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

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.

Efficacy of pantoprazole plus perforation repair for peptic ulcer and its effect on the stress response

BACKGROUND

Peptic ulcer (PU) is an abnormal phenomenon in which there is rupture of the mucosa of the digestive tract, which not only affects patients' normal life but also causes an economic burden due to its high medical costs.

AIM

To investigate the efficacy of pantoprazole (PPZ) plus perforation repair in patients with PU and its effect on the stress response.

METHODS

The study subjects were 108 PU patients admitted between July 2018 and July 2022, including 58 patients receiving PPZ plus perforation repair [research group (RG)] and 50 patients given simple perforation repair [control group (CG)]. The efficacy, somatostatin (SS) concentration, stress reaction [malondialdehyde (MDA), lipid peroxide (LPO)], inflammatory indices [tumor necrosis factor (TNF)-α, C-reactive protein (CRP), interleukin (IL)-1β], recurrence, and complications (perforation, hemorrhage, and pyloric obstruction) were compared.

RESULTS

The overall response rate was higher in the RG than in the CG. Patients in the RG had markedly elevated SS after treatment, which was higher than that of the CG, while MDA, LPO, TNF-, CRP, and IL-1β were significantly reduced to lower levels than those in the CG. Lower recurrence and complication rates were identified in the RG group.

CONCLUSION

Therefore, PPZ plus perforation repair is conducive to enhancing treatment outcomes in PU patients, reducing oxidative stress injury and excessive inflammatory reactions, and contributing to low recurrence and complication rates.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

Background

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

Aim of the work

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

Patients and methods

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

Results

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

Conclusion

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

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.

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

Background

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

Methods

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

Results

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

Conclusion

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

Primary versus delayed primary skin closure in operated patients due to perforated peptic ulcer disease: a randomized controlled clinical trial

PURPOSE

Perforated peptic ulcer (PPU) is a life-threatening complication of peptic ulcer disease. This condition is characterized by a dirty abdomen that predisposes to postoperative wound infection. Delayed primary skin closure is occasionally preferred over primary closure to reduce the risk of surgical site infection in dirty abdominal wounds. In primary skin closure, the skin is sutured immediately after surgery. Meanwhile, in delayed primary skin closure, the incision is left open, and sutured after 2-5 days. The current research aimed to compare the risk for surgical site infection, length of hospitalization, and mortality rate between primary versus delayed primary skin closure among patients who underwent surgery for PPU.

METHODS

This single-blind randomized clinical trial included 120 patients who were randomly allocated into the primary and delayed primary closure groups. A research assistant who was blinded to the study examined the wounds for surgical site infection based on the 1992 Center for Disease Control criteria. The outcomes were mortality rate and duration of hospitalization.

RESULTS

The delayed primary and primary closure groups did not significantly differ in terms of postsurgical wound infection occurring on the 3rd, 7th, 14th, and 30th days after surgery, mortality rate, and duration of hospitalization.

CONCLUSION

In patients who underwent surgery for PPU, delayed primary closure is not recommended over primary closure due to the risk of postoperative surgical site infection.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Outcomes of Laparoscopic vs Open Repair of Perforated Peptic Ulcers: An ACS-NSQIP Study

BACKGROUND

Perforated peptic ulcer (PPU) is a surgical emergency needing swift operative resolution. While laparoscopic and open approaches are viable options, it remains unclear whether laparoscopic repair has significantly improved outcomes. We use a national surgical database to compare perioperative and 30-d postoperative (30POP) outcomes.

MATERIALS AND METHODS

The 2016-2018 ACS-NSQIP database was used to create the patient cohort, using ICD-10 and CPT codes. An unmatched analysis identified factors that likely contributed to the laparoscopic versus open treatment allocation. Propensity score matching (PSM) was used to identify outcomes that were not explained by underlying differences in the patient cohorts.

RESULTS

A total of 3475 patients were included: 3135 in open group (OG), 340 (~10%) in laparoscopic group (LG). After PSM to control for comorbidities and illness severity that differed between groups on univariate analysis, 288 patients remained in each group. Analysis of the matched cohorts revealed no statistically significant difference in mortality (5.9% OG versus 3.8% LG, P = 0.245). The LG had significantly longer operative times (92 versus 79 min, P = 0.003), shorter hospital stays (8.2 versus 9.4 d, P = 0.044) and higher probability of being discharged home (81% versus 73%, P = 0.017). 30POP outcomes were largely equivalent, except that OG had higher risk for bleeding (14.6% versus 8%, P = 0.012) and pneumonia (8.7% versus 4.5%, P = 0.044).

