R. Allen1, S. Jayaraman1, C. B. Feather1, J. Turcotte1, J. Klune1 1Anne Arundel Medical Center,Department Of Surgery,Annapolis, MD, USA
Introduction:
Perforated peptic ulcer (PPU) is a surgical emergency that necessitates swift operative resolution. Repair can be performed either laparoscopically or open, though laparoscopic repair has historically accounted for a small number. We use the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to compare perioperative and 30-day postoperative (30POP) outcomes of open and laparoscopic repair of PPUs.
Methods:
The 2016-2018 ACS-NSQIP database was used to create the patient cohort, using ICD-10 and procedure (CPT) codes. An unmatched analysis was performed to identify factors that likely contributed to the laparoscopic vs open treatment allocation. Propensity score matching (PSM) was then used to reduce confounding and identify outcomes that were not explained by the underlying differences in the patient cohorts.
Results:
A total of 3375 patients were included in the study: 3135 patients in the open group (OG) and 340 (~10%) in the laparoscopic group (LG). The use of laparoscopy remained the same at 10%, 9.7% and 9.7% of repairs during 2016, 2017 and 2018 respectively. In this complete study cohort, septic shock was present in 10.5% of patients in OG, and 4.4% in LG (p<0.001). Patients in OG were older, more likely to be male, be functionally dependent, have chronic obstructive pulmonary disease (COPD), ascites, hypertension, acute renal failure (ARF), and weight loss (p < 0.05 for all). Patients in OG were also more likely to be American Society of Anesthesiologists (ASA) Class 4 or 5 (31% vs 18%, p < 0.001). There was no difference in ulcer location (gastric vs duodenal) between groups.
After PSM to control for comorbidities and illness severity that differed between groups on univariate analysis, 288 patients remained in each group; no significant differences in comorbidity burden or illness severity remained after matching. ASA, which was held out of the PSM to assess cohort balance, was also equivalent after matching.
Analysis of the matched cohorts revealed that there is no statistically significant difference in in-hospital mortality when comparing OG (5.9%) and LG (3.8%) repairs of PPUs (p=0.245). The LG was associated with significantly longer operative times (92 vs 79 min, p = 0.003), shorter lengths of stay (8.2 vs 9.4 days, p = 0.044) and a higher probability of being discharged home (81% vs 73%, p = 0.017). Outcomes in the 30POP were largely equivalent, except that OG still carried a higher risk for bleeding (14.6% vs 8%, p = 0.012) and pneumonia (8.7% vs 4.5%, p = 0.044).
Conclusion:
While laparoscopic repairs take longer, they lead to shorter hospital stays and higher likelihood of discharge home. There is no difference in in-hospital mortality between open and laparoscopic repair. However, there has not been an increased adoption of this technique over time. Further study to identify patients that are candidates for this technique is warranted.