Management of Perforated Peptic Ulcer

Importance: Perforated peptic ulcer disease (PUD) affects 4 million people annually worldwide, with a lifetime prevalence of 5% to 10%. Of those affected, 5% will progress to the point of perforation. Despite advances in the understanding and treatment, perforated PUD continues to have a high rate of morbidity (48.5%) and mortality (9.3%). This review summarizes the current evidence on management of perforated PUD, including management of failed repairs. Observations: Approaches for repair include primary closure and omental patch closure. Omental patch may be most useful in large perforations with friable tissue. Minimally invasive surgery is the preferred approach in perforated PUD, with improved outcomes compared with open techniques. Leak from the ulcer after repair is seen in approximately 12% to 17% of cases. Approaches to releak include expectant management, radiologic and/or endoscopic intervention, and repeat surgery. Morbidity and mortality after releak are especially high, and complete healing of the leak may take time. Conclusions and Relevance: Despite advances in medical management and surgical techniques, perforated PUD continues to have a relatively high rate of morbidity and mortality. Minimally invasive surgery is the current preferred treatment approach.