Sheraz R Markar, Astrid Leusink, Tom Wiggins, Hugh Mackenzie, Omar Faiz, George B Hanna. Department of Surgery & Cancer, Imperial College London, United Kingdom
Background: Previous randomized controlled trials have suggested a laparoscopic approach to the surgical treatment of perforated peptic ulcer (PPU) is associated with a reduced length of hospital stay and postoperative pain. However there is limited evidence concerning the national impact of laparoscopic PPU surgery. The aim of this investigation was to evaluate the effect of laparoscopic approach to PPU surgery upon mortality and morbidity from a national English cohort.
Methods: Patients with a primary diagnosis of PPU, admitted as an emergency to a hospital in England, and receiving surgical intervention, between 2005 and 2012 were identified from the Hospital Episode Statistics database. Outcomes analyzed included 30-day and 90-day mortality, 30-day complications and length of hospital stay. Univariate and multivariate analyses were used to identify patient, hospital and treatment related factors associated with use of laparoscopy and mortality.
Results: Over the eight-year study period, 13,022 patients in England, underwent emergency surgery for PPU, this included 12,127 patients by open surgery and 895 patients by a laparoscopic approach. From 2005 to 2012, utilization of laparoscopic surgery for PPU increased from 0% to 13%; P<0.001.
Univariate analysis
Laparoscopic surgery group had a reduced proportion of patient’s aged ≥70 years (25% vs. 37.8%; P<0.001), male sex (38% vs. 42.1%; P=0.016), Charlson Comorbidity Index ≥2 (7.8% vs. 12.5%; P<0.001), and cancer (0.1% vs. 0.8%; P=0.021). Laparoscopic surgery was associated with significant reductions in 30-day (7% vs. 15.7%; P<0.001) and 90-day mortality (8.9% vs. 19.6%; P<0.001), pneumonia (6% vs. 10.1%; P<0.001), ischemic cardiac events (1% vs. 2.4%; P=0.007), and length of hospital stay (median 5 vs. 7 days; P<0.001).
Multivariate analysis
High volume emergency center status was the only factor associated with an increased utilization of laparoscopic surgery (OR=1.37; 95%CI 1.15–1.64). Laparoscopic surgery was associated with significant reductions in 30-day (OR=0.49; 95%CI 0.37–0.65) and 90-day mortality (OR=0.49; 95%CI 0.38–0.63). Factors associated with increased 30-day and 90-day mortality in all patents and in those undergoing laparoscopic surgery included patient age ≥70 years, male sex and CCI ≥ 2.
Conclusion: The large national population-based cohort study, suggests improvements in mortality and morbidity from PPU associated with laparoscopic surgery. In more recent years there have been marked increases in the laparoscopic surgery for PPU mainly seen in high volume emergency centers, identifying heterogeneity in operative approach across England, and the need for improved training in the performance of emergency laparoscopic intervention.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 84810
Program Number: S067
Presentation Session: Acute Care Session
Presentation Type: Podium
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