Propensity score matching analysis of laparoscopic surgery vs. open approach in 4 297 adult patients with acute appendicitis, acute cholecystitis or gastrointestinal tract perforation: a prospective multicentre study of nationwide outcomes

Background and aims:

Previous studies indicated that laparoscopic surgery could improve postoperative outcomes in acute appendicitis, acute cholecystitis, perforated gastroduodenal ulcer, or acute diverticulitis, but some reported opposite results or differences in the magnitude of improvement. A contemporary analysis using propensity score matching that compares outcomes is lacking.

Methods:

Over a 6-month period, 38 centres (5% of all public hospitals) attending emergency general surgery patients on a 24 h, 7 days a week basis, enroled all consecutive adult patients who underwent laparoscopic surgery or open approach.

Results:

The study included 2 645 patients with acute appendicitis [32 years (22–51), 44.3% women], 1 182 with acute cholecystitis [65 years (48–76); 46.7% women], and 470 with gastrointestinal tract perforation [65 years (50–76); 34% women]. After propensity score matching, hospital stays decreased in acute appendicitis [open, 2 days (2–4); lap, 2 days (1–4); P<0.001], acute cholecystitis [open, 7 days (4–12); lap, 4 days (3–6); P<0.001], and gastrointestinal tract perforation [open, 11 days (7–17); lap, 6 days (5–8.5); P<0.001]. A decrease in 30-day morbidity was observed in acute appendicitis (open, 15.7%; lap, 9.7%; P<0.001), acute cholecystitis (open, 41%; lap, 21.7%; P<0.001), and gastrointestinal tract perforation (open, 45.2%; lap, 23.5%; P<0.001). A decrease in 30-day mortality was found in acute cholecystitis (open, 8.8%; lap, 2.8%; P=0.013) and gastrointestinal tract perforation (open, 10.4%; lap, 1.7%; P=0.013).

Conclusions:

This clinically based, multicentre study suggests that an initial laparoscopic approach could be considered not only in patients with acute appendicitis or acute cholecystitis but also in patients with a perforation of the gastrointestinal tract.

Introduction

Highlights

• Laparoscopic surgery could improve outcomes of open approach in emergency general surgery.

• Propensity score matching analysis is an alternative to randomized controlled trials.

• Outcomes were examined in appendicitis, cholecystitis, or gastrointestinal tract perforation.

• Laparoscopic surgery reduced length of hospital stays, 30-day morbidity, and 30-day mortality.

• Initial laparoscopic surgery could be considered in gastrointestinal tract perforation.

According to the Global Burden of Disease Study, the 2010 mortality rate per 100 000 world population was 0.5%, 1.3%, 3.5%, and 2.1% for acute appendicitis, biliary disease, perforated peptic ulcer, and ileus and obstruction, respectively¹. Updated analyzes of these conditions from the most recent reports are gradually being released, and some data are already available for acute appendicitis. The Global Health Data Exchange has recently reported an increase in the incidence of appendicitis from 1990 to 2019, accompanied by a decrease in mortality rates². However, the 2019 Global Burden of Disease Study indicates a 20.4% increase in age-standardized years lived with disability rate for acute appendicitis during the same timeframe³. The cross-sectional decrease in mortality detected in acute appendicitis, biliary disease, and perforated peptic ulcer over the last decades could be due, at least in part, to better health care, more available resources, and novel surgical techniques. Minimally invasive surgical procedures are becoming the preferred approach in high-income countries, and their use is increasing in low-income and middle-income countries as well^4–6. They aim to reduce the burden of postoperative complications, mortality and cost, and improve the quality of life of patients.

So far, the outcomes of laparoscopic surgery vs. open approach have been examined for all emergency general surgery procedures taken together⁷ or, specifically, for prevalent conditions separately (i.e. acute appendicitis, acute cholecystitis, perforated gastroduodenal ulcer, perforated diverticulitis, iatrogenic colonoscopy perforations). To assess the impact of laparoscopic surgery, meta-analysis of randomized controlled trials and propensity score matching analysis are available. The meta-analyses revealed that laparoscopic surgery decreased hospital stays in the three first conditions mentioned above and in iatrogenic colonic perforation; furthermore, laparoscopic surgery reduced morbidity and mortality in acute cholecystitis^5,6,8,9. The propensity score analysis has shown benefit as a substitute for the gold standard that is the randomized controlled trial¹⁰. The studies with propensity score matching indicated that laparoscopic surgery could improve one or several outcomes in acute appendicitis^4,11–16, acute cholecystitis¹⁷, perforated gastroduodenal ulcer^18–22, and perforated diverticulitis^23,24, but offered somewhat contradictory findings and disagreement in the magnitude of improvement. These studies were carried out in different years and in separate settings, and a contemporary analysis that compares outcomes between conditions is lacking.

