Page 47 - World Journal of Laparoscopic Surgery

Use of Laparoscopic vs Open Repair for Perforated Peptic Ulcers
The goal of our study was to distinguish which factors were PPU disease. Specifically, educational efforts should be directed to
most influential in surgical decision making to repair a PPU community surgeons without MIS training, as it will benefit their
laparoscopically. These factors were broken down into three main patient population.
groups; the clinical status of the patient, the surgeon’s experience,
and circumstantial factors relating to the case. Of the many patient conclusIon
factors analyzed, only BMI and ulcer location (duodenum) were Our study further validates the use of laparoscopic repair for
found to be statistically significant for choosing laparoscopic over PPU disease as an option with better outcomes. The majority of
open repair. Laparoscopic surgery in obese patients has decreased surgeons do not perform laparoscopic repair of PPU because the
13
rates of wound infection and incisional hernias. Open repair in very choice to perform laparoscopic PPU repair is based largely on the
obese patient can be more difficult to perform, and this would lead experience and technical ability of the surgeon. Surgeons may
a surgeon to opt for a laparoscopic approach. benefit from education and training to laparoscopically address
Based on our data, the ulcer location being found in the duodenum PPU, particularly community surgeons without MIS fellowship
is difficult to explain as it is an intraoperative finding that could not training. This additional investment in training would benefit
definitively be confirmed in preoperative planning. Additionally, the both the patient and reduce hospital costs by decreasing LOS
preoperative imaging localization on the CT scan was not found to and the need for SNF discharges.
be a significant factor for the surgeon choosing laparoscopic repair or
open. For this reason, we do not feel it is a relevant factor in determining
the operative approach. Given the BMI was the only significant orcId
patient related factor, we can infer that the decision for a surgeon to Omar El-Ghazzawy https://orcid.org/0000-0002-8003-0589
repair a PPU laparoscopically was otherwise only influenced by the
surgeon’s experience. MIS fellowship training (46.2% laparoscopic if references
MIS fellowship vs 19.2% laparoscopic if no MIS fellowship p ≤0.001)
proved to be the most important factor in determining the operative 1. Ramakrishnan K, Salinas R. Peptic ulcer disease. Am Fam Physician
2007;76(7):1005–1012. DOI: 10.1007/978-0-387-33754-8_344.
approach. Patient characteristics that typically indicate a patient to 2. Savarino V, Marabotto E, Zentilin P, et al. The appropriate use of
be a poor laparoscopic candidate were not found to be significant. proton-pump inhibitors. Minerva Med 2018;109(5):386–399. DOI:
These factors included prior abdominal surgeries, septic presentation, 10.23736/S0026-4806.18.05705-1.
medical comorbidities, and anticoagulation. This finding suggests 3. Hermansson M, Ekedahl A, Ranstam J, et al. Decreasing incidence
that a MIS trained surgeon was more willing to resuscitate the patient, of peptic ulcer complications after the introduction of the proton
reverse anticoagulation, provide supportive measures for their pump inhibitors, a study of the Swedish population from 1974-
patients’ comorbidities, and still proceed with laparoscopic surgery 2002. BMC Gastroenterol 2009;9:1–13. DOI: 10.1186/1471-230X-
rather than choosing to proceed with the open procedure due to the 9-25.
known benefits of laparoscopic surgery. 4. Yuan Y, Padol IT, Hunt RH. Peptic ulcer disease today. Nat Clin
Pract Gastroenterol Hepatol 2006;3(2):80–89. DOI: 10.1038/
Our study was limited by the fact that it was a retrospective ncpgasthep0393.
chart review and this inherently makes the study prone to selection 5. Svanes C. Trends in perforated peptic ulcer: Incidence, etiology,
bias. Our data may have been a reflection of surgeons at our treatment, and prognosis. World J Surg 2000;24(3):277–283. DOI:
specific hospital network rather than the surgical community as a 10.1007/s002689910045.
whole as only 25 or the 77 surgeons in the study accounted for the 6. Sanabria A, Villegas MI, Morales Uribe CH. Laparoscopic repair
laparoscopic group. Further randomized control trials need to be for perforated peptic ulcer disease. Cochrane Database Syst Rev
performed to combat this type of bias. 2013;2013(2). DOI: 10.1002/14651858.CD004778.pub3.
One particular obstacle to address regarding the adoption 7. Siu WT, Leong HT, Li M. Laparoscopic treatment of perforated
peptic ulcers. Asian J Surg 1998;21(1):22–25. DOI: 10.1097/00000658-
of laparoscopic repair of PPU is the surgeon’s comfort with 200203000-00001.
intracorporeal suturing. Lim et al. study cited this particular issue 8. Guadagni S, Cengeli I, Galatioto C, et al. Laparoscopic repair
15
as a “barrier to the greater adoption” of MIS. Laparoscopic knot of perforated peptic ulcer: Single-center results. Surg Endosc
tying was inferior to open knot tying across all levels of surgical 2014;28(8):2302–2308. DOI: 10.1007/s00464-014-3481-2.
16
training. Surgeons who are performing laparoscopic PPU repair 9. Lau H. Laparoscopic repair of perforated peptic ulcer: a meta-analysis.
are likely more technically proficient laparoscopic surgeons due to Surg Endosc Other Interv Tech 2004;18(7):1013–1021. DOI: 10.1007/
their training (i.e., MIS fellowship). The improved outcomes found s00464-003-8266-y.
in our laparoscopic group may not be reflective of surgeons who 10. Siu WT, Leong HT, Law BKB, et al. Laparoscopic repair for
perforated peptic ulcer: a randomized controlled trial. Ann Surg
do not have the same level of laparoscopic training. 2002;235(3):313–319. DOI: 10.1097/00000658-200203000-00001.
Although the data did not ultimately reveal a clear and specific 11. Lau WY, Leung KL, Kwong KH, et al. A randomized study comparing
subgroup of patients or “indications” to perform laparoscopic laparoscopic versus open repair of perforated peptic ulcer using
surgery, the question must be asked; should we be performing more suture or sutureless technique. Ann Surg 1996;224(2):131–138. DOI:
PPU repairs laparoscopically? Based on our findings, laparoscopic PPU 10.1097/00000658-199608000-00004.
disease repair is safe, decreases LOS, and improves overall patient 12. Cirocchi R, Soreide K, Di Saverio S, et al. Meta-analysis of perioperative
outcomes when compared to open repair. Many surgeries that outcomes of acute laparoscopic versus open repair of perforated
were done as open procedures are now done laparoscopically. 14,17 gastroduodenal ulcers. J Trauma Acute Care Surg 2018;85(2):417–425.
DOI: 10.1097/TA.0000000000001925.
And thus, we believe the management of PPU disease should 13. Shabanzedah D, Sorenson L. Laparoscopic surgery compared with
also evolve. Surgeon experience is a modifiable factor, and with open surgery decreases surgical site infection in obese patients: a
better surgical education and laparoscopic training, we feel more systematic review and meta-analysis. Ann Surg 2012;256(6):934–945.
surgeons would be capable of performing a laparoscopic repair of DOI: 10.1097/SLA.0b013e318269a46b.

World Journal of Laparoscopic Surgery, Volume 15 Issue 1 (January–April 2022) 45