Retrospective comparative study of different surgical methods for gastric ulcer perforation: Efficacy and postoperative complications

Abstract

BACKGROUND

Gastric ulcer perforation is a critical condition that can lead to significant morbidity and mortality if not promptly addressed. It is often the result of chronic peptic ulcer disease, which is characterized by a breach in the gastric wall due to ulceration. Surgical intervention is essential for managing this life-threatening complication. However, the optimal surgical technique remains debatable among clinicians. Various methods have been employed, including simple closure, omental patch repair, and partial gastrectomy, each with distinct advantages and disadvantages. Understanding the comparative efficacy and postoperative outcomes of these techniques is crucial for improving patient care and surgical decision-making. This study addresses the need for a comprehensive analysis in this area.

AIM

To compare the efficacy and postoperative complications of different surgical methods for the treatment of gastric ulcer perforation.

METHODS

A retrospective analysis was conducted on 120 patients who underwent surgery for gastric ulcer perforation between September 2020 and June 2023. The patients were divided into three groups based on the surgical method: Simple closure, omental patch repair, and partial gastrectomy. The primary outcomes were the operative success rate and incidence of postoperative complications. Secondary outcomes included the length of hospital stay, recovery time, and long-term quality of life.

RESULTS

The operative success rates for simple closure, omental patch repair, and partial gastrectomy were 92.5%, 95%, and 97.5%, respectively. Postoperative complications occurred in 20%, 15%, and 17.5% of patients in each group, respectively. The partial gastrectomy group showed a significantly longer operative time (P < 0.001) but the lowest rate of ulcer recurrence (2.5%, P < 0.05). The omental patch repair group demonstrated the shortest hospital stay (mean 7.2 days, P < 0.05) and fastest recovery time.

CONCLUSION

While all three surgical methods showed high success rates, omental patch repair demonstrated the best overall outcomes, with a balance of high efficacy, low complication rates, and shorter recovery time. However, the choice of the surgical method should be tailored to individual patient factors and the surgeon’s expertise.

Key Words: Gastric ulcer perforation; Surgical methods; Simple closure; Omental patch repair; Partial gastrectomy; Postoperative complications

Core Tip: This study evaluated three surgical techniques for gastric ulcer perforation: Simple closure, omental patch repair, and partial gastrectomy. While all methods are effective, omental patch repair offers the best balance of efficacy, lower complication rates, and quicker recovery. These findings emphasize the importance of tailoring surgical choices according to individual patient needs and surgeon experience.

INTRODUCTION

Gastric ulcer perforation is a life-threatening complication of peptic ulcer disease, accounting for approximately 2%-14% of peptic ulcer cases worldwide[1]. Therefore, immediate surgical intervention is necessary to prevent severe peritonitis, sepsis, and potential mortality[2]. Despite advancements in the medical management of peptic ulcers, the incidence of gastric ulcer perforation remains significant, particularly in developing countries and older populations[3].

The primary objectives of surgical intervention for gastric ulcer perforation are to achieve complete defect closure, prevent peritoneal contamination, and address the underlying ulcer pathogenesis[4]. Several surgical techniques have been developed and refined over the years, the most common being simple closure, omental patch repair (also known as the Graham patch), and partial gastrectomy[5].

Simple closure involves direct suturing of the perforation site and is often reinforced with adjacent tissue[6]. This technique is rapid and straightforward, making it a popular choice in emergency settings, particularly for small perforations[7]. Omental patch repair, introduced by Graham in 1937, involves placing a segment of the greater omentum over the sutured perforation, providing an additional barrier and promoting healing[8]. Partial gastrectomy, a more extensive procedure, involves resectioning the perforated area along with a portion of the stomach and is typically reserved for large perforations, multiple ulcers, or cases with suspected malignancy[9].

Although these surgical methods have been used for decades, an ongoing debate exists regarding their relative efficacy, postoperative complications, and long-term outcomes[10]. Factors such as the size and location of the perforation, degree of peritoneal contamination, patient’s overall health status, and surgeon’s expertise play crucial roles in determining the most appropriate surgical approach[11].

Previous studies have compared these surgical methods with varying results. A meta-analysis by Chan et al[12] suggested that omental patch repair may have advantages over simple closure in terms of leakage rate and hospital stay. However, Chndan et al[13] found no significant difference in mortality rates between simple closure and omental patch repair in their systematic review. The role of partial gastrectomy in the era of effective acid suppression therapy has also been a subject of debate, with some studies suggesting its superiority in preventing ulcer recurrence, whereas others argue that its increased operative complexity may not justify its use in all cases[14,15].

