Randomized clinical trial of laparoscopic versus open repair of the perforated peptic ulcer: the LAMA Trial

Laparoscopic Repair Versus Open Repair for Perforated Peptic Ulcers: Quality of Life Assessment

PURPOSE

This study was designed to assess the relative efficacy of laparoscopic repair (LR) as opposed to open surgical repair (OR) in the treatment of perforated peptic ulcer (PPU) and its impact on quality of life.

BACKGROUND

Studies reporting patient-centered outcomes, including quality of life and satisfaction, in PPU treatment are insufficient.

METHODS

This investigation performed a retrospective review of patients who underwent treatment for PPU at a secondary care hospital from December 2016 to November 2020. Patients were categorized into two separate groups according to the type of surgical procedure received: LR and OR. Comparisons were made based on a variety of factors, such as demographic data, intra- and postoperative metrics, pain control, patient contentment, and quality of life indicators.

RESULTS

In the analysis, there were no statistically significant differences in demographic or clinical characteristics between the LR (n=35) and OR (n=62) groups (p > 0.05). Conversely, the rates of incisional hernia and surgical site infection were significantly greater in the OR group (p < 0.05). Moreover, the LR exhibited benefits such as a shorter length of hospital stay (p < 0.05), more rapid resumption of a normal diet, and fewer surgical site infections-factors that contributed to a lower rate of overall postoperative complications. According to the quality of life questionnaire, the LR group exhibited significantly greater scores for physical function, role, pain, and general health by the 30th postoperative day (p=0.003, p<0.001, p=0.006 and p=0.001, respectively), and by the 1-year follow-up, the LR group showed substantial improvements in physical function, physical role, emotional role, pain and general health (p=0.047, p=0.004, p=0.039, p=0.001, p=0.021, respectively), indicating its effectiveness in patient recovery and quality of life enhancement postsurgery.

CONCLUSION

This study showed that LR could provide certain benefits in managing PPUs, such as reduced lengths of hospital stay and lower incidences of surgical site infections. Although LR reported promising directions in patient satisfaction and quality of life indicators, the limited duration of postoperative monitoring necessitates caution in broadly applying these results.

Approaches for the treatment of perforated peptic ulcers: a network meta-analysis of randomised controlled trials - study protocol

INTRODUCTION

Perforated peptic ulcers are a life-threatening complication associated with high morbidity and mortality. Several treatment approaches are available. The aim of this network meta-analysis (NMA) is to compare surgical and alternative approaches for the treatment of perforated peptic ulcers regarding mortality and other patient-relevant outcomes.

METHODS AND ANALYSIS

A systematic literature search of PubMed/MEDLINE, Cochrane Library, Embase, CINAHL, ClinicalTrials.gov trial registry and ICTRP will be conducted with predefined search terms.To address the question of the most effective treatment approach, an NMA will be performed for each of the outcomes mentioned above. A closed network of interventions is expected. The standardised mean difference with its 95% CI will be used as the effect measure for the continuous outcomes, and the ORs with 95% CI will be calculated for the binary outcomes.

ETHICS AND DISSEMINATION

In accordance with the nature of the data used in this meta-analysis, which involves aggregate information from previously published studies ethical approval is deemed unnecessary. Results will be disseminated directly to decision-makers (eg, surgeons, gastroenterologists) through publication in peer-reviewed journals and presentation at conferences.

PROSPERO REGISTRATION NUMBER

CRD42023482932.

How to do laparoscopic repair of perforated anterior duodenal ulcers: a 'three arches' falciform patch technique simplifies the approach

Laparoscopic repair of perforated duodenal ulcers has proven superior results to open procedures though uptake has been poor. We describe the 'three arches' technique as a means of reducing technical difficulty and improving operative efficiency. Our case series of patients undergoing this technique for perforated peptic ulcer disease demonstrates comparable results to other methods of repair.

Perforated Gastric Cancer: A Case Report and Literature Review

Gastric cancer perforation is a rare but life-threatening complication of gastric cancer. We present the case of a 53-year-old male with acquired immune deficiency syndrome (AIDS) who presented to the emergency department with severe abdominal pain, was found to have an acute abdomen, and was eventually diagnosed with gastric perforation due to metastatic gastric cancer. This case highlights the challenges in diagnosing and managing perforated gastric cancer and discusses the surgical management options, including the use of laparoscopic techniques and the role of chemotherapy, particularly hyperthermic intraperitoneal chemotherapy (HIPEC).

Improvement of Russian clinical guidelines and reduction of mortality in perforated ulcers

OBJECTIVE

To analyze the results of laparoscopic surgery in patients with perforated ulcers using evidence-based medicine approaches.

MATERIAL AND METHODS

We compared the efficacy and effectiveness of laparoscopic and open surgeries in patients with perforated ulcers. Meta-analysis of mortality after laparoscopic surgeries (randomized controlled trials) and trial sequential analysis were carried out.

RESULTS

We clarified the differences between the efficacy and effectiveness of laparoscopic surgeries regarding postoperative mortality. In the Russian Federation, mortality after laparoscopic surgery is 9-11 times lower compared to open procedures. According to evidence-based researches (efficacy of laparoscopic interventions in 10 meta-analyses), these differences are less obvious (1.4-3.0 times) and not significant. The diversity-adjusted required information size to draw reasonable conclusions about differences in mortality in trial sequential analysis was 68 181 participants. Meta-analyses of RCTs also demonstrate lower incidence of wound complications (1.8-5.0% after laparoscopic surgery and 6.3-13.3% after laparotomy), shorter hospital-stay (mean difference from -0.13 to -2.84) and less severe pain syndrome (mean difference in VAS score from -2.08 to -2.45) after laparoscopic technologies.

CONCLUSION

The obvious advantage of laparoscopic surgery in patients with perforated ulcers is fast-truck recovery following shorter hospital-stay, mild pain and rarer wound complications. Comparison of postoperative mortality regarding efficacy and effectiveness is difficult due to insufficient introduction of laparoscopic technologies in clinical practice and diversity-adjusted required information size.

A comparative study on laparoscopic and open surgical approaches for perforated peptic ulcer repair: efficacy and outcomes analysis

PURPOSE

This study aimed to compare the clinical outcomes of the clinical outcomes of laparoscopic and open sutures for peptic ulcer perforation (PPU).

MATERIALS AND METHODS

PubMed, EMBASE, and Cochrane Library databases were searched for eligible studies from inception to March 31, 2023. Odds ratios (OR) and 95% confidence intervals (Cl) were also calculated. The Newcastle-Ottawa Scale (NOS) was used to evaluate the quality of the included studies. This study was performed using the Stata (V.16.0) software.

RESULTS

A total of 29 studies involving 17,228 patients were included in this study. In terms of postoperative outcomes, the laparoscopic group had a shorter postoperative hospital stay (MD = -0.29, 95%CI = -0.44 to -0.13, P = 0.00), less blood loss (MD = -0.45, 95%CI = -0.82 to -0.08, P = 0.02), fewer wound infection (OR = 0.20, 95%CI = 0.17 to 0.24, P = 0.00), fewer pneumonia (OR = 0.59, 95%CI = 0.41 to 0.87, P = 0.01), fewer respiratory complications (OR = 0.26, 95%CI = 0.13 to 0.55, P = 0.00) and lower postoperative morbidity (OR = 0.51, 95%CI = 0.33 to 0.78, P = 0.00). The laparoscopic group had a lower mortality rate (OR = 0.36, 95%CI = 0.27 to 0.49, P = 0.00) than the open group. We also found that the laparoscopic group had a higher overall complication rate than the open group (OR = 0.45, 95%CI = 0.34 to 0.60, P = 0.00).

CONCLUSION

Laparoscopic repair was associated with a lower risk of mortality than open repair in patients with PPU. Laparoscopic repair may be a better option in patients with PPU.