Gastrointestinal tract perforation is a life-threatening emergency that requires immediate action. If left unattended, mortality reaches 30%. The finding and location of the associated pneumoperitoneum, as well as indirect signs obtained by computed tomography scan, point to the location of the injured hollow viscus²⁵. Prompt surgery is the standard management modality. To the best of our knowledge, comparison of open and laparoscopic approaches using propensity score matching analysis has not been performed by pooling gastrointestinal tract conditions that can lead to perforation. This novel approach could facilitate the surgeon’s decision regardless of the specific perforated site in the abdominal gastrointestinal tract.

This prospective multicentre study analyzed data from patients who underwent emergency surgery for acute appendicitis, acute cholecystitis, or perforation of the gastrointestinal tract over a 6-month period. The study aimed to compare length of hospital stays, 30-day overall and specific morbidity, and 30-day mortality between patients who underwent laparoscopic vs. open surgery.

Patients and methods

Study design

The present study is a post hoc secondary analysis of the data collected in the LUCENTUM --aLicante sUrgical Community Emergencies New Tool for the enUmeration of Morbidities-- project, an observational, prospective, multicenter, nationwide study endorsed by the Spanish Association of Surgeons (AEC), designed to find avenues for quality improvement in emergency general surgery^26–28. The study followed the guidelines for Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)²⁹. The study is registered in www.researchregistry.com/with the unique identification number (UIN) 7097. The medical ethics committee judged that no informed consent from the patients was necessary because of the observational nature of the study without additional burden for the patient. Subsequently, the ethics committee approved (Ref CEIm: PI2018/104) the analysis of data. Planning and analysis of the study was carried out according to the STROCCS Reporting Guidelines for Cohort Studies³⁰. Supplemental Digital Content 1, http://links.lww.com/JS9/A359.

Setting

Thirty-eight centres distributed throughout the national territory, totalling 5% of all public hospitals, agreed to participate in the project. In most centres, emergency general surgery was covered on a 24 h, 7 days a week basis by surgeons who also attend elective surgery.

Population

For the present study, patients included in the LUCENTUM project with diagnoses more likely to undergo laparoscopic surgery were selected. All consecutive patients with acute appendicitis (-10 Codes: K35, K36, K37, K38) undergoing appendectomy, with acute cholecystitis (international classification of diseases-10 Codes: K81, K82) undergoing cholecystectomy, and those operated for upper [abdominal] and lower gastrointestinal tract perforation (international classification of diseases-10 Codes K22.3, K25, K26, K57, K63.1) from 1 October 2017 to 31 March 2018 at participating hospitals, were selected for the study. The inclusion of patients with small bowel obstruction was explored, but too few underwent laparoscopic surgery to ensure comparison with the open approach. Patients were managed according to the standard of care at each hospital, and had to be older than 14 years—the cutoff set for paediatric patients in our country. Both laparoscopic and open operations were included. From the outset, the investigators of this multicentre study chose not to apply the intention-to-treat principle to the surgical approach. It was felt that following the usual protocols at each participating centre would avoid additional pressure on surgeons and better reflect current practice. Thus, conversion was left to the discretion of the operating surgeon and was not recorded. Consequently, patients who underwent conversion from laparoscopic surgery to open were included in the open group. All procedures were performed under general anaesthesia, and patients were followed for 30 days after surgery. Patients managed nonoperatively were excluded.

Variables and data collection

Preoperative variables included patient demographics, vital signs, and laboratory tests on admission. Postoperative events and clinical outcomes were recorded using the definitions of morbidity and complications set by POSSUM²⁷. Local investigators collected centre-specific data using a secure online data-entry management system which accommodated smartphone, tablet, or desktop formats. The anonymized data were entered into a web page with protected username and password for each centre, from which data files were generated.

Exposure assessment

Exposure was the type of abdominal approach, open or laparoscopic, used in patients with acute appendicitis, acute cholecystitis, or perforation of the gastrointestinal tract. The choice was based on surgical criteria and centre protocol.

Outcome definition

In all three conditions (acute appendicitis, acute cholecystitis, gastrointestinal tract perforation), length of hospital stays, 30-day morbidity, and 30-day mortality, both after laparoscopic surgery and open approach, were recorded for all patients—baseline population—and in the subgroup of patients selected by the propensity score matching.

