A randomized comparison of acute phase response and endotoxemia in patients with perforated peptic ulcers receiving laparoscopic or open patch repair

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 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.

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.

[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 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 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.

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.

LAPAROSCOPIC TECHNOLOGIES IN SURGERY OF PERFORATED GASTRODUODENAL ULCERS

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Perforated Peptic Ulcer Repair: Factors Predicting Conversion in Laparoscopy and Postoperative Septic Complications

OBJECTIVE

The surgical treatment for perforated peptic ulcers can be safely performed laparoscopically. The aim of the study was to define simple predictive factors for conversion and septic complications.

METHODS

This retrospective case-control study analyzed patients treated with either laparoscopic surgery or laparotomy for perforated peptic ulcers.

RESULTS

A total of 71 patients were analyzed. Laparoscopically operated patients had a shorter hospital stay (13.7 vs. 15.1 days). In an intention-to-treat analysis, patients with conversion to open surgery (analyzed as subgroup from laparoscopic approach group) showed no prolonged hospital stay (15.3 days) compared to patients with a primary open approach. Complication and mortality rates were not different between the groups. The statistical analysis identified four intraoperative risk factors for conversion: Mannheim peritonitis index (MPI) > 21 (p = 0.02), generalized peritonitis (p = 0.04), adhesions, and perforations located in a region other than the duodenal anterior wall. We found seven predictive factors for septic complications: age >70 (p = 0.02), cardiopulmonary disease (p = 0.04), ASA > 3 (p = 0.002), CRP > 100 (p = 0.005), duration of symptoms >24 h (p = 0.02), MPI > 21(p = 0.008), and generalized peritonitis (p = 0.02).

CONCLUSION

Our data suggest that a primary laparoscopic approach has no disadvantages. Factors necessitating conversions emerged during the procedure inhibiting a preoperative selection. Factors suggesting imminent septic complications can be assessed preoperatively. An assessment of the proposed parameters may help optimize the management of possible septic complications.

Laparoscopic versus open operation for perforated peptic ulcer in pediatric patients: A 10-year experience

BACKGROUND

Perforated peptic ulcer (PPU) is a relatively uncommon condition in children. We aim to evaluate and compare the outcomes of laparoscopic omental patch repair versus open repair for PPU in pediatric patients.

METHODS

Children who underwent omental patch repair for PPU from 2004 to 2014 in our hospital were reviewed retrospectively. Patient demographics, perioperative as well as intraoperative details and surgical outcomes, were analyzed.

RESULTS

Thirteen patients were identified, and all presented with abdominal pain. The median age of the study group was 14.9years (range 6.3 to 18.4years). Radiological evidence of pneumoperitoneum on erect chest x-ray (CXR) was found only in five patients (38.5%). None of the patients had a known history of peptic ulcer disease. Diagnosis other than PPU was made in five patients preoperatively. Laparoscopic repair was attempted in eight patients with one of them requiring conversion. There was no significant difference in patient demographics when compared with the open repair group. The perforation site was in the duodenum in 11 patients and in the antrum in two patients. The mean size of perforation was larger in the open repair group (p=0.005). Although the operating time was longer in the laparoscopic group (p=0.51), the length of hospital stay was significantly shorter (p=0.048). Only two patient diseases were Helicobacter pylori related.

CONCLUSION

Clinical features of perforated peptic ulcer in children are different from adults. Risk factors are less frequently identified. Laparoscopic omental patch repair is a feasible surgical option and is associated with satisfactory outcomes in pediatric practice.

An Updated Meta-Analysis of Laparoscopic Versus Open Repair for Perforated Peptic Ulcer

Laparoscopic repair (LR) for perforated peptic ulcer (PPU) has been introduced since 1990. Although many studies comparing LR with open repair (OR) have been published, controversy remains regarding the clinical utility of laparoscopic techniques for the treatment of PPU. Thus, it is necessary for us to broaden our knowledge on this subject with the newly published articles. Twenty-four nonrandomized controlled studies (NRS) and five randomized controlled trails (RCTs) were included in our meta-analyses, which comprised 5,268 patients (1,890 in the LR group and 3,378 in the OR group). In the analysis of high quality NRS and RCTs, compared with OR, high quality evidence suggested that LR was associated with a lower incidence of overall postoperative complications; moderate evidence showed that the two procedures had the similar reoperation rate; based on the low quality evidence, LR had reduced hospital mortality and similar operative time; Moreover, LR was observed having the advantages of earlier resumption of oral intake, shorter hospital stay and less analgesic use, which were supported by very low evidence. All the evidences suggest that LR is better than OR for PPU, but more high-quality RCTs are still needed for further validation.

Strategies to improve the outcome of emergency surgery for perforated peptic ulcer

BACKGROUND

Perforated peptic ulcer (PPU) is a common surgical emergency that carries high mortality and morbidity rates. Globally, one-quarter of a million people die from peptic ulcer disease each year. Strategies to improve outcomes are needed.

METHODS

PubMed was searched for evidence related to the surgical treatment of patients with PPU. The clinical registries of trials were examined for other available or ongoing studies. Randomized clinical trials (RCTs), systematic reviews and meta-analyses were preferred.