A comparative study of laparoscopic versus laparotomy repair of perforated peptic ulcer: A prospective study

Background

Laparoscopic surgery is still gaining popularity in conditions associated with peritonitis, such as a perforated peptic ulcer.

Aim of the work

This study aimed to compare laparoscopic and laparotomy repair of perforated peptic ulcers regarding intraoperative parameters, postoperative pain, time of the start of oral feeding, postoperative complication, hospital stay, resuming normal activity, and outcomes.

Patients and methods

This is a prospective study of 50 patients (males and females), of any age with perforated peptic ulcer. Those patients will be divided by the random serial number method into two groups: the laparoscopic group and the open (laparotomy) group. In a period from 15th April 2022 to 15th February 2023 data related to patients were recorded and subjected to analysis.

Results

All patients were divided into two groups: Laparoscopic group with 25 patients (23 of them underwent successful laparoscopic repair and two patients were converted to open) and the open (laparotomy) group with 25 patients underwent laparotomy repair (of which 23 patients were living, and two patients died on the third and tenth postoperative days). There were no significant differences in baseline characteristics between both groups in terms of age, gender, special habits, preoperative risk factors, comorbidities, laboratory, and radiological findings; also both groups showed insignificant differences regarding the American Society of Anesthesiologists (ASA) scores (P=0.83), total Boey’s score (P=0.77), shock on admission (P= 1.00), and the duration of symptoms > 24 hours (P= 0.77). Operative time was significantly increased in the laparoscopic versus open group (P=0.0001). While, first-day pain score (VAS), opioid requirements, time of starting oral feeding, length of hospital stay, and return to normal activity were highly significantly decreased in laparoscopic repair compared with open repair (P= <0.0001 for each). Total postoperative complications showed insignificant difference between the studied groups (P=0.16), but they were more prevalent between the open group (14 patients, 56%) versus the laparoscopic group (9 patients, 36%). Good cosmetic results of wounds were more prevalent in the laparoscopic group [20 patients (80.00%)] than the open group [13 patients (56.52%)], but insignificant, P=0.17.

Conclusion

Laparoscopic repair had an upper hand over open repair regarding less intraoperative blood loss, less postoperative pain, requiring less postoperative analgesia, early starting of oral feeding, less postoperative complications, shorter hospital stay, early return to normal activity, and good cosmetic results of wounds.

Perforated peptic ulcer (PPU) treatment: an Italian nationwide propensity score-matched cohort study investigating laparoscopic vs open approach

BACKGROUND

Perforated peptic ulcer (PPU) remain a surgical emergency accounting for 37% of all peptic ulcer-related deaths. Surgery remains the standard of care. The benefits of laparoscopic approach have been well-established even in the elderly. However, because of inconsistent results with specific regard to some technical aspects of such technique surgeons questioned the adoption of laparoscopic approach. This leads to choose the type of approach based on personal experience. The aim of our study was to critically appraise the use of the laparoscopic approach in PPU treatment comparing it with open procedure.

METHODS

A retrospective study with propensity score matching analysis of patients underwent surgical procedure for PPU was performed. Patients undergoing PPU repair were divided into: Laparoscopic approach (LapA) and Open approach (OpenA) groups and clinical-pathological features of patients in the both groups were compared.

RESULTS

A total of 453 patients underwent PPU simple repair. Among these, a LapA was adopted in 49% (222/453 patients). After propensity score matching, 172 patients were included in each group (the LapA and the OpenA). Analysis demonstrated increased operative times in the OpenA [OpenA: 96.4 ± 37.2 vs LapA 88.47 ± 33 min, p = 0.035], with shorter overall length of stay in the LapA group [OpenA 13 ± 12 vs LapA 10.3 ± 11.4 days p = 0.038]. There was no statistically significant difference in mortality [OpenA 26 (15.1%) vs LapA 18 (10.5%), p = 0.258]. Focusing on morbidity, the overall rate of 30-day postoperative morbidity was significantly lower in the LapA group [OpenA 67 patients (39.0%) vs LapA 37 patients (21.5%) p = 0.002]. When stratified using the Clavien-Dindo classification, the severity of postoperative complications was statistically different only for C-D 1-2.

CONCLUSIONS

Based on the present study, we can support that laparoscopic suturing of perforated peptic ulcers, apart from being a safe technique, could provide significant advantages in terms of postoperative complications and hospital stay.

Outcomes of laparoscopic modified Cellan-Jones repair versus open repair for perforated peptic ulcer at a community hospital

INTRODUCTION

Minimally invasive or open Graham Patch repair remains the gold standard approach for management of perforated peptic ulcers (PPU). Herein, we report outcomes of laparoscopic technique and compare it with open approach at a community hospital.

METHODS

Retrospective observational study conducted comparing laparoscopic modified Cellan-Jones repair (mCJR) versus the standard open repair of PPU. Patients aged 18-90 years during 2016-2021 were offered either a minimally invasive or open approach depending on surgeon laparoscopic capability, and were compared in terms of demographics, co-morbidities, intra-operative details, and short-term outcomes.

RESULTS

A total of 49 patients were included (46.9% males, mean age 52.9 years, mean BMI 25.0, ASA ≥ III 75.5%, 75.5% smokers, 26.5% current NSAIDs use, and 71.4% alcohol drinkers). Duodenum was the most common perforation site (57.1%), and majority of ulcers were 1-2 cm (72.9%). Laparoscopic approach was performed in 16 consecutive patients (32.7%) by a single surgeon, with no conversions. Preoperative characteristics were similar for both groups. Compared to open approach, laparoscopic group were taken to operation immediately (< 4 h) (87.5% vs. 15.2%, p < 0.001), had lower estimated blood loss (11.8 ml vs. 73.8 ml, p = 0.063), and longer operative time (117.1 min vs. 85.6 min, p = 0.010). Postoperatively, nasogastric tube was removed earlier in laparoscopic group (POD1-2, 87.5% vs. 24.2%, p = 0.001), with earlier resumption of diet (POD1-2, 62.6% vs. 9.1%, p = 0.002), less narcotic usage (< 3 days, 58.3% vs. 6.1%, p < 0.001), earlier return of bowel function (POD1-2, 43.8% vs. 9.1%, p = 0.003) and shorter length of stay (LOS) (3.7 days vs. 16.1 days, p < 0.001). Both in-house mortality and morbidity rates were lower in the laparoscopic group, but not statistically significant [(0% vs. 6.1%, p = 0.347) and (12.5% vs. 39.4%, p = 0.500), respectively].

CONCLUSION

Laparoscopic mCJR is a feasible method for repair of PPU, and it is associated with shorter LOS, and less narcotics usage in comparison to the open repair approach.

A systematic review and meta-analysis comparing postoperative outcomes of laparoscopic versus open omental patch repair of perforated peptic ulcer

BACKGROUND

The mainstay of surgical management of perforated peptic ulcer is omental patch repair. Advances in minimally invasive techniques have shown feasibility of laparoscopic omental patch repair (LOPR). Laparoscopic omental patch repair is limited by learning curve (LC), but there is a lack of reporting of LC in LOPR. This study aims to compare outcomes following LOPR versus open omental patch repair (OOPR) with reporting of LC.

METHODS

PubMed, Embase, The Cochrane Library, and Scopus were systematically searched from inception till January 2022 for randomized controlled trials (RCTs) and non-RCTs comparing LOPR and OOPR in perforated peptic ulcer. Exclusion criteria were primary repair without use of omental patch repair. Primary outcomes were 30-day mortality, postoperative leak, and LC analysis.

