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Laparoscopic Versus Open Surgical Management of Perforated Peptic Ulcer - a Comparison of Outcomes
Luciano Ambrosini*, Fady Saleh, M. Carolina Jimenez, James P. Byrne, Joshua J. Gnanasegaram, Fayez a. Quereshy, Todd Penner, Timothy Jackson, Allan Okrainec
General Surgery, University Health Network, Division of General Surgery, University of Toronto, Toronto, ON, Canada
BACKGROUND:
Laparoscopic management of perforated peptic ulcer (PPU) is a rapidly developing tool in the armamentarium of the acute care surgeon. As experience with laparoscopy in the emergency treatment of PPU grows, it is critical that outcomes are tracked and analyzed to aid surgeons in making evidence-based decisions with regards to management of their patients. The objective of this study was to investigate the outcomes of patients with perforated peptic ulcer treated laparoscopically as compared to those treated by open surgery.
METHODS:
We performed a retrospective review of all patients managed surgically for perforated peptic ulcer at our institution between January 2005 and October 2012. Data abstracted included patient demographics, comorbidities, and operative details. Outcomes collected included short-term postoperative morbidity and mortality, reoperation, and length of stay (LOS). Patients admitted to the intensive care unit with a primary or secondary diagnosis of PPU were excluded from the analysis. The laparoscopic group included patients with conversion to open. Continuous variables were compared using the student t-test and categorical variables with the Chi-square test. Univariate analysis and multivariate logistic regression provided a comparison of the rates of complications between both groups.
RESULTS:
A total of 105 patients managed surgically for perforated peptic ulcer were included in our study. 36 patients (34.2%) were treated with initial laparoscopy, while 69 had conventional open surgery. While the laparoscopic group tended to be younger (mean age 54.2 vs. 61.8, p=0.036), there were no significant differences with respect to gender (72.2% vs. 63.8% males, p=0.383) or the presence of important comorbidities, history of previous operation, and use of steroids (p>0.05). Of the 36 patients initiated laparoscopically, 7 (19.4%) were converted to the open approach. The overall complication rate was significantly lower in those treated with laparoscopic surgery (59.4% vs. 30.5%, p = 0.005), while our multivariable logistical regression, adjusting for important patient characteristics, confirms a significant reduction in the odds of adverse outcome (OR 0.27, 95%CI 0.08 - 0.93, p = 0.037). Median length of stay was shorter in those treated with laparoscopy (median of 5 vs. 9 days, p=0.009).
CONCLUSIONS:
Treatment of patients with perforated peptic ulcer by an initial laparoscopic approach appears to be safe, and was associated with a reduction in adverse outcomes as compared to conventional open management. In addition, it appears to result in a reduction in length stay. The laparoscopic approach may be considered a therapeutic tool in cases of suspected perforated ulcer. Further research is needed to understand predictors of successful laparoscopic completion.
Complications in Laparoscopic vs. Open Surgery for PPU: Univariate Analysis
| Complication | Open, n(%) | Laparoscopic, n(%) | P-value |
| SSI | 10(14.4) | 1(2.7) | 0.063 |
| UTI | 2(2.9) | 1(2.7 | 0.972 |
| Acute Renal Failure | 3(4.3) | 0(0) | 0.204 |
| Leak | 8(11.5) | 4(11.1) | 0.941 |
| Septic Shock | 15(21.7) | 6(16.6) | 0.537 |
| Pneumonia | 9(13.0) | 1(2.7) | 0.089 |
| Reintubation | 4(5.8) | 4(11.1) | 0.330 |
| MI | 5(7.2) | 1(2.7) | 0.349 |
| PE | 1(1.4) | 1(2.7) | 0.636 |
| Early reoperation | 5(7.2) | 4(11.1) | 0.502 |
| Death | 10(14.4) | 2(5.5) | 0.172 |
| Overal Complication | 41(59.4) | 11(30.5) | 0.005 |
PPU, Perforated Peptic Ulcer; SSI, Surgical Site Infection; UTI, Urinary Tract Infection; MI, Myocardial Infartion ; PE, Pulmonary Embolism *Number of patients with one or more of anastomotic leak, pneumonia, acute renal failure, myocardial infarction, thromboembolic event, septic shock, ileus, failure to wean >48h, unplanned intubation, early reoperation, cardiac arrest and death
Predictors of Adverse Outcome: Multivariable Logistic Regression Analysis
| Variable | Odds Ratio | 95% CI | P-value |
| Laparoscopic vs open approach | 0.27 | 0.08 - 0.93 | 0.037 |
| Age | 1.07 | 1.02 - 1.11 | 0.001 |
| ASA 3* | 1.21 | 0.10 - 14.6 | 0.881 |
| ASA 4-5* | 4.61 | 0.41 - 50.8 | 0.212 |
| Boey score > 0 | 4.9 | 1.54 - 15.5 | 0.007 |
CI, Confidence Interval; ASA, American Society of Anesthiologists *Compared to ASA 1 and 2.
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