RESULTS

Deaths from peptic ulcer disease eclipse those of several other common emergencies. The reported incidence of PPU is 3.8-14 per 100,000 and the mortality rate is 10-25 per cent. The possibility of non-operative management has been assessed in one small RCT of 83 patients, with success in 29 (73 per cent) of 40, and only in patients aged less than 70 years. Adherence to a perioperative sepsis protocol decreased mortality in a cohort study, with a relative risk (RR) reduction of 0.63 (95 per cent confidence interval (c.i.) 0.41 to 0.97). Based on meta-analysis of three RCTs (315 patients), laparoscopic and open surgery for PPU are equivalent, but patient selection remains a challenge. Eradication of Helicobacter pylori after surgical repair of PPI reduces both the short-term (RR 2.97, 95 per cent c.i. 1.06 to 8.29) and 1-year (RR 1.49, 1.10 to 2.03) risk of ulcer recurrence.

CONCLUSION

Mortality and morbidity from PPU can be reduced by adherence to perioperative strategies.

Meta-analysis of laparoscopic versus open repair of perforated peptic ulcer

A meta-analysis of four randomized trials comparing laparoscopic versus open repair of perforated ulcer did not demonstrate significant superiority of the laparoscopic or open approach.

Background and Objectives:

Laparoscopic treatment of perforated peptic ulcer (PPU) has been introduced as an alternative procedure to open surgery. It has been postulated that the minimally invasive approach involves less operative stress and results in decreased morbidity and mortality.

Methods:

We conducted a meta-analysis of randomized trials to test this hypothesis. Medline, EMBASE, and the Cochrane Central Register of Randomized Trials databases were searched, with no date or language restrictions.

Results:

Our literature search identified 4 randomized trials, with a cumulative number of 289 patients, that compared the laparoscopic approach with open sutured repair of perforated ulcer. Analysis of outcomes did not favor either approach in terms of morbidity, mortality, and reoperation rate, although odds ratios seemed to consistently support the laparoscopic approach. Results did not determine the comparative efficiency and safety of laparoscopic or open approach for PPU.

Conclusion:

In view of an increased interest in the laparoscopic approach, further randomized trials are considered essential to determine the relative effectiveness of laparoscopic and open repair of PPU.

Systemic inflammation and immune response after laparotomy vs laparoscopy in patients with acute cholecystitis, complicated by peritonitis

AIM: To evaluate acute cholecystitis, complicated by peritonitis, acute phase response and immunological status in patients treated by laparoscopic or open approach.

METHODS: From January 2002 to May 2012, we conducted a prospective randomized study on 45 consecutive patients (27 women, 18 men; mean age 58 years). These subjects were taken from a total of 681 patients who were hospitalised presenting similar preoperative findings: acute upper abdominal pain with tenderness, involuntary guarding under the right hypochondrium and/or in the flank; fever higher than 38 °C, leukocytosis greater than 10 × 10⁹/L or both, and ultrasonographic evidence of calculous cholecystitis possibly complicated by peritonitis. These patients had undergone cholecystectomy for acute calculous cholecystitis, complicated by bile peritonitis. Randomly, 23 patients were assigned to laparoscopic cholecystectomy (LC), and 22 patients to open cholecystectomy (OC). Blood samples were collected from all patients before operation and at days 1, 3 and 6 after surgery. Serum bacteraemia, endotoxaemia, white blood cells (WBCs), WBC subpopulations, human leukocyte antigen-DR (HLA-DR), neutrophil elastase, interleukin-1 (IL-1) and IL-6, and C-reactive protein (CRP) were measured at 0, 30, 60, 90, 120 and 180 min, at 4, 6, 12, 24 h, and then daily (8 A.M.) until post-op day 6.

RESULTS: The two groups were comparable in the severity of peritoneal contamination as indicated by the viable bacterial count (open group = 90% of positive cultures vs laparoscopic group = 87%) and endotoxin level (open group = 33.21 ± 6.32 pg/mL vs laparoscopic group = 35.02 ± 7.23 pg/mL). Four subjects in the OC group (18.1%) and 1 subject (4.3%) in the LC group (P < 0.05) developed intra-abdominal abscess. Severe leukocytosis (range 15.8-19.6/mL) was observed only after OC but not after LC, mostly due to an increase in neutrophils (days 1 and 3, P < 0.05). This value returned to the normal range within 3-4 d after LC and 5-7 d after OC. Other WBC types and lymphocyte subpopulations showed no significant variation. On the first day after surgery, a statistically significant difference was observed in HLA-DR expression between LC (13.0 ± 5.2) and OC (6.0 ± 4.2) (P < 0.05). A statistically significant change in plasma elastase concentration was recorded post-operatively at days 1, 3, and 6 in patients from the OC group when compared to the LC group (P < 0.05). In the OC group, the serum levels of IL-1 and IL-6 began to increase considerably from the first to the sixth hour after surgery. In the LC group, the increase of serum IL-1 and IL-6 levels was delayed and the peak values were notably lower than those in the OC group. Significant differences between the groups, for these two cytokines, were observed from the second to the twenty-fourth hour (P < 0.05) after surgery. The mean values of serum CRP in the LC group on post-operative days (1 and 3) were also lower than those in the OC group (P < 0.05). Systemic concentration of endotoxin was higher in the OC group at all intra-operative sampling times, but reached significance only when the gallbladder was removed (OC group = 36.81 ± 6.4 ρg/mL vs LC group = 16.74 ± 4.1 ρg/mL, P < 0.05). One hour after surgery, microbiological analysis of blood cultures detected 7 different bacterial species after laparotomy, and 4 species after laparoscopy (P < 0.05).

CONCLUSION: OC increased the incidence of bacteraemia, endotoxaemia and systemic inflammation compared with LC and caused lower transient immunological defense, leading to enhanced sepsis in the patients examined.