Despite the wealth of literature on this topic, a lack of consensus exists on the optimal surgical approach for gastric ulcer perforation. Many existing studies are limited by small sample sizes and heterogeneous patient populations or focus only on short-term outcomes[16]. The rapid evolution of laparoscopic and minimally invasive techniques in recent years has added another layer of complexity to the debate[17].

Considering these ongoing controversies and the critical nature of this surgical emergency, there is a clear need for comprehensive, up-to-date studies comparing the outcomes of different surgical methods for gastric ulcer perforation. Such research is essential for guiding clinical decision-making and improving patient care in this high-stakes scenario.

This study aimed to address this gap by conducting a retrospective comparative analysis of simple closure, omental patch repair, and partial gastrectomy for the treatment of gastric ulcer perforations. By examining a cohort of 120 patients treated between September 2020 and June 2023, we sought to provide a contemporary assessment of these surgical methods, focusing not only on immediate operative success but also on postoperative complications, recovery time, and long-term outcomes.

Our primary hypothesis was that while all three methods can be effective in managing gastric ulcer perforation, there may be significant differences in postoperative complication rates and long-term outcomes. We also hypothesized that patient-specific factors influence the relative success of each method, potentially providing insights into tailored surgical approaches.

By elucidating these differences, we aimed to contribute to the ongoing refinement of surgical strategies for gastric ulcer perforation, ultimately leading to improved patient outcomes and more informed clinical decision-making in this critical area of gastrointestinal surgery.

MATERIALS AND METHODS

Study design and patient selection

This retrospective comparative study was conducted at the Affiliated Hospital of Southwest Medical University in Luzhou, China. We reviewed the cases of patients who underwent surgery for gastric ulcer perforation between September 1, 2020, and June 30, 2023. The study protocol was approved by the Ethics Committee of the Affiliated Hospital of Southwest Medical University.

The inclusion criteria were: (1) Age ≥ 18 years; (2) Confirmed diagnosis of gastric ulcer perforation; and (3) Underwent one of the three surgical procedures: Simple closure, omental patch repair, or partial gastrectomy.

The exclusion criteria were: (1) Perforations due to trauma or malignancy; (2) Patients with severe comorbidities [American Society of Anesthesiologists (ASA) score > III]; and (3) Incomplete medical records.

A total of 120 patients who met the criteria were included in this study. Patients were divided into three groups based on the surgical method used: Group A: Simple closure (n = 40); Group B: Omental patch repair (n = 40); Group C: Partial gastrectomy (n = 40).

Data collection

Demographic and clinical data, including age, sex, body mass index, comorbidities, symptom duration before surgery, ASA score, and preoperative laboratory values, were extracted from the patients’ medical records. Operative details such as the duration of surgery, estimated blood loss, and intraoperative findings (size and location of perforation and degree of peritoneal contamination) were recorded.

Surgical procedures

Experienced gastrointestinal surgeons performed all surgeries. The choice of the surgical method was based on the surgeon’s assessment of the individual case, considering factors such as perforation size, location, and degree of contamination.

Simple closure: The perforation was closed with interrupted sutures using a nonabsorbable material (3-0 silk). The suture line was reinforced with the adjacent healthy gastric tissue.

Omental patch repair: After suturing the perforation as in simple closure, a segment of the omentum was mobilized and placed over the closure site. The omental patch was secured using interrupted sutures.

Partial gastrectomy: This involved resection of the perforated area along with the margins of healthy tissue. Billroth I (gastroduodenostomy) or Billroth II (gastrojejunostomy) reconstruction was performed based on the location of the resection and the surgeon’s preference.

In all cases, thorough peritoneal lavage was performed, and drains were placed as deemed necessary by the operating surgeon.

Postoperative management

All patients received standard postoperative care, including nasogastric decompression, intravenous fluids, antibiotics, and proton pump inhibitors. Oral intake was resumed based on individual patient recovery, typically starting with clear liquids on postoperative days 3-5, advancing as tolerated.

Outcome measures

Primary outcomes: (1) Operative success rate (defined as successful closure of perforation without reoperation within 30 days); and (2) Incidence of postoperative complications within 30 days (classified according to the Clavien-Dindo system).

Secondary outcomes: (1) Length of hospital stay; (2) Time to resumption of oral diet; (3) 30-day mortality rate; (4) Ulcer recurrence rate at 6 months and 1 year; and (5) Quality of life at 6 months [assessed using the gastrointestinal quality of life index (GIQLI)].

Follow-up

The patients were followed up at 2 weeks, 1 and 6 months, and 1 year postoperatively. Follow-up included clinical examination, upper gastrointestinal endoscopy at 6 months, and quality of life assessment using the GIQLI questionnaire at 6 months.

