omentum patch over the duodenal
perforation and place drains in close proximity to it

13. Complication
• Leakage from duodenal closure
• Duodenal obstruction
• Failure of pylorus to reopen
• Alternatively pylorus may reopen before repair is
healed

14. Partial gastrectomy (antrectomy)
• Dissect the distal half of the greater
curvature, and separate greater omentum
from the transverse mesocolon.
• Divide and ligate branches of gastroepiploic
arcade with 2-0 vicryl sutures from the mid-
portion of stomach to duodenum.

15. • Free posterior wall of first part of duodenum
from the pancreas and divide
• Identify and ligate right gastric artery
• Divide gastrohepatic ligament and spare lt
gastric artery
• Reconstruction with a Billroth II anastomosis

16. Reference
• Management of perforated large/giant peptic
ulcers: a comparative prospective study between
omental plug, duodenal exclusion, and jejunal
serosal patch
• The Jejunal Serosal Patch Procedure: A Successful
Technique for ManagingbDifficult Peptic Ulcer
Perforation By Abebe Bekel addis ababa ethiopia
• Fischer’s mastery of surgery 7th ed

17. •Thank you