Laparoscopic simple closure alone is adequate for low risk patients with perforated peptic ulcer

The effect of omentoplasty in various surgical operations: systematic review and meta-analysis

BACKGROUND

Omentoplasty is commonly used in various surgeries. However, its effectiveness is unsure due to lack of convincing data and research. To clarify the impact of omentoplasty on postoperative complications of various procedures, this systematic review and meta-analysis was performed.

METHODS

A systematic review of published literatures from four databases: PubMed, Web of Science, Cochrane Library, and Embase before 14 July 2022. The authors primarily included publications on five major surgical operations performed in conjunction with omentoplasty: thoracic surgery, esophageal surgery, gastrointestinal surgery, pelvi-perineal surgery, and liver surgery. The protocol was registered in PROSPERO.

RESULTS

This review included 25 273 patients from 91 studies ( n =9670 underwent omentoplasty). Omentoplasty was associated with a lower risk of overall complications particularly in gastrointestinal [relative risk (RR) 0.53; 95% CI: 0.39-0.72] and liver surgery (RR 0.54; 95% CI: 0.39-0.74). Omentoplasty reduced the risk of postoperative infection in thoracic (RR 0.38; 95% CI: 0.18-0.78) and liver surgery (RR 0.39; 95% CI: 0.29-0.52). In patients undergoing esophageal (RR 0.89; 95% CI: 0.80-0.99) and gastrointestinal (RR 0.28; 95% CI: 0.23-0.34) surgery with a BMI greater than 25, omentoplasty is significantly associated with a reduced risk of overall complications compared to patients with normal BMI. No significant differences were found in pelvi-perineal surgery, except infection in patients whose BMI ranged from 25 kg/m 2 to 29.9 kg/m 2 (RR 1.25; 95% CI: 1.04-1.50) and anastomotic leakage in patients aged over 60 (RR 0.59; 95% CI: 0.39-0.91).

CONCLUSION

Omentoplasty can effectively prevent postoperative infection. It is associated with a lower incidence of multiple postoperative complications in gastrointestinal and liver surgery.

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.

Comparison of Omental Patch Closure Versus Simple Closure for Laparoscopic Repair of Perforated Peptic Ulcer: A Systematic Review and Meta-Analysis

AIMS

To evaluate comparative outcomes of laparoscopic repair of perforated peptic ulcer with omental patch versus without omental patch.

METHODS

A systematic search of multiple electronic data sources was conducted, and all studies comparing laparoscopic repair of perforated peptic ulcer (PPU) with and without omental patch were included. Operative time, postoperative complications, re-operation and mortality were the evaluated outcome parameters for the meta-analysis. Revman 5.3 was used for data analysis.

RESULTS

Four observational studies reporting a total number of 438 patients who underwent laparoscopic repair of PPU with (n = 268) or without (n = 170) omental patch were included. Operative time was significantly shorter in no-omental patch group (NOP) when compared to omental patch group (P = .02). There was no significant difference in the risk of postoperative ileus (Odd ratio (OR) .76, P = .61), leakage (OR 1.17, P = .80), wound infection (OR 1.89, P = .34), intra-abdominal abscess (OR 1.17, P = .87), re-operation (OR .00, P = .94) and mortality (OR .55, P = .48). Moreover, length of hospital stay was comparable between the two groups (P = .81).

CONCLUSION

Laparoscopic repair of PPU with or without omental patch have comparable postoperative complications and mortality rate. However, considering the shorter operative time, no-omental patch approach is an attractive and more favourable choice. Well-designed randomized controlled trials are needed to investigate this comparison.

WSES/GAIS/SIS-E/WSIS/AAST global clinical pathways for patients with intra-abdominal infections

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in hospitals worldwide. The cornerstones of effective treatment of IAIs include early recognition, adequate source control, appropriate antimicrobial therapy, and prompt physiologic stabilization using a critical care environment, combined with an optimal surgical approach. Together, the World Society of Emergency Surgery (WSES), the Global Alliance for Infections in Surgery (GAIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), and the American Association for the Surgery of Trauma (AAST) have jointly completed an international multi-society document in order to facilitate clinical management of patients with IAIs worldwide building evidence-based clinical pathways for the most common IAIs. An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting information was shared by an international task force from 46 countries with different clinical backgrounds. The aim of the document is to promote global standards of care in IAIs providing guidance to clinicians by describing reasonable approaches to the management of IAIs.