RESULTS

There were a total of 29 studies including 5,311 patients (LOPR, n = 1,687; OOPR, n = 3,624), with 4 RCTs with 238 patients (LOPR, n = 118; OOPR, n = 120). Majority of ulcers were located in the duodenum (57.0%) followed by stomach (30.7%). Mean ulcer size ranged from 5 to 16.2 mm in LOPR and 4.7 to 15.8 mm in OOPR. Laparoscopic omental patch repair was associated with lower 30-day mortality (odds ratio [OR], 0.57; 95% confidence interval [CI], 0.35-0.92; p = 0.02), overall morbidity (OR, 0.31; 95% CI, 0.18-0.53; p < 0.0001), surgical site infection (OR, 0.27; 95% CI, 0.18-0.42; p < 0.00001), and length of stay (mean difference, -2.84 days; 95% CI, -3.63 to -2.06; p < 0.00001). Postoperative leakage (OR, 1.06; 95% CI, 0.43-2.61; p = 0.90) was comparable between LOPR and OOPR. Only three studies analyzed the proportion of consultants to trainees; LOPR was performed mainly by consultants (range, 82.4-91.4%), while OOPR was mainly performed by trainees (range, 52.8-96.8%). One study showed that consultants who performed open conversion had shorter operating time compared with chief residents (85 vs. 186.6 minutes, p < 0.003).

CONCLUSION

Laparoscopic omental patch repair has lower mortality, overall morbidity, length of stay, intraoperative blood loss, and postoperative pain compared with OOPR. More prospective studies should be conducted to evaluate LC in LOPR.

LEVEL OF EVIDENCE

Systematic Review and Meta-Analysis; Level IV.

Laparoscopic distal gastric and D1 resection for large perforated duodenal bulb peptic ulcer, with intracorporeal antecolic gastrojejunal anastomosis

BACKGROUND

Peptic ulcer perforation is a common surgical emergency and a major cause of death especially in elderly patients, despite the fact of the presence of effective drug treatments and an increased understanding of its etiology. Giant duodenal perforations, in particular, pose a significant challenge and there is scarce data regarding their optimal management. Laparoscopic surgery is advocated in the surgical treatment of perforated duodenal ulcer disease, in experienced hands.

METHODS

Herein we present an 84-year-old man with past medical history of type II diabetes mellitus and hypertension who was admitted to our Department due to epigastric pain and diffuse peritonitis. CT scan revealed the presence of a significant amount of free air and fluid in the upper abdomen secondary to a duodenal perforation.

RESULTS

The patient was taken immediately to the theater for an urgent laparoscopy. Methylene blue via the NG tube better defined the extent of the duodenal perforation which was not amenable to a primary repair. Consequently, a decision was made for a laparoscopic pancreas-sparing, ampulla preserving gastroduodenectomy with intracorporeal Billroth II gastrojejunal anastomosis. The postoperative period was uneventful and the patient was discharged on the 13th postoperative day. Histopathology revealed a large benign duodenal ulcer.

CONCLUSIONS

Although the incidence of peptic ulcer disease is decreasing, it appears that the incidence of complications is rising. Laparoscopic approach, especially when performed by laparoscopic surgery experts, could be a treatment option for difficult duodenal ulcer perforations with less pain, shorter hospital stay and reduced morbidity.

Surgical Management of Perforated Peptic Ulcer: A Comparative Meta-analysis of Laparoscopic Versus Open Surgery

BACKGROUND

Despite the widescale success of proton pump inhibitors to reducing the incidence of peptic ulcer disease, perforated peptic ulcer (PPU) remains a significant cause of severe complications and death. The implementation of open or surgical repair of PPU should be guided by reliable guidelines which are based on current systematic evidence.

OBJECTIVES

To assess the comparative efficacy and safety of laparoscopic and open repair of PPU.

METHODS

A systematic review and meta-analysis was conducted based on retrospective, prospective cohort studies, and randomized clinical trials. Duration of surgery and postoperative complications and death were collected from eligible studies, and the outcomes were pooled using mean differences (MD) or relative risks (RRs) for numerical and binary outcomes, respectively. The estimated variance was expressed as 95% confidence intervals (95% CIs).

RESULTS

Forty-five studies were included (8456 patients, 56.08% underwent open repair, 6 prospective studies, 7 randomized clinical trials, and 32 retrospective studies). Compared with open repair, laparoscopic surgeries were associated with longer operative times (MD=8.36, 95% CI, 0.49-16.22), shorter hospital stay (MD=-2.74, 95% CI, -3.70 to-1.79), a higher risk of suture leakage (RR=1.91, 95% CI, 1.04-3.49) and lower risks of mortality (RR=0.57, 95% CI, 0.47-0.70), septic shock (RR=0.69, 95% CI, 0.49-0.98), renal failure (RR=0.38, 95% CI, 0.18-0.79), and wound infection (RR=0.26, 95% CI, 0.19-0.37).

CONCLUSION

Laparoscopic repair of PPU showed promising safety outcomes; however, future well-designed randomized studies are warranted to reduce the observed performance bias and possible selection bias in individual studies.

Laparoscopic repair of perforated peptic ulcer: a multicenter, propensity score matching analysis

Background

Perforated peptic ulcer (PPU) is a common emergency condition requiring surgery using laparoscopy or open repair of the perforated site. The aim of this study was to assess the role of laparoscopic surgery (LS) based on the safety and efficacy for PPU.

Methods

Medical records of the consecutive patients who underwent LS or open surgery (OS) for PPU at five hospitals between January 2009 and December 2019 were retrospectively reviewed. After propensity score matching, short-term perioperative outcomes were compared between LS and OS in selected patients.

Results

Among the 598 patients included in the analysis, OS was more frequently performed in patients with worse factors, including older age, a higher American Society of Anesthesiologists score, more alcohol use, longer symptom duration, a higher Boey score, a higher serum C-reactive protein level, a lower serum albumin level, and a larger-diameter perforated site. After propensity score matching, 183 patients were included in each group; variables were well-balanced between-groups. Postoperative complications were not different between groups (24.6% LS group vs. 31.7% OS group, p = 0.131). However, postoperative length of hospital stay (10.03 vs. 12.53 days, respectively, p = 0.003) and postoperative time to liquid intake (3.75 vs. 5.26 days, p < 0.001) were shorter in the LS group.

Conclusions

LS resulted in better functional recovery than OS and can be safely performed for treatment of PPU. When performed by experienced surgeons, LS is an alternative option, even for hemodynamically unstable patients.

Outcome of Laparoscopic Repair for Perforated Peptic Ulcers in a Resource-Limited Setting

Background

Perforation of peptic ulcers is a common cause of emergency surgery and has significant morbidity and mortality. The use and range of laparoscopic surgery have greatly increased over the past three decades. Laparoscopic approach is an option for perforated peptic ulcers because of the simple nature of the intervention. The aim of this study was to evaluate the outcome of laparoscopic approach for peptic ulcer repair in emergency setting by means of operative time, post-operative pain, mean hospital stay, and post-operative complications.

Methods

In this study, we enrolled patients presenting with perforated peptic ulcers in the emergency department of a tertiary care hospital in Lahore, Pakistan. Approval from the hospital ethical committee and informed consent were taken from all patients. After resuscitation, the patient underwent laparoscopic repair of perforation. Post-operative course of patients was monitored. Duration of surgery, post-operative pain, length of hospital stay, and post-operative complications were noted for all patients.

Results

Between December 2018 and December 2021, 31 patients with perforated peptic ulcers underwent laparoscopic repair at our hospital. Mean age of patients was 37.25 ± 7.80 years. Most of the patients were male (70.76%). The mean operation time was 109.35 ± 17.02 minutes for laparoscopic repair. Mean duration of hospital stay was 5.10 ± 0.87 days. Mean post-operative pain was 3.55 ± 0.85 assessed using the Visual Analogue Scale. There were no mortalities during the 30-day post-operative window.

Conclusion

With proper patient selection, laparoscopic surgery offers better results as compared to open surgery in patients undergoing emergency surgery for perforated peptic ulcers.

