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Year : 2013  |  Volume : 1  |  Issue : 2  |  Page : 33-36

Modified Grahams' omentopexy in acute perforation of first part of duodenum; A tertiary level experience in South India

Department of General Surgery, M.K.C.G. Medical College and Hospital, Brahmapur, Odisha, India

Date of Web Publication15-Jan-2014

Correspondence Address:
Mani Charan Satapathy
Department of General Surgery, M.K.C.G. Medical College and Hospital, Brahmapur, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2320-3846.125032

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Background: Despite the rarity (5%) of acute perforation of first part of duodenum (D1) and the advancement in surgical, anesthetic and ancillary facilities, still there are life-threatening dimensions. A variety of surgical techniques evolved over time, but none is without drawbacks. Thus, the need arise for surgeon friendly, suitable surgical technique with better outcome. By this retrospective analysis, we aimed to compare between the Graham's omentopexy (GO) and modified Grahams' omentopexy (MGO) to find the suitable method of managing this acute catastrophe. Materials and Methods: This is a retrospective study design for the period June 2009-May 2012. All the patients with only D1 perforation admitted and treated at our institution were included. Patients with perforation other than D1 site, multiple perforations, poly-trauma and associated co-morbidity were excluded. Patients were randomly subjected for either GO or MGO. Post-operatively, all were followed-up for 3 months at out-patients department. Results: Out of the 122 patients, 112 were males and 10 were females with M:F ratio 11.2:1. MGO group had comparatively less chances of biliary fistula, burst abdomen and mortality, but, more chances of wound infections with longer hospital stay and better outcome at 3 month follow-up in contrast to GO group. The overall mortality rate was 4.09%. Conclusion: MGO is surgically suitable technique than GO for patients with D1 perforation with better post-surgical outcome.

Keywords: Duodenal perforation, first part of duodenum, Graham′s omentopexy, modified Grahams′ omentopexy

How to cite this article:
Satapathy MC, Dash D, Panda C. Modified Grahams' omentopexy in acute perforation of first part of duodenum; A tertiary level experience in South India. Saudi Surg J 2013;1:33-6

How to cite this URL:
Satapathy MC, Dash D, Panda C. Modified Grahams' omentopexy in acute perforation of first part of duodenum; A tertiary level experience in South India. Saudi Surg J [serial online] 2013 [cited 2023 May 28];1:33-6. Available from: https://www.saudisurgj.org/text.asp?2013/1/2/33/125032

  Introduction Top

The well-accepted therapeutic goal in patients with acute first part of duodenum (D1) perforation is simple closure of perforation in order to halt the consequences secondary to peritoneal contamination. Roscoe Graham, published his results by placing three sutures with a piece of free omentum laid over these sutures, which are then tied (without any attempt for primary closure of the perforation). [1] Subsequent modifications came with the principal aim to close the perforation to prevent releaking (the major concern with Graham's technique). [2] The surgical approaches rely on two principles i.e. direct and indirect omentopexy. [3],[4],[5],[6] We followed the principle of indirect omentopexy, keeping the omentum sandwiched between two layers of knots similar to the study by Rajput et al. [6] Despite several techniques and modifications, none have gained wide acceptance nor appear to be the best solution to the problem due to (1) high intraluminal pressure, (2) the tendency of duodenal mucosa to extrude through closures, adding to leakage and (3) breakdown of sutures by autodigestive enzymes of pancreas and bile. Thus, the need is to find, evaluate and apply a suitable method for managing this acute catastrophe.

  Materials and Methods Top

This is a retrospective study analyzing patients with acute D1 perforation (n = 122) admitted and surgically treated in the Department of Surgery, M.K.C.G. Medical College, Brahmapur, Odisha, India during the period June 2009-May 2012. Provisional diagnosis was made from history, clinical findings, radiological finding of gas under the domes of diaphragm, but confirmed only intraoperatively. All patients, on hospitalization, received intravenous fluids, antibiotics, nasogastric aspirations, timely monitoring of vitals until surgical intervention. Upper midline incision was given in all cases. After confirmation of diagnosis, peritoneum lavage was done with 2-3 L of warm normal saline with special attention to irrigate the suprahepatic and infrahepatic recesses, the lesser sac, the paracolic gutters and pelvis. After the omentopexy, two drains e.g. in Morrison's pouch and pelvis were placed and fixed. The midline abdominal wound was closed with Smead-Jones closure technique.