Statistical analysis

Categorical variables were expressed as relative frequencies and analyzed using χ² test or Fisher’s exact test. Continuous variables were expressed as median and interquartile range and differences between groups were explored using the Student’s t-test or Mann–Whitney U test. Shapiro test was used to assess normality. Propensity score matching (1:1 optimal-match, or nearest neighbour when deemed appropriate) was performed with the MatchIt package for R software. Propensity score was determined by logistic regression, using the demographic and preoperative characteristics listed in Supplementary Tables 1–3, Supplemental Digital Content 2, http://links.lww.com/JS9/A360 to reduce the effect of selection bias, and a 0.1-caliper width was used. The effect of the procedure was estimated by comparing outcomes (medians for continuous data, proportions if dichotomous) between open and laparoscopic approaches after matching³¹. All reported P values were two-sided, and P values lower than .05 were considered to be significant. All calculations were performed using the Rstudio Version 1.2.5001 (The R Foundation for Statistical Computing).

Results

Baseline population characteristics

A total of 2 645 patients with acute appendicitis were included. Median age was 35 years [interquartile range (IQR), 22–51], and 1 171 (44.3%) were women (Supplementary Table 1, Supplemental Digital Content 2, http://links.lww.com/JS9/A360). A total of 772 patients (29.2%) underwent appendectomy through the open approach, and 1 873 patients (70.8%) through the laparoscopic approach. Patients with acute appendicitis who underwent the laparoscopic approach were older, with a higher female ratio (46.2%), and lower serum urea than those with the open approach, and were admitted to teaching hospitals with more beds (Supplementary Table 1, Supplemental Digital Content 2, http://links.lww.com/JS9/A360).

A total of 1 182 patients with acute cholecystitis were included. Median age was 65 years (IQR, 48–76), and 552 (46.7%) were women (Supplementary Table 2, Supplemental Digital Content 2, http://links.lww.com/JS9/A360). A total of 217 patients (18.4%) underwent cholecystectomy through the open approach, and 965 patients (81.6%) through the laparoscopic approach. Patients with acute cholecystitis who underwent the laparoscopic approach were younger, with a higher female ratio (49.0%) and displayed better physiological status in most of the preoperative variables than those undergoing an open approach (Supplementary Table 2, Supplemental Digital Content 2, http://links.lww.com/JS9/A360).

A total of 470 patients with gastrointestinal tract perforation were included: oesophagus (n=8), gastric and duodenal ulcer (n=143), lower gastrointestinal tract (n= 309), miscellaneous (n=10). Median age was 65 years (IQR, 50–76), and 160 (34%) were women (Supplementary Table 3, Supplemental Digital Content 2, http://links.lww.com/JS9/A360). A total of 355 patients (75.5%) underwent surgery through the open approach, and 115 patients (24.5%) through the laparoscopic approach. Patients with gastrointestinal tract perforation who underwent the laparoscopic approach were younger and had better physiological status in some preoperative variables than those with the open approach (Supplementary Table 3, Supplemental Digital Content 2, http://links.lww.com/JS9/A360).

Baseline population outcomes

Patients with acute appendicitis, acute cholecystitis or gastrointestinal tract perforation who underwent the laparoscopic approach had a shorter length of hospital stay and less 30-day morbidity than those who underwent the open approach (Tables 1–3). The improvement in morbidity was noted in 3/15 specific complications in patients with acute appendicitis, in 13/15 specific complications in patients with acute cholecystitis, and in 7/15 specific complications in patients with gastrointestinal tract perforation. Except for patients with acute appendicitis, the patients with acute cholecystitis or gastrointestinal tract perforation who underwent the laparoscopic approach had lower 30-day mortality (Tables 1–3).

Table 1.

Postoperative outcomes of patients undergoing open or laparoscopic appendectomy for acute appendicitis.