Laparoscopic repair for perforated peptic ulcer disease

BACKGROUND

Perforated peptic ulcer is a common abdominal disease that is treated by surgery. The development of laparoscopic surgery has changed the way to treat such abdominal surgical emergencies. The results of some clinical trials suggest that laparoscopic surgery could be a better strategy than open surgery in the correction of perforated peptic ulcer but the evidence is not strongly in favour for or against this intervention.

OBJECTIVES

To measure the effect of laparoscopic surgical treatment versus open surgical treatment in patients with a diagnosis of perforated peptic ulcer in relation to abdominal septic complications, surgical wound infection, extra-abdominal complications, hospital length of stay and direct costs.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (2004, Issue 2), PubMed/MEDLINE (1966 to July 2004), EMBASE (1985 to November 2004) and LILACS (1988 to November 2004) as well as the reference lists of relevant articles. Searches in all databases were updated in December 2009 and January 2012. We did not confine our search to English language publications.

SELECTION CRITERIA

Randomized clinical trials comparing laparoscopic surgery versus open surgery for the repair of perforated peptic ulcer using any mechanical method of closure (suture, omental patch or fibrin sealant).

DATA COLLECTION AND ANALYSIS

Primary outcome measures included proportion of septic and other abdominal complications (surgical site infection, suture leakage, intra-abdominal abscess, postoperative ileus) and extra-abdominal complications (pulmonary). Secondary outcomes included mortality, time to return to normal diet, time of nasogastric aspiration, hospital length-of-stay and costs. Outcomes were summarized by reporting odds ratios (ORs) and 95% confidence intervals (CIs), using the fixed-effect model.

MAIN RESULTS

We included three randomized clinical trials of acceptable quality. We found no statistically significant differences between laparoscopic and open surgery in the proportion of abdominal septic complications (OR 0.66; 95% CI 0.30 to 1.47), pulmonary complications (OR 0.43; 95% CI 0.17 to 1.12) or number of septic abdominal complications (OR 0.60; 95% CI 0.32 to 1.15). Heterogeneity was significant for pulmonary complications and operating time.

AUTHORS' CONCLUSIONS

This review suggests that a decrease in septic abdominal complications may exist when laparoscopic surgery is used to correct perforated peptic ulcer. However, it is necessary to perform more randomized controlled trials with a greater number of patients to confirm such an assumption, guaranteeing a long learning curve for participating surgeons. With the information provided it could be said that laparoscopic surgery results are not clinically different from those of open surgery.

Peritonitis from Perforated Appendicitis: Stress Response after Laparoscopic or Open Treatment

Elevated intra-abdominal pressure during laparoscopy may promote systemic inflammatory response. In patients with generalized peritonitis from perforated appendicitis, we sought to compare acute phase response and immunologic status from laparoscopic and open approach. One hundred and forty-seven consecutive patients underwent appendectomy for perforated appendicitis (73 patients had laparoscopic appendectomy and 74 patients had open appendectomy. Bacteremia, endotoxemia, white blood cells, peripheral lymphocytes subpopulation, human leukocyte antigen-DR (HLA-DR), neutrophil-elastase, interleukin-1 and 6 (IL-1 and 6), and C-reactive protein were investigated. One hour after intervention, bacteremia was significantly higher in the open group compared with the laparoscopic group ( P < 0.05). A significantly higher concentration of systemic endotoxin was detected intraoperatively in the open group of patients in comparison with the laparoscopic group ( P < 0.05). Laparotomy caused a significant increase in neutrophil concentration, neutrophil-elastase, IL-1 and 6, and C-reactive protein and a decrease of HLA-DR. We recorded 6 cases (8.1%) of intra-abdominal abscess in the open group and one (1.3%) in the laparoscopic group ( P < 0.05). Open appendectomy, in case of peritonitis, increased the incidence of bacteremia, endotoxemia, and systemic inflammation compared with laparoscopic appendectomy. Early enhanced postoperative systemic inflammation may cause lower transient immunologic defense after laparotomy (decrease of HLA-DR), leading to enhanced sepsis in these patients.

Perforated duodenal ulcer associated with anterior abdominal abscess: A case report

Computed tomography (CT) has been regarded as the method of choice for detecting the presence, site and cause of gastrointestinal tract perforation. In addition to determining the presence of perforation, CT can also localise the perforation size and demonstrate direct and indirect findings relative to the perforation. In this case study, we report the CT results in a patient with perforated duodenal ulcer associated with anterior abdominal abscess, and highlight the diagnostic value of CT imaging.

Laparoscopic correction of perforated peptic ulcer: first choice? A review of literature

BACKGROUND

Perforated peptic ulcer (PPU), despite antiulcer medication and Helicobacter eradication, is still the most common indication for emergency gastric surgery associated with high morbidity and mortality. Outcome might be improved by performing this procedure laparoscopically, but there is no consensus on whether the benefits of laparoscopic closure of perforated peptic ulcer outweigh the disadvantages such as prolonged surgery time and greater expense.

METHODS

An electronic literature search was done by using PubMed and EMBASE databases. Relevant papers written between January 1989 and May 2009 were selected and scored according to Effective Public Health Practice Project guidelines.

RESULTS

Data were extracted from 56 papers, as summarized in Tables 1-7. The overall conversion rate for laparoscopic correction of perforated peptic ulcer was 12.4%, with main reason for conversion being the diameter of perforation. Patients presenting with PPU were predominantly men (79%), with an average age of 48 years. One-third had a history of peptic ulcer disease, and one-fifth took nonsteroidal anti-inflammatory drugs (NSAIDs). Only 7% presented with shock at admission. There seems to be no consensus on the perfect setup for surgery and/or operating technique. In the laparoscopic groups, operating time was significant longer and incidence of recurrent leakage at the repair site was higher. Nonetheless there was significant less postoperative pain, lower morbidity, less mortality, and shorter hospital stay.

