Laparoscopic Repair of Perforated Peptic Ulcer in the Elderly: An Interim Analysis of the FRAILESEL Italian Multicenter Prospective Cohort Study

Abstract

Introduction:The number of elderly patients requiring emergency surgical intervention has increased dramatically. Perforated peptic ulcer (PPU) complications, such as perforation, have remained relatively stable and associated morbidity remains between 10% and 20%. Advances in perioperative care have greatly improved the outcomes of laparoscopic emergency surgery, allowing increasing numbers of patients, even the elderly, to undergo safe repair. The aim of this study was to evaluate the feasibility, safety, and outcome of laparoscopic gastric repair in the elderly using the database of the FRAILESEL (Frailty and Emergency Surgery in the Elderly) study.Materials and Methods: This is a retrospective analysis carried out on data of the FRAILESEL study. Data on all the elderly patients who underwent emergency abdominal surgery for PPU from January 2017 to December 2017 at 36 Italian surgical departments were analyzed. Patients who underwent PPU repair were further divided into a laparoscopic gastroduodenal repair (LGR) cohort and an open gastroduodenal repair (OGR) cohort, and the clinicopathologic features of the patients in both the groups were compared.Results: Sixty-seven patients fulfilled the inclusion criteria. Thirtythree patients (47.8%) underwent LGR. The LGR patients had less blood loss and shorter postoperative stay, even if the difference was not statistically significant. The mean operative time was significantively higher in the OGR (OGR 96.5 ± 27.7 vs. LGR 78.6 ± 16.3 P = 0.000). The rate of death after laparoscopic surgery was similar to the rate of the open surgery. Multivariate analysis indicated that only age (P = 0.018), admission haemoblogbin (Hb) level (P = 0.006), platelet count (P = 0.16), lactate level (P = 0.47), and Mannheim Peritonitis Index (P = 0.18) were independent variables associated with the risk of overall mortality. Conclusions:LGR is safe and feasible in elderly patients with PPU and it is associated with better perioperative outcomes. However, patient selection and preoperative frailty evaluation in the elderly population are the key to achieving better outcomes.

Surgical Management of Perforated Peptic Ulcer: A Comparative Meta-analysis of Laparoscopic Versus Open Surgery

“…Subsequently, 1466 records were screened; of them, 48 studies were assessed for eligibility against the inclusion/exclusion criteria. However, 9 articles were excluded owing to a lack of primary outcomes, 19,20 lack of access to a full article, 21,22 recruiting specific populations (elderly and pediatrics), 23 article retraction, 24,25 and article writing in a nonEnglish language. 26,27 Concomitantly, 6 articles were identified from the bibliographies of the screened articles, and all those studies were included.…”

Gastric emergencies in older adults: not always the same old story! A tertiary care emergency department observational cohort study

“…Regarding acute gastric perforation, the number of elderly patients requiring emergency procedures has increased dramatically. 20 …”

“…However, patient selection and preoperative frailty evaluation in the elderly population are the key to achieve better outcomes. 20 …”

“…In a recent Italian multicentre prospective study, Fransvea et al 20 demonstrated that laparoscopic gastric repair is safe and feasible in elderly patients with perforation from gastric ulcer and is associated with better perioperative outcomes. However, patient selection and preoperative frailty evaluation in the elderly population are the key to achieve better outcomes 20…”

Gastro-intestinal emergency surgery: Evaluation of morbidity and mortality. Protocol of a prospective, multicenter study in Italy for evaluating the burden of abdominal emergency surgery in different age groups. (The GESEMM study)

“…In addition to the complexity of the urgent surgical patient (often suffering from multiple co-morbidities), there is the unpredictability and the severity of the event. Frequently, it is necessary a rapid decision-making that allows a correct diagnosis and an adequate and timely treatment (12)(13)(14). Moreover, in other study Havens JM et al report that patient undergoing EGS operation are up to 8 times more likely to die postoperatively than are patients undergoing the same procedures electively (15).…”