	Baseline population				After propensity score matching
Postoperative outcomes	All patients (n=2 645)	Open (n=772)	Laparoscopy (n=1 873)	P value*	Laparoscopy (n=772)	P value*
Hospital stays
Total days, median (IQR)	2 (1–4)	2 (2–4)	2 (1–3)	<0.001	2 (1–4)	<0.001
30-day morbidity
Patients who developed morbidity events, n (%)	305 (11.5)	121 (15.7)	184 (9.8)	<0.001	75 (9.7)	<0.001
Postoperative complications, n (%)
Anastomotic leak / dehiscence	9 (0.3)	1 (0.1)	8 (0.4)	0.41	3 (0.4)	0.62
Wound dehiscence	30 (1.1)	16 (2.1)	14 (0.7)	0.006	6 (0.8)	0.053
Cardiac failure	12 (0.5)	5 (0.6)	7 (0.4)	0.53	3 (0.4)	0.72
Fever / pyrexia of unknown origin	36 (1.4)	10 (1.3)	26 (1.4)	1.0	15 (1.9)	0.42
Wound haemorrhage	8 (0.3)	5 (0.6)	3 (0.2)	0.09	2 (0.3)	0.45
Deep wound haemorrhage	9 (0.3)	2 (0.3)	7 (0.4)	0.93	4 (0.5)	0.68
Hypotension	8 (0.3)	3 (0.4)	5 (0.3)	0.90	0 (0.0)	0.25
Wound infection	110 (4.2)	70 (9.1)	40 (2.1)	<0.001	15 (1.9)	<0.001
Deep wound infection	117 (4.4)	28 (3.6)	89 (4.8)	0.24	38 (4.9)	0.26
Chest infection	20 (0.8)	5 (0.6)	15 (0.8)	0.87	4 (0.5)	1.0
Urinary tract infection	7 (0.3)	2 (0.3)	5 (0.3)	1.0	1 (0.1)	1.0
Renal failure	19 (0.7)	9 (1.2)	10 (0.5)	0.13	6 (0.8)	0.60
Respiratory failure	13 (0.5)	8 (1.0)	5 (0.3)	0.02	2 (0.3)	0.11
Septicaemia	15 (0.6)	2 (0.3)	13 (0.7)	0.28	6 (0.8)	0.29
Deep vein thrombosis, pulmonary embolism	1 (0.0)	1 (0.1)	0 (0.0)	0.29	0 (0.0)	1.0
30-day mortality
Patients who died, n (%)	2 (0.1)	0 (0.0)	2 (0.1)	1.0	1 (0.1)	1.0

^*Laparoscopic vs. Open.

IQR, interquartile range.

Table 3.

Postoperative outcomes of patients undergoing open or laparoscopic approach for gastrointestinal tract perforation.

	Baseline population				After propensity score matching
Postoperative outcomes	All patients (n=470)	Open (n=355)	Laparoscopy (n=115)	P value*	Open (n=115)	P value*
Hospital stays
Total days, median (IQR)	9 (6–13.2)	12 (7–20)	6 (5–8.5)	<0.001	11 (7–17)	<0.001
30-day morbidity
Patients who developed morbidity events, n (%)	238 (50.6)	211 (59.4)	27 (23.5)	<0.001	52 (45.2)	<0.001
Postoperative complications, n (%)
Anastomotic leak / dehiscence	42 (8.9)	33 (9.3)	9 (7.8)	0.77	9 (7.8)	1.0
Wound dehiscence	38 (8.1)	36 (10.1)	2 (1.7)	0.007	9 (7.8)	0.06
Cardiac failure	37 (7.9)	34 (9.6)	3 (2.6)	0.03	7 (6.1)	0.33
Fever / pyrexia of unknown origin	24 (5.1)	22 (6.2)	2 (1.7)	0.10	7 (6.1)	0.17
Wound haemorrhage	7 (1.5)	6 (1.7)	1 (0.9)	0.85	1 (0.9)	1.0
Deep wound haemorrhage	8 (1.7)	7 (2.0)	1 (0.9)	0.70	2 (1.7)	1.0
Hypotension	53 (11.3)	44 (12.4)	9 (7.8)	0.24	10 (8.7)	1.0
Wound infection	67 (14.3)	62 (17.5)	5 (4.3)	<0.001	13 (11.3)	0.09
Deep wound infection	57 (12.1)	45 (12.7)	12 (10.4)	0.63	11 (9.6)	1.0
Chest infection	35 (7.4)	32 (9.0)	3 (2.6)	0.04	9 (7.8)	0.14
Urinary tract infection	9 (1.9)	8 (2.3)	1 (0.9)	0.58	2 (1.7)	1.0
Renal failure	57 (12.1)	54 (15.2)	3 (2.6)	<0.001	9 (7.8)	0.14
Respiratory failure	73 (15.5)	68 (19.2)	5 (4.3)	<0.001	16 (13.9)	0.022
Septicaemia	40 (8.5)	36 (10.1)	4 (3.5)	0.04	12 (10.4)	0.07
Deep vein thrombosis, pulmonary embolism	5 (1.1)	4 (1.1)	1 (0.9)	1.0	0	1.0
30-day mortality
Patients who died, n (%)	59 (12.6)	57 (16.1)	2 (1.7)	<0.001	12 (10.4)	0.013

^*Open vs. Laparoscopic.