Comparative study of postoperative complications after open and laparoscopic surgery of the perforated peptic ulcer: Advantages of the laparoscopic approach

BACKGROUND

Despite the acceptance of the laparoscopic approach for the treatment of perforated peptic ulcers, its definitive implantation is still a matter of discussion. We performed a comparative study between the open and laparoscopic approach focused on postoperative surgical complications.

METHODS

Retrospective observational study in which patients operated on for perforated peptic ulcus in our center between 2001 and 2017 were analyzed. Only those in whom suture and/or omentoplasty had been performed were selected, either for open or laparoscopic approach. Demographic, clinical, and intraoperative variables, complications, mortality and length of stay were collected. Both groups, open and laparoscopic surgery patients, were compared.

RESULTS

The final study sample was 250 patients, 190 (76%) men and 60 (24%) women, mean age 54 years (SD ± 16.7). In 129 cases (52%), the surgical approach was open, and in 121 (48%) it was laparoscopic. Grades III-V complications of the Clavien-Dindo Classification occurred in 23 cases (9%). Operative mortality was 1.2% (3 patients). Laparoscopically operated patients had significantly fewer complications (p = 0.001) and shorter hospital stay (p < 0.001). In multivariate analysis, laparoscopic approach (p = 0.025; OR:0.45-95%CI: 0.22-0.91), age (p = 0.003; OR:1.03-95%CI: 1.01-1.06), and Boey score (p = 0.024 - OR:1.71 - CI95%: 1.07-2.72), were independent prognostic factors for postoperative surgical complications.

CONCLUSION

Laparoscopic surgery should be considered the first-choice approach for patients with perforated peptic ulcer. It is significantly associated with fewer postoperative complications and a shorter hospital stay than the open approach.

Laparoscopy in Emergency: Why Not? Advantages of Laparoscopy in Major Emergency: A Review

A laparoscopic approach is suggested with the highest grade of recommendation for acute cholecystitis, perforated gastroduodenal ulcers, acute appendicitis, gynaecological disorders, and non-specific abdominal pain (NSAP). To date, the main qualities of laparoscopy for these acute surgical scenarios are clearly stated: quicker surgery, faster recovery and shorter hospital stay. For the remaining surgical emergencies, as well as for abdominal trauma, the role of laparoscopy is still a matter of debate. Patients might benefit from a laparoscopic approach only if performed by experienced teams and surgeons which guarantee a high standard of care. More precisely, laparoscopy can limit damage to the tissue and could be effective for the reduction of the overall amount of cell debris, which is a result of the intensity with which the immune system reacts to the injury and the following symptomatology. In fact, these fragments act as damage-associated molecular patterns (DAMPs). DAMPs, as well as pathogen associated molecular patterns (PAMPs), are recognised by both surface and intracellular receptors of the immune cells and activate the cascade which, in critically ill surgical patients, is responsible for a deranged response. This may result in the development of progressive and multiple organ dysfunctions, manifesting with acute respiratory distress syndrome (ARDS), coagulopathy, liver dysfunction and renal failure. In conclusion, none of the emergency surgical scenarios preclude laparoscopy, provided that the surgical tactic could ensure sufficient cleaning of the abdomen in addition to resolving the initial tissue damage caused by the “trauma”.

Surgery for Perforated Peptic Ulcer: Is Laparoscopy a New Paradigm?

Introduction

Laparoscopic repair of perforated peptic ulcer (PPU) remains controversial mainly due to its safety and applicability in critically ill patients. The aim of this study is to compare the outcomes of laparoscopy versus laparotomy in the treatment of PPU.

Methods

Single-institutional, retrospective study of all patients submitted to surgical repair of PPU between 2012 and 2019.

Results

During the study period, 169 patients underwent emergent surgery for PPU. A laparoscopic approach was tried in 60 patients and completely performed in 49 of them (conversion rate 18.3%). The open group was composed of 120 patients (included 11 conversions). Comparing the laparoscopic with the open group, there were significant differences in gender (male/female ratio 7.2/1 versus 2.2/1, respectively; p=0.009) and in the presence of sepsis criteria (12.2% versus 38.3%, respectively; p=0.001), while the Boey score showed no differences between the two groups. The operative time was longer in the laparoscopic group (median 100' versus 80', p=0.01). Laparoscopy was associated with few early postoperative complications (18.4% versus 41.7%, p=0.004), mortality (2.0% versus 14.2%; p=0.02), shorter hospital stay (median 6 versus 7 days, p=0.001), and earlier oral intake (median 3 versus 4 days, p=0.021).

Conclusion

Laparoscopic repair of PPU may be considered the procedure of choice in patients without sepsis criteria if expertise and resources are available. This kind of approach is associated with a shorter length of hospital stay and earlier oral intake. In patients with sepsis criteria, more data are required to access the safety of laparoscopy in the treatment of PPU.

Clinical Characteristics of Primary Repair for Perforated Peptic Ulcer: 10-Year Experience in a Single Center

Background: Perforated peptic ulcer (PPU) is a disease whose incidence is decreasing. However, PPU still requires emergency surgery. The aim of this study was to review the clinical characteristics of patients who received primary repair for PPU and identify the predisposing factors associated with severe complications. Method: From January 2011 to December 2020, a total of 75 patients underwent primary repair for PPU in our hospital. We reviewed the patients’ data, including general characteristics and perioperative complications. Surgical complications were evaluated using the Clavien-Dindo Classification (CDC) system, with which we classified patients into the mild complication (CDC 0–III, n = 61) and severe complication (CDC IV–V, n = 14) groups. Result: Fifty patients had gastric perforation, and twenty-five patients had duodenal perforation. Among surgical complications, leakage or fistula were the most common (5/75, 6.7%), followed by wound problems (4/75, 5.3%). Of the medical complications, infection (9/75, 12%) and pulmonary disorder (7/75, 9.3%) were common. Eight patients died within thirty days after surgery (8/75, 10.7%). Liver cirrhosis was the most significant predisposing factor for severe complications (HR = 44.392, p = 0.003). Conclusion: PPU is still a surgically important disease that has significant mortality, above 10%. Liver cirrhosis is the most important underlying disease associated with severe complications.

Perforation on the superior side of duodenum is a risk factor of laparoscopic primary repair for duodenal ulcer perforation

Purpose

Primary repair is the standard surgical method for treating duodenal ulcer perforations, with very good results usually anticipated because of the simplicity of the associated surgical techniques. Therefore, this study aimed to analyze the risk factors that affect laparoscopic primary repair outcomes for duodenal ulcer perforation.

Methods

Between June 2010 and June 2020, 124 patients who underwent laparoscopic primary repair for duodenal ulcer perforations were reviewed. Early surgical outcomes were evaluated and risk factors for postoperative complications were assessed.

Results

All surgeries were performed laparoscopically without open conversion. Multivariate analysis showed that the elderly (over 70 years), and perforations that needed more than 2 stitches for closure were risk factors for overall postoperative complications. Perforations that needed more than 2 stitches and perforations on the superior side of the duodenum were major risk factors for severe postoperative complications. Severe postoperative complications occurred in 6 of the patients, and 1 of them died of multiorgan failure.

Conclusion

Based on our results, we suggest that laparoscopic primary repair can be safely performed in duodenal ulcer perforation. However, more careful surgery and postoperative care are needed to improve the surgical outcomes of patients who need more than 2 stitches to close their perforation or who have perforations on the superior side of the duodenum.