In Graham's omentopexy (GO), laparotomy pads were placed around the perforation site to contain any further spill while 3-4 full thickness suture bites perpendicularly between the edges were placed approximately 0.5 cm away from one margin to the other sutures were being placed followed by mobilization of a vascularized tongue of free omentum so that sutures are successively tied from superior to inferior aspect across the omental patch to anchor the omental graft in place, based on the principle of direct omentopexy [Figure 1]a-c.
Figure 1: (a) Through and through sutures. (b) Final repair as seen from anterior with omentum secured in place on to the defect itself. (c) Final repair of the defect

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Modified Graham's omentopexy (MGO) (our technique) was based on the principle of indirect omentopexy. After placing through and through sutures, they are tied in an attempt to approximate the wall defect [Figure 2]a and without cutting the sutures, a vascularized segment of omentum is then brought on top of the closed perforation and tied knots and the same sutures are used to tie down the omental patch over the already approximated perforation with second level of knots [Figure 2]b, thus the omentum remain sandwiched between two levels of secured knots.
Figure 2: (a) Primary closure of perforation of first part of duodenum (first layer of knots). (b) Second layer of knots secured over the free vascularized omentum

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Detailed data (age, sex and duration of presentation, size of perforation and post-operative complications) were revealed from the case records and analyzed. Both groups were compared in terms of post-operative complications, average hospital stay statistically using Fischer's exact test. Post-operatively, all patients were prescribed for a 14 days course of standard triple drug therapy to eradicate Helicobacter pylori and followed-up for 3 months to note any adverse effects or recurrence, secondary to the surgical approach adopted.

  Results Top

Out of total 122 cases, 112 were males and 10 were females with M:F ratio as 11.2:1. Data revealed, 60 patients (49 males and 11 females) had undergone GO and 62 patients (54 males and 8 females) had undergone MGO technique. Most of the perforations were in the range of 0.6-1 cm. In total, wound infection was found in 50.82% patients with overall mortality rate as 4.09% [Table 1]. Comparison between the two groups was made in terms of postoperative complications (wound infection , biliary fistula, burst abdomen and death) [Table 2]. Data were analyzed by using Fischer's exact test and found statistically significant with P < 0.0001.
Table 1: Analysis of data (pre - operative, intraoperative and post - operative) in D1 perforation

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Table 2: Comparison between Graham's and Modified Graham's omentopexy in first part of duodenum perforation

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  Discussion Top

Graham in his series treated 51 cases with free omental patch without initial closure of the perforation. [1] In his technique, there were risks for partial duodenal obstruction, chances of releaking (as the sutures are not passed through the omentum but only tied around it). Releak was a significant factor influencing mortality rate after omental patch closure of perforated duodenal ulcer. [2]

The subsequent modifications stressed on primary closure of the perforation. The most important feature of a sturdy repair is reliant on the tying technique. The applied tension to the sutures should be strong enough to stabilize the omentum in place, but loose enough to preserve the omental blood supply. Strangulation of the omental patch due to increased tension on the knots is associated with a failure of the repair and continued post-operative leakage.

We followed the principle of indirect omentopexy as adopted by Rajput et al. of Karachi. [6] Wound infection, biliary fistula and death were the major post-operative complications in our series [Table 2]. Etiology of these complications are multifactorial e.g. delay in presentation, delay in surgical intervention, gross peritonitis, septicemia and shock. [7] Post-operative wound infection was the major complication seen in 50.81% of our cases comparable to few studies. [6],[8] The incidence of wound infection was closely comparable in both the groups i.e. thirty patients in GO group and 32 among MGO group. Biliary fistula, burst abdomen and mortality is slightly higher in GO group might be due to incomplete and insecure sealing of the perforation by the omentum leading to releaking with the aforesaid complications. [2]

Mortality rate in literatures varies with the range of 6.5-20%. [9] We found overall mortality as 4.09% comparable to several studies. [9],[10] We found the mean hospital stay as 10.68 days in GO group and 11.35 days in MGO group similar to another study. The hospital stay varies with the size of perforation, duration of illness and condition of the patient on arrival. [11]

Several literatures support the role of therapy for H. pylori in postoperative period. [12] H. pylori eradication speeds up healing and decrease the relapse rate of ulcer disease as reported by Sebastian et al. [13] Hence, we prescribed anti-H. pylori therapy to all our patients at the time of discharge. In 3 months follow-up, two patients of GO group readmitted with recurrence of symptom and the patients of MGO group had better outcome without any recurrences.