IQR, interquartile range.

Table 2.

Postoperative outcomes of patients undergoing open or laparoscopic cholecystectomy for acute cholecystitis.

	Baseline population				After propensity score matching
Postoperative outcomes	All patients (n=1 182)	Open (n=217)	Laparoscopy (n=965)	P value*	Laparoscopy (n=217)	P value*
Hospital stays
Total days, median (IQR)	4 (2–6)	7 (4–12)	3 (2–5)	<0.001	4 (3–6)	<0.001
30-day morbidity
Patients who developed morbidity events, n (%)	203 (17.2)	89 (41.0)	114 (11.8)	<0.001	47 (21.7)	<0.001
Postoperative complications, n (%)
Anastomotic leak / dehiscence	15 (1.3)	12 (5.5)	3 (0.3)	<0.001	0 (0.0)	<0.001
Wound dehiscence	8 (0.7)	3 (1.4)	5 (0.5)	0.34	1 (0.5)	0.62
Cardiac failure	36 (3.0)	19 (8.8)	17 (1.8)	<0.001	8 (3.7)	0.047
Fever / pyrexia of unknown origin	17 (1.4)	8 (3.7)	9 (0.9)	0.006	2 (0.9)	0.11
Wound haemorrhage	4 (0.3)	3 (1.4)	1 (0.1)	0.02	0 (0.0)	0.25
Deep wound haemorrhage	6 (0.5)	5 (2.3)	1 (0.1)	<0.001	0 (0.0)	0.06
Hypotension	28 (2.4)	18 (8.3)	10 (1.0)	<0.001	5 (2.3)	0.01
Wound infection	20 (1.7)	9 (4.1)	11 (1.1)	0.005	7 (3.2)	0.80
Deep wound infection	55 (4.7)	21 (9.7)	34 (3.5)	<0.001	11 (5.1)	0.10
Chest infection	20 (1.7)	10 (4.6)	10 (1.0)	<0.001	5 (2.3)	0.29
Urinary tract infection	9 (0.8)	5 (2.3)	4 (0.4)	0.014	1 (0.5)	0.22
Renal failure	49 (4.1)	26 (12.0)	23 (2.4)	<0.001	13 (6.0)	0.04
Respiratory failure	42 (3.6)	24 (11.1)	18 (1.9)	<0.001	9 (4.1)	0.01
Septicaemia	34 (2.9)	27 (12.4)	7 (0.7)	<0.001	2 (0.9)	<0.001
Deep vein thrombosis, pulmonary embolism	3 (0.3)	2 (0.9)	1 (0.1)	0.16	1 (0.5)	1.0
30-day mortality
Patients who died, n (%)	27 (2.3)	19 (8.8)	8 (0.8)	<0.001	6 (2.8)	0.013

^*Laparoscopic vs. Open.

IQR, interquartile range.

Outcome after propensity score matching analysis

Propensity score matching selected cohorts of patients (Supplementary Fig 1, top panels, Supplemental Digital Content 2, http://links.lww.com/JS9/A360) with similar demographic and preoperative characteristics when comparing open and laparoscopic approaches, except for sex in patients with acute appendicitis and pulse in patients with gastrointestinal tract perforation (Supplementary Tables 1-3, Supplemental Digital Content 2, http://links.lww.com/JS9/A360).

After propensity score matching, the length of hospital stay was significantly shorter when the laparoscopic approach was used instead of the open approach (Tables 1–3, and Fig. 1). This decrease was subtle in patients with acute appendicitis (open, 2 days [2–4]; lap, 2 days [1–4]; P<0.001), but relevant in patients with acute cholecystitis (open, 7 days [4–12]; lap, 4 days [3–6]; P<0.001) or gastrointestinal tract perforation (open, 11 days [7–17]; lap, 6 days [5–8.5]; P<0.001).

Figure 1.

Postoperative outcome of patients selected by propensity score matching, operated on for acute appendicitis, acute cholecystitis, or gastrointestinal tract perforation using an open or laparoscopic approach. Length of hospital stay values are depicted as median. Labels indicate P value, laparoscopic vs. open.

