The role of laparoscopy in perforated peptic ulcer: a comment on the Australian cohort study

We read with particular interest the article entitled “Laparoscopic versus open repair of perforated peptic ulcer: A retrospective cohort study” (1).

The authors have shown that in their Australian cohort the laparoscopic management of perforated peptic ulcer (PPU) requires an extra operative time, without any convincing advantages in terms of complications or hospital stay. Although this pathology represents one of the most important indication of urgent surgery, its incidence is declined worldwide thinks to medical therapies with variations related to geographic areas (2). Based on these data it’s very difficult to perform studies with big samples and, as rightly addressed by authors, the few randomized trials have been based on China and Europe (3,4). The latest Cochrane library involving all the most important studies (5) about this argument, shows an equivalent outcome between open and laparoscopic ulcer repair with a trend towards a reduction of septic complications in the latter group. A lot of factors may influence the outcome of the procedure, in part related to the patient’s condition, to the PPU itself and technical aspects.

It’s quite obvious that younger patients and patients with ASA score I or II are quite suitable for laparoscopic repair meanwhile surgeons tend to be reluctant to treat high risk patients with this approach. For the same reasons it is better to manage a case of a patient with systolic blood pressure <90 mmHg and Boey score of 2 with open procedure due to its intrinsic high mortality and high risk of conversion in case of laparoscopy. The delayed presentation (>24 h) is a quite defined risk factor for suture leakage that may be related to the ulcer margin and fragility of edges. In the present article a lot of patients beloinging to the laparoscopic group have a delayed presentation and this may influence the suture performed laparoscopically (6). Instead the abdominal collections are prevented by meticulous irrigation of all abdominal cavities, and the dead spaces with warm saline in order to reduce the bacterial load. We believe that the concomitant peritonitis is a major cause of morbidity and mortality among these patients in particularly the pulmonary complications, although the role of laparoscopy in this setting should be clarified.

The expertise in laparoscopy is another key-point that is just stressed because it strongly influences mainly the conversion rate and consequently the costs and the operative time of the procedure. A small amount of studies about this specific argument have demonstrated an increased number of cases completed successfully completed in laparoscopy when the surgeon had gained proper skills (7). An emergency surgeon should know these “risk factors” when choosing the proper method of approach.

From an intra-operative standpoint, ulcer size and its location are the major risks for conversion during the procedure and therefore ulcers bigger than 8–10 mm (8) or difficult laparoscopic access often require fast conversion to open surgery in order to avoid to waste time laparoscopically. The ulcer location also affects the operative time as juxta-pyloric ulcers are associated to faster laparoscopic procedure respect to gastric ones that are difficult to treat and also they also may be malignant. Moreover the adopted technique is important with the Graham’s omental patch the most used and safe. It’s obvious that these factors can be determined only during the operation but an expert surgeon should attempt a laparoscopic approach for two reasons: firstly the diagnostic laparoscopy may become important in clinical cases of doubt, avoiding extensive laparotomies; secondly gaining experience in this setting gives the possibilities to face with more and more “difficult PPU cases”.

In conclusion, we completely agree with authors that laparoscopic approach to PPU represents a valid alternative to an open procedure (9) although it may take an extra operative time; however the correct patients selection and the increased experence may improve these results. A good strategy is to initially approach with laparoscopy young, low risks patients then, with increased experience in PPU repair, the surgeon manage the other cases. Patient selection for laparoscopic PPU repair is still a relevant concern, stressing the importance of further studies also in Australia comparing both early and late outcomes of standard laparotomy and laparoscopic repair especially in high risk, critically ill patients Initially when there is an intra-operative doubt about the ulcer size or its margins, it’s better to stop the procedure and convert to open surgery. The fundamentals about the technique are: Graham’s omental patch when possible and peritoneal lavage in case of diffuse peritonitis.

Acknowledgments

We thank the ARPA foundation (www.fondazionearpa.it).

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Laparoscopic Surgery. The article did not undergo external peer review.

Conflicts of Interest: The authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/ls.2018.12.01). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Smith RS, Sundaramurthy SR, Croagh D. Laparoscopic versus open repair of perforated peptic ulcer: A retrospective cohort study. Asian J Endosc Surg 2018; [Epub ahead of print]. [Crossref] [PubMed]
2. Svanes C. Trends in perforated peptic ulcer: incidence, etiology, treatment, and prognosis. World J Surg 2000;24:277-83. [Crossref] [PubMed]
3. Siu WT, Leong HT, Law BK, et al. Laparoscopic repair for perforated peptic ulcer: a randomized controlled trial. Ann Surg 2002;235:313-9. [Crossref] [PubMed]
4. Ge B, Wu M, Chen Q, et al. A prospective randomized controlled trial of laparoscopic repair versus open repair for perforated peptic ulcers. Surgery 2016;159:451-8. [Crossref] [PubMed]
5. Sanabria AE, Villegas MI, Morales Uribe CH. Laparoscopic repair for perforated peptic ulcer disease. Cochrane Database Syst Rev 2013;CD004778 [PubMed]
6. Lunevicius R, Morkevicius M. Risk factors influencing the early outcome results after laparoscopic repair of perforated duodenal ulcer and their predictive value. Langenbecks Arch Surg 2005;390:413-20. [Crossref] [PubMed]
7. Guadagni S, Cengeli I, Galatioto C, et al. Laparoscopic repair of perforated peptic ulcer: single-center results. Surg Endosc 2014;28:2302-8. [Crossref] [PubMed]
8. Lee FY, Leung KL, Lai PB, et al. Selection of patients for laparoscopic repair of perforated peptic ulcer. Br J Surg 2001;88:133-6. [Crossref] [PubMed]
9. Bertleff MJ, Lange JF. Laparoscopic correction of perforated peptic ulcer: first choice? A review of literature. Surg Endosc 2010;24:1231-9. [Crossref] [PubMed]