Minilaparotomy for perforated duodenal ulcer

[Open and laparoscopic surgery via minimally invasive approach in the treatment of perforated ulcer: a systematic review and metaanalysis]

OBJECTIVE

Systematic review and metaanalysis of the effectiveness of open and minimally invasive laparoscopic suturing of perforated peptic ulcer.

MATERIAL AND METHODS

Searching for Russian and English language reports included Scientific Electronic Library, Cochrane Collaboration Library and PubMed databases. We have analyzed contents of specialized journals, reviews and their references. Unpublished data were obtained via communication with chiefs of national surgical hospitals. RevMan 5.3 software was used for metaanalysis.

RESULTS

We found no international randomized trials in available literature. Metaanalysis was based on national non-randomized studies. Total sample was 1177 cases. Laparoscopic minimally invasive surgery was performed in 43% of cases (n=503), open suturing - in 57% (n=674) of patients. Choice of these procedures is not currently not standardized. Minimally invasive procedures are shorter in time (mean difference -8.02, 95% CI -11.26 - -4.77, p<0.00001) and ensure less hospital-stay (mean difference -1.93, 95% CI -2.97 - -0.88, p=0.0003). Complications were less common (OR 0.14, 95% CI 0.07-0.27, p<0.00001) after minimally invasive operations (2.4%, 12/503) compared to laparotomy (11.4%, 77/674). Incidence of suture failure was similar (OR 0.4, 95% CI 0.1-1.6, p=0.2) (0.4% (2/503) vs. 0.7% (5/674)). Postoperative mortality was higher (OR 0.14, 95% CI 0.05-0.37, p<0.0001) after laparotomy (8%, 54/674) compared to laparoscopy (0.8%, 4/503).

CONCLUSION

A metaanalysis indicates the advantage of laparoscopy-assisted suturing of perforated ulcer via minimally invasive approach over laparotomy. The absence of a standardized approach in choosing of minimally invasive laparotomy and conventional approach is a limitation of these results.

Predicting the amount of intraperitoneal fluid accumulation by computed tomography and its clinical use in patients with perforated peptic ulcer

The correlation between the amount of peritoneal fluid and clinical parameters in patients with perforated peptic ulcer (PPU) has not been investigated. The authors' objective was to derive a reliable formula for determining the amount of peritoneal fluid in patients with PPU before surgery, and to evaluate the correlation between the estimated amount of peritoneal fluid and clinical parameters. We investigated 62 consecutive patients who underwent emergency surgery for PPU, and in whom prediction of the amount of accumulated intraperitoneal fluid was possible by computed tomography (CT) using the methods described by Oriuchi et al. We examined the relationship between the predicted amount of accumulated intraperitoneal fluid and that measured during surgery, and the relationship between the amount of fluid predicted preoperatively or measured during surgery and several clinical parameters. There was a significant positive correlation between the amount of fluid predicted by CT scan and that measured during surgery. When patients with gastric ulcer and duodenal ulcer were analyzed collectively, the predicted amount of intraperitoneal fluid and the amount measured during surgery were each associated with the period from onset until CT scan, perforation size, the Mannheim peritoneal index, and the severity of postoperative complications according to the Clavien-Dindo classification. Our present results suggest that the method of Oriuchi et al is useful for predicting the amount of accumulated intraperitoneal fluid in patients with PPU, and that this would be potentially helpful for treatment decision-making and estimating the severity of postoperative complications.