Statistical analysis

Data were analyzed using statistical product and service solutions version 25.0 (IBM Corp., Armonk, NY, United States). Continuous variables are expressed as mean ± SD or median (interquartile range), depending on the data distribution. Categorical variables are expressed as frequencies and percentages. Comparisons among the three groups were performed using one-way analysis of variance or the Kruskal-Wallis test for continuous variables and χ² or Fisher’s exact test for categorical variables. Post-hoc pairwise comparisons were conducted using the Bonferroni correction. Multivariate logistic regression analysis was performed to identify independent predictors of postoperative complications and ulcer recurrence. Significance was set at P < 0.05.

Sample size calculation

Based on previous studies, we estimated that a sample size of 40 patients per group would provide 80% power to detect a 20% difference in the primary outcome measures between the groups, with a two-sided alpha of 0.05.

RESULTS

Patient demographics and baseline characteristics

A total of 120 patients (40 in each group) were included in this study. The mean age of the overall cohort was 52.7 ± 15.3 years, with a male predominance (72.5%). No significant differences were observed in age, sex distribution, body mass index, or comorbidities among the three groups (P > 0.05). The baseline characteristics of the patients are summarized in Table 1.

Table 1 Baseline characteristics of patients, mean ± SD/n (%).

Characteristic	Simple closure (n = 40)	Omental patch (n = 40)	Partial gastrectomy (n = 40)	P value
Age (years)	51.8 ± 14.9	53.2 ± 15.7	53.1 ± 15.4	0.89
Sex (male/female)	30/10	28/12	29/11	0.88
BMI (kg/m²)	24.3 ± 3.7	24.7 ± 3.5	24.1 ± 3.9	0.75
Diabetes mellitus	8 (20)	7 (17.5)	9 (22.5)	0.86
Hypertension	12 (30)	14 (35)	13 (32.5)	0.89
Smoking history	18 (45)	20 (50)	19 (47.5)	0.90
ASA score (I/II/III)	12/22/6	14/20/6	11/23/6	0.95
Duration of symptoms (hour)	14.2 ± 6.8	13.8 ± 7.1	15.1 ± 6.5	0.67

BMI: Body mass index; ASA: American Society of Anesthesiologists.

Primary outcomes

Operative success rate: The operative success rates were 92.5% (37/40) for simple closures, 95% (38/40) for omental patch repairs, and 97.5% (39/40) for partial gastrectomies. Although the partial gastrectomy group had the highest success rate, the difference was not statistically significant (P = 0.58).

Postoperative complications: The overall complication rate within 30 days was 17.5% (21/120). The incidence of complications was 20% (8/40), 15 % (6/40), and 17.5 % (7/40) in the simple closure, omental patch, and partial gastrectomy groups, respectively. No significant difference was seen in the overall complication rate among the three groups (P = 0.83). The distribution of complications according to the Clavien-Dindo classification is presented in Table 2.

Table 2 Postoperative complications (Clavien-Dindo classification), n (%).

Complication grade	Simple closure (n = 40)	Omental patch (n = 40)	Partial gastrectomy (n = 40)
Grade I	3 (7.5)	2 (5)	2 (5)
Grade II	3 (7.5)	3 (7.5)	3 (7.5)
Grade III	2 (5)	1 (2.5)	1 (2.5)
Grade IV	0 (0)	0 (0)	1 (2.5)
Grade V	0 (0)	0 (0)	0 (0)
Total	8 (20)	6 (15)	7 (17.5)

Secondary outcomes

Length of hospital stay: The mean length of hospital stay was significantly different among the three groups (P < 0.001). The omental patch group had the shortest stay (7.2 ± 2.1 days), followed by simple closure (8.5 ± 2.4 days) and partial gastrectomy (10.3 ± 3.2 days).

Time to resumption of oral diet: Patients in the omental patch group resumed oral diet earlier (mean 4.1 ± 1.2 days) compared with simple closure (4.8 ± 1.5 days) and partial gastrectomy (5.7 ± 1.8 days) groups (P < 0.001).

30-day mortality: No deaths were reported within 30 days in any group.

Ulcer recurrence rate: At 6 months follow-up, ulcer recurrence was observed in four (10%) patients in the simple closure group, two (5%) in the omental patch group, and one (2.5%) in the partial gastrectomy group (P = 0.35). At 1 year, the recurrence rates were 15% (6/40), 7.5% (3/40), and 2.5% (1/40), respectively (P = 0.12).

Quality of life: The mean GIQLI scores at 6 months were 110.2 ± 15.3 for simple closure, 118.7 ± 14.8 for omental patch, and 114.5 ± 16.1 for partial gastrectomy. The omental patch group had significantly higher scores than the simple closure group (P = 0.02); however, no significant difference was observed from the partial gastrectomy group (P = 0.23).