Optimal treatment and complications of patients with the perforated upper gastrointestinal tract

PURPOSE

The perforation of the upper gastrointestinal tract is still associated with a high risk of complications and mortality. We aimed to evaluate the optimal treatment and post-treatment complications for this condition.

METHODS

This was a retrospective, single-center study conducted between 2010 and 2019. We analyzed 50 patients with intraperitoneal free air caused by peptic ulcer (44 cases) or cancer (six cases).

RESULTS

All patients initially received either conservative therapy (n = 7) or surgery (n = 43). The nonsurgically cured patients were significantly younger and had mild peritonitis and also had a shorter hospital stay. Two patients were converted to surgery due to worsening symptoms, and one of them was elderly and had a long perforation-to-treatment time. Regarding postoperative complications, patients with Grade II-V (n = 21) were significantly older and had a poorer physical status, longer perforation-to-surgery time, and higher preoperative CRP and lactate than those with Grade 0-I (n = 24). Multivariable analyses identified elevated preoperative lactate as an independent risk factor for postoperative complications. The patients with noncurative surgery for perforated advanced gastric cancer all died within 1 year after surgery.

CONCLUSIONS

Consideration should be given to the nonsurgical indications in elderly and delayed treatment patients and the postoperative outcomes of patients with preoperatively elevated lactate levels.

Identification of differentially expressed long non-coding RNAs associated with dilated cardiomyopathy using integrated bioinformatics approaches

The aim of this study was to identify novel long non-coding RNA (lncRNA) biomarkers associated with dilated cardiomyopathy (DCM) and reveal the potential molecular mechanisms of DCM development using bioinformatics approaches. The array data of GSE5406, including 108 DCM samples and 16 non-failing control samples, were obtained from the Gene Expression Omnibus database. The differentially expressed lncRNAs were identified using limma package in R. Pearson's correlation analyses were performed between the differentially expressed lncRNAs and protein-coding genes based on their expression levels. Pathway enrichment of these lncRNAs was conducted based on the significantly co-expressed genes. From the receiver operating characteristic (ROC) curve, the area under the ROC curve (AUC) value was obtained and used for evaluating discriminatory ability. IDI2-AS1 and XIST were differentially expressed in DCM patients. A total of 510 co-expressed genes were identified. The enriched functions and pathways of the co-expressed genes mainly included NADH dehydrogenase activity, cardiac muscle contraction, and oxidative phosphorylation. The ROC curve analysis indicated that the two lncRNAs have favorable diagnostic values in DCM. The AUC values of XIST, IDI2-AS1, and the combination of XIST and IDI2-AS1 were 0.733 (95% CI: 0.646-0.809), 0.796 (95% CI: 0.715-0.863), and 0.823 (95% CI: 0.745-0.886), respectively. This study identified IDI2-AS1 and XIST lncRNAs and related pathways involved in the pathogenesis of DCM, thus providing potential diagnostic and therapeutic targets for DCM.

Perforated and bleeding peptic ulcer: WSES guidelines

Background

Peptic ulcer disease is common with a lifetime prevalence in the general population of 5-10% and an incidence of 0.1-0.3% per year. Despite a sharp reduction in incidence and rates of hospital admission and mortality over the past 30 years, complications are still encountered in 10-20% of these patients. Peptic ulcer disease remains a significant healthcare problem, which can consume considerable financial resources. Management may involve various subspecialties including surgeons, gastroenterologists, and radiologists. Successful management of patients with complicated peptic ulcer (CPU) involves prompt recognition, resuscitation when required, appropriate antibiotic therapy, and timely surgical/radiological treatment.

Methods

The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the board of the WSES to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the 5th WSES Congress, and for each statement, a consensus among the WSES panel of experts was reached.

