What is the correct code for a graham patch omentoplasty used to repair a perforated duodenal ulcer. Graham omentoplasty is the default method of closure of peptic perforation. Intraoperatively, a prepyloric perforated ulcer approximately 2 mm in size was discovered. Diagnosis and treatment of perforated or bleeding peptic. According to the operative report, the omentoplasty was performed after placing lembert sutures of 30 silk. Almost all perforated gastric ulcers can be effectively managed by laparotomy and omental patch repair. Omental patch or graham patch closure of perforated duodenal ulcers was first described in 1929 by cellenjones and by graham in 1937. The technique is named after a canadian doctor who successfully used a flap of skin inside the abdominal cavity to repair perforated ulcers. Perforated peptic ulcer ppu is relatively rare, but lifethreatening with the mortality varying from 10% to 40% 2, 46. Clinical profile and outcome of surgical treatment of. A piece of omentum is used to cover the perforation.
The classic triad of sudden onset of abdominal pain, tachycardia and abdominal rigidity is the hallmark of perforated peptic ulcer. Gastric resection gr is reserved for difficult pathologies. Early diagnosis, prompt resuscitation and urgent surgical intervention are essential to improve outcomes. Every year peptic ulcer disease pud affects 4 milion people around the world. Rr graham, the treatment of perforated duodenal ulcers, surg gynec obstet. The aim of this study is to evaluate and compare between both management strategies of perforated peptic ulcer. A graham patch defines a surgical procedure to close an opening in the duodenum caused by a peptic ulcer. Called the omentum, this piece of fatty tissue hangs from. We will focus on the nowrecognized role of helicobacter pylori in the genesis of the majority of duodenal ulcers and on the high rate of success of therapy with a combination of antibiotics and a protonpump inhibitor or histamine 2 blocker in treatment of such ulcers. Experimental endoscopic repair of gastric perforations. Perforated marginal ulcer represents a significant complication of rygb. Although helicobacter pylori and use of nonsteroidal antiinflammatory drugs are common causes, demographic. Historically, repair with the adjunct of an omental patch was considered the standard laparoscopic procedure for perforated peptic ulcer repair. A perforated ulcer, also known as a gastric perforation or peptic ulcer, is a serious medical condition in which an already formed untreated ulcer burns through the walls of the stomach or any other section of the gastrointestinal tract, thereby allowing the digestive juices and other stomach acids to flow into the abdominal cavity, causing.
Repair of perforated ulcer department of health, victoria. Hypothesis laparoscopic management of perforated duodenal ulcers is safe and effective design prospective nonrandomized controlled trial setting tertiary care academic center patients and methods between october 1993 and october 1997, 30 patients underwent laparoscopic graham patch repair of perforated duodenal ulcers and 16 had an open repair. The definitive diagnosis of perforated peptic ulcer and omental patch leakage was obtained at surgery. Lap graham patch of duodenal ulcer general surgery. Called the omentum, this piece of fatty tissue hangs from the stomach and drapes into the abdomen, covering the intestines. This video is a stepbystep approach to the technique of laparoscopic repair of perforated peptic ulcer with omental patch. Omental patch repair comparable to gastrectomy for large.
The traditional management of a perforated duodenal ulcer has been a graham omental patch and a thorough abdominal lavage. Laparoscopic repair of perforate gastric ulcer with primary. Laparoscopic surgery, when optimized by a simple repair without an omental patch and 10 mm of a largechannel aspiratorirrigator, may be safely and effectively applied to the patients with small duodenal perforated peptic ulcers may 08, 2020 a graham patch defines a surgical procedure to close an opening in the duodenum caused by a peptic ulcer. The current treatment of perforated peptic ulcer is primary closure, covered by omentoplasty. Sep 25, 2019 introduction omental patching began in 1937, when dr. Initial biopsy and followup endoscopy with repeat biopsy is essential to avoid missing an underlying malignancy. Similar surgical treatment pattern was reported in other studies 3, 4, 21, 22. Main outcome measures morbidity, operating time, analgesic requirements, length of hospital stay, and time to return to work. Decision omental patch for repair of bleeding gastric ulcer is coded to 3050500 874 control of. More than half of the cases are female and they are.
Laparoscopic repair of peptic ulcer perforation without. A graham patch is a surgical technique that is used to close duodenal perforations. Graham patch for duodenal ulcer medical billing and. Studies have shown that the ulcer recurrence rate was as high as 42% in perforated duodenal ulcer patients who underwent simple omental patch repair 72, 73. Few prospective randomized studies also reported substantially less ulcer recurrence in patients who underwent vagotomy in addition to omental patch repair 37, 74. The current treatment of perforated peptic ulcers is primary closure, supported by the application of an omental patch. The classic, pedicled omental patch that is performed for the plugging of these perforations was first described by cellanjones in 1929, 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. Outcomes of omental patch repair in large or giant. More recently this has been shown to be able to performed using a laparoscope.
