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Tratamiento quirúrgico de la úlcera péptica perforada: comparación entre los abordajes laparoscópico y abierto
A comparison of laparoscopic versus open repair for the surgical treatment of perforated peptic ulcers
Gerardo Domínguez-Vega, Manuel Pera
Autor para correspondencia
pera@parcdesalutmar.cat

Autor para correspondencia.
, José M. Ramón, Sonia Puig, Estela Membrilla, Joan Sancho, Luis Grande
Sección de Cirugía Gastrointestinal, Hospital Universitario del Mar, Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona, Barcelona, España
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Los pacientes fueron operados por un cirujano adjunto o por un residente bajo la supervisi&#243;n de un adjunto&#46; La decisi&#243;n de realizar un procedimiento laparosc&#243;pico o abierto se dej&#243; a discreci&#243;n del cirujano adjunto y dependi&#243; de su experiencia en cirug&#237;a m&#237;nimamente invasiva&#46; Se excluy&#243; a aquellos pacientes que presentaron evidencia de hemorragia digestiva durante el preoperatorio&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Variables del estudio</span><p id="par0020" class="elsevierStylePara elsevierViewall">Se recogieron los siguientes datos&#58; edad&#44; sexo&#44; duraci&#243;n de los s&#237;ntomas&#44; consumo de tabaco&#44; consumo de alcohol&#44; consumo de antiinflamatorios no esteroideos &#40;AINE&#41;&#44; consumo de coca&#237;na y sus derivados&#44; consumo de cannabis y sus derivados&#44; comorbilidades&#44; clasificaci&#243;n del riesgo quir&#250;rgico seg&#250;n la American Society of Anestesiologists &#40;ASA&#41;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#44; &#237;ndice pron&#243;stico de Boey<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#44; cirug&#237;as abdominales previas&#44; la frecuencia cardiaca en el momento del ingreso&#44; estado de shock en el momento de la admisi&#243;n &#40;presi&#243;n sist&#243;lica &#60;&#160;80<span class="elsevierStyleHsp" style=""></span>mm&#160;Hg&#41;&#44; n&#250;mero de leucocitos en el hemograma realizado al llegar al hospital&#44; evidencia o no de aire libre en las radiograf&#237;as simples y tomograf&#237;a computarizada &#40;TC&#41;&#44; tipo de procedimiento quir&#250;rgico &#40;abierto o laparosc&#243;pico&#41;&#44; tipo de reparaci&#243;n realizada sobre la perforaci&#243;n&#44; tiempo operatorio &#40;definido como el tiempo transcurrido desde la incisi&#243;n inicial en piel hasta el cierre de la misma&#41;&#44; tiempo de estancia en el quir&#243;fano &#40;definido como el tiempo transcurrido desde su entrada en el quir&#243;fano hasta su salida&#41;&#44; localizaci&#243;n de la perforaci&#243;n&#44; tama&#241;o de la perforaci&#243;n&#44; necesidad de conversi&#243;n a cirug&#237;a abierta&#44; complicaciones y su clasificaci&#243;n seg&#250;n Dindo-Clavien<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#44; tiempo de uso de sonda nasog&#225;strica durante el periodo postoperatorio&#44; tiempo de reinicio de la ingesta oral y el tiempo de estancia hospitalaria&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">An&#225;lisis estad&#237;stico</span><p id="par0025" class="elsevierStylePara elsevierViewall">Se analizaron los datos de acuerdo con el principio de la intenci&#243;n de tratar&#46; Los datos se presentan como mediana con su rango m&#225;ximo y m&#237;nimo para las variables cuantitativas y como frecuencias absolutas y relativas para las variables cualitativas&#46; Las variables categ&#243;ricas se expresaron como n&#250;mero y porcentajes&#46; Se utiliz&#243; la prueba t de Student para la comparaci&#243;n de variables continuas&#46; Las variables categ&#243;ricas y binarias fueron evaluadas con la prueba de 2 colas de Pearson&#44; la prueba de X<span class="elsevierStyleSup">2</span> con correcci&#243;n de Yates o la prueba exacta de Fisher&#46; La prueba U de Mann Whitney se utiliz&#243; para otros datos cuantitativos no param&#233;tricos&#46; Se consideraron los valores de p&#160;&#60;&#160;0&#44;05 como estad&#237;sticamente significativos&#46; Para realizar el an&#225;lisis se utiliz&#243; el Statistical Package for the Social Sciences versi&#243;n 20&#46;0 &#40;SPSS