Conclusions

The population considered in these guidelines is adult patients with suspected complicated peptic ulcer disease. These guidelines present evidence-based international consensus statements on the management of complicated peptic ulcer from a collaboration of a panel of experts and are intended to improve the knowledge and the awareness of physicians around the world on this specific topic. We divided our work into the two main topics, bleeding and perforated peptic ulcer, and structured it into six main topics that cover the entire management process of patients with complicated peptic ulcer, from diagnosis at ED arrival to post-discharge antimicrobial therapy, to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.

Simple laparoscopic repair of perforated peptic ulcer without omental patch

OBJECTIVE

We evaluated the outcomes of laparoscopic repair of perforated peptic ulcers using simple closure only.

METHODS

This retrospective study included 79 patients who underwent laparoscopic repair of perforated peptic ulcers from January 2011 to February 2016. They were divided into two groups: repair with an omental patch and repair with simple closure only. All of them underwent peritoneal cavity lavage with several litres of warm normal saline. A closed suction drain system was placed for drainage of intra-abdominal abscess. Patients' age, sex, Boey score, perforation size, operation time, overall complications, and length of hospital stay were evaluated.

RESULTS

A total of 79 patients diagnosed with perforated peptic ulcers who underwent emergency laparoscopic operations were enrolled in this study. Thirty patients underwent simple closure without an omental patch (group A), and 49 patients underwent simple closure with an omental patch (group B). Between the two groups, there were no statistically significant differences in the patients' age, size of perforation, and Boey score. However, the operation time was significantly different (p < 0.05) between the groups, with the average time being 84.4 min in group A and 106.65 min in group B. There was no statistically significant difference in the complication rate or the average length of hospital stay. No patient underwent reoperation for complications.

CONCLUSION

Laparoscopic repair of a perforated peptic ulcer without an omental patch is a safe option and does not increase the morbidity and mortality rate.

Long non-coding RNA XIST expression as a prognostic factor in human cancers: A meta-analysis

A large number of literature has shown that high expression of X inactive-specific transcript (XIST) is associated with poor prognosis and metastasis of cancer in patients. However, most of this literature is limited by the small sample sizes and discrete outcomes. Therefore, a meta-analysis was performed to investigate the relation between XIST expression and tumor node metastasis (TNM) stage, lymph node metastasis, distant metastasis, and overall survival of cancer patients. We searched for literature in PubMed, Embase, and Web of Science. The pooled hazard ratios (HRs) or odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to evaluate the association of XIST expression with prognosis and clinicopathological characteristics of cancer patients. Finally, a total of 14 articles involving 1123 patients were included in this meta-analysis. The results suggested that high expression of XIST has a significant relationship with a relatively poor overall survival for patients with malignant tumors (HR 1.82; 95% CI 1.32, 2.52; P = 0.0003). Moreover, high expression of XIST was significantly associated with poor TNM stage (OR 3.64; 95% CI 2.62, 5.07; P < 0.0001), lymph node metastasis (OR 2.39; 95% CI 1.65, 3.46; P < 0.0001) and distant metastasis (OR 2.84; 95% CI 1.90, 4.23; P < 0.0001). In conclusion, high expression of lncRNA XIST may be a predictive factor of poor prognosis in human cancers.

Laparoscopic and open repair for perforated duodenal ulcer: single-center experience

Introduction

Perforation is a dangerous complication of peptic ulcer disease and requires emergency surgical treatment. In recent decades laparoscopic repair of duodenal perforation has been widely used in emergency abdominal surgery.

Aim

To analyze laparoscopic and open surgical treatment of 120 consecutive patients with perforated duodenal ulcer.

Material and methods

The study included a group of 120 consecutive patients, operated on for perforated duodenal ulcer in a single institution. Laparoscopic or open repair with or without an omental patch was performed. The value of the Boey score was investigated in predicting the outcomes of treatment in the entire study group.