CONCLUSION

There are good arguments that laparoscopic correction of PPU should be first treatment of choice. A Boey score of 3, age over 70 years, and symptoms persisting longer than 24 h are associated with higher morbidity and mortality and should be considered contraindications for laparoscopic intervention.

64-Slice multidetector computed tomography evaluation of gastrointestinal tract perforation site: detectability of direct findings in upper and lower GI tract

OBJECTIVE

To evaluate wall discontinuity, as observed using 64-slice multidetector-row computed tomography (64-MDCT), as a direct finding (DF) indicating the perforation site in patients with gastrointestinal (GI) tract perforations.

METHODS

We retrospectively studied 41 consecutive patients presenting with acute abdomen and exhibiting extraluminal air (EA) on 64-MDCT. Three readers evaluated the distribution of EA, extraluminal faeces, dirty mass, dirty fat sign, extraluminal fluid collection and bowel wall thickening (i.e. conventional findings, CFs) as well as DFs.

RESULTS

Twenty-two cases were surgically or endoscopically confirmed to have upper GI tract perforations, and 19 had lower GI tract perforations. The DFs correctly identified the sites of perforation in 80.5% of patients when 2-mm-thick imaging slices were used. For the detection of upper GI tract perforations, the sensitivity, specificity and accuracy were 95.5%, 94.7% and 95.1% for the DFs and 50.0%, 100% and 73.2% for the CFs, respectively. Significant differences in sensitivity (p < 0.001) and diagnostic accuracy (p < 0.05) were observed between the DFs and CFs for upper GI perforations but not for lower GI tract perforations.

CONCLUSION

DFs of the perforation site by using 64-MDCT were more sensitive and accurate than CFs for the detection of upper GI tract perforations.

CO(2) pneumoperitoneum prolongs survival in an animal model of peritonitis compared to laparotomy

BACKGROUND

The advantages of laparoscopic surgery have been well documented. However, the impact of pneumoperitoneum on sepsis sequelae is still equivocal. This study aimed to evaluate the effect of CO(2) pneumoperitoneum, applied under different pressures and exposure times, on sepsis cascade and mortality.

MATERIAL AND METHODS

In 42 New Zealand rabbits, peritonitis was induced by the cecum ligation and puncture model. After 12 h, the animals were randomized in seven groups: a control group, four groups with pneumoperitoneum (10-15 mmHg for 60-180 min), and two groups with laparotomy (for 60 and 180 min). Blood samples were collected before cecum ligation and puncture, 12 h later and 1, 3, and 6 h after pneumoperitoneum desufflation or abdominal trauma closure to evaluate bacteremia, endotoxemia, white blood cells count, C-reactive protein, and procalcitonin levels. Furthermore, the mortality time was recorded in all animals.

RESULTS

Bacteremia and endotoxemia were induced in all groups. Endotoxemia levels were significantly more elevated in the group where pneumoperitoneum was performed under 15 mmHg for 180 min compared with all other groups at 1 and 3 h after pneumoperitoneum desufflation (P < 0.05), except when compared with the group where pneumoperitoneum was performed under 10 mmHg for 180 min. White blood cell and C-reactive protein levels showed similar trends for all groups. However, serum procalcitonin reached statistically higher levels (P < 0.05) in groups with laparotomy compared with groups with pneumoperitoneum and with the control group at 6 h. Survival was lower in the laparotomy groups compared with the pneumoperitoneum groups and with the control group (P < 0.05).

CONCLUSIONS

In the presence of peritonitis, CO(2) pneumoperitoneum applied in clinically standard pressures, even for extended time intervals, reduces the severity of sepsis and prolongs survival.

Development of a lethal model of peritonitis for assessment of laparoscopic and laparotomic treatments in rats

PURPOSE

Development of a lethal model of peritonitis to assess the results of treating that peritonitis using videolaparoscopy and laparotomy.

METHODS

We developed a model of peritonitis in rats using cecal ligation (CLP) against a 2-mm diameter rigid mold and puncture. Two experiments were performed: determination of seven-day lethality; and analysis of white cell counts, blood cultures and cytokines (Interleukin-1 beta, Tumor Necrosis Factor-alpha and IL-6). The animals were divided into four groups: I--Sham surgery; II--CLP; III--CLP + Videolaparoscopy; and IV--CLP + Laparotomy .

RESULTS

Seven-day lethality was 0% in group I, 80% in the group II (p<0.05), 60% in group III , and 20 % in group IV. There was a significant reduction in leukocyte counts and higher levels of serum IL-1 beta, TNF-alpha and IL-6 in the group II compared to controls. The percentages of positive blood cultures were higher after videolaparoscopic compared to laparotomic treatment.

CONCLUSION

The experimental model provoked a lethal form of peritonitis and that videolaparoscopic treatment had more bacteraemia than laparotomy.

Influence of laparoscopy and laparotomy on gasometry, leukocytes and cytokines in a rat abdominal sepsis model

PURPOSE

Laparoscopic surgery is associated with reduced surgical trauma, and less acute phase response, as compared with open surgery. Cytokines are important regulators of the biological response to surgical and anesthetic stress. The aim of this study was to determine if CO2 pneumoperitoneum would change cytokine expression, gas parameters and leukocyte count in septic rats.

