JUSTIFICATION OF THE CHOICE OF SURGICAL APPROACH IN PERFORATED PEPTIC ULCER

Background: Peptic ulcer perforation accounts for 10-15% of all complications of peptic ulcer and is one of the main causes of high mortality.Study Purpose: Optimization of the choice of surgical intervention and improvement of the surgical outcomes in patients with perforated peptic ulcers based on the Boey prognostic score and national clinical guidelines.Study material and methods: We performed the analysis involving data of 263 patients who undergone surgery in the Botkin Memorial Hospital from 2012 to 2018 in which the perforated peptic ulcer was sutured. There were 181 men (68.8%), 82 (31.2%) women. Patients were aged 19 to 87 years. Mean age was 52.4±11.6 years. Perforated gastric ulcer occurred in 74 (28.2%) patients, and ulcer on the duodenal bulb in 189 (71.8%) patients. Group 1 included patientswho were treated over the period from 2012 to 2014 (n = 127). In this group, laparoscopic intervention was performed in 76 (59.8%) patients. Laparotomy with subsequent suturing of the perforation hole was performed in 51 (40.2%) patients. Group 2 included patients who were treated from 2015 to 2018 (n = 145), in which the surgical method was determined based on the Boey score and national clinical guidelines. In this group, laparoscopic suturing of the perforated ulcer was performed in 90 (62.1%) patients. In 55 (36.6%) patients, surgery was performed from laparotomy access. The study groups were compared in terms of the time of the surgical intervention, the frequency of conversions and postoperative complications, hospital stay, mortality rates.Outcomes: In Group 1, a perforated ulcer suturing with complete lavage of the abdominal cavity using the laparoscopic method was feasible to be performed in 76 (59.8%) of 84 patients. Conversion occurred in 8 (9.5%) patients. Surgery duration was 117.5±19.8 minutes. Complications were observed in 12 (15.8%) patients. Postoperative inpatient days were 5.6±1.4. After the laparotomy suturing of the perforated ulcer, complications were present in 14 (22.6%) patients. Surgery duration was 96.7±12.3 minutes and postoperative inpatient days were 9.6±2.3 days. The overall mortality rates in this group were 4.8%. In Group 2, laparoscopic intervention was feasible to be performed in 90 (62.1%) of 92 patients. Conversion occurred in 2 (2.2%) patients. The duration of the laparoscopic intervention was 86.7±14.3 minutes and the laparotomy intervention was 83.7±11.8 minutes. Complications were observed in 5 (5.4%) and 12 (22.6%) patients, respectively. Postoperative inpatient days with laparoscopic method were 4.1±1.7 days and with laparotomy 8.7±2.5 days. The overall mortality rates in this group were 2.8%.Conclusion: Laparoscopic suture of perforated peptic ulcer is a minimally invasive and effective method of treatment, this leads to a decrease in the number of conversions, postoperative complications, hospitalization time, reduced mortality and improved results of surgical treatment. The use of the Boey prognostic scale, taking into account national clinical guidelines, allows reasonable application of the optimal method of surgical treatment, surgical intervention in62.1 % of patients by laparoscopic method and reduce the number of conversions to 2.2%.

perforated ulcer, laparoscopy, Boey's score