Retrospective comparison of outcomes of patients undergoing omental patch versus falciform patch repair of perforated peptic ulcers

Introduction

The global lifetime prevalence of peptic ulcer disease ranges from 5% to 10% and incidence rates ranging from 0.1% to 3% per year.^{1, 2} Peptic ulcer disease can be complicated by haemorrhage, perforation or obstruction from chronic fibrosis which is now rarely seen; 2% to 14% of peptic ulcers will perforate.² The lifetime risk of perforation in those with peptic ulcer disease is 5%. The 30-day mortality can reach up to 20%.²

There has been increased uptake of laparoscopy for the emergency repair of peptic ulcer perforation and the Graham patch repair has remained the gold standard since it was first described in 1937 by Dr RR Graham. This is a free or attached omental patch placed within the perforation, held with three interrupted sutures tied over the patch with enough tension to hold the omental plug but not enough to cause the sutures to cut through the friable, inflamed ulcer edge.³ The perforated ulcer edges are not approximated, but the omentum plug placed stimulates the formation of fibrin which is responsible for the actual closure of the perforation.^3-5 However, in some patients, the greater omentum is inadequate for a Graham patch repair and a falciform ligament patch repair is used as an alternative. This was first described in 1978,⁶ however literature assessing its effectiveness against the omental patch is sparse. The falciform ligament is mobilized by dividing the ligament at its insertion to the anterior abdominal wall in a cephalad direction, until the pedicle has enough length for a tension-free repair at the identified perforation site.⁶ Then similar to the omental patch, the interrupted sutures are placed at the ulcer edge and tied over the tension-free falciform ligament placed within the perforation.⁶ Most evidence comes from case reports describing the technique performed through either a laparotomy or laparoscopically and indicating uncomplicated post-operative patient recovery.^{7, 8} There is only one Turkish study of 289 patients, retrospectively comparing the efficacy and feasibility of the omental patch repair to falciform patch repair however this is only performed in those undergoing laparotomy.⁹ They found that the falciform patch repair was an acceptable alternative and was not superior to the omental patch repair for peptic ulcer perforation especially as they observed greater patch failure among patients with falciform ligament repair.⁹

This is the first Western Australian study comparing the outcomes of patients undergoing omental patch repair to falciform patch repair for their perforated peptic ulcer and includes patients who underwent laparotomy or laparoscopic approach. The aim is to compare patient outcomes following each of the techniques and determine if one is superior to the other when used to repair perforated peptic ulcers.

Methods

Ethics approval was obtained from the South Metropolitan Health Service and Department of Health WA Human Research Ethics Committees respectively with approval for a waiver of consent given the retrospective nature and size of the study. ICD-10-AM and ACHI 6th to 10th Edition codes were used to identify specific primary and secondary diagnoses related to perforated peptic ulcers and related surgeries and interventions to select relevant patients. Patients who underwent an emergency surgical repair of perforated gastric or duodenal ulcer from 1 January 2010 to 31 December 2017 at Fremantle Hospital Health Service (FHHS), Royal Perth Hospital (RPH) and Sir Charles Gairdner Hospital (SCGH) were included. All included patients were aged 18 years and above at the time of index operation. Hard copies and electronic files of all included patients were reviewed for data collection. Patient demographics such as age, gender, American Society of Anaesthesiologists (ASA) score, presence of pre-operative shock, surgical approach (laparoscopy vs. laparotomy vs. laparoscopy converted to laparotomy) and use of omental patch versus falciform ligament patch repair were documented. Ulcer perforation characteristics such as size and location were also collected. Outcome measures such as the occurrence of post-operative intra-abdominal sepsis, return to theatre, ICU admission, inpatient mortality and 30-day readmission post-discharge for those surviving were assessed. Post-operative intra-abdominal sepsis here refers to patients who developed leaks or intra-abdominal collections managed either conservatively, radiologically or required return to theatre. The use of follow-up gastroscopy and ulcer healing between omental and falciform repair groups were also assessed.

Mann–Whitney non-parametric test was used to compare median age and ASA score between the omental and falciform groups. Chi-squared test was used to compare gender distribution, presence of pre-operative shock, ulcer perforation size and location between the omental and falciform groups. Logistic regression analysis was used to assess the impact of the omental or falciform patch along with other variables such as age, gender, ASA Score, presence of shock and surgical approach on post-operative outcomes. The outcomes measured were intra-abdominal sepsis, return to theatre, ICU admission, inpatient mortality and 30-day readmission post-discharge. The use of follow-up gastroscopy and ulcer healing between the omental and falciform groups were assessed using binomial tests.

Statistical analysis was performed using the R program¹⁰ by the statistician based at the South Metropolitan Health Service.

Results

There were 292 patients who received an omental patch repair and 37 patients who received a falciform ligament patch repair. There was no significant difference in gender or median age between the omental and falciform groups. The falciform group had an ASA score of 2 and omental group had an ASA score of 3 which were statistically significantly different. There was no significant difference in the presence of shock or the distribution of ulcer perforation size between the two groups (Table 1). Sixty-eight percent of ulcer perforations were 1 cm or less in size. While most duodenal and gastric ulcer perforations were repaired using an omental patch, duodenal ulcer perforations were more likely to receive the falciform ligament patch with statistical significance (Table 1).