METHODS

Wistar rats were randomly assigned to five groups: control (anesthesia only), laparotomy, CO2 pneumoperitoneum, cecum ligation and puncture by laparotomy, and laparoscopic cecum ligation and puncture. After 30 min of the procedures, arterial blood samples were obtained to determine leukocytes subpopulations by hemocytometer. TNFalpha, IL-1beta, IL-6 were determined in intraperitoneal fluid (by ELISA). Gas parameters were measured on arterial blood, intraperitoneal and subperitoneal exudates.

RESULTS

Peritoneal TNFalpha, IL-1beta and IL-6 concentrations were lower in pneumoperitoneum rats than in all other groups (p<0.05). TNFalpha, IL-1beta and IL-6 expression was lower in the laparoscopic than in laparotomic sepsis (p<0.05). Rats from laparoscopic cecum ligation and puncture group developed significant hypercarbic acidosis in blood and subperitoneal fluid when compared to open procedure group. Total white blood cells and lymphocytes were significantly lower in laparoscopic cecum ligation and puncture rats than in the laparotomic (p<0.01). Nevertheless, the laparotomic cecum ligation rats had a significant increase in blood neutrophils and eosinophils when compared with controls (p<0.05).

CONCLUSIONS

This study demonstrates that the CO2 pneumoperitoneum reduced the inflammatory response in an animal model of peritonitis with respect to intraperitoneal cytokines, white blood cell count and clinical correlates of sepsis. The pneumoperitoneum produced hypercarbic acidosis in septic animals.

Management strategies, early results, benefits, and risk factors of laparoscopic repair of perforated peptic ulcer

The primary goal of this study was to describe epidemiology and management strategies of the perforated duodenal ulcer, as well as the most common methods of laparoscopic perforated duodenal ulcer repair. The secondary goal was to demonstrate the value of prospective and retrospective studies regarding the early results of surgery and the risk factors. The tertiary goal was to emphasize the benefits of this operation, and the fourth goal was to clarify the possible risk factors associated with laparoscopic repair of the duodenal ulcer. The Medline/Pubmed database was used. Review was done after evaluation of 96 retrieved full-text articles. Thirteen prospective and twelve retrospective studies were selected, grouped, and summarized. The spectrum of the retrospective studies' results are as follows: median overall morbidity rate 10.5 %, median conversion rate 7%, median hospital stay 7 days, and median postoperative mortality rate 0%. The following is the spectrum of results of the prospective studies: median overall morbidity rate was slightly less (6%); the median conversion rate was higher (15%); the median hospital stay was shorter (5 days) and the postoperative mortality was higher (3%). The risk factors identified were the same. Shock, delayed presentation (> 24 hours), confounding medical condition, age > 70 years, poor laparoscopic expertise, ASA III-IV, and Boey score should be considered preoperative laparoscopic repair risk factors. Each of these factors independently should qualify as a criterion for open repair due to higher intraoperative risks as well as postoperative morbidity. Inadequate ulcer localization, large perforation size (defined by some as > 6 mm diameter, and by others as > 10 mm), and ulcers with friable edges are also considered as conversion risk factors.

Effect of intraperitoneal application of an endotoxin inhibitor on survival time in a laparoscopic model of peritonitis in rats

Gram-negative sepsis due to fecal peritonitis is a hazardous disease with a high percentage having a lethal course. The inflammatory effects are induced by endotoxin release. We performed this study to evaluate the potential of direct intraperitoneal application of an endotoxin inhibitor in a laparoscopic peritonitis model in rats. The human feces specimen was prepared, and a standard fecal specimen (0.5 ml/kg b.w.) was applied via minilaparotomy. The rats were randomized to two studies. First, rats were randomized to three groups to define the survival time: (1) rats without further manipulation; (2) rats with laparoscopic lavage using NaCl; (3) rats with laparoscopic lavage using endotoxin inhibitor. Second, rats underwent the same procedure used in the first part of the study and an additional group with only NaCl lavage without peritonitis was randomized. To evaluate the immunologic or biochemical effects, animals were killed at a standard time of 20 hours until the postmortem examination was established. Interleukins 6 and 10 (IL-6, IL-10), malondialdehyde, and protein carbonyl group levels in plasma and particularly in peritoneal fluid were assayed. The first part of the experiment showed significantly increased survival after endotoxin inhibitor lavage. In the second part, administration of endotoxin inhibitor intraperitoneally caused a significant reduction of IL-6 in the peritoneal fluid, in contrast to that in the other groups. Laparoscopic application of endotoxin inhibitor intraperitoneally thus produced a beneficial effect on survival and reduction of IL-6 in peritoneal fluid. Hence, it is possible to influence the inflammation cascade by causing intraperitoneal endotoxin inhibition.

Laparoscopic repair for perforated peptic ulcer disease

BACKGROUND

Perforated peptic ulcer is a common abdominal disease that is treated by surgery. The development of laparoscopic surgery has changed the way to treat such abdominal surgical emergencies. The results of some clinical trials suggest that laparoscopic surgery could be a better strategy than open surgery in the correction of perforated peptic ulcer but the evidence is not strongly in favour or against this intervention.

OBJECTIVES

To measure the effect of laparoscopic surgical treatment versus open surgical treatment in patients with a diagnosis of perforated peptic ulcer in relation to abdominal septic complications, surgical wound infection, extra-abdominal complications, hospital length of stay and direct costs.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 2, 2004), PubMed/MEDLINE (1966 to July 2004), EMBASE (1985 to November 2004) and LILACS (1988 to November 2004) as well as reference lists of relevant articles.

