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

EAES/SAGES evidence-based recommendations and expert consensus on optimization of perioperative care in older adults

BACKGROUND

As the population ages, more older adults are presenting for surgery. Age-related declines in physiological reserve and functional capacity can result in frailty and poor outcomes after surgery. Hence, optimizing perioperative care in older patients is imperative. Enhanced Recovery After Surgery (ERAS) pathways and Minimally Invasive Surgery (MIS) may influence surgical outcomes, but current use and impact on older adults patients is unknown. The aim of this study was to provide evidence-based recommendations on perioperative care of older adults undergoing major abdominal surgery.

METHODS

Expert consensus determined working definitions for key terms and metrics related to perioperative care. A systematic literature review and meta-analysis was performed using the PubMed, Embase, Cochrane Library, and Clinicaltrials.gov databases for 24 pre-defined key questions in the topic areas of prehabilitation, MIS, and ERAS in major abdominal surgery (colorectal, upper gastrointestinal (UGI), Hernia, and hepatopancreatic biliary (HPB)) to generate evidence-based recommendations following the GRADE methodology.

RESULT

Older adults were defined as 65 years and older. Over 20,000 articles were initially retrieved from search parameters. Evidence synthesis was performed across the three topic areas from 172 studies, with meta-analyses conducted for MIS and ERAS topics. The use of MIS and ERAS was recommended for older adult patients particularly when undergoing colorectal surgery. Expert opinion recommended prehabilitation, cessation of smoking and alcohol, and correction of anemia in all colorectal, UGI, Hernia, and HPB procedures in older adults. All recommendations were conditional, with low to very low certainty of evidence, with the exception of ERAS program in colorectal surgery.

CONCLUSIONS

MIS and ERAS are recommended in older adults undergoing major abdominal surgery, with evidence supporting use in colorectal surgery. Though expert opinion supported prehabilitation, there is insufficient evidence supporting use. This work has identified evidence gaps for further studies to optimize older adults undergoing major abdominal surgery.

Laparoscopic Treatment of Perforated Peptic Ulcer: A Propensity Score-Matched Comparison of Interrupted Stitches Repair versus Knotless Barbed Suture

Background: Peptic ulcers result from imbalanced acid production, and in recent decades, proton pump inhibitors have proven effective in treating them. However, perforated peptic ulcers (PPU) continue to occur with a persistent high mortality rate when not managed properly. The advantages of the laparoscopic approach have been widely acknowledged. Nevertheless, concerning certain technical aspects of this method, such as the best gastrorrhaphy technique, the consensus remains elusive. Consequently, the choice tends to rely on individual surgical experiences. Our study aimed to compare interrupted stitches versus running barbed suture for laparoscopic PPU repair. Methods: We conducted a retrospective study utilizing propensity score matching analysis on patients who underwent laparoscopic PPU repair. Patients were categorised into two groups: Interrupted Stitches Suture (IStiS) and Knotless Suture (KnotS). We then compared the clinical and pathological characteristics of patients in both groups. Results: A total of 265 patients underwent laparoscopic PPU repair: 198 patients with interrupted stitches technique and 67 with barbed knotless suture. Following propensity score matching, each group (IStiS and KnotS) comprised 56 patients. The analysis revealed that operative time did not differ between groups: 87.9 ± 39.7 vs. 92.8 ± 42.6 min (p = 0.537). Postoperative morbidity (24.0% vs. 32.7%, p = 0.331) and Clavien-Dindo III (10.7% vs. 5.4%, p = 0.489) were more frequently observed in the KnotS group, without any significant difference. In contrast, we found a slightly higher mortality rate in the IStiS group (10.7% vs. 7.1%, p = 0.742). Concerning leaks, no differences emerged between groups (3.6% vs. 5.4%, p = 1.000). Conclusions: Laparoscopic PPU repair with knotless barbed sutures is a non-inferior alternative to interrupted stitches repair. Nevertheless, further research such as randomised trials, with a standardised treatment protocol according to ulcer size, are required to identify the best gastrorraphy technique.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

The impact of standardized perioperative care management on improving outcomes in patients with peptic ulcer disease

The present study investigated the impact of standardized perioperative nursing management on improving outcomes in patients with peptic ulcer disease. A total of 90 patients with peptic ulcers were admitted to the Wuhan Wuchang Hospital between July 2020 to July 2022. These patients were included in the present study. They were divided into 2 groups based on the nursing management that they received, with 45 patients classified into each group. The control group received routine nursing care, while the observation group received standardized perioperative nursing management. The improvement in clinical symptoms, recurrence rate, negative emotions and disease management capacity were compared between the 2 groups. The results demonstrated that the improvement rate of clinical symptom in the observation group was significantly higher as compared with the control group (P < .05). The recurrence rate in the observation group was significantly lower than in the control group (P = .026). Patients in the observation group had better psychological status, and better disease management capacity as compared with those in the control group (P < .05). The application of standardized perioperative nursing management for patients with peptic ulcer can help improve the patients' clinical symptoms, enhance their disease management capacity, reduce anxiety, and ensure the quality of nursing care.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Laparoscopic Repair Modality of Perforated Peptic Ulcer: Less Is More?