CONCLUSIONS

While laparoscopic repairs take longer, they lead to shorter hospital stays and higher likelihood of discharge home. Further study to identify patients that are candidates for this technique is warranted.

[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 omental patch for perforated peptic ulcer disease reduces length of stay and complications, compared to open surgery: A SWSC multicenter study

RCTs showed benefits in Lap repair of perforated peptic ulcer (PPU). The SWSC Multi-Center Trials Group sought to evaluate whether Lap omental patch repairs compared to Open improved outcomes in PPU in general practice. Data was collected from 9 SWSC Trial Group centers. Demographics, operative time, 30-day complications, length of stay and mortality were included. 461 PATIENTS: Open in 311(67%) patients, Lap in 132(28%) with 20(5%) patients converted from Lap to Open. Groups were similar at baseline. Significant variability was found between centers in their utilization of Lap (0-67%). Complications at 30 days were lower in Lap (18.5% vs. 27.5%, p < 0.05) as was unplanned re-operation (4.7% vs 14%, p < 0.05). Lap reduced LOS (6 vs 8 days, p < 0.001). Ileus was more in Lap (42% vs 18 p < 0.001) operative time was 14 min higher in Lap(p < 0.01) and admission to OR time was 4 h higher in Lap(<0.05). No significant difference readmission or mortality. Our results suggest Lap should be considered a first-line option in suitable PPU patients requiring omental patch repair in centers that have the capacity and resources 24/7.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Laparoscopic 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.

Endoscopic management of perforations, leaks and fistulas

The endoscopic management armamentarium of gastrointestinal disruptions including perforations, leaks, and fistulas has slowly but steadily broadened in recent years. Previously limited to surgical or conservative medical management, innovations in advanced endoscopic techniques like natural orifice transluminal endoscopic surgery (NOTES) have paved the path towards development of endoscopic closure techniques. Early recognition of a gastrointestinal defect is the most important independent variable in determining successful endoscopic closure and patient outcome. Some devices including through the scope clips and stents have been well studied for other indications and have produced encouraging results in closure of gastrointestinal perforations, leaks and fistulas. Over the scope clips, endoscopic sutures, vacuum therapy, glue, and cardiac device occluders are other alternative techniques that can be employed for successful endoscopic closure.

Impact of laparoscopic approach in emergency major abdominal surgery: single-centre analysis of 748 consecutive cases

Background Acute abdominal pathology requiring emergency laparotomy is a common surgical presentation. Despite its widespread implementation in other surgical procedures, laparoscopy, rather than laparotomy, is sparingly used in major emergency surgery. This study reports outcomes and impact of rising use of laparoscopy for a single high-volume district general hospital. Methods Data were retrieved from the prospective National Emergency Laparotomy Audit database for a 30-month period. Patient, procedural, and in-hospital outcome data were collated. Temporal trends were assessed and regression analysis conducted for clinical outcomes. Results A total of 748 consecutive cases were recorded. There was an increasing use of laparoscopy over the study period, with 49% of cases attempted laparoscopically in the final six-month interval. Patients treated laparoscopically were at reduced risk of mortality (odds ratio 0.114, 95% confidence interval 0.024 to 0.550) and experienced reduced length of intensive care stay (regression coefficient –1.571, 95% confidence interval –2.625 to –0.517) in multivariate adjusted analysis. Conclusions Laparoscopy is safe and feasible in a large proportion of cases. It is associated with improved outcomes versus laparotomy.

Methodological overview of systematic reviews to establish the evidence base for emergency general surgery

BACKGROUND

The evidence for treatment decision-making in emergency general surgery has not been summarized previously. The aim of this overview was to review the quantity and quality of systematic review evidence for the most common emergency surgical conditions.

METHODS

Systematic reviews of the most common conditions requiring unplanned admission and treatment managed by general surgeons were eligible for inclusion. The Centre for Reviews and Dissemination databases were searched to April 2014. The number and type (randomized or non-randomized) of included studies and patients were extracted and summarized. The total number of unique studies was recorded for each condition. The nature of the interventions (surgical, non-surgical invasive or non-invasive) was documented. The quality of reviews was assessed using the AMSTAR checklist.