Results

In 61 (50.8%) cases open repair was performed, in 56 (46.7%) cases laparoscopic repair, and in 3 (2.5%) cases conversion was performed. In the laparoscopy group the mean hospital stay was 5 days (range: 3–14), in the open group 11.7 days (range: 6–63), and in the conversion group 9.3 days (8–10) (p < 0.001). There was a significant difference between characteristics of patients in the laparoscopic groups: in the second period of laparoscopic procedures (2014–2017) the duration of the operation was significantly shorter and the number of postoperative complications was significantly lower than in the initial study group (2010–2013).

Conclusions

The laparoscopic approach is an effective method for treatment of perforated duodenal ulcer in selected cases. A number of 20–25 cases for the surgeon operating with the laparoscopic method is sufficient to achieve an acceptable level of expertise. More prospective randomized studies are needed to evaluate the effectiveness of laparoscopic repair of perforated duodenal ulcer.

Laparoscopic Repair for Perforated Peptic Ulcer: A Retrospective Study

BACKGROUNDS

The incidence of patients presenting with perforated peptic ulcers (PPU) has decreased during the last decades. At the same time, a laparoscopic approach to this condition has been adopted by increased number of surgeons. The aim of this study was to evaluate the early postoperative results of the laparoscopic treatment of perforated peptic ulcer performed in eight Romanian surgical centers with extensive experience in laparoscopic surgery.

METHODS

Between 2009 and 2013, 297 patients with perforated peptic ulcer were operated in the eight centers participating in this retrospective study. The patients' charts were reviewed for demographics, surgical procedure, complications and short-term outcomes.

RESULTS

Boey score of 0 was found in 122 patients (41.1%), Boey 1 in 169 (56.9%), Boey 3 in 6 (2.0%). For 145 (48.8%) patients, primary suture repair was performed, in 146 (49.2%) primary suture repair with omentopexy. There were 6 (2.0%) conversions to open surgery. The operative time was between 25 and 120 min, with a mean of 68 min. Two (0.7%) deaths were noted. Mean hospital stay was 5.5 days, ranges 3-25 days. Postoperative complications included: 7 (2.4%) superficial surgical site infections, 5 (1.6%) cardiovascular, 3 (1.0%) pulmonary, 2 (0.7%) duodenal leakages, 3 (1.0%) deep space infections and 1 (0.3%) upper digestive hemorrhage.

CONCLUSIONS

This study shows that the laparoscopic approach for PPU is feasible; the procedure is safe, with no increased risk of duodenal fistulae or residual intraperitoneal abscesses. We now consider the laparoscopic approach for PPU as the "gold standard" in patients with Boey score 0 or 1.

The natural history of perforated foregut ulcers after repair by omental patching or primary closure

BACKGROUND

The treatment of perforated foregut ulcers by omental patching (OP) or primary closure has mostly replaced vagotomy and pyloroplasty/antrectomy (VPA). We sought to determine the natural history and recurrence rate of ulceration in patients treated by omental patching or primary closure.

STUDY DESIGN

An 11-year retrospective study.

RESULTS

From 2004 through 2015, 94 patients had perforated foregut ulcers, 53 gastric, and 41 duodenal. 77 (82%) were treated by OP alone (study group) and 17 (18%) were treated with VPA (comparison group). All OP patients were discharged on PPIs, but only 86% took the drugs for a median of 22 months (1-192, SD 40). Endoscopy in the OP group showed recurrent ulcers in nine (12% recurrence rate) and gastritis in three (4%) This group also had three later recurrent perforations. Another recurrent ulcer hemorrhaged causing death (3% late mortality). Two other patients required non-emergent re-do ulcer operations for recurrent disease/symptoms (surgical re-intervention rate 4%). Total length of follow-up was median 44 months (1-192, SD 40) and was complete in 82 (87%). 18 (23%) patients in the OP group developed recurrent abdominal pain attributed to ulcer disease during follow-up, compared to 2 (12%) in the VPA group (p = 0.15). No patient in the VPA group had an endoscopic recurrence or re-intervention.

CONCLUSION

Omental patching does not correct the underlying disease process which causes foregut perforation, and has a 12% endoscopically proven recurrent ulceration rate and a 23% incidence of recurrent symptoms within 44 months. Patients tend to stop taking PPIs after 22 months at which time their risk increases.

