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

Abstract

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

“…Although laparoscopic repair of PPU was documented as early as 1990, the adoption rates for this approach have been variable [ 34 ]. International studies report laparoscopic repair rates ranging from 41% to 76%, a range consistent with our previous findings [ 17 , 21 , 35 , 36 ]. Additionally, the 2020 WSES guidelines suggest the laparoscopic approach as the primary treatment for stable patients with small ulcers, provided surgeons possess the necessary skills and appropriate equipment [ 37 ].…”

“…Proposed explanations from the current literature include difficulties in laparoscopic knot tying, ulcer diameter (>2 cm), and abdominal contamination [ 53 , 54 ]. Our previous multivariate analysis identified the ulcer site (pyloric/duodenal), a higher Boey Score, and a higher Age–Shock Index as factors associated with leaks [ 21 ]. Concerning leaks, the present analysis did not show any difference between the two gastrorrhaphy techniques.…”

“…This study derives from previous research [ 17 , 21 ]. The IGo-GIPS (Italian Group for Gastro-Intestinal Postoperative Surveillance) is a nationwide network created with the aim to investigate the perioperative outcomes of specific topics mainly concerning emergency gastrointestinal surgery [ 22 ].…”

“…All the investigators were informed about the objectives of the project and asked for complete details about the management of patients. The protocols were already extensively described [ 21 , 22 ]. Data regarding patients were prospectively collected from the study participating centres from January 2017 to June 2018, while data regarding patients from July 2018 to June 2023 were retrieved either retrospectively from hospital electronic databases or prospectively collected following well-designed studies.…”

“…Data regarding patients were prospectively collected from the study participating centres from January 2017 to June 2018, while data regarding patients from July 2018 to June 2023 were retrieved either retrospectively from hospital electronic databases or prospectively collected following well-designed studies. Both the prospective study protocols [ 21 , 22 ] were approved by the Ethics Committees, the former by Sapienza University of Rome and the latter by University Campus Bio-Medico of Rome. No formal approval was requested for any other retrospective non-interventional study except in case of specific indication deemed by a single centre.…”