SELECTION CRITERIA

Randomised clinical trials comparing laparoscopic surgery versus open surgery for the repair of perforated peptic ulcer using any mechanical method of closure (suture, omental patch or fibrin sealant).

DATA COLLECTION AND ANALYSIS

Primary outcome measures included proportion of septic and other abdominal complications (surgical site infection, suture leakage, intra-abdominal abscess, postoperative ileus) and extra-abdominal complications (pulmonary). Secondary outcomes included mortality, time to return to normal diet, time of nasogastric aspiration, hospital length of stay and costs. Outcomes were summarized by reporting odds ratios and 95% confidence intervals, using the fixed-effect model.

MAIN RESULTS

We included two randomised clinical trials, which were of acceptable quality. We found no statistically significant differences between laparoscopic and open surgery in the proportion of abdominal septic complications (OR 0.66, 95% CI 0.30 to 1.47), pulmonary complications (OR 0.37, 95% CI 0.11 to 1.31) or actual number of septic abdominal complications (OR 0.72, 95% CI 0.33 to 1.58). Heterogeneity was significant only for pulmonary complications.

AUTHORS' CONCLUSIONS

This systematic review suggests that a decrease in septic abdominal complications may exist when laparoscopic surgery is used to correct perforated peptic ulcer. However, it is necessary to develop more randomised controlled trials that include a greater number of patients to confirm such an assumption, guaranteeing a long learning curve for participating surgeons. With the information provided by the available clinical trials it could be said that laparoscopic surgery results are not clinically different from those of open surgery.

Hepatic carbohydrate metabolism in rats after laparotomy and laparoscopy

BACKGROUND

Portal venous and mesenteric blood flow are reduced by 40-60% in humans and animals during laparoscopic surgery compared to laparotomy. Little is known about whether these intraabdominal micro- and macrocirculatory changes are associated with alterations in the hepatic energy metabolism.

METHODS

We operated on male Sprague-Dawley rats, performing either laparoscopy (CO2, 6 mmHg; n = 27) or laparotomy (n = 28), and compared the results with two control groups: intraperitoneal (i.p.) endotoxin administration (n = 28, positive control) and anesthesia only (n = 28, negative control). We investigated the impact of the two different surgical techniques on daily food intake, body weight gain, glycogen content in the liver, levels of blood glucose, and liver function tests (LFTs) on postoperative days 1, 2, 4, and 8. Local (hepatic) and systemic inflammatory responses (interleukin-6 and tumor necrosis factor-alpha) during the postoperative time course were also determined. Data were analyzed using the Kruskal-Wallis test or univariate analysis of variance.

RESULTS

Body weight gain, food intake, liver and spleen weights, as well as LFTs [except aspartate aminotransferase (AST)] did not differ among the four groups. The significant increase in the AST level following laparoscopy compared to the anesthesia-only group was found on postoperative days 1 and 2; however, a similar difference was not detected after laparotomy or i.p. endotoxin injection. Laparoscopy showed no alterations in the hepatic glycogen stores compared to anesthesia only, whereas laparotomy and endotoxinemia significantly reduced the hepatic glycogen stores on postoperative days 2 and 4. The systemic postoperative inflammatory response did not differ between laparotomy and laparoscopy, but it was higher in both groups than in anesthesia only. In rats treated with endotoxin, the systemic inflammatory response was even higher than in the two surgical groups. The hepatic inflammatory response did not differ between the four groups.

CONCLUSION

This study shows a significant postoperative decrease in the hepatic glycogen content after laparotomy and i.p. endotoxin injection but not after laparoscopy. Food intake and inflammatory response cannot explain this difference between the two surgical groups, which suggests that alterations in the postsurgical hormonal stress response are the most likely explanation for these findings.

Laparoscopic treatment of gastroduodenal perforations: comparison with conventional surgery

BACKGROUND

Laparoscopic techniques have been proposed as an alternative to open surgery for the treatment of peptic ulcer perforation. This study compared the outcome of laparoscopic and open approaches for the repair of gastroduodenal perforations.

METHODS

A retrospective review was conducted with 134 consecutive patients treated for gastroduodenal perforations. These patients included 122 with perforated duodenal ulcers, 10 with perforated gastric ulcers, and 2 with iatrogenic duodenal perforations. Whereas 68 patients were treated laparoscopically, 66 patients underwent conventional (open) surgery.

RESULTS

Laparoscopic repair was successful in 65 cases (96 %). The mean operating time was shorter with the laparoscopic technique (68 vs 59 min), but the difference was not significant. The duration of postoperative nasogastric aspiration and time to resumed oral intake were shorter in the laparoscopic group (2.6 vs 4.1 days and 4.4 vs. 5.2 days, respectively; p = 0.043). The postoperative analgetic requirements, and overall complications rate were significantly lower after laparoscopic surgery (p = 0.03 and p = 0.004, respectively). There was no statistically significant difference in hospital stay (5.1 vs 6.1 days) or mortality rate between the two procedures.

CONCLUSION

Laparoscopic repair of gastroduodenal perforations is a safe alternative treatment offering certain significant short-term advantages.

