Duodenal ulcer perforation is a common surgical emergency in our part of the world. The overall reported mortality rate varies between 1.3 to nearly 20 % [9–11] in different series, and recent studies have shown it to be around 10 % . Factors such as advancing age, concomitant disease, preoperative shock, size of the perforation, delay in presentation and operation, have all been defined by various authors to be risk factors for mortality in such a situation [9–11]. Although the size of a perforation is an important measure in determining the outcome, a review of literature failed to reveal, any accepted definition of either small or giant perforations of duodenal ulcers. Neither could we come across any specific recommendations regarding the management of giant / large perforations, which are said to be "difficult" to manage and have anecdotally been associated with high leak rates and mortality. This is in contrast to the well accepted and documented definition of giant duodenal ulcers (more than 2 cms in size), which may or may not perforate, but are usually considered to be an indication for definitive, elective ulcer surgery [8, 12].
Commonly, duodenal ulcer perforations are less than 1 cm in greatest diameter, and as such, are amenable to closure by omentopexy . Our experience does seem to validate this, and this subset of 'small' perforations does seem to have the best outcome. It is the perforations that are larger that have been the cause of much confusion in their definition and management. The size of such 'giant' sized perforations has arbitrarily been defined by various authors as being greater than 0.5 cms , 1 cm [3, 4], or 2.5 cms  in greatest diameter, but we failed to uncover any specific size in available English language literature beyond which to label these perforations as "giant". These perforations are considered particularly hazardous because of the extensive duodenal tissue loss and surrounding tissue inflammation, which are said to preclude simple closure using omental patch, often resulting into post-operative leak or gastric outlet obstruction [3, 4]. The tendency to leak may further be aggravated by the high intraluminal pressures, extrusion of the duodenal mucosa through the closure, and, autodigestion by the pancreatic enzymes and bile, thereby further compromising an already sick patient .
Our data seems to suggest that based on the size, duodenal perforations can be classified into three main groups (1) small perforations that are less than 1 cm in size, and have the best outcome; (2) large perforations, that have a size between 1 cm and 3 cms; and, (3) giant perforations that exceed 3 cm size. The usage of the word 'giant' for a duodenal perforation should be restricted to such large defects, where omentopexy may be deemed unsafe, and other options may be thought to be necessary.
In the absence of any specific definition and guidelines regarding the management of such large / giant perforations in literature, different authors have recommended varied surgical options from time to time, based on their experience and research. These have included resection of the perforation bearing duodenum and the gastric antrum in the form of a partial gastrectomy, with reconstruction as either a Billroth I or II anastomosis, or the more morbid procedure of gastric disconnection in which vagectomy, antrectomy, gastrostomy, lateral duodenostomy and feeding jejunostomy are performed, with restoration of intestinal continuity electively after 4 weeks of discharge . Others have recommended conversion of the perforation into a pyloroplasty, or, closure of the perforation using a serosal patch or a pedicled graft of the jejunum, or, the use of a free omental plug to patch the defect, and even, suturing of the omentum to the nasogastric tube [3–8]. Proximal gastrojejunostomy and / or vagotomy may be added to these procedures to provide diversion and a definitive acid reducing procedure respectively . However, as can be appreciated, each of these procedures not only prolongs the operating time, but also requires a level of surgical expertise that may not be available in the emergency . In addition, each of these procedures has it own morbidity that may add up significantly to alter the final outcome of the patient, and more importantly, none of them is immune to the risk of leak in the post-operative period, which has been the main concern against performing the omental patch in larger perforations [3, 4].
The results of omentopexy in small and large sized perforations in the present series give statistically similar results. The leak rates and mortality of the two groups after omentopexy remain comparable, thereby suggesting that this may be considered as the procedure of choice in all perforations upto a size of 3 cms. The procedure is simple and easy to master, and, avoids the performance of a major resection in a patient who is already compromised. In fact, Sharma et al also reported the success of the omental plug in perforations of duodenal ulcers more than 2.5 cms in size; only, they preferred using a free graft of the omentum rather than a pedicled one . We feel that mobilization of the omentum on its pedicle from the colon, and placement of sutures into the normal duodenum away from the perforation makes the performance of omental patch safe even in the presence of large sized perforations.
In the present series, only 2 cases were defined to be 'giant' according to the size (more than 3 cm) that we have defined – one underwent antrectomy and Billroth II reconstruction, the other, a jejunal serosal patch. The first patient (antrectomy) succumbed to the ongoing septicaemia on the very first post-operative day, but the other patient survived. This is the group of patients with truly giant perforations who need to be analyzed further to determine the best course of action i.e. resectional versus non-resectional surgery. However, the less number of patients in this group did not allow us to reach any definite conclusion regarding their ideal management. Further study is needed to optimize our efforts to this target group.