Omental plug closure of large duodenal defects--an experimental study

This study was conducted to evaluate the efficacy of omental plugging in the management of large duodenal defects and analyse the serial histopathological changes occurring in the omental plug and the edges of the defect until healing occurred as evidenced by complete mucosal cover. The study was conducted in 12 dogs. Through a laparotomy wound a 20 mm diameter defect was created in the first part of the duodenum. The abdomen was closed, leaving the defect open, for a period of three hours to allow peritonitis to set in. Subsequently the abdomen was reopened and the perforation was plugged with omentum pulled into the duodenal lumen and fixed to the edges. They were randomly sacrificed two at a time on the first week, second week, fourth week, sixth week and eight week post operatively. The morphology of the perforation site, adequacy of the duodenal lumen, and the histological picture at each stage were studied. There was no morbidity except in one dog which showed signs of high intestinal obstruction that resolved after conservative management. There was one mortality due to sepsis unrelated to the procedure. The omentum was firmly adherent and there was no evidence of leak from the site of closure. The omental plug underwent inflammation, necrotic changes, granulation, reduction in size and fibrosis. The defects decreased rapidly in size and healing was complete at eight weeks with the mucosa taking a normal histological appearance. None of the dogs exhibited luminal obstruction on autopsy. This study reaffirms the reliability of the omental plug in safely occluding large duodenal defects and producing healing through a process of inflammation, granulation, vascularisation and fibrosis eventually providing a normal duodenal mucosal cover to the perforation site.