Similarly, after propensity score matching, the 30-day morbidity was significantly lower in patients operated by the laparoscopic approach compared with the open approach (Tables 1–3, and Fig. 1). A moderate decrease in 30-day morbidity was observed in patients with acute appendicitis (open, 15.7%; lap, 9.7%; P<0.001), while a decrease to almost half was observed in patients with acute cholecystitis (open, 41%; lap, 21.7%; P<0.001) or gastrointestinal tract perforation (open, 45.2%; lap, 23.5%; P<0.001).

Overall, the incidence of specific postoperative complications was low for acute appendicitis, and moderate / high for acute cholecystitis and gastrointestinal tract perforation after propensity score matching (Tables 1–3, and Supplementary Fig 2, Supplemental Digital Content 2, http://links.lww.com/JS9/A360). The laparoscopic approach showed uneven benefit depending on the condition. Thus, only the incidence of wound infection decreased in patients with acute appendicitis (open, 9.1%; lap, 1.9%; P<0.001), while only the incidence of respiratory failure decreased in patients with gastrointestinal tract perforation (open, 13.9%; lap, 4.3%; P=0.022). On the other hand, the laparoscopic approach reduced the incidence of several complications in patients with acute cholecystitis: anastomotic leak / dehiscence (open, 5.5%; lap, 0%; P<0.001), cardiac failure (open, 8.8%; lap, 3.7%; P=0.047), hypotension (open, 8.3%; lap, 2.3%; P=0.01), renal failure (open, 12%; lap, 6%; P=0.04), respiratory failure (open, 11.1%; lap, 4.1%; P=0.01), and septicaemia (open, 12.4%; lap, 0.9%; P<0.001).

After propensity score matching, the 30-day mortality in patients operated on for acute appendicitis was negligible for both the open and the laparoscopic approach (Tables 1–3, and Fig. 1). In contrast, a prominent decrease in 30-day mortality was found when using the laparoscopic approach in patients with acute cholecystitis (open, 8.8%; lap, 2.8%; P=0.013) or gastrointestinal tract perforation (open, 10.4%; lap, 1.7%; P=0.013).

For the sake of comparison with other published series, a separate analysis of patients with gastroduodenal ulcer perforation was performed. The propensity score matching analysis of patients with gastroduodenal ulcer perforation led to the selection of too few patients in each matched pair (n=39) (Supplementary Fig 1, bottom panels, Supplemental Digital Content 2, http://links.lww.com/JS9/A360), and made irrelevant the statistical comparison for morbidity and mortality (Supplementary Tables 4–5, Supplemental Digital Content 2, http://links.lww.com/JS9/A360). Only the length of hospital stays remained shorter when the laparoscopic approach was used for gastroduodenal ulcer perforation [open, 9 days (6.5–13); lap, 6 days (5–8); P=0.04].

Discussion

For patients with acute appendicitis, laparoscopic surgery resulted in a small but significant reduction in hospital stays and 30-day morbidity, although it did not have any effect on 30-day mortality. However, laparoscopic surgery saved 3 days of hospital stay for patients with acute cholecystitis and 5 days for patients with gastrointestinal tract perforation. Moreover, in patients with acute cholecystitis or perforation of the gastrointestinal tract, laparoscopic surgery led to a significant reduction in 30-day morbidity of 19.3% and 21.7%, respectively. For these conditions, laparoscopic surgery also resulted in a 6% and 8.7% reduction in 30-day mortality, respectively.

Acute appendicitis

A Cochrane review of 45 randomized controlled trials performed in adults prior to 2004 showed that laparoscopic appendectomy was associated with a lower risk of wound infection, and shortened hospital stay by 1.1 day⁸. In the early 2010s, several articles compared the laparoscopic and open approaches in acute appendicitis using propensity score matching analysis. A multicentre study with a small sample size carried out in patients with acute appendicitis operated on in US Veterans hospitals, found that 30-day morbidity was similar between open and laparoscopic approaches after propensity score matching¹¹. A study in a large sample of patients from the American Colle of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database showed that laparoscopic surgery shortened hospital stays by half a day, and decreased superficial wound infection and sepsis¹². A second study, in patients aged 65 years or older from the ACS-NSQIP database, found that the laparoscopic approach decreased hospital stays and overall 30-day morbidity, without influencing mortality¹³.

Data collected from the Taiwan National Health Insurance Research database on thousands of patients with acute appendicitis found that the laparoscopic approach reduced hospital stays and 30-day readmissions¹⁴. In those years, the percentage of laparoscopic surgery in the baseline population ranged from 33% in the Veterans and Taiwan studies, to 72% in the ACS-NSQIP studies. A recent multicenter study in China showed that laparoscopic surgery reduced wound infection and hospital stays, although a low percentage of laparoscopic surgery (40%) was used in the baseline population, and hospital stays were too long, 8 and 4 days, respectively, for the open and laparoscopic approaches¹⁵.