The management of perforated gastric ulcers sciencedirect. Society of american gastrointestinal and endoscopic surgeons sages 1,995 views 7. The dominant treatment of perforated duodenal ulcer in the first half of the 20th century was surgical closure. Perforated peptic ulcer ppu is a surgical emergency and is associated with shortterm mortality and morbidity in up to 30 and 50% of patients, respectively. Perforated peptic ulcer is a common emergency condition worldwide, with associated mortality rates of up to 30%. The perforation was closed transversely with interrupted 20 polygalactin sutures after placing an omental patch over the perforation. The management of large perforations of duodenal ulcers bmc. The diagnosis of a perforated duodenal ulcer in a rygp patient can be challenging, and there is variability in the surgical treatment, especially when it comes to the possible role of removing the gastric remnant.
Download citation laparoscopic treatment of perforated gastric ulcer background. Called the omentum, this piece of fatty tissue hangs from the stomach and drapes into the abdomen. A scarcity of highquality studies about the condition limits the knowledge base for clinical decision making, but a few published randomised trials are available. This patch is typically used for holes with a size of 5mm or less.
To clarify these mechanism and differences, we investigated ulcer healing in two groups. An appropriatelysized tongue of tensionfree, wellvascularized omentum is. Omental patch repair for duodenal ulcer perforation analysis of. There was no obvious explanation to account for these duodenal to gastric ulcer ratio differences. Gastrointestinal endoscopy in patients with perforated ulcer. As there is no specific cpt for graham patch operation in. Jan 25, 2017 laparoscopic graham patch repair of a perforated marginal ulcer 6 yrs after rygb duration. Outcomes of omental patch repair in large or giant perforated. Laparoscopic way of dealing the perforated peptic ulcer is now frequently performed in areas of expertise worldwide. Complications are encountered in 10%20% of these patients and 2%14% of the ulcers will perforate 2, 3. Laparoscopy allows the confirmation of the diagnosis and furthermore allows the identification of the position, site, and size of the ulcer 27, 48, 49. Graham patch for duodenal ulcer medical billing and coding.
Omental patch repair is the mainstay of surgical management and gastric resectional procedures are advocated for a largegiant ulcer or suspected malignancy. This case illustrates a pneumoperitoneum from perforated gastric ulcer. Perforated peptic ulcer ppu is a common surgical emergency and treatment involves omental patch repair pr. The only proven advantage of the laparoscopic technique appears to be decreased postoperative pain. Comparison of closure of gastric perforation ulcers with. The rationale to add an omental patch is based on the assumption that it may. Laparoscopic surgery, when optimized by a simple repair without an omental patch and 10 mm of a largechannel aspiratorirrigator, may be safely and effectively applied to the patients with small duodenal perforated peptic ulcers sep 25, 2019 introduction omental patching began in 1937, when dr. A standardized gastric perforation was created in 10 pigs. Jun 25, 2005 duodenal ulcer perforations are a common cause of peritonitis. Laparoscopic graham patch repair of a perforated marginal ulcer 6 yrs after rygb duration.
The stitch was left open, and a tongue of omentum was then placed over the ulcer and tied down with stitches. The doctor creates the omental flap and sutures it to the site of the duodenal ulcer wound to repair it. Comparison between omental implantation and omental patch. Diagnosis and management of perforated duodenal ulcers.
We present two cases of a perforated duodenal ulcer following rouxeny gastric bypass and discuss the management of these patients. Duodenal ulcer perforations are a common cause of peritonitis. Graham of toronto reported 51 cases of perforated peptic ulcer successfully treated. The correct code to assign is 9030400 887 other repair of stomach for omental patch repair of an ulcer that is not bleeding. Traditional surgical teaching recommends partial gastrectomy rather than omental patch repair for the management of perforated gastric ulcer. This study analysed the outcome of these operative options in a single institution. Graham of toronto reported 51 cases of perforated peptic ulcer successfully treated with an omental patch.
Recent reports confirm that omental patch closure of peptic ulcer perforations, combined with medical therapy for acid hypersecretion and helicobacter pylori, yield excellent results with low. The patient underwent urgent laparoscopic omental patch repair. The omental patch is a standard surgical treatment of gastroduodenal ulcer perforation. Omental patch repair effectively treats perforated marginal ulcers following rouxeny gastric bypass mark r wendling, md, john g linn, md, kara keplinger, md, vimal k narula, md, jeffrey w hazey, md, dean j mikami, md, kyle a perry, md, w. Laparoscopic omental patch variable techniques convert to open with.