Logistic regression analysis was used to compare outcomes between patients who received omental patch and falciform ligament patch repairs (Table 2). Variables such as age, gender, ASA score, pre-operative shock and surgical approach (laparotomy vs. laparoscopy vs. laparoscopy converted to laparotomy) were considered.

There was no significant difference in post-operative intra-abdominal sepsis between patients who received omental patch repair and falciform ligament repair (Table 2) however increasing ASA score (P = 0.019, CI: 0.089:0.980), significantly affected this outcome. There was no significant difference in post-operative return to theatre between the two groups (Table 2). Increasing ASA score (P = 0.017, CI: 0.138:1.340) significantly contributed to this outcome. There was no significant difference in post-operative ICU admissions between omental and falciform patients (Table 2), while increasing age (P = 4.04 × 10⁻⁶, CI: 0.022:0.056), increasing ASA score 4.81 × 10⁻⁶, CI: 0.725:1.447), and the presence of shock (P = 0.0003, CI: 0.662:2.263) were significant contributors to ICU admission. There was no significant difference in inpatient mortality (P = 0.993, CI: −94.208:686.876) between the two groups (Table 2) though increasing age (P = 0.0001, CI: 0.063:0.182) and ASA score (P = 0.0002, CI: 0.726:2.287) significantly worsened inpatient mortality. 30-day readmission post-discharge (P = 0.646, CI: −0.886:1.821) was not significantly different between the omental and falciform groups (Table 2), though increasing ASA score (P = 0.013, CI: 0.102:0.898) significantly contributed to this outcome.

One hundred forty-one of the included 329 (43%) patients underwent a follow-up gastroscopy post discharge. Amongst those with a gastroscopy report, there was no statistically significant difference in ulcer healing between the omental and falciform groups (Table 2).

Discussion

The falciform ligament has been used as an alternative to the gold standard Graham patch repair especially when the greater omentum is inadequate; either non-existent or scant, non-viable or unhealthy when repairing perforated peptic ulcers. Anatomically, it is well vascularised with the arterial supply from the left phrenic artery and/or the middle hepatic artery and^11-13 venous drainage from the left inferior phrenic vein and portal vein.^{12, 13} It is also ideally located across the first part of the duodenum, making a tension-free patch with minimal or without mobilization possible^{6, 12} especially for duodenal ulcer perforations. This explains it's use for duodenal ulcer perforations in this study. However, comparison of patient outcomes to those who receive the omental patch repair is scarce. They are mostly in the form of case reports,^{8, 11} one retrospective Turkish study comparing the two techniques in patients undergoing open repair of perforated peptic ulcer⁹ and a retrospective case-controlled study assessing outcomes in 40 patients who underwent open surgery with falciform ligament repair.¹²

The consensus in current literature is that those receiving an omental patch experience less frequent leaks, the omentum has lymphocyte rich vascular supply and is able to adhere to the area of inflammation¹² and should therefore be used preferentially when the greater omentum is available.

This first Western Australian (WA) study demonstrated that patient outcomes following falciform ligament repair was comparable to omental patch repair though was mainly performed in patients with ASA 2, duodenal perforations, or ulcers which are 1 cm or less in size. Ulcer healing rates were also comparable between the two groups though only 43% of included patients were assessable. Patient factors such as increasing age and ASA scores were found to be more important predictors of poor outcomes such as post-operative intra-abdominal sepsis, return to theatre, ICU admission, mortality and 30-day readmission, than the type of tissue used to repair the perforations. This indicates that the use of falciform ligament if omentum is unavailable can be used safely regardless of patient age or ASA score.

This study has a slightly larger inclusion population than the Turkish study⁹ (303 included patients) published in 2019 comparing outcomes between patients who underwent falciform ligament repair versus omental patch repair. Their study population were similar to this study where those who received the falciform patch were also generally ASA 2 patients and those who received omental patch repairs were ASA 3 patient.⁹ However, they only included patients who underwent laparotomy while this study included patients who underwent open or laparoscopic surgery. Those who received falciform patch repairs did not have more leaks in this study than those who received omental patch repairs as was the case in the Turkish study.⁹ Patient comorbidities or surgical technique may be contributing factors for this difference though this is difficult to demonstrate here.

This study contributes positive evidence of feasibility, safety, and efficacy of the falciform patch repair amongst patients with perforated peptic ulcers performed open or laparoscopically. Some limitations here include the retrospective nature of this audit and the reasons for choosing the falciform patch by Western Australian surgeons was not investigated. A larger population may further strengthen this evidence given there were only 37 patients who underwent falciform ligament repair here. In addition, only less than half of the included patients in this study underwent follow-up gastroscopy and assessment of ulcer healing, highlighting an area for improvement.

Future larger prospective studies, investigating the reasons for choosing falciform ligament repair as well as surgical technique will be useful. The role of ulcer perforation location in the choice of repair should also be investigated. A prospective study will also improve the uptake of follow-up gastroscopy and yield of assessment of ulcer healing.

Author contributions

Vidya Seenarain: Conceptualization; data curation; funding acquisition; investigation; methodology; project administration; writing – original draft; writing – review and editing. Tamalee Wilson: Data curation. David R. Fletcher: Supervision; writing – review and editing. Amanda J. Foster: Supervision; writing – review and editing.

Conflicts of interest

None declared.

Ethical approval

Ethical approval to conduct this study was obtained from the South Metropolitan Health Service Human Research Ethics Committee, Department of Health Western Australia on the 10th of December 2018, in accordance with the Declaration of Helsinki as revised in Brazil 2013.