Evaluating the Evolving Morbidity of Omentoplasty for Perforated Peptic Ulcer Disease

Mortality for perforated peptic ulcer (PPU) surgery ranges from 2-22% with morbidity ranging from 15-45%. Traditionally, these had been repaired with vagotomy and antrectomy or pyloroplasty with smaller perforations repaired with an omentoplasty. Laparoscopic repair has become increasingly prevalent and demonstrated to have shorter length of stay (LOS) and fewer complications. We are evaluating the surgical repair of PPU with omentoplasty to determine trends of utilization and surgical outcomes. We conducted a 13-year (2005-2017) retrospective review, utilizing the National Surgical Quality Improvement Program database. A total of 6873 patients had open or laparoscopic repair of a PPU, with 2285 patients identified as utilizing omentoplasty. Five hundred eighty-eight omentoplasty patients were further identified as having a laparoscopic technique. We compared patient demographics, comorbidities, and perioperative morbidity and mortality for surgical patients between 2005-2011 and 2012-2017. We trended the perioperative outcomes across the study intervals. Parametric and nonparametric tests were used to evaluate outcomes. Between 2005 and between 2017, laparoscopic surgical repair with omentoplasty has increased from 3.8% to 34.6%. Overall mortality for open operations declined during this interval (12.7%-9.3%) while it remained unchanged for laparoscopic operations (4.6%-4.2%), there was not a significant difference between the laparoscopic and open 30-day mortality. Both open surgery and laparoscopic surgery are being used on an increasingly healthy cohort (increased functional status decreased predicted perioperative morbidity). Relative to the 2005-2011, the laparoscopic surgery 2012-2017 cohort had increases in both serious and overall morbidity, although this was not statistically significant. Compared to the 2005-2011, the 2012-2017 open surgery cohort had increasing serious morbidity (OR 2.03) and overall morbidity (OR 1.91). There was a trend of decreasing LOS and increased return to the operating room for patients with laparoscopic surgery. Laparoscopic Graham patch repair of peptic ulcers significantly increased, although open repair still constitutes the majority of the cases. Despite Graham patch repair being utilized on a healthier patient population, morbidity and mortality for laparoscopic repair have remained unchanged. Postoperative morbidity and mortality for open surgery have increased. This indicates that laparoscopic repair is more commonly utilized for low- or medium risk patients, leaving an increasingly sick patient population selected to open repair.

Potential use of peptic ulcer perforation (PULP) score as a conversion index of laparoscopic-perforated peptic ulcer (PPU) repair

BACKGROUND

Laparoscopic repair is a well-accepted treatment modality for perforated peptic ulcer (PPU). However, intraoperative conversion to laparotomy is still not uncommon. We aimed to identify preoperative factors strongly associated with conversion.

METHODS

A retrospective review of records of all PPU patients treated between January 2011 and July 2019 was performed. Patients were divided into three groups: laparoscopic repair (LR), conversion to laparotomy (CL), and primary laparotomy (PL). Patient demographics, operative findings, and outcomes were compared between the groups. Logistic regression analyses were performed, taking conversion as the outcome.

RESULTS

Of 822 patients, there were 236, 45, and 541 in the LR, CL, and PL groups, respectively. The conversion rate was 16%. Compared with those in the LR group, patients in the CL group were older (p < 0.001), had higher PULP scores (p < 0.001), had higher ASA scores (p < 0.001) and had hypertension (p = 0.003). PULP score was the only independent risk factor for conversion. The area under the curve (AUC) for the PULP score to predict conversion was 75.3%, with a best cut-off value of ≥ 4. The operative time was shorter for PL group patients than for CL group patients with PULP scores ≥ 4. For patients with PULP scores < 4, LR group patients had a shorter length of stay than PL group patients.

CONCLUSION

The PULP score may have utility in predicting and minimizing conversion for laparoscopic PPU repair. Laparoscopic repair is the procedure of choice for PPU patients with PULP scores < 4, while open surgery is recommended for those with PULP scores ≥ 4.

Open Versus Laparoscopic Repair of Perforated Peptic Ulcer Disease: A Propensity-matched Study of the National Emergency Laparotomy Audit

OBJECTIVE

The aim of this study was to compare open surgery (OS) with laparoscopic surgery (LS) for perforated peptic ulcer (PPU) disease using a National dataset BACKGROUND:: PPU disease is typically treated surgically with an omental patch. This can be performed through OS or a LS. Current evidence in OS versus LS suggests equivalence in mortality and postoperative complications, but a decrease in pain and wound infections with LS.

METHODS

A one-to-one propensity score-matched analysis of patients who underwent PPU repair from December 2013 to December 2017 using data from the National Emergency Laparotomy Audit was performed. Patients with an initially laparoscopic approach were classed as LS even if converted to OS. The primary end-point was 90-day mortality; secondary endpoints were length of stay (LOS), re-operation, and re-admission to critical care. Multivariable logistic and linear models were created to compare the effect of operative approach on binary and continuous outcomes with log-rank tests for time-to-event data.

RESULTS

A total of 5253 patients underwent surgery in the study period. After propensity-matching, 2 groups of 1158 patients were created. Overall 90-day mortality was 7.5%. There was no difference between the LA and OA for 90-day mortality (7.2% vs 8.5%, OR 0.80, 95% CI 0.56-1.15, P = 0.23), median LOS (equivalent at 7 days, P = 0.09), reoperation (3.6% vs 4.0%, P = 0.74), or re-admission to critical care (2.8% vs 2.9%, P = 0.92). Across the 4-year study period LS use increased from 20% to 26% and the conversion rate decreased from 40% to 31%.

CONCLUSIONS

Short outcomes from laparoscopic PPU repair appear equivalent to open repair. There is increasing adoption of LS with decreasing conversion rates. LS for PPU appears to be an acceptable approach in this setting.

An Overview of Gastroduodenal Perforation

Gastroduodenal perforation may be spontaneous or traumatic and the majority of spontaneous perforation is due to peptic ulcer disease. Improved medical management of peptic ulceration has reduced the incidence of perforation, but still remains a common cause of peritonitis. The classic sub-diaphragmatic air on chest x-ray may be absent and computed tomography scan is a more sensitive investigation in the stable patient. The management of perforated peptic ulcer disease is still a subject of debate. The majority of perforated peptic ulcers are caused by Helicobacter pylori, so definitive surgery is not usually required. Perforated peptic ulcer is an indication for operation in nearly all cases except when the patient is asymptomatic or unfit for surgery. However, non-operative management has a significant incidence of intra-abdominal abscesses and sepsis. Primary closure is achievable in traumatic perforation, but the management follows the Advanced Trauma Life Support (ATLS) principles.

Laparoscopy: A Better Approach for Perforated Duodenal Ulcer

Background

Laparoscopic surgery is becoming the gold standard for most abdominal surgeries in recent times. Laparoscopic repair of perforated duodenal ulcer (PDU), however, is still an area of debate. The purpose of this study was to evaluate the safety and efficacy of laparoscopic repair of PDU versus open repair.

Methods

In this cross-sectional study, patients were consecutively sampled. Out of 101 patients with clinically diagnosed PDU, 36 patients underwent laparoscopic Graham patch repair and 65 underwent open Graham patch repair in a tertiary care academic hospital. Open repair was via upper midline incision, and laparoscopic repair by the three-port technique. The following stages were calculated: operative time, duration of postoperative analgesia, time taken to mobilize, and patient length of stay after the operation.

Results

The mean operative time was somewhat longer in the laparoscopy group compared to the open repair group (74.01 vs 56.17 minutes, respectively). Mean postoperative analgesia requirement, time taken to mobilize, and hospital stay were significantly shorter after laparoscopy than after open repair (1.21 days, 9.32 hours, and 3.12 days vs 3.83 days, 16.20 hours, and 4.85 days, respectively). Three patients (8%) in the laparoscopy group and 35 (54%) in the open repair group had postoperative complications.

Conclusions

Laparoscopic repair of PDU is a safe approach and better than open repair in terms of operative time with the right level of expertise only, postoperative analgesia requirement, mobilization, duration of hospital stay, and incidence of postoperative respiratory and wound complications.