Inc&#46;&#44; Chicago&#44; IL&#44; EE&#46;&#160;UU&#46;&#41;&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Resultados</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Datos demogr&#225;ficos y cl&#237;nicos</span><p id="par0030" class="elsevierStylePara elsevierViewall">Durante el periodo de estudio se oper&#243; a 112 pacientes con UPP&#44; 52 por v&#237;a abierta y 60 por v&#237;a laparosc&#243;pica&#46; Se observ&#243; una frecuencia constante de 11 casos por a&#241;o con un predominio en los meses de marzo&#44; julio y diciembre&#46; Las caracter&#237;sticas demogr&#225;ficas de los 2 grupos se muestran en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46; Destaca que los pacientes operados por v&#237;a laparosc&#243;pica eran significativamente m&#225;s j&#243;venes&#44; el tiempo de evoluci&#243;n de los s&#237;ntomas agudos que condujeron a la intervenci&#243;n quir&#250;rgica era menor y el consumo de tabaco&#44; alcohol y cannabis era mayor&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a> figuran los datos cl&#237;nicos de los pacientes al ingreso en el servicio de urgencias&#46; No se observaron diferencias significativas entre ambos grupos&#44; a excepci&#243;n de que entre los pacientes intervenidos por cirug&#237;a laparosc&#243;pica exist&#237;a una mayor concentraci&#243;n de pacientes con puntuaci&#243;n 0 y 1 en la escala de Boey&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Por lo que respecta a las variables quir&#250;rgicas recogidas &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#44; no se observaron diferencias significativas con relaci&#243;n a la localizaci&#243;n y tama&#241;o de la perforaci&#243;n&#46; Pr&#225;cticamente a todos los pacientes se les realiz&#243; una sutura simple de la &#250;lcera con o sin omentoplastia asociada&#46; El tiempo operatorio y el tiempo de ocupaci&#243;n de quir&#243;fano fueron significativamente m&#225;s largos en el grupo laparosc&#243;pico&#46; El procedimiento laparosc&#243;pico pudo ser completado en 45 pacientes y en 15 &#40;25&#37;&#41; pacientes fue necesario convertir a un procedimiento abierto por las siguientes causas&#58; dificultad para identificar el sitio de la perforaci&#243;n &#40;11 casos&#41;&#44; bordes friables de la &#250;lcera &#40;3 casos&#41; y un caso con una &#250;lcera de 30<span class="elsevierStyleHsp" style=""></span>mm de di&#225;metro&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">En relaci&#243;n con los datos del periodo postoperatorio inmediato&#44; no se observaron diferencias en el tiempo de uso de la sonda nasog&#225;strica &#40;48 vs&#46; 48&#160;h&#41; ni en el tiempo de reinicio de la ingesta oral &#40;72 vs&#46; 72&#160;h&#41;&#46; La mediana de la estancia hospitalaria fue de 8 &#40;3-50&#41; d&#237;as para el grupo abierto y de 6 &#40;3-40&#41; d&#237;as para el grupo laparosc&#243;pico&#44; siendo esta diferencia estad&#237;sticamente significativa &#40;p&#160;&#61;&#160;0&#44;04&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Morbimortalidad</span><p id="par0045" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a> se resumen las complicaciones en ambos grupos&#46; No se observaron diferencias estad&#237;sticamente significativas en ninguna de las variables analizadas&#46; Cuatro pacientes del grupo laparosc&#243;pico presentaron evidencia de dehiscencia de la sutura&#46; Tres casos se resolvieron con tratamiento m&#233;dico a base de antibi&#243;ticos&#44; drenaje percut&#225;neo y el uso de la nutrici&#243;n parenteral total &#40;NPT&#41;&#44; pero un caso precis&#243; una reintervenci&#243;n y se le realiz&#243; una antrectom&#237;a con anastomosis gastroyeyunal en Y de Roux&#46; Se observaron 3 muertes en el grupo abierto&#46; El primer paciente falleci&#243; por un tromboembolismo pulmonar masivo&#59; el segundo&#44; debido a un fallo org&#225;nico m&#250;ltiple despu&#233;s de presentar una sepsis grave de origen respiratorio&#59; y el &#250;ltimo fue un paciente que lleg&#243; al hospital en estado de shock e intubado y que falleci&#243; en las primeras 24&#160;h postoperatorias&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discusi&#243;n</span><p id="par0050" class="elsevierStylePara elsevierViewall">Este estudio demuestra que el abordaje laparosc&#243;pico para el tratamiento de la UPP es una opci&#243;n segura y viable&#44; con una