The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in the emergency departments worldwide. The cornerstones of effective treatment of IAIs are early recognition, adequate source control, and appropriate antimicrobial therapy. Prompt resuscitation of patients with ongoing sepsis is of utmost important. In hospitals worldwide, non-acceptance of, or lack of access to, accessible evidence-based practices and guidelines result in overall poorer outcome of patients suffering IAIs. The aim of this paper is to promote global standards of care in IAIs and update the 2013 WSES guidelines for management of intra-abdominal infections.

MicroRNA-92b promotes hepatocellular carcinoma progression by targeting Smad7 and is mediated by long non-coding RNA XIST

MicroRNA (miRNA) and long non-coding RNA (lncRNA) have been demonstrated to participate in the progression of many cancers. Hepatocellular carcinoma (HCC) is one of the most common and aggressive malignant tumors worldwide, while the molecular mechanisms underlying HCC tumorigenesis are not completely clear. In this study, we showed that miR-92b was significantly upregulated in tumor tissue and plasma of HCC patients, and its expression level was highly correlated with gender and microvascular invasion. Functionally, miR-92b could promote cell proliferation and metastasis of HCC in vitro and in vivo. Mechanistic investigations suggested that Smad7, which exhibited an inverse relationship with miR-92b expression in HCC, was a direct target of miR-92b and could reverse its effects on HCC tumorigenesis. Furthermore, long non-coding RNA (lncRNA) X-inactive specific transcript (XIST) and miR-92b could directly interact with and repress each other, and XIST could inhibit HCC cell proliferation and metastasis by targeting miR-92b. Taken together, our study not only revealed for the first time the importance of XIST/miR-92b/Smad7 signaling axis in HCC progression but also suggested the potential value of miR-92b as a biomarker in the clinical diagnosis and treatment of HCC.

Introduction of Flexible Cyanoacrylates in Sutureless Gastric Closure

Background Clinical effectiveness and safety of biological and synthetic adhesives in digestive closures have been evaluated. Their use is becoming more prevalent, as rigidity and inflexibility are its more remarkable weaknesses. However, little is known about their role in gastric and anastomotic closures. Moreover, usefulness of novel flexible types of synthetic adhesives as n-butyl-cyanoacrylate has not been assessed yet. Materials and Methods One centimeter long gastrotomy was performed in 24 male Wistar rats, which were divided depending on the type of closure method employed: manual USP 5/0 silk interrupted suture versus sutureless closure with Histoacryl Flexible (n-butyl-cyanoacrylate with softener) or Histoacryl Double Component (n-butyl-cyanoacrylate with softener and hardener). Microscopic evaluation of the suture viability and integrity was performed, and adhesion formation during the cicatrization process were assessed. During an 8-week follow-up clinical and histopathological aspects as well as hematologic and inflammatory biomarkers were studied. Results No differences among groups where found in any of the clinical, analytical, or histopathological issues assessed except for a higher incidence rate of adhesions in the Histoacryl Double Component group when compared with hand-sewn suture group (P = .04). Our results support experimental studies in large mammals (pigs) for further study of sutureless hollow viscera closure.

Sutureless onlay omental patch for the laparoscopic repair of perforated peptic ulcers

BACKGROUND

Because the feasibility and safety of laparoscopic approaches for the treatment of perforated peptic ulcer (PPU) have been fully recognized, laparoscopic repair of PPU (LPPU) has become a widely accepted procedure. Following closure of a PPU, the rationale to add an omental patch is based on the assumptions that a patch may decrease the possibility of leakage and make the closure more secure. However, one of the often mentioned disadvantages of LPPU is that it requires a significantly longer operating time. The purpose of the present study was to evaluate the efficacy of LPPU with a sutureless onlay omental patch.

METHODS

Over 60 months, 43 patients underwent LPPU with sutureless onlay omental patch, and another 64 patients underwent LPPU with sutured omental patch. Patient demographics, operation parameters, and surgical outcomes were analyzed retrospectively.

RESULTS

All patients in both groups survived to the end of the study. There were no leaks in either group. The operating time and length of stay in the sutureless onlay omental patch group were significantly shorter than in the sutured omental patch group.