A Large Stomach Ulcer Is Associated With Raised Mortality in a Cohort of Patients Who Underwent Open Repair of Perforated Peptic Ulcer: A Five-Year Follow-Up Study

Introduction

Perforated peptic ulcer disease (PPUD) is associated with a high postoperative mortality and morbidity rates especially within the first 90 days. The size and site of the ulcer may contribute to the prognosis of PPUD. In this study, we will describe the association of size and site of PPUD with the overall mortality and in-hospital morbidities in a tertiary care university hospital.

Methods

A retrospective observational cohort study was conducted at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. A total of 50 patients who had PPUD and underwent open exploratory laparotomy with surgical treatment were analyzed. Patients were divided into two groups: a small ulcer group when the ulcer diameter was less than equal to 1 cm and a large ulcer group when it was more than 1 cm. For the subgroup analysis, patients were categorized according to site into small duodenum, large duodenum, small stomach, and large stomach PPUD. The primary outcome was overall mortality that was measured by survival analysis and Cox regression. Secondary outcomes were intensive care unit (ICU) admission, ICU and hospital length of stay, and in-hospital mortality, which were assessed by stepwise logistics and linear regression.

Results

Overall mortality at 10, 30, and 90 days was 14% (95% CI: 0.06-0.27), 24% (95% CI: 0.14-0.39), and 34% (95% CI: 0.23-0.49), respectively. Saudi patients had a 72% decreased risk of overall mortality compared to non-Saudi patients (P=0.03) over the follow-up period. Overall, patients who had stomach PPUD had a 2.23-fold increased risk of overall mortality over time compared to those who had duodenum PPUD (P=0.10). Large PPUD, >1 cm, had a 3.20-fold increased risk of overall mortality over time compared to small PPUD (P=0.04). Large stomach PPUD had a 4.22-fold increased risk of overall mortality over time compared to other ulcers (P=0.01).

Conclusions

Large stomach PPUD is associated with increased overall mortality and morbidity. These findings indicate that patients who have a large stomach PPUD might need careful perioperative and postoperative personalized surgical plans as these patients may eventually undergo complicated surgical procedures.

Variation in descriptors of patient characteristics in randomized clinical trials of peptic ulcer repair: a systematic review

BACKGROUND

The ability to compare findings across surgical research is important. Inadequate description of participants, interventions or outcomes could lead to bias and inaccurate assessment of findings. The aim of this study was to assess consistency of description of participants using studies comparing laparoscopic and open repair of peptic ulcer as an example.

METHODS

This systematic review is reported in line with the PRISMA checklist. Searches of MEDLINE and Embase databases were performed to identify studies comparing laparoscopic and open repair of perforated peptic ulcer in adults, published in the English language. Manuscripts were dual-screened for eligibility. Full texts were retrieved and dual-screened for inclusion. Data extracted from studies included descriptors of participants in studies from tables and text. Descriptors were categorized into conceptual domains by the research team, and coverage of each domain by study was tabulated.

RESULTS

Searches identified 2018 studies. After screening, 37 full texts were retrieved and 23 studies were included in the final synthesis. A total of 76 unique descriptors were identified. These were classified into demographics (11 descriptors), vital signs (9 descriptors), disease-specific characteristics (10 descriptors), presentation and pathway factors (4 descriptors), risk factors (8 descriptors), laboratory tests (14 descriptors) and baseline health (28 descriptors). The number of descriptors in a single study ranged from three to 31. All studies reported at least one demographic descriptor. Laboratory tests was the least frequently described domain.

CONCLUSION

Study participants are described inconsistently in studies of a single example surgical condition.

Laparoscopic Repair of Perforated Peptic Ulcer in the Elderly: An Interim Analysis of the FRAILESEL Italian Multicenter Prospective Cohort Study

INTRODUCTION

The number of elderly patients requiring emergency surgical intervention has increased dramatically. Perforated peptic ulcer (PPU) complications, such as perforation, have remained relatively stable and associated morbidity remains between 10% and 20%. Advances in perioperative care have greatly improved the outcomes of laparoscopic emergency surgery, allowing increasing numbers of patients, even the elderly, to undergo safe repair. The aim of this study was to evaluate the feasibility, safety, and outcome of laparoscopic gastric repair in the elderly using the database of the FRAILESEL (Frailty and Emergency Surgery in the Elderly) study.

MATERIALS AND METHODS

This is a retrospective analysis carried out on data of the FRAILESEL study. Data on all the elderly patients who underwent emergency abdominal surgery for PPU from January 2017 to December 2017 at 36 Italian surgical departments were analyzed. Patients who underwent PPU repair were further divided into a laparoscopic gastroduodenal repair (LGR) cohort and an open gastroduodenal repair (OGR) cohort, and the clinicopathologic features of the patients in both the groups were compared.

RESULTS

Sixty-seven patients fulfilled the inclusion criteria. Thirty-three patients (47.8%) underwent LGR. The LGR patients had less blood loss and shorter postoperative stay, even if the difference was not statistically significant. The mean operative time was significantively higher in the OGR (OGR 96.5±27.7 vs. LGR 78.6±16.3 P=0.000). The rate of death after laparoscopic surgery was similar to the rate of the open surgery. Multivariate analysis indicated that only age (P=0.018), admission haemoblogbin (Hb) level (P=0.006), platelet count (P=0.16), lactate level (P=0.47), and Mannheim Peritonitis Index (P=0.18) were independent variables associated with the risk of overall mortality.

CONCLUSIONS

LGR is safe and feasible in elderly patients with PPU and it is associated with better perioperative outcomes. However, patient selection and preoperative frailty evaluation in the elderly population are the key to achieving better outcomes.

[Comparison of laparoscopic and open suturing of perforated peptic ulcer complicated by advanced peritonitis]

AIM

To compare the results of open and laparoscopic interventions for PGDU complicated by advanced peritonitis.

MATERIAL AND METHODS

A retrospective analysis enrolled 172 patients with PGDU who underwent surgery for the period 2014-2016. The research was performed at the bases of the Department of Faculty-Based Surgery No. 1 of the Medical Faculty of the Pirogov Russian National Research Medical University. Further analysis enrolled 138 patients in accordance with inclusion and exclusion criteria (laparoscopic intervention - 116 patients, open surgery - 22). Propensity score matching (pseudorandomization) was applied after comparative analysis of patients' characteristics and treatment outcomes in order to ensure maximum comparability of both groups.

RESULTS

Length of hospital-stay (7.1 vs. 9.8 days), incidence of extra-abdominal complications (6.3%. vs. 41.2%) and adverse events Clavien-Dindo grade II (6.3% vs. 35.3%) were significantly lower after minimally invasive surgery (p<0.05).

CONCLUSION

Analysis of comparable groups of patients with PGDU complicated by peritonitis revealed that laparoscopic surgery is accompanied by significantly lower incidence of extra-abdominal postoperative complications and shorter hospital-stay compared with open surgery. Mortality and incidence of intra-abdominal postoperative complications were similar in both groups.

Laparoscopic repair of perforated peptic ulcer is not prognostic factor for 30-day mortality (a nationwide prospective cohort study)

BACKGROUND

Laparoscopic surgery has become increasingly popular in treating perforated peptic ulcer (PPU). However, currently it is not recognized as a prognostic factor for mortality within this group of patients. The aim of this study was to investigate whether laparoscopic surgery was an independent mortality risk factor in patients treated surgically for perforated peptic ulcer.

MATERIALS AND METHODS

This was a Danish nationwide cohort study based on prospectively collected data of 1008 patients treated surgically for PPU between September 2011 and December 2015. A propensity score matching analysis, considering most of the known prognostic factors for mortality and baseline characteristics, was used to adjust mortality estimates in patients treated with open and laparoscopic surgery. The primary outcome was postoperative 30-day mortality.