reducci&#243;n significativa de la estancia hospitalaria&#46; Sin embargo&#44; estas conclusiones deben ser matizadas en el contexto del dise&#241;o del estudio&#46; No se trata de un estudio prospectivo aleatorizado&#44; sino de un estudio retrospectivo de 2 cohortes contempor&#225;neas en las que se realiz&#243; una u otra t&#233;cnica seg&#250;n el criterio y la experiencia del equipo quir&#250;rgico&#46; Un punto fuerte&#44; sin embargo&#44; es la minuciosidad de la revisi&#243;n de los datos&#44; al disponer el hospital de una historia cl&#237;nica informatizada con acceso a los datos de los pacientes de los centros de Atenci&#243;n Primaria&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">La poblaci&#243;n incluida en este estudio&#44; si se analiza de forma global&#44; no difiere de la de otros estudios que analizan diferentes aspectos de la UPP y&#44; muy especialmente&#44; de las 2 &#250;ltimas revisiones publicadas en 2010<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a>&#46; El enfermo tipo ser&#237;a un paciente var&#243;n&#44; de 50 a&#241;os&#44; de los que solo una cuarta parte tiene antecedentes de historia ulcerosa&#44; pero que muy probablemente tiene alg&#250;n tipo de comorbilidad y asocia un consumo de t&#243;xicos como el tabaco o el alcohol&#44; e incluso drogas&#46; Si hacemos referencia al momento en que el paciente acude a urgencias&#44; nos encontrar&#237;amos ante un paciente con un &#237;ndice de riesgo bajo &#40;seg&#250;n las clasificaciones ASA y de Boey&#41;&#44; taquic&#225;rdico y con leucocitosis&#46; Al igual que en otras publicaciones<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#44; son muy pocos los pacientes que presentan un estado de shock en el momento de su ingreso&#46; Llama la atenci&#243;n en nuestro estudio que&#44; al contrario de otras publicaciones<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21</span></a>&#44; la visualizaci&#243;n de una de las caracter&#237;sticas m&#225;s importantes para confirmar el diagn&#243;stico&#44; como es la presencia de neumoperitoneo&#44; solo haya sido posible en menos de la mitad de los pacientes utilizando la radiolog&#237;a simple&#46; Sin embargo&#44; con la adici&#243;n de la TC&#44; esta se elev&#243; al 93&#37;&#44; una cifra incluso superior a otros estudios<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#46; Al analizar las cohortes sometidas a abordaje convencional o laparosc&#243;pico se pueden apreciar algunas diferencias&#44; probablemente inherentes al dise&#241;o del estudio&#46; Por una parte&#44; los pacientes en los que se utiliz&#243; la v&#237;a laparosc&#243;pica fueron significativamente m&#225;s j&#243;venes&#44; con menos comorbilidades asociadas y&#44; seguramente relacionado con su juventud&#44; con un mayor consumo de alcohol&#44; tabaco y drogas&#46; Tambi&#233;n en ellos&#44; el &#237;ndice pron&#243;stico de Boey y la duraci&#243;n de los s&#237;ntomas que llevaron al paciente al servicio de urgencias fue significativamente menor&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Desde el punto de vista quir&#250;rgico&#44; los pacientes fueron operados 90&#160;min despu&#233;s del diagn&#243;stico&#44; presentaron habitualmente &#250;lceras prepil&#243;ricas y&#44; en la gran mayor&#237;a&#44; se realiz&#243; una sutura simple con o sin omentoplastia&#44; sin que se observasen diferencias estad&#237;sticamente significativas entre los 2 grupos analizados&#44; a excepci&#243;n de que los tiempos operatorios y de utilizaci&#243;n de quir&#243;fano fueron significativamente mayores entre los pacientes incluidos en el grupo laparosc&#243;pico&#46; Conviene se&#241;alar que el an&#225;lisis estad&#237;stico de este estudio se realiz&#243; bajo el principio de &#171;intenci&#243;n de tratar&#187; y&#44; dado que entre los pacientes en los que la cirug&#237;a se inici&#243; por v&#237;a laparosc&#243;pica fue necesaria la conversi&#243;n a cirug&#237;a abierta en el 25&#37; de los casos&#44; este factor puede influir en las diferencias observadas&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">La mortalidad global de este estudio es inferior al 3&#37;&#44; mucho m&#225;s baja que en otras series publicadas recientemente en las que se llega al 6-18&#37;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#8211;24</span></a>&#46; Se