Operative characteristics

The mean operative time was significantly longer in the partial gastrectomy group (152.3 ± 28.7 minutes) than in the omental patch (93.5 ± 18.2 minutes) and simple closure (78.6 ± 15.4 minutes) groups (P < 0.001). The estimated blood loss was also higher in the partial gastrectomy group (P < 0.001).

Multivariate analysis

In multivariate logistic regression analysis, age > 60 years [odds ratio (OR) = 2.31, 95% confidence interval (CI): 1.15-4.63, P = 0.018] and ASA score III (OR = 3.12, 95%CI: 1.42-6.87, P = 0.005) were independent predictors of postoperative complications. Analysis of the surgical method as a predictor of complications showed that, after adjusting for confounding factors, neither omental patch repair (OR = 0.84, 95%CI: 0.42-1.68, P = 0.62) nor partial gastrectomy (OR = 1.12, 95%CI: 0.58-2.16, P = 0.74) demonstrated significantly different complication rates compared with simple closure. For ulcer recurrence, simple closure technique (OR = 2.87, 95%CI: 1.24-6.65, P = 0.014) and perforation size > 10 mm (OR = 2.53, 95%CI: 1.18-5.42, P = 0.017) were identified as independent risk factors.

DISCUSSION

This retrospective study compared three surgical techniques for gastric ulcer perforation: Simple closure, omental patch repair, and partial gastrectomy, examining their efficacy, safety, and long-term outcomes in contemporary clinical practice. Our analysis revealed several key findings that contribute to the ongoing debate on optimal surgical management.

The operative outcomes demonstrated consistently high success rates across all three methods (92.5%-97.5%), with no significant differences. This finding supports previous research indicating that experienced surgeons can effectively manage gastric ulcer perforations using any established techniques[18]. The marginally higher success rate (97.5%) in the partial gastrectomy group likely reflects the comprehensive approach of the procedure in addressing both immediate perforation and the underlying pathology.

A notable finding was the comparable complication rates among the three groups, challenging the conventional assumptions regarding the relationship between procedural complexity and postoperative complications. The observation that partial gastrectomy, despite its greater invasiveness, showed safety profiles similar to those of less-extensive procedures is particularly significant. This outcome likely reflects recent advances in surgical techniques and perioperative care protocols[19], suggesting that the choice of surgical approach can be based primarily on individual patient factors rather than concerns about procedure-specific complications.

The omental patch repair group had the shortest hospital stay and fastest return to oral intake. This advantage may be attributed to the balance between effectively sealing the perforation and minimizing the surgical trauma. Longer hospital stays and delayed oral intake in the partial gastrectomy group were expected, given the more extensive nature of the surgery and the need for anastomotic healing[20].

The lower ulcer recurrence rate in the partial gastrectomy group, particularly at 1-year follow-up, supports the theoretical advantage of this technique in addressing the underlying ulcer diathesis. However, this benefit must be weighed against the longer operative time, increased blood loss, and potential long-term nutritional consequences of partial gastrectomy[21].

The higher quality of life scores in the omental patch group at 6 months is an interesting finding that warrants further investigation. This may reflect an optimal balance between effective treatment and minimal disruption of normal anatomy and physiology.

Our findings suggest that omental patch repair offers the best overall balance of outcomes in most patients with gastric ulcer perforations. Its high success rate, low complication profile, short hospital stay, and favorable quality of life outcomes make it an attractive option. However, the choice of surgical technique should be individualized based on patient factors, perforation characteristics, and surgeon expertise.

Partial gastrectomy may be the most appropriate treatment for large perforations, multiple ulcers, or suspected malignancies. Its lower recurrence rate could benefit patients at a high risk of ulcer recurrence, although this advantage should be balanced against a more complex postoperative course.

Simple closure, although effective in many cases, may be best reserved for small perforations or critically ill patients who would benefit from a shorter operative time.

The retrospective nature of this study and its single-center design limit its generalizability. A multicenter, prospective, randomized controlled trial would provide stronger evidence. Additionally, longer follow-up periods could better elucidate long-term outcomes, particularly ulcer recurrence and quality of life.

Future research should also explore the role of laparoscopic approaches in these procedures as minimally invasive techniques continue to evolve. Furthermore, investigating the effect of enhanced recovery protocols on the outcomes of each surgical method could provide valuable insights into optimizing perioperative care.

CONCLUSION

Although all three surgical methods for gastric ulcer perforation demonstrated efficacy, omental patch repair appeared to offer the best overall balance of outcomes. However, the choice of the surgical approach should be tailored to individual patient characteristics, perforation details, and the surgeon’s experience. These findings contribute to the ongoing refinement of surgical strategies for this critical condition to improve patient outcomes in the management of gastric ulcer perforation.