The management of large perforations of duodenal ulcers

The case files of 162 patients who underwent emergency laparotomy for duodenal ulcer perforations over a period of three years (2001 – 2003) were retrospectively reviewed and sorted into groups based on the size of the perforations – one group was defined as 'small 'perforations (less than 1 cm in diameter), another 'large' (when the perforation was more than 1 cm but less than 3 cms), and the third, 'giant'(when the perforation exceeded 3 cm). These groups of patients were then compared with each other in regard to the patient particulars, duration of symptoms, surgery performed and the outcome.A total of 40 patients were identified to have duodenal ulcer perforations more than 1 cm in size, thus accounting for nearly 25 % of all duodenal ulcer perforations operated during this period. These patients had a significantly higher incidence of leak, morbidity and mortality when compared to those with smaller perforations.There are three distinct types of perforations of duodenal ulcers that are encountered in clinical practice. The first, are the 'small' perforations that are easy to manage and have low morbidity and mortality. The second are the 'large' perforations, that are also not uncommon, and omental patch closure gives the best results even in this subset of patients. The word 'giant' should be reserved for perforations that exceed 3 cms in diameter, and these are extremely uncommon.Duodenal ulcer perforations are a common cause of peritonitis. The classic, pedicled omental patch that is performed for the 'plugging' of these perforations was first described by Cellan-Jones in 1929 [1], 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 [2]. In this, a strand of omentum is drawn over the perforation and held in place by full thickness sutures placed on either side of the perforation, and this procedure has become the "gold standard" for the treatment of such perforatio