European Journal of Cardiovascular Medicine

Peptic ulcer perforation is a serious complication which affects 2-10% of peptic ulcer patients. Peptic ulcer perforation presents with an overall mortality of 10% although various authors had reported incidence between 1.3% and 20%. Being a life-threatening complication of peptic ulcer disease, it needs special attention with prompt resuscitation and appropriate surgical management if morbidity and mortality are to be contained. [1-5]

Perforation occurs when ulcer erodes through full thickness of stomach or duodenum. Perforation is most common complication of peptic ulcer. Bleeding ulcer and use of non-steroidal anti-inflammatory drugs (NSAID) and/or aspirin have been inextricably linked with perforated peptic ulcer disease (PUD), especially in the elderly. More than 20% of patients over the age of 60 years presenting with a perforated ulcer are taking NSAIDs at the time of perforation. [6]

Graham’s omentopexy technique was later modified and called as Modified Graham patch repair (MGPR), in which the three or four sutures are placed as described above and are then tied to close the ulcer. The omental patch placed on the tied suture, and another set of knots are tied to hold the omentum in place over the duodenal perforation closure. There is concern that the omentum will not be as intimately applied to the duodenal perforation and may not represent as good a seal as is the case 8 when the omentum is laid directly on the open ulcer bed.

Aims and Objectives

This prospective, single center, interventional cohort study done in Birsa Munda government medical Shahdol Madhya Pradesh from 2021 to 2023 for two years period in patient admitted in surgical emergency department. Total 180 patients included in our study. The main aim of study ‘’ comparison between Graham’s patch omentopexy and modified Graham’s patch omentopexy’’. 

This prospective, single centre, interventional cohort study done in Birsa Munda government medical Shahdol Madhya Pradesh from 2021 to 2023 for two years period in patient admitted in surgical emergency department. Total 180 patients included in our study.

Inclusion criteria

-All the patients of gastric ulcer perforation were included

Exclusion criteria

-Ilea, appendicular, caecal, colonic or jejuna perforation,

-Giant duodenal ulcers > 2cm in diameter, posterior duodenal ulcers and sealed duodenal ulcer perforation.

Total 200 patients enrolled in the study in which 40 patients excluded. Total 160 patients were taken and divided in two groups. Each group consisted of 80 patients. Group A underwent Graham Patch repair and Group B underwent Modified Graham Patch repair. Their outcome was collected in preformed proforma, and data so collected were subjected to SPSS 19 for analysis.

All patients were admitted with acute abdomen in emergency department, vital checked after proper resuscitation with IV fluids, nasogastric aspiration, urinary catheterization, analgesics & antibiotics proper history taken, thorough clinical examination, radiological investigations (Ultrasonography of abdomen pelvis & X-Ray chest PA view showing both dome of diaphragm to look for air under right diaphragm) that signifies hollow viscus perforation. All operative findings and post-operative complications were recorded. All operations carried out under general/regional anaesthesia. After confirmation of the site of perforation peritoneal lavage was done with 4-5 litres of warm normal saline. Special attention was made to irrigate the sub hepatic pouch, the lesser sac, the paracolic gutters & pelvis. After omentopexy, two drains, one in Morrison's pouch and other in pelvis, were placed & fixed. The midline abdominal wound was closed with mass closure technique.

Most of the patients fall between 20-78 years of age in both A and B groups. The maximum number of patients in group A were 30(37.5%) found in the age group of 40-50 years. Similarly, the maximum number of patients in group B was 28(35%), found in the age group of 40-50 years.

Table no- 1

Graph no-1

There is 146 male and 14 females are present the study. In group A there were 72(90%) males and 8(10%) females. In group B there were 74(92.5%) males and 6(7.5%) females.

Table no- 2

Graph no- 2

Table no- 3 Preoperative and intraoperative data analysis

From this study most of the patients operated between 24-48 hours in both of the group. Size of the perforation is 0.5-1cm most of the patient. Associated comorbidities present in 22.5% in group A and 20% patients in group B. Preoperative shock present in 15% in group A and 12.5% patients in group B.

Table no-4 Postoperative Outcomes of technique

Comparisons of two groups was made in term of mean operative time, bile leak/fistula, wound infection, respiratory complications, electrolyte imbalance, paralytic ileus, septic shock, abdominal abscess, mean hospital stays, oral feed allow, re-exploration and death.

The postoperative complications in group A [graham’s patch omentopexy] were wound infection 10[12.5%] cases, bile leakage 6 [7.5%] cases, respiratory complications 8 [10%] cases, electrolyte imbalance 12 [15%] cases, paralytic ileus 3 [3.75%] cases, septic shock 5 [6.25%] cases and abdominal abscess in 5 [6.25%] cases.

The postoperative complications in group B [modified graham’s patch omentopexy] were wound infection 6[7.5%] cases, bile leakage 1 [1.25%] cases, respiratory complications 3 [3.75%] cases, electrolyte imbalance 5 [6.25%] cases, paralytic ileus 2 [2.5%] cases, septic shock 2 [2.5%] cases and abdominal abscess in 2 [3.75%] cases.

This study significant value found in mean operative time, mean hospital stay and oral food allow from the day of surgery in both groups, which is clearly better in modified graham’s patch omentopexy group and significant.

Re-exploration found in 5[6.25%] in group A and 1 [1.25%] in group B patients, which is also improved in group B patients.

