Laparoscopic repair of perforated peptic ulcer A meta-analysis H. Lau Department of Surgery, University of Hong Kong Medical Center, Tung Wah Hospital, 12 Po Yan Street, Sheung Wan, Hong Kong, China Received: 14 October 2003/Accepted: 7 January 2003/Online publication: 12 May 2004

To compare the safety and efficacy of open and laparoscopic repair of perforated peptic ulcer in an evidence-based approach using meta- analytical techniques OBJECTIVE SUMMARY BACKGROUND DATA Although laparoscopic repair combines the principles of open repair with the advantages of minimal access surgery, it has not been widely accepted by general surgeons

Literature search: Search of electronic databases, including MEDLINE and EMBASE between January 1990 and December 2002 Inclusion criteria: All prospective randomized trials or case–control studies that compared the outcomes of laparoscopic and open repair of perforated peptic ulcer were included. For the laparoscopic treatment group, only patients who underwent laparoscopic suture repair were recruited Data extraction: Standardized data abstract form Data pooling and statistics: An effect size for the outcome parameter of individual studies was calculated by the odds ratio (OR). The effect sizes of all trials were tested for heterogeneity by Q Statistics. A qualitative review of the outcome data was performed when a formal meta-analysis was not feasible. Statistical analysis was performed with the Statistical Package for the Social Sciences (SPSS, Chicago, IL,USA) software program and Comprehensive Meta-analysis All reports (13) were critically appraised with respect to their methodology and outcome METHODS

RESULTS Meta-analyses demonstrated a significant reduction in the wound infection rate after laparoscopic repair, as compared with open repair, but a significantly higher reoperation rate was observed after laparoscopic repair. Factors considered in the comparison of laparoscopic and open surgery were as follows: Length of operation Conversion Postoperative pain Postoperative complications Reoperation Mortality Length of hospital stay Recovery variables

Length of operation: Five studies demonstrated a significantly longer operative time for laparoscopic repair Conversion: Reported rates of conversion to open repair ranged from 0% to 29.1% Postoperative pain: A postoperative assessment of pain score consistently showed a lower pain score after laparoscopic repair than after open repair Postoperative complications: Chest infection was the most common postoperative morbidity. Naesgaard et al. in their retrospective study, demonstrated a significantly higher incidence of chest infection in the laparoscopic group. But subsequent meta-analyses showed a lower overall chest infection rate after laparoscopic repair Wound infection was the next most common morbidity after open repair of perforated peptic ulcer. Subsequent meta-analyses proved that laparoscopic repair conferred a significant reduction in wound infection rate, as compared with open repair.

Leakage was more common after laparoscopic repair than after open repair. Intraabdominal collection was more prevalent after laparoscopic repair than after open repair. Most of the studies demonstrated a higher incidence of intraabdominal collection or abscess formation after laparoscopic repair. Reoperation: The overall reoperation rate was 3.7% (n = 11) for laparoscopic repair (n = 294) and 1.9% (n = 7) for open repair (n = 364). Leakage was the chief reason for reoperation. Subsequent meta-analyses found a significantly lower reoperation rate after open repair. Mortality None of the mortality was attributed directly to the adoption of laparoscopic repair. The subsequent pooled estimate of the overall mortality favored laparoscopic repair. Length of hospital stay All the studies showed that the length of hospital stay after laparoscopic repair was either shorter than or equal to that associated with open repair. Recovery variables: Only Katkhouda et al. showed significantly earlier resumption of the normal diet after laparoscopic repair. Siu et al. found that patients returned to normal activities after laparoscopic repair within an average of 10 ± 6.9 days, which was significantly earlier than the return of those who underwent open repair (26 ± 15.1 days).

DISCUSSION The rationale for the sutureless technique is both to simplify the procedure and to shorten the operative time. However, sutureless repair using a plug of gelatin sponge with fibrin glue has not gained wide acceptance because of its associated higher leakage rate, particularly if the ulcer is larger than 5 mm in diameter. One main drawback of laparoscopic repair was the increase in operating time. Another disadvantage of laparoscopic repair was a significantly increased reoperation rate, which was a consequence of postoperative leakage. The higher incidence of leakage after laparoscopic repair may be attributable in part to a faulty technique of laparoscopic closure. Furthermore, the higher incidence of intraabdominal collection was secondary to inadequate lavage and suctioning of the peritoneal cavity. Perfection and standardization of the laparoscopic technique for the repair of perforated ulcer is therefore necessary.

CONCLUSION Laparoscopic repair is effective and superior to open repair in terms of early postoperative outcomes including pain, wound infection, and functional recovery. However, the relative benefits of the laparoscopic approach must be weighted against the increased risk of mortality, which can be reliably predicted by preoperative assessment of Boey’s risk factors and the APACHE II score. It is therefore of paramount importance that patients be selected carefully for the laparoscopic approach. Patients who have one or more of Boey’s risk factors are therefore less suitable for laparoscopic surgery. Other relative contraindications for laparoscopic repair include the concomitant presence of other ulcer complications such as bleeding and obstruction, large perforation, technical difficulty, previous upper abdominal operations, and serious associated cardiopulmonary diseases.

Meta-analyses of the 13 recruited trials demonstrated that laparoscopic repair was associated with a significantly lower wound infection rate. Laparoscopic repair of perforated peptic ulcer also was associated with reduced postoperative pain and diminished analgesic consumption. Currently, the main drawbacks of laparoscopic repair are a longer operation and a higher reoperation rate. Both laparoscopic and open repairs of perforated peptic ulcer, being complementary to each other, have their roles in the management of perforated peptic ulcer. **Boey’s risk factors: concurrent major medical illness, preoperative shock, and delayed presentation of more than 24 hours