  Conclusion Top

MGO can be a surgeon friendly and technically suitable procedure over GO for D1 perforation, provided proper caution was exercised during approximation of perforation such that the ligature is neither too tight to cause tissue damage nor too loose to have recurrence with the goal to secure the omentum, allowing for subsequent adhesion to the inflamed serosa that enables sealing of the perforation. Opponents of this modified technique express concern regarding the seal obtained from the omentum when suture knots are interposed between the duodenal serosa and the omental patch and apposition of omentum is not as broad as with the original omental patch. Hence, a prospective study design with longer follow-up can help further dilate the surgical benefits and outcome to establish this procedure in surgical practice.

  References Top

1.Graham RR. Treatment of perforated duodenal ulcers. Surg Gynecol Obstet 1937;64:235-8.  Back to cited text no. 1
2.Kumar K, Pai D, Srinivasan K, Jagdish S, Ananthakrishnan N. Factors contributing to releak after surgical closure of perforated duodenal ulcer by Graham's Patch. Trop Gastroenterol 2002;23:190-2.  Back to cited text no. 2
3.Dudley H. The stomach and duodenum. In: Rob and Smith's Operative Surgery. 4 th ed. London: Butterworths; 1986. p. 281-6.  Back to cited text no. 3
4.Ellis BW, Brown SP. Hamilton Bailey's Emergency Surgery. 12 th ed. Cambridge: Butterworth Heinemann; 1995. p. 356-64.  Back to cited text no. 4
5.Rintoul RF, editor. Farquharson's Textbook of Operative Surgery. 8 th ed. Edinburgh: Churchill and Livingstone; 1995. p. 387-91.  Back to cited text no. 5
6.Rajput IA, Iqbal M, Manzar S. Comparison of omentopexy techniques for duodenal perforation. Pak J Surg 2000;16:1-6.  Back to cited text no. 6
7.Rajesh V, Chandra SS, Smile SR. Risk factors predicting operative mortality in perforated peptic ulcer disease. Trop Gastroenterol 2003;24:148-50.  Back to cited text no. 7
8.Mehboob M, Khan JA, Rehman SU, Saleem SM, Iqbal M, Qayyum A, et al. Peptic duodenal perforation-An audit. J Coll Physicians Surg Pak 2000;10:101-3.  Back to cited text no. 8
9.Pai D, Sharma A, Kanungo R, Jagdish S, Gupta A. Role of abdominal drains in perforated duodenal ulcer patients: A prospective controlled study. Aust N Z J Surg 1999;69:210-3.  Back to cited text no. 9
10.Bin-Taleb AK, Razzaq RA, Al-Kathiri ZO. Management of perforated peptic ulcer in patients at a teaching hospital. Saudi Med J 2008;29:245-50.  Back to cited text no. 10
11.Arveen S, Jagdish S, Kadambari D. Perforated peptic ulcer in South India: An institutional perspective. World J Surg 2009;33:1600-4.  Back to cited text no. 11
12.Ng EK, Chung SC, Sung JJ, Lam YH, Lee DW, Lau JY, et al. High prevalence of Helicobacter pylori infection in duodenal ulcer perforations not caused by non-steroidal anti-inflammatory drugs. Br J Surg 1996;83:1779-81.  Back to cited text no. 12
13.Sebastian M, Chandran VP, Elashaal YI, Sim AJ. Helicobacter pylori infection in perforated peptic ulcer disease. Br J Surg 1995;82:360-2.  Back to cited text no. 13


  [Figure 1], [Figure 2]

  [Table 1], [Table 2]

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