RESULTS

The study population comprised 1008 patients; 507 were treated laparoscopically and 501 by open surgery. There was significantly higher mean age, and higher ASA scores, as well as other mortality risk factors in the open surgery group. The unadjusted 30-day mortality was significantly lower in patients undergoing laparoscopic surgery compared to open surgery (HR = 0.48, 95% CI: 0.36-0.65). After matching and weighting controls, the adjusted difference in mortality was reduced and was not significant (HR = 0.82, 95% CI: 0.59-1.15). The 30-day mortality was 13.1% for laparoscopy and 14.7% for the matched controls in the open surgery group.

CONCLUSIONS

Compared to open surgery, laparoscopic surgery in patients with PPU does not reduce short term mortality. More well powered randomized clinical trials are needed to investigate the role of laparoscopic surgery in treatment of patients with PPU.

Perforated Peptic Ulcer Surgery: Decreased Length of Stay but No Difference in Mortality with Laparoscopic Repair

BACKGROUND

Perforated peptic ulcer (PPU) surgery mortality ranges 1% to 24%. We hypothesized a decrease in length of stay (LOS) with laparoscopic surgical repair (LSR) compared with open surgical repair (OSR).

METHODS

Patients undergoing PPU surgery 2005 to 2015 were identified in NSQIP. LSR was compared with OSR 2005 to 2015. LSR 2005 to 2010 was compared with 2011 to 2015. OSR 2005 to 2010 was compared with 2011 to 2015. The primary outcome was LOS. Secondary outcomes were mortality and morbidity.

RESULTS

Between 2005 and 2015, LSR had a decreased LOS, was more likely to wean from the ventilator, but had no significant difference in mortality compared with OSR. There was no significant difference in mortality for LSR or OSR over time.

CONCLUSIONS

When patients are appropriately selected, LSR for PPU is a viable alternative to OSR, decreasing LOS and pulmonary complications. This demonstrates significant benefit to patients and hospital throughput.

Laparoscopic versus open repair of perforated peptic ulcer: A retrospective cohort study

INTRODUCTION

Perforated peptic ulcer disease (PPU) is a condition subject to wide geographical variations in incidence. It remains a significant cause of morbidity and mortality, even in the era of Helicobacter pylori eradication and proton-pump inhibitor therapy. There is no clear consensus on whether laparoscopic or open approaches are superior, and with most studies in this area originating from Europe and Asia, Australian data addressing this issue are lacking.

METHODS

This retrospective cohort study included all patients who underwent surgery for PPU within a hospital network in Australia. Baseline variables and primary outcomes, including length of hospital stay, chest and abdominal complications, and mortality, were recorded. Secondary outcomes, including reasons for conversion, were also considered.

RESULTS

In total, 109 patients underwent operations for PPU between January 2011 and December 2015. There were no significant differences with regard to baseline comorbidities. There were no statistically significant differences in terms of median length of hospital stay or rates of chest and abdominal complications, but the operative time was 28.5 min longer (P = <0.001) in the laparoscopic group than in the open group.

CONCLUSION

Open operations were faster to perform than laparoscopic operations for repair of PPU. Despite increased experience treating many surgical diseases laparoscopically, this study did not find it to be superior in terms of length of hospital stay or complication rates.

Laparoscopic Single Figure of Eight Suturing Omentopexy for the Treatment of a Perforated Duodenal Ulcer

Purpose

Safe and effective surgical treatment of peptic ulcer perforations is fundamental to achieve favorable outcomes. We present laparoscopic single figure of eight suturing omentopexy for perforated duodenal ulcer and review associated clinical outcomes. This is a new formulaic surgical technique for laparoscopic omentopexy.

Methods

Laparoscopic single figure of eight suturing omentopexies for perforated duodenal ulcer were completed in 15 consecutive patients between April 2008 and November 2017 at Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea. Using prospectively collected data, we performed an observational study on an intention-to-treat basis.

Results

The mean age of the 15 patients who underwent laparoscopic repair was 41.7±13.9 years. The perforation site was the anterior duodenal bulb in all patients. The median perforation size was 5 mm (range: 3~8 mm). The mean operation time was 66.7±19.6 minutes. There was no evidence of leakage from the omentopexy site clinically or in the postoperative upper gastrointestinal series. One patient (6.7%) experienced the postoperative complication of pneumothorax. There were no cases of postoperative mortality or reoperation within 30 days after surgery. The median time to tolerance of regular diet was 6 (range: 4~9) days. The median postoperative hospital stay was 7 days (range: 5~11 days).

Conclusion

Laparoscopic single figure of eight suturing omentopexy can be a viable option in the surgical management of perforated duodenal ulcer in selected patients without surgical risk factors. Laparoscopic single figure of eight suturing omentopexy is safe and easy to perform, and may therefore reduce operation time.

Laparoscopic Repair for Perforated Peptic Ulcer Disease Has Better Outcomes Than Open Repair

PURPOSE

Over the last 3 decades, laparoscopic procedures have emerged as the standard treatment for many elective and emergency surgical conditions. Despite the increased use of laparoscopic surgery, the role of laparoscopic repair for perforated peptic ulcer remains controversial among general surgeons. The aim of this study was to compare the outcomes of laparoscopic versus open repair for perforated peptic ulcer.

METHODS

A systemic literature review was conducted using Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. A search was conducted using MEDLINE, EMBASE, PubMed and Cochrane Database of all randomised controlled trials (RCT) that compared laparoscopic (LR) with open repair (OR) for perforated peptic ulcer (PPU). Data was extracted using a standardised form and subsequently analysed.

RESULTS

The meta-analysis using data from 7 RCT showed that LR for PPU has decreased overall post-operative morbidity (LR = 8.9% vs. OR = 17.0%) (OR = 0.54, 95% CI 0.37 to 0.79, p < 0.01), wound infections, (LR = 2.2% vs. OR = 6.3%) (OR = 0.3, 95% CI 0.16 to 0.5, p < 0.01) and shorter duration of hospital stay (6.6 days vs. 8.2 days, p = 0.01). There were no significant differences in length of operation, leakage rate, incidence of intra-abdominal abscess, post-operative sepsis, respiratory complications, re-operation rate or mortality. There was no publication bias and the quality of the studies ranged from poor to good.

CONCLUSION

These results demonstrate that laparoscopic repair for perforated peptic ulcer has a reduced morbidity and total hospital stay compared with open approach. There are no significant differences in mortality, post-operative sepsis, abscess and re-operation rates. LR should be the preferred treatment option for patients with perforated peptic ulcer disease.

Imaging of Gastrointestinal and Abdominal Emergencies in Binge Drinking

Excess alcohol consumption is a leading cause of preventable morbidity and mortality globally. The pattern of consumption of alcoholic beverages has changed in our society in the recent past, with binge drinking becoming more and more common, especially among young adults. Abdominal pain following alcohol consumption can be secondary to a wide range of pathologies, the treatment algorithm of which can range from medical supportive treatment to more invasive life-saving procedures such as transarterial embolization and emergency laparotomy. Correct diagnosis, differentiation among these conditions, and implementing the correct management algorithm is heavily reliant on accurate and appropriate imaging. We review the pathophysiology, clinical presentation, imaging features and management options of acute abdominal emergencies secondary to binge drinking, based on a selection of illustrative cases.

Evaluating the effects of surgical subspecialisation on patient outcomes following emergency laparotomy: A retrospective cohort study

BACKGROUND

General surgeons have become increasingly subspecialised in their elective practice. Emergency laparotomies, however, are performed by a range of subspecialists who may or may not have an interest in the affected area of gastrointestinal tract. This retrospective cohort study evaluates the impact of surgical subspecialisation on patient outcomes following emergency laparotomy.