RESULTS

The 106 included reviews focused mainly on bowel conditions (42), appendicitis (40) and gallstone disease (17). Fifty-one (48·1 per cent) included RCTs alone, 79 (74·5 per cent) included at least one RCT and 25 (23·6 per cent) summarized non-randomized evidence alone. Reviews included 727 unique studies, of which 30·3 per cent were RCTs. Sixty-five reviews compared different types of surgical intervention and 27 summarized trials of surgical versus non-surgical interventions. Fifty-seven reviews (53·8 per cent) were rated as low risk of bias.

CONCLUSION

This overview of reviews highlights the need for more and better research in this field.

Outcomes of abdominal surgery in patients receiving mechanical ventilation for more than 48 hours

BACKGROUND

Abdominal surgery in critically ill patients has high mortality, contributing to high US healthcare costs. This study sought to identify specific predictors of mortality in this population.

METHODS

Using the National Surgical Quality Improvement Program database 2006 to 2012, we identified 4,901 patients who were intubated for more than 48 hours before undergoing common abdominal procedures. Mortality and predictors of mortality were determined using chi-square and/or regression analysis.

RESULTS

Overall 30-day mortality was 44.2% with increasing mortality for additional procedures performed. Ventilated patients with the following preoperative risk factors were 2 to 3 times as likely to die within 30 days of surgery: age greater than 65-years old, coma, preoperative international normalized ratio greater than 3.0, esophageal varices, and disseminated cancer.

CONCLUSIONS

Mortality is significant in ventilated patients who undergo abdominal surgery and is especially high with advanced age, disseminated cancer, and complications of liver disease. Physicians should carefully discuss this with patients and/or family and consider palliative options when appropriate.

Perforated peptic ulcer

Perforated peptic ulcer is a common emergency condition worldwide, with associated mortality rates of up to 30%. A scarcity of high-quality studies about the condition limits the knowledge base for clinical decision making, but a few published randomised trials are available. Although Helicobacter pylori and use of non-steroidal anti-inflammatory drugs are common causes, demographic differences in age, sex, perforation location, and underlying causes exist between countries, and mortality rates also vary. Clinical prediction rules are used, but accuracy varies with study population. Early surgery, either by laparoscopic or open repair, and proper sepsis management are essential for good outcome. Selected patients can be managed non-operatively or with novel endoscopic approaches, but validation of such methods in trials is needed. Quality of care, sepsis care bundles, and postoperative monitoring need further assessment. Adequate trials with low risk of bias are urgently needed to provide better evidence. We summarise the evidence for perforated peptic ulcer management and identify directions for future clinical research.

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.

Simple patch closure for perforated peptic ulcer in children followed by helicobacter pylori eradication

OBJECTIVE

Peptic ulcer disease in children is rare. Therefore, the diagnosis can be missed until complications such as perforation or hemorrhage occur. Few reports have investigated the procedures and outcomes of children who have undergone operations for perforated duodenal ulcers. We report our experience with the modified Graham technique for perforated duodenal ulcers in nine children and review the literature. Methods : The records of patients operated on for a perforated duodenal ulcer in the last 8 years in two pediatric surgery centers were evaluated retrospectively. Patient demographics, symptoms, time to admission to hospital, operative findings, and postoperative clinical course were evaluated. Results : Nine children (mean age 13.2 years, range 6-170 years) were included. All patients were admitted in the first six hours after their abdominal pain started. In three patients, there was free air on plain x-rays, while the x-rays were normal in six. All perforations were located on the anterior surface of the first part of the duodenum and repaired with primary suturing and Graham patch omentoplasty. The recovery was uneventful in all patients. In five patients, urea breath tests were performed postoperatively for Helicobacter Pylori, and the results were positive. All patients underwent triple therapy with lansoprazole, amoxicillin, and clarithromycin. The mean follow-up time was 58 (range 3-94) months. Conclusions : Peptic ulcer perforation should be suspected in children who have acute abdominal pain and peritoneal signs, especially when their suffering is intense. The simple patch repair and postoperative triple therapy for Helicobacter Pylori are safe and satisfactory for treating peptic ulcer perforation in children.

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.