Recent data from 52 countries worldwide showed that laparoscopic surgery was associated with fewer complications even in low-income and middle-income countries, despite the limited use of this approach due to lack of resources⁴. Our findings, in a contemporary multicenter cohort of patients older than 14 years, with 70.8% use of laparoscopic surgery, showed that the laparoscopic approach slightly shortened hospital stays, and decreased overall 30-day morbidity, specifically, wound infection. These outcomes coincide with those of a recent single-centre study in our country¹⁶.

Acute cholecystitis

A study published in 2010, using propensity score matching analysis in patients older than 65 years of age with acute cholecystitis, showed that laparoscopic surgery shortened the length of hospital stays and reduced postoperative complications¹⁷. So far, we have found no other published articles that use propensity score matching analysis to compare postoperative outcomes of the laparoscopic or open approach in acute cholecystitis. This topic was reviewed in a meta-analysis of ten randomized controlled trials, which included more than 600 patients in each arm operated on in the 1990s and 2000s⁵. It therefore seemed appropriate to provide data obtained in a contemporary multicentre study. The aforementioned meta-analysis concluded that laparoscopic cholecystectomy reduced morbidity, mortality and hospital stays, as well as specific complications such as pneumonia and wound infection.

The findings of our multicenter study were consistent with these outcomes in terms of overall morbidity, mortality, and hospital stays. They only differed in specific complications that decreased with laparoscopic surgery. In our study, there was less anastomotic leak / dehiscence, cardiac failure, hypotension, renal failure, respiratory failure, and septicaemia. Laparoscopic cholecystectomy is the current standard procedure for acute cholecystitis. The mean percentage of unconverted laparoscopic surgery in our baseline population reached 81.6%, a common rate in most high-income countries.

Gastrointestinal tract perforation

In our study, the low number of patients with perforated gastroduodenal ulcer after propensity score matching prevented us from comparing specific outcomes such as 30-day morbidity and 30-day mortality, although we did find that laparoscopic surgery achieved a significant reduction in length of hospital stay. Several recent studies have examined, using propensity score matching, the influence of laparoscopic surgery vs. the open approach on the postoperative outcomes of patients with perforated gastroduodenal ulcer^18–22. It seems appropriate to speculate on possible reasons that could explain, at least in part, the differences in outcomes revealed by these studies. There is divergence in terms of length of hospital stays, global morbidity, and specific complications, but the most contradictory findings focus on the impact on mortality.

Two separate analyzes of the ACS-NSQIP database that spanned overlapping years and included unequal numbers of patients, found opposite outcomes in terms of 30-day mortality, with similar mortality rates for both approaches in one study and a lower mortality rate for laparoscopic surgery in the other^18,19. A Swedish multicenter study found no difference in 30-day mortality²⁰. The National Emergency Laparotomy Audit (NELA) of England found no difference in 90-day mortality²¹. A recent analysis of the ACS-NSQIP database revealed no difference in 30-day mortality²². Size and characteristics of the baseline population, administrative or clinically-derived database, multicenter or single-centre, prospective or retrospective design, percentage of use of laparoscopic surgery in the baseline population, conversion index, type of matching and caliper width used in the propensity score analysis, selection of lower-risk patients after propensity score matching, follow-up period (30 vs. 90 days), and characteristics of the health provision system, could all influence outcomes.

A recent meta-analysis of five randomized controlled trials that assigned a total of 300 patients with perforated gastroduodenal ulcer to each approach did not show significant differences in most complications, except for less wound infection after laparoscopic surgery⁹. The meta-analysis found a marginal decrease in hospital stays, although with variations due to the diversity of health provision models in each country. Likewise, the meta-analysis detected a marginal reduction in postoperative mortality rate that fell from 4.3% with the open approach to 1.6% after laparoscopic surgery. Therefore, it seems that additional studies are still needed in current series of patients with perforated gastroduodenal ulcer to clarify the likely advantages of laparoscopic surgery vs. the open approach.