CONCLUSIONS

A sutureless onlay omental patch is as safe and effective as a sutured omental patch for the laparoscopic repair of PPU.

The relationship between computed tomography findings and the locations of perforated peptic ulcers: it may provide better information for gastrointestinal surgeons

BACKGROUND

Computed tomography (CT) plays an important role in diagnosing gastrointestinal perforation. This study explored the relationship between CT findings and the locations of perforated peptic ulcers (PPUs), which may help further surgical planning.

METHODS

During a 34-month period, 175 patients had CT scans. We categorized those 175 patients into 2 groups: patients with and without a PPU at a difficult ulcer site for a laparoscopic approach. Both clinical data and the CT images were reviewed and analyzed.

RESULTS

Based on the univariate analysis results, we conducted multivariate analyses of 3 factors: age, American Society of Anesthesiologists classification of 3 or more, and positive lesser sac image findings. The positive lesser sac findings in CT were the only independent factor that was correlated to the PPU site.

CONCLUSIONS

Positive lesser sac CT findings may help to predict PPUs in sites where a laparoscopic approach might be difficult. Our study re-evaluates the additional value of CT scanning in diagnosing PPU, and the results may assist with surgical planning in clinical practice.

Laparoscopic Surgery in Luminal Gastrointestinal Emergencies-a Review of Current Status

Laparoscopy has already established itself as the preferred surgical approach in a variety of elective surgical conditions. Along with its usual advantages of less tissue trauma and faster recovery, its diagnostic as well as therapeutic role is making it an attractive option in emergency surgery. In this paper, we have reviewed the current status of laparoscopic surgery in luminal gastrointestinal emergencies. Relevant papers were selected using Medline database from 2007 to the present. These were reviewed, and outcomes were stated under the headings of appendicitis, perforated peptic ulcer, colorectal emergencies and small bowel obstruction. The laparoscopic intervention was found to be of clear benefit in most of the patients with appendicitis. Its role, however, is not absolutely clear in managing perforated peptic ulcers. Laparoscopic lavage and drainage have been recommended in diverticular perforation with limited contamination. Small case series and studies have shown benefits of laparoscopic surgery in iatrogenic colonic perforations, colonic obstruction, emergency colectomy and small bowel obstruction. Laparoscopic surgery can be recommended in appendicitis and low-risk cases of perforated peptic ulcers. Its definitive role in other conditions needs more evidence. The surgeon's experience and careful patient selection are very important to improve the outcome.

Laparoscopic closure of perforated gastro-duodenal ulcer: 15 years' experience in our centre

Introduction

The objective of the study is to share the results and development findings on the laparoscopic closure technique applied in our centre during a 15-year period (1998–2012).

Aim

To compare statistically the standard parameters (hospitalization, duration of operation) versus conventional surgery, and at the same time we compared mainly morbidity and mortality.

Material and methods

During the period under review we operated on a total of 259 patients, 115 (44.4%) of them laparoscopically, and 144 (55.6%) of them conventionally. The sample was divided into two groups: patients with ASA physical status classification system 1–3, and patients with ASA 4–5.

Results

The results favour laparoscopy within the group with ASA 1–3 in terms of several parameters, namely: duration of hospitalization – 7.7 days in the case of laparoscopic intervention, vs. 10.6 days for conventional surgery (p < 0.05); and duration of operation – 61 min vs. 85.1 min respectively (p < 0.05). Total morbidity was 27.5% in the case of patients with conventional surgery, vs. 10.9% with laparoscopic intervention (p < 0.05). The sample of patients with ASA 4–5 suffered a high mortality of 82.7%.

Conclusions

Laparoscopic closure of perforated ulcer is a safe therapeutic method, as confirmed by the results of many other studies around the world, which in many aspects favour the laparoscopic technique.

Five year experience in management of perforated peptic ulcer and validation of common mortality risk prediction models - are existing models sufficient? A retrospective cohort study

BACKGROUND

Emergency surgery for perforated peptic ulcer (PPU) is associated with significant morbidity and mortality. Accurate and early risk stratification is important. The primary aim of this study is to validate the various existing MRPMs and secondary aim is to audit our experience of managing PPU.