Endoscope-Assisted Laparoscopic Repair of Perforated Peptic Ulcers

Laparoscopic repairs for perforated peptic ulcer (PPU) are likely to fail in patients with shock, gastric outlet obstruction, or large perforations. This prospective study was performed to evaluate a revised approach of laparoscopic repair with endoscopic assistance to treat these patients. Between April 2001 and February 2002, 30 consecutive patients with PPU were enrolled in this study. The mean age was 43.1 ± 12.2 years. Male to female ratio was 27:2. One patient was excluded from laparoscopic repair due to a gastric outlet obstruction. The other 29 patients were managed according to a protocol of preoperative upper endoscopy and laparoscopic intracorporeal suture repair with an omental patch. The average operative time was 58.1 ± 13.5 minutes (range, 36–96 min). The average diameter of perforation was 4.2 ± 2.0 mm (range, 1–12 mm). The average time to resume oral fluids was 3.2 ± 0.8 days (range, 2–8 days). The average hospital stay was 4.7 ± 1.1 days (range, 3–10 days). There was no leakage or mortality. Most patients did not receive parenteral analgesics postoperatively. We conclude that endoscope-assisted laparoscopic repair for PPU is safe and effective. This revised technique allows surgeons to exclude patients who are likely to fail the laparoscopic repair.

Increased transperitoneal bacterial translocation in laparoscopic surgery

BACKGROUND

The indications for laparoscopic surgery have expanded to include diseases possibly associated with peritonitis such as appendicitis, perforated peptic ulcers, and diverticulitis. The safety of carbon dioxide (CO2) pneumoperitoneum in the presence of peritonitis has not been proved. Our previous investigations demonstrated increased bacteremia associated with CO2 insufflation. In effort to clarify the relative effects of intraabdominal pressure and type of gas, this study was designed to measure bacterial translocation with different gases at different pressures of pneumoperitoneum.

METHODS

For this study, 110 rats were given intraperitoneal bacterial innoculations with Escherichia coli and equally divided into five groups of 20 animals each. The study groups included a control group with no pneumoperitoneum administered (n = 30), insufflation at a commonly used pressure of 14 mmHg with helium (n = 20) and CO2 (n = 20), and low insufflation at 3 mmHg with helium (n = 20) and CO2 (n = 20) in an effort to minimize influences related to pressure. Blood cultures were checked at 15-min intervals for the first 45 min, then hourly thereafter for a total of 165 min after peritoneal inoculation with 2 x 10(7) E. coli.

RESULTS

There is increased risk of bacterial translocation in comparing groups that underwent pneumoperitoneum with those that did not in the rat peritonitis model. Furthermore, these findings are dependent on the presence or absence of gas, but not necessarily on the type of gas used for insufflation. In the low-pressure groups of both gases (helium and CO2), bacterial translocation was significantly increased, as compared with the control group. Low pressure also was associated with increased bacterial translocation, as compared with high pressure, but beyond 30 min of insufflation, no significant differences were apparent.

CONCLUSIONS

The risk of bacterial translocation in the E. coli rat peritonitis model is increased with insufflation using CO2 or helium, and this effect is more significant at lower pressures (3 mmHg) than at higher pressures (14 mmHg). However, no clinically applicable conclusions regarding the relative effects from type of gas or insufflation pressures could be confirmed.

Neuroendocrine stress response in patients undergoing benign ovarian cyst surgery by laparoscopy, minilaparotomy, and laparotomy

STUDY OBJECTIVE

To quantify and compare neuroendocrine stress responses during and immediately after surgery by laparoscopy, minilaparotomy, and laparotomy for benign ovarian cysts.

DESIGN

Prospective study (Canadian Task Force classification II-1).

SETTING

Tertiary care university hospital.

PATIENTS

Thirty healthy women with no major diseases and without endocrine disorders.

INTERVENTIONS

Surgery for benign ovarian cysts performed by laparoscopy (10), minilaparotomy (10), or laparotomy (10).

MEASUREMENTS AND MAIN RESULTS

Venous blood samples were collected at fixed times as follows: at 8 A.M. in the ward before transferring the patient to the operating room (time 0), 30 minutes after the beginning of surgery (time 1), at the end of surgery after extubation with the patient awake (time 2), and 2 and 4 hours after the end of surgery (times 3 and 4). We evaluated intraoperative and postoperative variations of the following stress-related markers: norepinephrine (NE), epinephrine (E), adrenocorticotropic hormone (ACTH), human growth hormone (hGH), prolactin (PRL), and cortisol, and postoperative pain. No differences were present in demographic characteristics and operating times in the three groups. No anesthesiologic or surgical complications occurred. Postoperative pain was similar in the laparoscopy and minilaparotomy group but significantly higher in the laparotomy group (p <0.001). Serum levels of markers were not significantly different among the groups at baseline. In the laparoscopy group the increase of hGH was limited to intraoperative time (p <0.05); increases in NE, E, ACTH, and PRL were limited to intraoperative and early postoperative time after extubation (p <0.01), with only PRL persisting with significantly higher levels after the end of surgery (p <0.05). In the minilaparotomy group no increase was detected for hGH, a significant intraoperative increase in cortisol was present (p <0.05), and NE, E, ACTH, and PRL were significantly higher even after the end of surgery (p <0.01). In this group levels of NE, E, and hGH were significantly higher than in the laparoscopy group 2 and 4 hours after the end of surgery (p <0.05). In the laparotomy group significant intraoperative increases were present for all stress markers and persisted until after extubation for ACTH (p <0.01) and to the postoperative period for NE (p <0.01), E (p <0.01), cortisol (p <0.01), PRL (p <0.05), and hGH (p <0.01). In this group levels of NE, E, ACTH, and hGH were significantly higher than those in the laparoscopy group from the beginning (NE p <0.05, E p <0.01, ACTH p <0.05, hGH p <0.01) until after the end of surgery. Comparison of laparotomy and minilaparotomy groups showed the former to have significantly higher plasma levels of E, cortisol, and hGH in intraoperative and postoperative times (p <0.001); significantly higher NE at sampling times 1 and 2 (p <0.001) and time 4 (p <0.01), and no difference at sampling time 3; and ACTH significantly higher only during surgery (p <0.01).

