The selective use of laparoscopy-first approach for high-risk patients suffering perforated peptic ulcer is safe.

Anth Y Teoh, MD, Enders K Ng, MD, Philip W Chiu, MD, Simon K Wong, MD. Prince of Wales Hospita, Chinese University of Hong Kong.

Background: Since the conclusion of a randomized trial, the laparoscopy-first approach (LFA) was adopted as a routine in our institution for managing patients suffering from PPU. The aim of the current study was to review the outcomes of LFA for PPU and to assess if the approach is applicable to high-risk patients.

Method: This was a retrospective study of all patients who were diagnosed with PPU admitted between January 2002 and December 2012. LFA was offered unless the patient condition were deem inappropriate for the approach. Data retrieved included peri-operative and operative parameters, morbidities and mortalities.

Results: 373 patients suffering from PPU were included in the study and 50.9% received laparoscopic repair. There was a significant increase in the number of operations performed yearly by the LFA (P < 0.001). 25.2% of the patients had a Boey score of ≥ 2. High-risk patients that received LFA suffered from larger ulcers (P < 0.001) with more severe contamination (P = 0.006) that required conversion (P = 0.002). When compared to open surgery, more patients in the open group had ASA grade ≥ 3 (P = 0.007) and suffered from mortality (P = 0.001). The only significant predictor to mortality in high-risk patients was ASA grade ≥ 3 (P = 0.014).

Conclusion: The adoption of LFA in patients suffering from PPU was associated with acceptable rates of mortality and morbidity. The approach could also be selectively adopted in patients with Boey score ≥ 2 provided their ASA grading is low and hemodynamically stable.

Comparison of patients with Boey score ≥ 2 that received laparoscopic or open surgery.
	Laparoscopic N = 29	Open N =63	P value
Age (years)	66.62 (15.49)	70.41 (16.77)	0.292
ASA grade ≥ 3 (%)	7 (24.1)	34 (54)	0.007
Time to presentation (hours) *	46.30 (22.65)	50.57 (23.24)	0.448
Size of ulcer (mm) *	10.77 (8.52)	12.14 (10.72)	0.547
Operation time (minutes) *	131.31 (66.33)	113 (63.67)	0.254
Simple patch repair / other procedures (%)	12 (41.4) / 17 (58.6)	28 (44.4) / 35 (55.6)	0.783
Peri-operative inotropes (%)	1 (3.4)	10 (15.9)	0.163
Admission to intensive care unit (%)	6 (20.7)	20 (31.7)	0.274
30-day Mortality (%)	2 (6.9)	26 (41.3)	0.001