Page 5 - World Journal of Laparoscopic Surgery

Perforated Peptic Ulcer Disease
Table 3: Surgical outcomes of laparoscopic and open repair group reduced postoperative pain and analgesic requirements, a shorter
Open Laparoscopic p hospital stay, and an earlier return to normal daily activities.
5
The recent study of Siow et al., including 131 patients who
Leaks 3 0 0.2 underwent emergency repair for PPU (LR, n = 63, 48.1% vs OR,
Wound infection 2 0 0.5 n = 68, 51.9%) have demonstrated that LR group had fewer
Intra-abdominal abscess 2 0 0.5 complications compared to the OR group (p value = 0.005). When
Pneumonia 3 1 0.64 considering specific complications, the incidence of surgical site
Cardiovascular 4 0 infection was statistically significant (p value = 0.003). The LR group
UTI 2 0 0.51 had a significantly shorter mean hospital stay (p value = 0.008) and
Sepsis 7 0 reduced postoperative pain (p value < 0.05). However, mortality
Overall morbidity 21 2 0.0001 was similar in both the groups (p value < 0.99). 12
The meta-analysis study of Zhou et al., including
Medical complication 16 2 0.009 nonrandomized controlled studies (NRS) and five randomized
Surgical complication 7 0 0.04 controlled trails (RCTs), demonstrated a lower mortality rate in the
Mortality 6 0 0.04 LR group in NRS. However, in the analysis of five RCTs, the mortality
UTI, urinary tract infection was the same in both groups.
8
In the randomized controlled study reported by Siu et al., 130
patients with a clinical diagnosis of PPU were randomly assigned
Specific complication (surgical complication) was higher in OR to undergo either open or laparoscopic omental patch repair and
group (7 cases vs 0) (p value = 0.04). There were two patients in our showed that the complication rate for LR was low.
series who had intra-abdominal abscess postoperatively only in the However, some authors showed that LR compared to open
OR group and no case from the LR group. Intravenous antibiotics abdominal surgery for peptic ulcer disease was not superior
and percutaneous drainage with a good clinical outcome managed and may even have worse outcomes, including longer operative
intra-abdominal abscess. time. In addition, open abdominal surgery provides efficient and
Two patients had a surgical site infection in the OR group and easy training without the constraints and difficulties for young
none from the laparoscopic group. Revision surgery for suture site surgeons. 9,13
leakage occurred in three patients in the OR groups vs none in the On the other hand, some study found that LR and OR was equal.
laparoscopic groups. Indeed, in the meta-analysis of RCTs published by Tan et al., LR
13
Mortality was statistically higher in the OR group. There was had similar operative time as OR for PPU (WMD: 9.15, 95% CI: −1.83
no death in the LR group, while 6 deaths were recorded in the OR to 20.12, p value > 0.05) and the same postoperative hospital stays,
group (p value = 0.04). yet LR had shorter nasogastric tube duration than OR for PPU, similar
Correlation analysis was done between mortality and shock time to resume diet as OR, and the mortality was similar in both the
on presentation, and it was statistically significant (p value = groups (p value > 0.05).
0.001) but had no correlation between mortality and laparotomy Cochrane report, concerning three randomized clinical trials,
7
(p value = 0.06). found no statistically significant differences between LR and OR in
the abdominal septic complications (OR 0.66; 95% CI 0.30–1.47) and
dIscussIon pulmonary complications (OR 0.43; 95% CI 0.17–1.12).
14
In a recent study published by Wang et al., including 119
In this present study, LR was associated with a shorter operative time patients operated for PPU, no significant differences were found
(p value = 0.0001), reduced analgesic requirements (p value = 0.01), in operation time, morbidity of postoperative complication, and
a shorter hospital stay (p value = 0.001), and earlier return to normal mortality. The authors concluded that LR was preferable for treating
daily activities compared to open repair. Concerning morbidity, it PPU than OR; nevertheless, some preventive action must be taken
was low in LR group compared to open groups (p value = 0.0001). to avoid the risk of postoperative leak in perforation site.
Effectively, laparoscopic procedure was associated with fewer Our results indicate that LR for PPU was feasible and safe option
medical complications (p value = 0.009) compared to open repair. with fewer rates of morbidity, reoperation, and mortality compared
No postoperative surgical complications in the LR group, to OR. It can be considered as a treatment of choice. Nevertheless,
such as abscesses, wound infection, or revision surgery, occurred certain limitations apply to the current study. First, the study was
compared to the OR group (p value = 0.04). retrospective by nature. A selection bias of patients having shook
Mortality was statistically higher in the OR group (6 vs 0) (p at presentation was included only in the open groups. Therefore,
value = 0.04). In our practice, patients with shook does not receive this could explain the high rates of mortality in OR compared to
LR. Correlation analysis was done between mortality and shock on LR groups.
presentation, and it was statistically significant (p value = 0.001) but In conclusion, our series ensures that the LR became a gold
had no significant correlation between mortality and laparotomy standard in PPU. Therefore, we need more randomized prospective
(p value = 0.06). trial.
Therefore, this result was due of the selection bias of patients
having shook at presentation. ethIcs ApprovAl And consent to

Therefore, mortality was related to shock on presentation and
not to surgical technique. pArtIcIpAte
Several studies have shown results similar to our study. In fact, This work had been made with all due respect to the code of ethics
some authors report that laparoscopic approach has several benefits under the supervision of the medical and ethics committee of the
such as confirmation of the diagnosis and 8–12 shorter operative time, Salah Azaiez Institute.

World Journal of Laparoscopic Surgery, Volume 13 Issue 3 (September–December 2020) 99