Contrary to gastroduodenal ulcer perforation, few studies have used propensity score matching analysis to compare laparoscopic surgery vs. an open approach in the management of other gastrointestinal tract perforations. Two separate studies in patients undergoing sigmoidectomy for perforated diverticulitis showed that laparoscopic surgery shortened hospital stays and decreased morbidity, with no change in mortality^23,24. Similarly, a systematic review and meta-analysis by type of surgical approach used in the management of patients with iatrogenic colonic perforation as a complication of diagnostic and therapeutic colonoscopy concluded that, compared with the open approach, laparoscopic surgery shortened hospital stay and decreased postoperative morbidity⁶. In our study, the propensity score matching analysis showed that, compared to the open approach, laparoscopic surgery shortened the length of hospital stays, and decreased 30-day morbidity and 30-day mortality in patients with any perforation of the gastrointestinal tract.

The presence of peritonitis and sepsis is particularly important in cases of perforation. Both conditions were present in patients who underwent either laparoscopic or open surgery. Furthermore, patients’ baseline characteristics, such as peritoneal soiling and physiological and analytical parameters, were balanced using propensity score matching analysis. Therefore, our findings are likely to be applicable to the general population.

Although interventional studies and randomized controlled trials provide the best estimates of the effectiveness of a treatment or intervention, they do not provide the best estimates of the effectiveness of these actions in daily practice. Observational studies of unselected patients are likely to be the best source for estimating surgical outcomes. They provide the best estimates of the effectiveness of actions in daily practice, and lead to non-selected patient populations best suited for the estimation of surgical outcomes in real life^32,33. Therefore, the observational design may be considered as an additional strength of this multicenter study.

Limitations

By definition, patients in the propensity-matched groups have less physiological derangement and surgical risk than the baseline population. Therefore, caution should be exercised whenever the findings in these patients are transferred to the general population. In our study, this initial difference in the baseline population involved many characteristics in patients with acute cholecystitis, several in patients with gastrointestinal tract perforation, and a few in patients with acute appendicitis. The propensity score analysis selected patients to match the patient characteristics in both groups, except for sex in acute appendicitis and pulse in intestinal perforation, an occasional finding in this type of analysis¹⁰. Our study focused on the analysis of short-term outcomes of patients after surgery. It did not record conversion or readmission rates, medium-term or long-term outcomes, or information reported by patients related to quality of life.

Conclusions

This clinically based, multicentre study suggests that an initial laparoscopic approach is safe and achieves improved outcomes in all three conditions studied. The outcome improvement achieved by laparoscopic surgery is greater in acute cholecystitis and gastrointestinal tract perforation than in acute appendicitis. Therefore, laparoscopic surgery could be considered not only in patients with acute appendicitis or acute cholecystitis but also in patients with gastrointestinal tract perforation. However, due to the diversity of causes that lead to perforation and the unique characteristics of the different segments of the gastrointestinal tract, further comparative studies between laparoscopic and open approaches for the most prevalent conditions involved in gastrointestinal tract perforation are needed.

Ethical approval

The medical ethics committee at the General University Hospital in Alicante judged that no informed consent from the patients was necessary because of the observational nature of the study without additional burden for the patient. Subsequently, the ethics committee of the General University Hospital of Alicante approved (Ref CEIm: PI2018/104) the analysis of data.

Source of funding

This research was partially supported by research funds from the Institute of Health and Biomedical Research of Alicante (ISABIAL), Alicante, Spain (BOLA00060).

Author contribution

N.L.: conceptualization, data curation, formal analysis, investigation, methodology, writing—original draft, writing—review and editing. S.C.: data curation, investigation, validation. C.V.: conceptualization, data curation, formal analysis, investigation, methodology, project administration, resources, supervision, validation, visualization, writing—original draft, writing—review and editing, Guarantor of the study. P.Z.: conceptualization, data curation, formal analysis, investigation, methodology, resources, software, validation, writing—original draft, writing—review and editing. M.C.: conceptualization, formal analysis, data curation, investigation, methodology, project administration, resources, software, validation. L.M.: conceptualization, data curation, investigation, validation. J.M.R.: data curation, investigation, validation. F.L.: conceptualization, data curation, formal analysis, investigation, methodology, project administration, resources, supervision, validation, visualization, writing—original draft, writing—review and editing.

Conflicts of interest disclosure

None.

Research registration unique identifying number (UIN)

1. Name of the registry: www.researchregistry.com

2. Unique Identifying number or registration ID: researchregistry7097.

3. Hyperlink to your specific registration (must be publicly accessible and will be checked): https://www.researchregistry.com/browse-theregistry#home/registrationdetails/6128f5300e76e8001e3d2f56

Guarantor

Celia Villodre is the guarantor of the study.

Data statement

Due to the multicentre nature of the study, coordinators decided that raw data would remain confidential and would not be shared.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Supplementary Material

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js9-109-1603-s002.docx ^{(983.9KB, docx)}