METHODS

Data was collected for patients who underwent an emergency abdominal procedure on the gastrointestinal tract in the North of England from 2001 to 2016. This included demographics, co-morbidities, diagnoses and procedures undertaken. Patients were grouped according to consultants' subspecialist interest. The primary outcome of interest was 30-day postoperative mortality.

RESULTS

24,291 emergency laparotomies were performed with an associated 30-day postoperative mortality of 11.7%. Laparotomies undertaken by upper gastrointestinal (UGI) or colorectal surgeons have significantly lower mortality (10.1%) when compared with other subspecialities (13.5%). More specifically, mortality was decreased for UGI (7.9% vs. 12.9%) and colorectal procedures (10.9% vs. 14.2%) when performed by surgeons with a specialist interest in the relevant area of the gastrointestinal tract (both p < 0.001). The utilisation of laparoscopic surgery is higher, in both UGI (21.8% vs. 9.0%) and colorectal procedures (7.2% vs. 3.5%), when the causative pathology is relevant to the surgeon's subspeciality (both p < 0.001).

CONCLUSION

Mortality following emergency laparotomy is improved when performed under the care of gastrointestinal surgeons. Both UGI and colorectal emergency procedures have improved outcomes, with lower mortality and higher rates of laparoscopy, when under the care of a surgeon with a subspecialist interest in the affected area of the gastrointestinal tract.

Surgical repair of perforated peptic ulcers: laparoscopic versus open approach

INTRODUCTION

Perforated peptic ulcers are a surgical emergency that can be repaired using either laparoscopic surgery (LS) or open surgery (OS). No consensus has been reached on the comparative outcomes and safety of each approach.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, we conducted a 12-year retrospective review (2005-2016) and identified 6260 adult patients who underwent either LS (n = 616) or OS (n = 5644) to repair perforated peptic ulcers. To mitigate selection bias and adjust for the inherent heterogeneity between groups, we used propensity-score matching with a case (LS):control (OS) ratio of 1:3. We then compared intraoperative outcomes such as operative time, and 30-day postoperative outcomes including infectious and non-infectious complications, and mortality.

RESULTS

Propensity-score matching created a total of 2462 matched pairs (616 in the LS group, 1846 in the OS group). Univariate analysis demonstrated successful matching of patient characteristics and baseline clinical variables. We found that OS was associated with a shorter operative time (67.0 ± 28.6 min, OS versus 86.9 ± 57.5 min, LS; P < 0.001) but a longer hospital stay (8.6 ± 6.2 days, OS versus 7.8 ± 5.9 days, LS; P = 0.001). LS was associated with a lower rate of superficial surgical site infections (1.5%, LS versus 4.2%, OS; P = 0.032), wound dehiscence (0.3%, LS versus 1.6%, OS; P = 0.030), and mortality (3.2%, LS versus 5.4%, OS; P = 0.009).

CONCLUSION

Fewer than 10% of patients with perforated peptic ulcers underwent LS, which was associated with reduced length of stay, lower rate of superficial surgical site infections, wound dehiscence, and mortality. Given our results, a greater emphasis should be provided to a minimally invasive approach for the surgical repair of perforated peptic ulcers.

Laparoscopy in Acute Care Surgery: Repair of Perforated Duodenal Ulcer

INTRODUCTION

The use of laparoscopic management as a first choice for the treatment of duodenal perforation is gaining ground but is not routine in many centers. In this report, we aim to report our experience with laparoscopy as the first approach for the repair of duodenal perforation.

MATERIALS AND METHODS

This is a retrospective review of patients during our initial experience with the use of laparoscopy for the treatment of duodenal perforation between 2009 and 2013.

RESULTS

A total of 100 patients underwent management of duodenal perforation. Laparoscopy was attempted initially in 76 patients (76%) and completed in 64 patients (64%). The length of hospital stay was shorter in the laparoscopic group (mean 2.6) than in the open group (mean 3.1) (p = 0.008). Complications developed in 14 patients (20%). There was a tendency towards fewer admissions to intensive care, less acute kidney injuries, and less acute respiratory distress syndrome in the laparoscopic group. In patients who underwent laparoscopic surgery, the chances of uneventful recovery were 4.3 times higher than in those patients who underwent open surgery (95% CI 1.3-13.5, p = 0.014).

CONCLUSIONS

Laparoscopy in the treatment of perforated duodenal ulcer is safe and can be utilized as a routine approach for the treatment of this pathology.

Double Perforated Kissing Ulcers of Duodenum: A Brief Report

Helicobactor pylori infection has been associated with peptic ulcer disease and is currently treated with proton pump inhibitors (PPIs), which have reduced the complications of the disease. Perforation of either a gastric or duodenal ulcer is rarely treated with surgery. We report the case of double-perforated synchronous duodenal ulcers, which is an extremely infrequent condition. To our knowledge, no English case reports have yet been published. Therefore, awareness of the physician in the field of diagnosis and treatment of this peptic ulcer is required. We report the case of a 46-year-old male patient who presented with acute abdominal pain at the emergency surgical department of our hospital. According to patient history, smoking, alcohol consumption, and frequent postprandial abdominal pain were noted. A physical examination revealed a rigid abdomen and tachycardia, and the temperature was 37.8°C. Laboratory testing showed increased levels of leukocytes, and free subdiaphragmatic air was found in the chest X-ray. Due to rapid deterioration of his clinical condition, the patient underwent urgent surgery. An explorative laparotomy showed 2 perforated kissing ulcers at the first segment of the duodenum, in the anterior and posterior walls. A peripheral gastrectomy was performed. Postoperative follow-up did not result in any complications. In regard to this case we present, simultaneous perforation of two synchronous duodenal ulcers is an uncommon but possible incident of which the clinician should be aware. To our knowledge, this is the first case published in the literature.

Laparoscopic pyloroplasty for perforated peptic ulcer

Peptic ulcer is a common disease affecting millions of people every year. Despite improved understanding and treatment of the disease, the number of patients admitted with duodenal peptic ulcer perforation has not decreased. Deaths from peptic ulcer disease overcome other common emergency situations. Laparoscopic repair of the perforated peptic ulcer (PPU) is the gold standard approach for simple perforation. However, in patients with large perforated chronic ulcers laparotomy with pyloroplasty is the standard treatment. It is generally accepted to perform open surgery in PPU emergencies because of the greater knowledge and experience gathered over the past decades and less potential harm for the patient or surgical complications. We present a case of successful laparoscopic pyloroplasty of a perforated duodenal ulcer with stenosis.

Laparoscopic repair of perforated peptic ulcer: simple closure versus omentopexy

BACKGROUND

This report presents our experience with laparoscopic repair performed in 118 consecutive patients diagnosed with a perforated peptic ulcer (PPU). We compared the surgical outcome of simple closure with modified Cellan-Jones omentopexy and report the safety and benefit of simple closure.

METHODS

From January 2010 to December 2014, 118 patients with PPU underwent laparoscopic repair with simple closure (n = 27) or omentopexy (n = 91). Charts were retrospectively reviewed for demographic characteristics and outcome. The data were compared by Fisher's exact test, Mann-Whitney U test, Pearson's chi-square test, and the Kruskal-Wallis test. The results were considered statistically significant if P < 0.05.

RESULTS

No patients died, whereas three incurred leakage. After matching, the simple closure and omentopexy groups had similarity in sex, systolic blood pressure, pulse rate, respiratory rate, Boey score, Charlson comorbidity index, Mannheim peritonitis index, and leakage. There were statistically significant differences in age, length of hospital stay, perforated size, and operating time. Comparison of the operating time in the ≤4.0 mm and 5.0-12 mm groups revealed that the simple closure took less time than omentopexy in both groups (≤4.0 mm, 76 versus 133 minutes, P < 0.0001; 5.0-12 mm, 97 versus 139.5 minutes; P = 0.006).

CONCLUSIONS

Compared to the omentopexy, laparoscopic simple closure is a safe procedure and shortens the operating time.