This belief is a now matter of debate as multiple studies showed the addition of an omental patch does not add benefits to a simple suture repair, but it significantly increases the operation time. However, complications related to peptic ulcer disease continue to occur and include bleeding, perforation, and gastric outlet obstruction. Western australian coding rule department of health. An understanding of surgical management remains important since surgery is the mainstay of emergency treatment of these lifethreatening complications and for disease that is refractory to medical management. The repairment of perforated peptic ulcer can be done with a simple suture closure with omental patch graham. Oct 22, 2019 omental patch repair is the mainstay of surgical management and gastric resectional procedures are advocated for a largegiant ulcer or suspected malignancy, according to the researchers led by dr vishal shelat from tan tock seng hospital, singapore.
Perforated ulcers of the upper gastrointestinal tract are potentially complicated surgical emergencies. Setting department of surgery, moi grahams omental patch and copious irrigation of a proximal gastric vagotomy or taylor procedure laparoscopic repair of duodenal ulcer perforation is as peptic ulcer is the most common cause of ugib. Backgroundaim peptic ulcer perforations are a common emergency, but available literature is silent on the exact definition, incidence, management, and complications of peritonitis due to omental patch leakage. Perforated peptic ulcer disease is a condition for which the laparoscopic approach has significant attractions. The operation report states suture of perforated peptic ulcer, omental patch fixed operation report attached. Exploratory laparotomy and omental patch repair remains the gold standard and laparoscopic surgery should be considered when. Laparoscopic repair of perforate gastric ulcer with. As there is no specific cpt for graham patch operation in the current cpt manual, you should bill. The current advice at our organisation is to code as repair of site being patched. Another possible code would be suture, ulcer, perforated duodenal gastric 3037510 887. The classical graham patch technique, described by cellanjones in 1929 and in 1937 by graham can be applied. Patients and methods between october 1993 and october 1997, 30 patients underwent laparoscopic graham patch repair of perforated duodenal ulcers and 16 had an open repair.
Comparison between omental implantation and omental patch for. Compared to anastomotic revision, omental patch repair had shorter or time 101 57 vs. Experimental endoscopic repair of gastric perforations with. More recently, this technique has been performed using a laparoscopic approach. Pdf perforated gastric ulcer reappraisal of surgical options. Perforated gastric ulcer reappraisal of surgical options. In this study, grahams omental patch of the perforations with either a pedicled omental patch or a free graft of omentum was the operation of choice in our centre. Seventytwo patients mean age 43 years, 62 males with perforated gastric ulcers were managed by laparotomy.
An alternative plan for the treatment of a perforated duodenal ulcer is proposed. Omental patch repair effectively treats perforated. The surgeon uses sutures to secure the patch and close the perforation. The doctor creates the omental flap and sutures it to the site of the duodenal ulcerwound to repair it. Patients and methods retrospective data were collected on 422 patients who underwent omental patch repair of perforated peptic ulcer between march 20, 1999 and march 20, 2006. Sep 26, 2015 perforated peptic ulcer ppu is a surgical emergency and is associated with shortterm mortality and morbidity in up to 30 and 50% of patients, respectively. Omental implantation, a surgical procedure in which a perforated gastric or duodenal ulcer is repaired by drawing and implanting a portion of the omentum into the digestive tract, accelerates ulcer healing and inhibits ulcer recurrence compared with omental patch from clinical results. A the graham patch uses sutures placed on either side of the perforation with the addition of the omentum. Purulent contamination was reported in the right upper quadrant and pelvis. Fiftyfive patients underwent other surgical procedures for perforated peptic ulcers conventional open omental patch.
Laparoscopic omental patch repair of peptic ulcer perforation. This is a report of an experimental method for endoscopic repair of anterior gastric perforations with an omental patch developed by using a porcine model. Management of perforated gastric and duodenal ulcers. If laparotomy is undertaken and a straightforward duodenal ulcer encountered, closure with an omental patch is wellestablished as the optimal procedure. Introduction omental patching began in 1937, when dr. Perforated peptic ulcer ppu complicates 2 to 10% of patients with peptic ulcer disease and has mortality risk of up to 20%.
1119 1316 1316 667 1470 1167 594 398 362 425 582 1177 639 337 1309 381 1421 586 1457 1209 290 914 655 413 272 1046 1234 1285 496 1295 187 1503 301 1249 810 813 1193 689 252 78 1403 607 389 232 73 457