CONCLUSION

Laparoscopic surgery causes minimal activation of stress hormones, which in some instances is confined to the intraoperative period. Minilaparotomy may be a valid alternative to laparoscopy in high-risk patients who cannot tolerate abdominal distention.

Laparoscopic appendectomy for perforated appendicitis

Although laparoscopic appendectomy for uncomplicated appendicitis is feasible and safe, its application to perforated appendicitis is uncertain. A retrospective study of all patients with perforated appendicitis from 1992 to 1999 in a university hospital was performed. A series of 231 patients were diagnosed as having perforated appendicitis. Of these patients, 85 underwent laparoscopy (LA), among whom 40 (47%) required conversion to an open procedure. An open appendectomy (OA) was performed in 146 patients. The operating time was similar for the two groups. Return of fluid and solid diet intake were faster in LA than OA patients (p < 0.01). Postoperative infections including wound infections and abdominal abscesses occurred in 14% of patients in the laparoscopy group and in 26% of those with OA (p < 0.05). The surgeon's experience correlated with the conversion rate. Laparoscopic appendectomy is associated with a high conversion rate for perforated appendicitis. If successful, it offers patients faster recovery and less risk of infectious complications.

The management of leaking rectal anastomoses by minimally invasive techniques

BACKGROUND

The salvage of a leaking rectal anastomosis has been reported in selected cases. Herein we present our experience in the management of rectal anastomotic dehiscence by minimally invasive techniques.

METHODS

A total of 94 patients underwent anterior rectal resection for rectal cancer in an 18-month period. The operation was laparoscopic-assisted in 76 cases (81%).

RESULTS

Clinical anastomotic dehiscences occurred in 10 cases (10.6%). Conservative therapy, including the percutaneous drainage of pelvic abscesses, was successful in three cases. Among the seven patients who required reoperation, the anastomosis was taken down in only one case. In four of these cases, the reoperation was performed laparoscopically, including peritoneal lavage and the creation of a diverting stoma. There were no complications resulting from the use of laparoscopy in the early postoperative period. Closure of the stoma was possible in eight patients.

CONCLUSIONS

The salvage of a leaking rectal anastomosis is feasible in the vast majority of these cases (80%). The combination of laparoscopy and interventional radiology is a good alternative to laparotomy in patients who have had previous laparoscopic rectal excision.

Stress responses to endoscopic surgery

Growing evidence in the literature suggests that laparoscopic surgery should be performed instead of laparotomy for the treatment of pelvic benign diseases whenever feasible, as it results in a lower stress response on the part of the patient and possibly a shorter recovery time.

Laparoscopic surgery and surgical infection

INTRODUCTION

It has been observed that the metabolic response to surgical injury is less after laparoscopic surgery than after open surgery. However, the effect of laparoscopic surgery on surgical infection has not been given much attention in the surgical literature, even though it may decrease the incidence of infectious complications. The objective of this study was to assess the influence that laparoscopic surgery has on surgical infection and to highlight certain controversial aspects.

METHODS

A review of the literature was undertaken to examine the relationship between laparoscopic surgery and surgical infection. This was achieved primarily by using PubMed Medline as a source of material.

RESULTS AND CONCLUSION

Laparoscopic surgery is associated with better preservation of the immune system than open surgery. This results in a decreased incidence of infectious complications. Although carbon dioxide pneumoperitoneum affects the peritoneal response to injury, it seems to have no harmful effect in terms of intra-abdominal infection. Nevertheless, at laparoscopic operation the virulence of intestinal micro-organisms should be recognized and, while knowing the advantages of minimally invasive surgery, the surgeon should consider the complexity of this technique. Furthermore, maintenance of laparoscopic instruments should be governed by the same norms as those used in open surgery; recommendations offered by the manufacturers should be respected.

[Results of laparoscopic treatment of perforated ulcers]

STUDY AIM

The aim of this retrospective survey was to evaluate the results of laparoscopic treatment in perforated peptic ulcer.

PATIENTS AND METHODS

From 1989 to 1998, 84 patients were operated on for perforated ulcer. Sixty nine patients, operated on with videolaparoscopy, were included in this study: 53 men and 12 women with a mean age of 45 +/- 16 years (19-85). Nine had a history of peptic ulcer disease and 12 received anti-inflammatory drugs. Perforation occurred in the duodenum (60 patients) and in the stomach (five patients). Laparoscopic treatment included peritoneal lavage and either a simple duodenal closure (51 patients), a closure with a highly selective vagotomy (one patient), an epiplooplasty (eight patients), or an excision-closure for the gastric ulcers (five patients). Drainage was associated in 38 patients (58%).

RESULTS

A conversion into laparotomy was necessary in six patients. Among the 59 patients treated with laparoscopy, 56 were only managed laparoscopically, three had exploration and peritoneal lavage through laparoscopy, and underwent suture of the perforation through minilaparotomy. Mean operative time was 105 +/- 40 minutes (30-240). Mean postoperative hospital stay was 8.2 +/- 4 days. Reoperation was performed in three patients for leakage (n = 2) and gall bladder perforation (n = 1). Complications were medically treated in three patients. There was no in-hospital mortality.

CONCLUSION

Laparoscopic management in perforated peptic ulcer is successful in 90% of the patients. Results are good. There was no postoperative death in this series.