Perforation, per se, presents the most serious complication of peptic ulcer disease with a mortality rate that cannot be underestimated. Surgery is the only treatment option, which can be performed laparoscopically or via conventional laparotomy. The present study aimed to compare the short-term outcomes of laparoscopy and laparotomy techniques in the surgical treatment of peptic ulcer perforation. A retrospective study design was structured to compare the perioperative and short-term postoperative outcomes of 102 patients who had undergone laparoscopic and conventional repair of the perforated peptic ulcer over a six-year interval (January 1, 2016, to December 31, 2021). Of these, 44 (43.1%) had undergone laparoscopic repair while 58 (56.9%) had surgical repair via conventional laparotomy. The operative time and length of hospital stay were comparable in both subgroups (p=0.984 and p =0.585). Nevertheless, 30-day postoperative morbidity was significantly higher in the open surgery subgroup (75.9% vs. 59.1%, p= 0.032). The risk of relaparotomy was similar in both study subgroups; however, suture dehiscence as a reason for surgical revision was significantly more frequent in the laparoscopic subgroup (13.6% vs 3.4%). Of note, the mortality rate in the laparoscopic group of patients was 13.6%, and in the laparotomy group 41.4%. The laparoscopic approach to peptic ulcer perforation is the procedure of choice for low-risk patients. Conventional surgery seems to be associated with a significantly higher incidence of severe postoperative complications and mortality. However, the higher mortality in these patients is probably related to their worse initial clinical condition.

Gastro-intestinal emergency surgery: Evaluation of morbidity and mortality. Protocol of a prospective, multicenter study in Italy for evaluating the burden of abdominal emergency surgery in different age groups. (The GESEMM study)

Gastrointestinal emergencies (GE) are frequently encountered in emergency department (ED), and patients can present with wide-ranging symptoms. more than 3 million patients admitted to US hospitals each year for EGS diagnoses, more than the sum of all new cancer diagnoses. In addition to the complexity of the urgent surgical patient (often suffering from multiple co-morbidities), there is the unpredictability and the severity of the event. In the light of this, these patients need a rapid decision-making process that allows a correct diagnosis and an adequate and timely treatment. The primary endpoint of this Italian nationwide study is to analyze the clinicopathological findings, management strategies and short-term outcomes of gastrointestinal emergency procedures performed in patients over 18. Secondary endpoints will be to evaluate to analyze the prognostic role of existing risk-scores to define the most suitable scoring system for gastro-intestinal surgical emergency. The primary outcomes are 30-day overall postoperative morbidity and mortality rates. Secondary outcomes are 30-day postoperative morbidity and mortality rates, stratified for each procedure or cause of intervention, length of hospital stay, admission and length of stay in ICU, and place of discharge (home or rehabilitation or care facility). In conclusion, to improve the level of care that should be reserved for these patients, we aim to analyze the clinicopathological findings, management strategies and short-term outcomes of gastrointestinal emergency procedures performed in patients over 18, to analyze the prognostic role of existing risk-scores and to define new tools suitable for EGS. This process could ameliorate outcomes and avoid futile treatments. These results may potentially influence the survival of many high-risk EGS procedure.

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.

Gastric emergencies in older adults: not always the same old story! A tertiary care emergency department observational cohort study

OBJECTIVE

To analyse and compare the clinical outcomes between patients ≥80 years and 65-79 years, who presented to our emergency department (ED) with the two most common gastric emergency (GE) clinical presentation, that is, gastric bleeding and gastric perforation.

DESIGN

Single-centre retrospective cohort study.

PARTICIPANTS

A total of 1011 patients were enrolled: 421 patients aged ≥80 years were compared with a group of 590 patients aged 65-79 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was to compare the overall mortality. Secondary outcomes included major complications, in-hospital length of stay (LOS) and need for surgical procedures.

RESULTS

Patients ≥80 years with GE had different presentations at ED compared with younger patients: they had higher gastrointestinal bleeding (24.9% vs 16.3%, p=0.001), anemisation (14.5% vs 8.8%, p=0.005) and shock (10.9% vs 5.1%, p=0.001) rates. Median LOS, cumulative major complications and mortality rates were similar among the two groups.Multivariate analysis identified shock, gastric malignancy and gastric fistula as independent predictors for survival.

CONCLUSIONS

Patients ≥80 years with GE did not have a higher mortality rate and cumulative major complications as compared to younger elderly patients. Invasive treatments were not associated with a different prognosis in this age group.