The Jejunal Serosal Patch Procedure: A Successful Technique for Managing Difficult Peptic Ulcer Perforation
Background: The selection of the most appropriate technique for the repair of peptic ulcer perforations, especially when the initial attempt of closure has failed have been the concern of many surgeons. Since the experimental report regarding the jejunal serosal patch procedure by Koboldin in 1963, authors have reported its use with encouraging outcome. The main objective of this paper is to describe our experience with the Jejunal Serosal Patch procedure in patients with failed Omental patch procedure following perforated peptic ulcer disease. Methods: This is a retrospective report of cases with failed pedicled omental patch procedure initially performed for perforated peptic ulcer disease and who subsequently underwent Jejunal Patch Procedure at the Minilik II Hospital in Addis Ababa, Ethiopia. Details of their surgical procedure, complications observed and outcome is presented. Results: Five patients, who are all male with mean age of 32.2 years (Range= 31-40 years) were included in the study. The duration of illness of all patients before their first surgery ranged from 48- 360 hours (mean= 153.6 hours). All patients had significant collection of gastric and purulent material in the peritoneum during the first surgery and the mean size of the perforation was 1.3 cm (Range 1-2cm). All five patients were re-operated for the first time after a mean of 76.8 hours and all were managed with re-patching of the duodenal perforation. The second re-operation for jejunal patch procedure was within 24 hours in one patient and > 24 hours in four patients (Mean=34.8 hours). The omental patch was found completely detached in 4 patients and partially separated in one. All patients were treated in a similar fashion by using a standardized Jejunal omental patch procedure. Post operatively, a total of 16 complications were seen in the five patients. One patient died, yielding an overall mortality rate of 20%. The mean hospital stay was 25.5 days of (Range 17- 51 days) mean 25.4 days. Conclusion: The management of the leaking omental patch is very difficult. Although some leaks transform into fistulas and will eventually close after prolonged period of hyperalimentation and continuous nursing care, this approach requires extended hospitalization and the associated morbidity, mortality and financial/social depletion on the patient is enormous. On the other hand, prompt closure of these defects by serosal patching can result in a rapid return of fluid and electrolytes to normal and permits early oral feedings. Our limited experience with this procedure is encouraging and our post operative complications and mortality are within the acceptable range. We believe this procedure is learnable, and has the potential to be utilised in difficult perforations involving the other parts of the GIT.
Key words: Jejunal, Serosal, Patch Procedure, perforation, peptic ulcer