V. Gabriel1, A. Grigorian1, S. Schubl1, M. Pejcinovska1, E. Won1, M. Lekawa1, N. Bernal1, J. Nahmias1 1University Of California – Irvine,Division Of Trauma, Burns & Surgical Critical Care,Orange, CA, USA
Introduction: The lifetime prevalence of perforated peptic ulcer (PPU) in patients with peptic ulcer disease is estimated at 5%. Reported mortality rates after surgery for PPU have ranged from 1 to 24%. A recent meta-analysis by Tan et al demonstrated equivalent morbidity and mortality when comparing laparoscopic repair (LR) to open repair (OR). However, LR was shown to have lower operative time, less pain, shorter length of stay (LOS), and a lower rate of surgical site infection. We hypothesized a decrease in morbidity and mortality with LR from 2011-2015 compared to 2005-2010. Additionally, we hypothesized a decrease in morbidity and mortality for LR versus OR for the entire duration of 2005-2015.
Methods: Patients undergoing operative repair of PPU between 2005- 2015 were identified in the NSQIP database by CPT code. Patients with definitive acid-reducing operations were excluded. A comparison of OR from 2005-2010 versus 2011-2015 was performed. A similar comparison was performed for LR. Additionally, a comparison between LR and OR for the entire duration (2005-2015) was conducted. Primary outcomes were the differences in 30-day mortality and overall morbidity. After controlling for significant covariables such as age, American Society of Anesthesiologists class, functional status, pre-operative albumin and creatinine, steroid use, liver disease, time to surgery, and presence of malignancy, a multivariate regression analysis was performed.
Results: 5,413 patients between 2005-2015 were included in the study. From 2005-2010 there were 86 LR cases and 1,924 OR cases. Between 2011-2015 there were 221 LR cases and 3,182 OR cases. LR demonstrated no difference in 30-day mortality or overall morbidity between the two time periods (p>0.05). There was no significant difference in 30-day mortality for patients undergoing OR between the two time periods. However, overall morbidity (odds ratio (OR), 1.99; 95% CI, 1.71-2.33, p<0.05), development of sepsis (p<0.05), and septic shock (p<0.05) were all more prevalent in patients undergoing OR from 2011-2015. Comparing LR versus OR from 2005-2015, patients undergoing LR had a shorter length of stay (p<0.05), and were less likely to exhibit failure to wean from the ventilator at 2 days (OR, 0.34; 95% CI, 0.18-0.65, p<0.05).
Conclusion: While a 2.5% increase LR utilization was seen, there was not a decreased morbidity and mortality associated with more recent LR from 2011-2015. This may be secondary to increasing utilization of LR in more debilitated patients over time. When LR was compared to OR there was a significant decrease in LOS. Future prospective research is needed to confirm this finding and evaluate the safety of more widespread adoption of LR for PPU.
