Michael Jaroncyzk, MD, Courtney E Collins, MD, MS, Vladimir P Daoud, MD, MS, Ibrahim Daoud, MD. St. Francis Hospital; Hartford CT
Introduction: Several decades ago, surgical training was saturated with procedures to treated peptic ulcer disease. Since the introduction of histamine-2 blockers and proton pump inhibitors, these procedures have dwindled significantly. However, there are still instances where patients require surgical intervention for peptic ulcer disease. Perforation is one of the indications for surgery. The surgical options to treat a perforated peptic ulcer are numerous. One of the most common options is a Graham patch. We are presenting a case of a patient with a perforated ulcer that did not have available omentum for the repair.
Methods and Procedures: Recently, a 64-year-old female with a past history of an open total abdominal hysterectomy and bilateral salpingo-oophorectomy presented as an outpatient with chronic lower abdominal pain. She underwent a work-up and imaging that did not reveal any pathology. At diagnostic laparoscopy, she had diffuse lower abdominal adhesions, which were lysed. She was discharged on the same day, but presented to the Emergency Department two days later with severe abdominal pain and fevers. The work-up revealed tachycardia, diffuse abdominal tenderness with peritoneal signs, leukocytosis and a large amount of free air on imaging. She was emergently brought to the Operating Room for a diagnostic laparoscopy.During laparoscopic exploration, the lower abdominal cavity appeared normal for a recent lysis of adhesions. Attention was turned to the upper cavity to find the pathology. Bile-stained free fluid and peri-gastric exudates were identified, but no perforation was visualized. Intra-operative endoscopy revealed the site of perforation in the antrum on the lesser curvature. A biopsy was performed and the decision was made to perform a Graham patch. However, the omentum was already densely involved with the lower abdominal cavity from the enterolysis. Due to the close proximity of the falciform ligament, it was mobilized laparoscopically and the pedicle was used as a Graham patch. The patient recovered without any additional issues. The biopsy was reported as a chronic gastric ulcer.
.jpg)
Conclusion: Surgical history has given us many options to treat peptic ulcer disease that are not nearly as common as they were decades ago. Perforated ulcers can be managed laparoscopically and Graham patches are a common choice for repair. However, the lack of the omentum for a proper pedicle flap can pose a problem in some patients. We have shown in this patient that a falciform pedicle flap can be successfully used as a substitution.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87093
Program Number: P183
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster