[Perforated duodenal ulcer in high risk patients]

[Laparoscopic versus laparoscopy-assisted suturing of perforated peptic ulcers (meta-analysis)]

OBJECTIVE

To compare laparoscopic and laparoscopy-assisted repair of perforated peptic ulcer using evidence-based methods.

MATERIAL AND METHODS

A systematic review and meta-analysis were carried out in accordance with the recommendations of the Ministry of Health of Russian Federation and Cochrane Handbook for Systematic Reviews.

Data searching was carried out in Russian and English languages using the E-library, Cochrane Library and PubMed databases. We analyzed titles and references in specialized journals and thematic reviews, respectively. Clarifying information was obtained via personal contacts with the heads of surgical hospitals. The RevMan 5.4 software was used for statistical analysis.

RESULTS

We found no randomized trials devoted to comparison of laparoscopic and laparoscopy-assisted surgeries in patients with perforated peptic ulcer. Meta-analysis was based on non-randomized trials with satisfactory methodological quality according to the I-ROBINS formalized assessment. Overall clinical material included 478 observations: 229 (47.9%) laparoscopic surgeries and 249 (52.1%) laparoscopy-assisted procedures via minimally invasive access. There were no conversions. Incidence of postoperative complications was 4.36 and 8.83% (OR=0.39, 95% CI 0.08, 1.87), postoperative mortality 0.87 and 0.81%, respectively (OR=1.26, 95% CI 0.08, 8.24). Laparoscopic surgeries were shorter (MD= -8 min, 95% CI -9.7, -6.4). Length of hospital-stay was also shorter after laparoscopic surgery (MD= -4.6, 95% CI -9.7, -6.4).

CONCLUSION

Laparoscopic operations are shorter and accompanied by lower incidence of postoperative complications and less hospital-stay. Large statistical power is required to confirm these differences.

[Perforated peptic ulcer in patients with cancer: prediction of postoperative morbidity and mortality]

OBJECTIVE

To analyze treatment outcomes and approaches to predicting the postoperative morbidity and mortality in patients with perforated ulcers and cancer.

MATERIAL AND METHODS

A non-randomized trial included 194 patients. The first group enrolled 45 (23%) patients with perforated ulcers and concomitant cancer who underwent at the oncology center; the second group included 149 (77%) patients with perforated ulcers and no cancer who underwent surgery in general surgical hospitals. Organ-sparing procedures prevailed (40 (88.9%) and 138 (92.6%) cases, respectively). Resections were performed in 5 (11.1%) and 11 (7.4%) patients respectively. Analyzing the factors affecting treatment outcomes, we studied crude (COR) and adjusted (AOR) odds ratios. ROC-analysis was used to assess diagnostic significance of the models for prognosis of morbidity and mortality.

RESULTS

Length of hospital-stay was 10 (range 9-14) and 8 (range 7-9) days respectively. Postoperative complications (Clavien-Dindo grading system) occurred in 18 (40%) in 37 (24.8%) patients, respectively. According to multivariate analysis, predictors of complications in patients of the first group were treatment with NSAIDs/glucocorticoids and Charlson-Deyo index >3. Sensitivity of this model was 82.4%, specificity - 75.0%. Postoperative mortality was 15.6% (n=7) and 7.4% (n=11) respectively. According to multivariate analysis, predictors of mortality were age over 65 years and more than 5 chemotherapeutic courses. Sensitivity of the model was 85.7%, specificity - 97.4%.

CONCLUSION

The stratified approach makes it possible to improve prediction of postoperative morbidity and mortality in patients with perforated ulcers.

[Open and laparoscopic surgery via minimally invasive approach in the treatment of perforated ulcer: a systematic review and metaanalysis]

OBJECTIVE

Systematic review and metaanalysis of the effectiveness of open and minimally invasive laparoscopic suturing of perforated peptic ulcer.

MATERIAL AND METHODS

Searching for Russian and English language reports included Scientific Electronic Library, Cochrane Collaboration Library and PubMed databases. We have analyzed contents of specialized journals, reviews and their references. Unpublished data were obtained via communication with chiefs of national surgical hospitals. RevMan 5.3 software was used for metaanalysis.

RESULTS

We found no international randomized trials in available literature. Metaanalysis was based on national non-randomized studies. Total sample was 1177 cases. Laparoscopic minimally invasive surgery was performed in 43% of cases (n=503), open suturing - in 57% (n=674) of patients. Choice of these procedures is not currently not standardized. Minimally invasive procedures are shorter in time (mean difference -8.02, 95% CI -11.26 - -4.77, p<0.00001) and ensure less hospital-stay (mean difference -1.93, 95% CI -2.97 - -0.88, p=0.0003). Complications were less common (OR 0.14, 95% CI 0.07-0.27, p<0.00001) after minimally invasive operations (2.4%, 12/503) compared to laparotomy (11.4%, 77/674). Incidence of suture failure was similar (OR 0.4, 95% CI 0.1-1.6, p=0.2) (0.4% (2/503) vs. 0.7% (5/674)). Postoperative mortality was higher (OR 0.14, 95% CI 0.05-0.37, p<0.0001) after laparotomy (8%, 54/674) compared to laparoscopy (0.8%, 4/503).

CONCLUSION

A metaanalysis indicates the advantage of laparoscopy-assisted suturing of perforated ulcer via minimally invasive approach over laparotomy. The absence of a standardized approach in choosing of minimally invasive laparotomy and conventional approach is a limitation of these results.