Laparoscopic versus open repair for peptic ulcer perforation: a systematic review, meta-analysis and trial sequential analysis of randomised controlled trials. Time to conclude!

Abstract

Introduction: The aim of this study was to investigate comparative outcomes of laparoscopic and open repair for peptic ulcer perforation (PUP).

Methods: A PRISMA-compliant systematic review with a PROSPERO-registered protocol (registration number CRD42024529286) was conducted. All randomised controlled trials (RCTs) involving PUP patients managed by laparoscopic or open repair were identified and their risk of bias assessed. Outcome syntheses for perioperative mortality and morbidities, need for reoperation, procedure time and length of hospital stay were conducted using random-effects modelling to calculate risk ratios (RR) or mean difference (MD) with 95% confidence intervals (CI).

Findings: Nine RCTs met the inclusion criteria, enrolling 670 patients of whom 317 were randomised to receive laparoscopic surgery and 353 were managed with open surgery. Laparoscopic repair of PUP significantly reduced mortality (RR 0.37, p = 0.03), total complications (RR 0.57, p = 0.0009), ileus (RR 0.43, p = 0.04), wound complications (RR 0.36, p < 0.0001) and length of hospital stay (MD -2.37, p = 0.0003) compared with the open approach. There were no significant differences in rate of postoperative leak (RR 2.00, 95% CI 0.74-5.41, p = 0.17), abdominal collection (RR 1.19, 95% CI 0.46-3.07, p = 0.72), sepsis (RR 1.17, 95% CI 0.39-3.52, p = 0.65), respiratory complications (RR 0.68, 95% CI 0.32-1.46, p = 0.32), reoperation (RR 1.74, 95% CI 0.57-5.30, p = 0.33) and operating time (MD 15.31, 95% CI -4.86 to 35.47, p = 0.14) between the two groups.

Conclusions: Laparoscopic repair of PUP is associated with significantly lower mortality and morbidity and shorter length of stay compared with the open approach. The laparoscopic approach should be the management of choice subject to the existence of laparoscopic expertise.

Keywords: Meta-analysis; Outcomes; Peptic ulcer disease; Surgery.

Figure 1

PRISMA flow chart

Figure 2

Risk of bias assessment of included randomised controlled trials

Figure 3

Forest plots of comparison of (a) mortality, (b) total complications, (c) leak, (d) abdominal collection, (e) postoperative ileus, (f) postoperative sepsis, (g) respiratory complications, (h) wound complications, (i) length of stay, (j) reoperation and (k) operating time. Solid squares denote the odds ratio or risk difference. Horizontal lines represent 95% confidence intervals and the diamond denotes the pooled effect size. M–H = Mantel Haenszel test

Figure 3

Forest plots of comparison of (a) mortality, (b) total complications, (c) leak, (d) abdominal collection, (e) postoperative ileus, (f) postoperative sepsis, (g) respiratory complications, (h) wound complications, (i) length of stay, (j) reoperation and (k) operating time. Solid squares denote the odds ratio or risk difference. Horizontal lines represent 95% confidence intervals and the diamond denotes the pooled effect size. M–H = Mantel Haenszel test

Figure 3

Forest plots of comparison of (a) mortality, (b) total complications, (c) leak, (d) abdominal collection, (e) postoperative ileus, (f) postoperative sepsis, (g) respiratory complications, (h) wound complications, (i) length of stay, (j) reoperation and (k) operating time. Solid squares denote the odds ratio or risk difference. Horizontal lines represent 95% confidence intervals and the diamond denotes the pooled effect size. M–H = Mantel Haenszel test

Figure 4

Results of trial sequential analysis for (a) mortality, (b) total complications, (c) length of stay and (d) operating time. The red inward-sloping dashed lines make up the trial sequential monitoring boundaries. To the right, the outward sloping red dashed lines make up the futility region. The solid blue line is the cumulative Z-curve. The solid green line is the penalised Z-value.

Figure 4

Results of trial sequential analysis for (a) mortality, (b) total complications, (c) length of stay and (d) operating time. The red inward-sloping dashed lines make up the trial sequential monitoring boundaries. To the right, the outward sloping red dashed lines make up the futility region. The solid blue line is the cumulative Z-curve. The solid green line is the penalised Z-value.

Figure 4

Results of trial sequential analysis for (a) mortality, (b) total complications, (c) length of stay and (d) operating time. The red inward-sloping dashed lines make up the trial sequential monitoring boundaries. To the right, the outward sloping red dashed lines make up the futility region. The solid blue line is the cumulative Z-curve. The solid green line is the penalised Z-value.

Figure 4

Results of trial sequential analysis for (a) mortality, (b) total complications, (c) length of stay and (d) operating time. The red inward-sloping dashed lines make up the trial sequential monitoring boundaries. To the right, the outward sloping red dashed lines make up the futility region. The solid blue line is the cumulative Z-curve. The solid green line is the penalised Z-value.