Page 42 - World Journal of Laparoscopic Surgery

ORIGINAL ARTICLE
Use of Laparoscopic vs Open Repair for Perforated Peptic

Ulcers is Determined by Surgeon Experience

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Omar El-Ghazzawy , Christian Massier , William Walsh , Dwayne North , Abhiram Kondajji , Tu Chao 6
AbstrAct
Introduction: The incidence of perforated peptic ulcers (PPU) has decreased with effective medical treatment such that surgical repair has
become a relatively infrequent procedure. We hypothesized that the surgeon’s experience and the patient’s clinical presentation are the most
influential factors that determined the surgical approach.
Methods: A retrospective chart review of PPU repairs in the last 10 years was performed to collect surgeon demographics, patient clinical
condition, comorbidities, and whether surgeries were done at a regional or tertiary site. Outcome variables included length of stay, complications,
and readmissions. A multivariate analysis was used to establish statistically significant correlations.
Results: Of 219 operations for PPU, 49 were started laparoscopic (23.2%), 12 were converted to open (5.7%), and 162 were performed open
(76.5%). The open and laparoscopic cohorts were similar without statistical difference between the groups in terms of age, sex, comorbidities,
previous steroid use, NSAID, and anticoagulation use. Surgeons who attempted laparoscopy were more likely to have completed MIS fellowship
(60.2%, p <0.001). The patients who had laparoscopic repair had a significantly shorter length of stay (8.5 vs 12.6 days; p <0.01). The patients
who had an open repair had slightly more complications (18.4 vs 5.4%), readmissions (5.2 vs 2.7%), and hospital mortality (12.1 vs 5.4%) than
their laparoscopically treated counterparts, although none was statistically significant.
Conclusion: Surgeons who completed a minimally invasive fellowship were more likely to perform a laparoscopic repair of perforated peptic
ulcer, regardless of the patient’s clinical presentation, comorbid conditions, and demographics. Patients who underwent laparoscopic repair
had a significantly shorter LOS. Educational efforts directed toward community surgeons who do not have prior MIS training are likely to benefit
patients with PUD by increasing access to laparoscopic surgery for PPU.
Keywords: Laparoscopic, Minimally invasive surgery, Perforated peptic ulcer.
World Journal of Laparoscopic Surgery (2022): 10.5005/jp-journals-10033-1489

IntroductIon 1 Department of General Surgery, Cleveland Clinic-South Pointe,
The incidence of perforated peptic ulcer disease (PPU) has Shaker Heights, Ohio, United States of America
decreased over the years such that surgical repair has become 2,5 Department of General Surgery, Cleveland Clinic-South Pointe,
1,2
a relatively infrequent operation. This is due to the effective Warrensville Heights, Ohio, United States of America
medical management of peptic ulcers, mainly proton pump 3 Department of General Surgery, MetroHealth, Cleveland, Ohio, United
3
inhibitor (PPI) therapy. Additionally, endoscopy has led to earlier States of America
diagnosis of peptic ulcer disease (PUD) before complications such 4 Department of General Surgery, Riverside Health System, Gloucester,
as perforation can occur, as well as recognition and treatment of Virginia, United States of America
4
Helicobacter pylori. Nonetheless, PPU remains a surgical emergency 6
Department of Statistics, Cleveland Clinic, Cleveland, Ohio, United
that every general surgeon will encounter. States of America
Several studies have demonstrated the viability and
advantages of a laparoscopic repair when compared directly to Corresponding Author: Omar El-Ghazzawy, Department of General
the open approach for PPU. 5–11 Despite laparoscopic surgery being Surgery, Cleveland Clinic-South Pointe, Shaker Heights, Ohio, United
States of America, Phone: +2169702127, e-mail: omar.elg@gmail.com
a core skill in current surgical training, the majority of PPU are
repaired using an open approach. Our study aimed to address the How to cite this article: El-Ghazzawy O, Massier C, Walsh W, et al.
reasons for this discrepancy. We hypothesized that the decision to Use of Laparoscopic vs Open Repair for Perforated Peptic Ulcers is
Determined by Surgeon Experience. World J Lap Surg 2022;15(1):40–46.
repair a PPU laparoscopically over the open approach was based
on the surgeon’s experience (i.e., surgeon’s training). The clinical Source of support: Nil
presentation of the patient, and other circumstantial reasons not Conflict of interest: None
related to patient or surgeon factors (i.e., time of day, preoperative
diagnosis, or localization of perforation, etc.).
The primary objective of our study was to establish specific Methods
characteristics of patients and surgeons that contribute to a Our study was a retrospective chart review of patients admitted
surgeon choosing laparoscopic PPU repair over open repair. The for perforated peptic ulcers (PPU) from 2007 to 2017. We used
secondary objective of this study was to analyze the outcomes of ICD-10 codes for primary perforated gastric or duodenal ulcers
laparoscopic PPU repair vs open PPU repair, including mortality, to select patients from the database. Surgeries were performed
complications, readmission, and length of stay (LOS). in both tertiary care centers and community hospitals within the

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