METHODS

332 patients who underwent emergency surgery for PPU at a single intuition from January 2008 to December 2012 were studied. Clinical and operative details were collected. Four MRPMs: American Society of Anesthesiology (ASA) score, Boey's score, Mannheim peritonitis index (MPI) and Peptic ulcer perforation (PULP) score were validated.

RESULTS

Median age was 54.7 years (range 17-109 years) with male predominance (82.5%). 61.7% presented within 24 h of onset of abdominal pain. Median length of stay was 7 days (range 2-137 days). Intra-abdominal collection, leakage, re-operation and 30-day mortality rates were 8.1%, 2.1%, 1.2% and 7.2% respectively. All the four MRPMs predicted intra-abdominal collection and mortality; however, only MPI predicted leak (p = 0.01) and re-operation (p = 0.02) rates. The area under curve for predicting mortality was 75%, 72%, 77.2% and 75% for ASA score, Boey's score, MPI and PULP score respectively.

DISCUSSION AND CONCLUSION

Emergency surgery for PPU has low morbidity and mortality in our experience. MPI is the only scoring system which predicts all - intra-abdominal collection, leak, reoperation and mortality. All four MRPMs had a similar and fair accuracy to predict mortality, however due to geographic and demographic diversity and inherent weaknesses of exiting MRPMs, quest for development of an ideal model should continue.

Laparoscopy in the acute abdomen

Laparoscopy has become a routine procedure in the management of acute abdominal disease and can be considered both an excellent therapeutic and additional diagnostic tool in selected cases. However, a high level of expertise in laparoscopic and emergency surgery is required. Hemodynamic instability, huge abdominal distension, fecal peritonitis and perforated cancer are relative contraindications for the laparoscopic approach. In recent years, abdominal emergencies have increasingly been managed successfully by laparoscopy. In acute appendicitis, acute cholecystitis and perforated peptic ulcer, randomized controlled trials have proven that the laparoscopic approach is as safe and as effective as open surgery, with fewer complications and a quicker postoperative recovery. Other indications such as blunt and penetrating trauma to the abdomen, small bowel occlusion and perforated diverticular disease are under debate, indicating that more randomized controlled trials comparing laparoscopic and open surgery are still necessary.

2013 WSES guidelines for management of intra-abdominal infections

Despite advances in diagnosis, surgery, and antimicrobial therapy, mortality rates associated with complicated intra-abdominal infections remain exceedingly high.The 2013 update of the World Society of Emergency Surgery (WSES) guidelines for the management of intra-abdominal infections contains evidence-based recommendations for management of patients with intra-abdominal infections.

Eradication of Helicobacter pylori for prevention of ulcer recurrence after simple closure of perforated peptic ulcer: a meta-analysis of randomized controlled trials

BACKGROUND

Eradication of Helicobacter pylori has become part of the standard therapy for peptic ulcer. However, the role of H pylori eradication in perforation of peptic ulcers remains controversial. It is unclear whether eradication of the bacterium confers prolonged ulcer remission after simple repair of perforated peptic ulcer.

METHODS

A systematic review and meta-analysis of randomized controlled trials was performed to evaluate the effects of H pylori eradication on prevention of ulcer recurrence after simple closure of perforated peptic ulcers. The primary outcome to evaluate these effects was the incidence of postoperative ulcers; the secondary outcome was the rate of H pylori elimination.

RESULTS

The meta-analysis included five randomized controlled trials and 401 patients. A high prevalence of H pylori infection occurred in patients with perforated peptic ulcers. Eradication of H pylori significantly reduced the incidence of ulcer recurrence at 8 wk (risk ratio 2.97; 95% confidence interval: 1.06-8.29) and 1 y (risk ratio 1.49; 95% confidence interval: 1.10-2.03) postoperation. The rate of H pylori eradication was significantly higher in the treatment group than in the nontreatment group.

CONCLUSIONS

Eradication therapy should be provided to patients with H pylori infection after simple closure of perforated gastroduodenal ulcers.