Victor Vakayil, MD, MS, Brent Bauman, MD, Reema Mallick, MD, Sayeed Ikramuddin, MD, MHA, James Harmon, MD, PhD, FACS. University of Minnesota
Introduction: Perforated peptic ulcer disease (PPUD) is the second most common cause for an abdominal perforation requiring surgical intervention. Laparoscopic surgery(LS) or an open surgical approach(OS) is utilized to repair the bowel, however, there exists no consensus on the comparative effectiveness and safety of each technique. Few small, prospective trials, conducted in this patient cohort have been inconclusive. The rarity of this diagnosis precludes the design of an adequately powered, large-sized randomized study.
Methods: A 7-year retrospective review (2009-2015) of the American College of Surgeons National Surgical Quality Improvement Program database identified 3,654 adult patients (LP=485, OP= 3169) who underwent the OP or LP surgical approach for PPUD. All patients who had a concurrent surgical procedure, bleeding peptic ulcers, history of renal failure, severe COPD, and disseminated cancer were excluded from the analysis. Propensity scores were calculated using logistic regression models to eliminate the confounding effects of baseline demographic, clinical and laboratory variables between the two patient cohorts, and to adjust for the inherent heterogeneity in the model. Using a caliper distance ±0.2 and a case(LP): control(OP) ratio of 1:3; a propensity score(PS) matched analysis was performed to contrast and compare intraoperative and postoperative outcomes.
Results: PS matching created a total of 987 (LP=292, OP= 695) matched pairs. The robustness of the model was tested using an overall multivariate imbalance measure test L1( before matching= 0.995, vs after matching 0.980). Univariate analysis demonstrated successful matching of demographics, baseline clinical variables including Age, BMI, comorbidities, pre-operative laboratory variables and ASA scores. The laparoscopic approach was associated with increased operative time (LP= 96.8± 87.8 vs OP= 71.7± 46.1, P=0.001) but shorter duration of stay (LP= 6.6± 84.1vs OP= 8.4± 6.8, P=0.001). Laparoscopic surgery was associated with a decreased risk for superficial surgical site infection (LP= 0.3% vs OP= 2.3%, P=0.031) and postoperative wound dehiscence (LP= 0.3%% vs OP= 2.4%, P=0.02). There was no difference in the rates of 30-day mortality, deep space infections, pneumonia, UTI's, pulmonary embolism, sepsis and readmission rates between both matched groups.
Conclusion: Less than 13% of all PPUD’s were repaired laparoscopically. This approach had a shorter duration of hospitalization and was associated with a significant reduction in the rates of post-operative surgical site infections and wound dehiscence. Our data suggest that a minimally invasive approach may be superior to the open approach, provided the patient is a suitable candidate.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 88054
Program Number: S066
Presentation Session: Acute Care Session
Presentation Type: Podium