Death rates found in group A is 3 [3.75%] and 1 [1.25%] in group B patients which is also improved in group B patients.

In the present study a total of 160 patients were treated for acute perforated gastric ulcer in our hospital over a period of 2 year. These were divided into 2 groups. Group A and Group B, each consisted of 80 patients. They underwent Graham patch repair and Modified Graham patch repair respectively.

Age: Most of the patients fall between 20-78 years of age in both A and B groups. The maximum number of patients in group A were 30(37.5%) found in the age group of 40-50 years. Similarly, the maximum number of patients in group B was 28(35%), found in the age group of 40-50 years. Reviews from Africa which had an average of 64.80 (SD 11.4) years.[9] Study conducted by Dakubo shows age ranged from 4-87 years with mean age of 40.90. [10] Guglieminotti described age varied from 20 to 65 years. [11], while Mehboob described mean age 31.4 years with peak incidence in 3 decades.[17]

Sex: There is 146 male and 14 females are present the study. In group A there were 72(90%) males and 8(10%) females. In group B there were 74(92.5%) males and 6(7.5%) females.  Incidence of male was more as compared to study done by Plumer and Ohene in 2004 and 2006 respectively. [18]

Post operative leakage: Overall post operative complication in Graham patch and Modified Graham patch repair was low. Post operative leakage was 7.5% and 1.25% respectively. The p value from chi square test came out to 0.1221 which is not significant. This was similar to the study done by Nuhu et al. in 2009 where only 4 post operative leakages were present in 55 patients undergoing emergency exploratory laparotomy.

Burst abdomen: Similarly, there was 6.25% burst abdomen in group A and 1.25% in group B cases. The p value from chi square test was 0.2119 which is not significant. Chalya et al. concluded in a retrospective and prospective study of clinical profile and outcome of surgical treatment of perforated peptic ulcers in Northwestern Tanzania: A tertiary hospital experience. Total 84 patients (n=84) were included who had undergone Emergency Laparotomy with Graham's patch repair with omentopexy for duodenal ulcer perforation. Post operative complications were recorded in 25(29%) patients. Of these surgical sites infection was in 12(48%) patients, post operative pyrexia was in 9(36%) patients, wound dehiscence and burst abdomen was in 5(20%) patients and incisional hernia in 2(8%) patients. Overall complications rate in their series were higher than our series. [20]

Size of perforation: The size of the gastric perforation determines the amount of peritoneal contamination. The perforation >1cm has incidence of leakage, morbidity& mortality when compared with small perforation.[13] In this study out of 160 patients, 100 patients (67%) had perforation within range 0.5-1 cm in size similar result showed in Nishikant et al 75.5% had perforation within 0.11- 0.5cm. [30]

The postoperative complications in group A [graham’s patch omentopexy] were wound infection 10[12.5%] cases, bile leakage 6 [7.5%] cases, respiratory complications 8 [10%] cases, electrolyte imbalance 12 [15%] cases, paralytic ileus 3 [3.75%] cases, septic shock 5 [6.25%] cases and abdominal abscess in 5 [6.25%] cases. The postoperative complications in group B [modified graham’s patch omentopexy] were wound infection 6[7.5%] cases, bile leakage 1 [1.25%] cases, respiratory complications 3 [3.75%] cases, electrolyte imbalance 5 [6.25%] cases, paralytic ileus 2 [2.5%] cases, septic shock 2 [2.5%] cases and abdominal abscess in 2 [3.75%] cases.

The similar results of post-operative complications were also shown in other studies by Raj put et al and sat apathy et al. [24,25]

Mortality: In this study mortality rate in Group A Graham's omentopexy is 3 patients (3.75%) and in Group B Modified Graham' Omentopexy is 1 patient (1.25%). The overall mortality rate was 7.14% associated with late presentation while in other studies by A Nuhu et a1,[14] all was 16.4% and sat apathy et al,[25] ln another study by Umran–Muslu et al, the mortality is 3.9%.[26] Mortality rate in literature varies with the range of 6.5-20%.

Average Hospital stay: In this study average hospital stay was 12.4 days in group A Graham's Omentopexy and 9.0 days in group B Modified Graham's Omentopexy similar in other series the average hospital stay was 9+-1.4 days.

Recurrence: In follow–up of 12 months one patient from Group A Graham's Omentopexy was readmitted with recurrence of symptoms and in modified Graham's Omentopexy Group B had better outcome without any recurrence.

Predisposing factors to complications: The most important factors predisposing to complications are delay in admission to the hospital, associated diseases and shock on admission. Mortality & morbidity can be reduced by early admission, prompt resuscitation, and treatment of associated disease, early surgical intervention and prophylaxis of complications.

This prospective, single center, interventional cohort study done in Birsa Munda government medical Shahdol Madhya Pradesh from 2021 to 2023 for two years period in patient admitted in surgical emergency department. Total 180 patients included in our study. The main aim of study ‘’ comparison between Graham’s patch omentopexy and modified Graham’s patch omentopexy’’.  The analysis of results of present study consisting of altogether 160 patients undergoing gastric ulcer perforation repair showed that modified Graham's patch repair is as effective as Graham's patch repair in terms of mean operative time period, timing of oral feed allow and mean hospital stay timing. It is concluded that modified Graham's patch repair is better and effective procedure than Graham's patch repair.

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