1. Randomized Clinical Trial of Laparoscopic Versus Open Repair of the Perforated Peptic Ulcer: The LAMA Trial Marietta J. O. E. Bertleff, Jens A. Halm, Willem A. Bemelman, Arie C. van der Ham, Erwin van der Harst, Hok I. Oei, J. F. Smulders, E. W. Steyerberg, Johan F. Lange

2. Background Laparoscopic surgery has become popular during the last decade, mainly because it is associated with fewer postoperative complications than the conventional open approach. It remains unclear, however, if this benefit is observed after laparoscopic correction of perforated peptic ulcer (PPU).

3. Objective The goal of the present study was to evaluate whether laparoscopic closure of a PPU is as safe as conventional open correction using a multicenter randomized trial.

4. Methods: Participants The study was based on a randomized controlled trial in which nine medical centers from the Netherlands participated (March 2009 to July 2005). A total of 109 patients with symptoms of PPU and evidence of air under the diaphragm were scheduled to receive a PPU repair.

5. Methods: Participants Exclusion criteria: – inability to read the Dutch language patient information booklet – inability to complete informed consent – prior upper abdominal surgery and current pregnancy. After exclusion of 8 patients during the operation, outcomes were analyzed for laparotomy (n = 49) and for the laparoscopic procedure (n = 52)

6. Methods: Randomization Randomization took place by opening a sealed envelope. The envelope randomization was based on a computer-generated list provided by the trial statistician.

7. Methods: Surgical Procedure All patients received intravenous antibiotics prior to operation and were allocated for Helicobacter pylori eradication therapy. The open surgical procedure was performed through an upper abdominal midline incision. Closure of PPU was to be achieved by sutures alone or in combination with an omental patch.

8. Methods: Surgical Procedure Laparoscopic repair was performed with the patient and the team set up in the ‘‘French’’ position. Trocars were placed at the umbilicus (video scope) and on the left and right midclavicular line above the level of the umbilicus (instruments). If necessary a fourth trocar was placed in the subxiphoid space for lavage or retraction of the liver. The rest of the procedure was identical to that described for open repair.

9. Methods: Postoperative Follow-up Postoperative pain was scored by means of a visual analog scale (VAS) for pain on days 1, 3, 7, and 28 ranging from 0 (no pain) to 10 (severe pain). The days during which opiates were used by the patients were registered. All complications, minor and major, and length of hospital stay were monitored.

10. Methods: Statistical analysis Data analysis was carried out according to the intention-to- treat principle as established in the trial protocol. Data were collected in a database, and statistical analyses were per- formed with the Statistical Package for Social Sciences for Windows (SPSS 15.0, SPSS Inc., Chicago, IL). A researcher blinded to the nature of the procedures performed all data analyses.

11. Methods: Statistical Analysos The primary outcome of the trial was duration of hospital stay. – The power analysis was performed on basis of a reduction in hospital stay by 1.5 days (10–8.5 days from admission) in favor of the laparoscopically treated group using a b of 0.80 and an a of 0.05. This resulted in a trial size of 50 patients per group. Null hypotheses were tested two-sided and a P value of 0.05 or less was considered statistical significant.

12. Results

13. Table 1: Baseline Parameters

14. Table 2. Intraoperative Findings

15. Intraoperative complications Four patients on the laparoscopic group were required to convert to the open surgery group. Inability to visualize the ulcer defect because of bleeding (n=1/52) Inability to reach the defect because of the perforation in the vicinity of the gastroduodenal ligament and because of dorsal gastric ulcer (n=2/52) Inability to find the perforation (n=1/52)

16. Table 3.Postoperative Complications

17. Table 4. Duration of Hospital stay

18. Table 5. Postoperative Pain

19. Discussions

20. Since eight out of 109 patients were discovered to have a diagnosis different than PPU, this study supported the benefit of using laparoscopy as a diagnostic procedure. Conversion rate in the laparoscopy group were much lower than the reported literature (8% vs 60%), although this can be attributed to the fact that only trained and experienced (more than 50 procedures year) participated in the study.

21. Operating time was significantly longer in the laparoscopy group (75min vs 50min) which may be due to the following: – Laparoscopic suturing is more demanding – Longer irrigation procedure

22. This study further support the evidence that laparoscopic correction of PPU causes less postoperative pain. This study also proves the cosmetic benefit of laparoscopic surgery because it decreases the awareness or concern of the patients with the appearance of scars, as supported by the VAS scores. However, no statistical difference were noted on the hospital stay of both groups.

23. Conclusion This LAMA trial confirm the results of other trials that laparoscopic correction of PPU is safe, feasible for the experienced laparoscopic surgeon, and causes less operative pain. Operating time was longer in the laparoscopic group. No difference in the length of hospital stay or incidence of postoperative complications.

24. Thank You