han descrito 4 factores que pueden aumentar esta tasa hasta el 100&#37;&#58; edad &#62;&#160;60 a&#241;os&#44; tratamiento tard&#237;o &#40;&#62;&#160;24&#160;h&#41;&#44; el estado de shock al ingreso y las enfermedades concomitantes<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a>&#46; Tambi&#233;n se ha observado una mortalidad 2 o 3 veces superior en los pacientes con perforaciones g&#225;stricas<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;27</span></a>&#46; Teniendo en cuenta algunas de estas variables&#44; Boey et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> propusieron una escala de riesgo que ha sido validada por otros autores<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;28&#8211;30</span></a>&#46; Llama la atenci&#243;n en nuestro estudio que toda la mortalidad se haya concentrado en el grupo de pacientes sometidos a cirug&#237;a abierta pero&#44; tal como puede deducirse del an&#225;lisis de las causas&#44; es dif&#237;cil relacionarla con la v&#237;a de abordaje&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Al igual que en otros trabajos&#44; las complicaciones m&#225;s frecuentes tras la cirug&#237;a de la UPP fueron el &#237;leo paral&#237;tico y las infecciones respiratorias y de la herida quir&#250;rgica&#46; Sin embargo&#44; no se observaron diferencias en la morbilidad postoperatoria&#44; analizada de forma global&#44; mediante la clasificaci&#243;n de Dindo-Clavien o de forma pormenorizada para cada una de las complicaciones&#44; entre los 2 grupos de pacientes tratados&#46; En un an&#225;lisis espec&#237;fico&#44; llama la atenci&#243;n que todas las dehiscencias de sutura se concentren en el grupo sometido a cirug&#237;a laparosc&#243;pica&#46; Es probable que esta mayor incidencia pueda estar en relaci&#243;n con la dificultad del procedimiento por v&#237;a laparosc&#243;pica&#44; lo que enfatiza la necesidad de disponer de un cirujano con experiencia en cirug&#237;a m&#237;nimamente invasiva para afrontar este procedimiento&#46; En nuestro centro la t&#233;cnica de elecci&#243;n es la sutura simple&#44; reforzada o no con omentoplastia&#46; Algunos autores han probado t&#233;cnicas sin sutura&#44; utilizando pegamentos de fibrina o esponjas de gelatina&#44; pero su utilidad&#44; si la hubiera&#44; estar&#237;a centrada en perforaciones de peque&#241;o tama&#241;o<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;19</span></a>&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">En conclusi&#243;n&#44; el tratamiento quir&#250;rgico de la UPP por v&#237;a laparosc&#243;pica es seguro y proporciona algunas ventajas frente a la cirug&#237;a abierta&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicto de intereses</span><p id="par0080" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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              "titulo" => "Datos demogr&#225;ficos y cl&#237;nicos"
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              "titulo" => "Morbimortalidad"
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          "titulo" => "Agradecimientos"
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          "titulo" => "Bibliograf&#237;a"
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    "fechaRecibido" => "2012-08-08"
    "fechaAceptado" => "2012-10-14"
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec177969"
          "palabras" => array:5 [
            0 => "&#218;lcera p&#233;ptica"
            1 => "Perforaci&#243;n"
            2 => "Diagn&#243;stico"
            3 => "Cirug&#237;a"
            4 => "Laparoscopia"
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          "clase" => "keyword"
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          "palabras" => array:5 [
            0 => "Peptic ulcer"
            1 => "Perforation"
            2 => "Diagnosis"
            3 => "Surgery"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Analizar los resultados del abordaje quir&#250;rgico laparosc&#243;pico frente al abierto en el tratamiento de las &#250;lceras p&#233;pticas perforadas &#40;UPP&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Pacientes y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo de todos los pacientes operados de una UPP durante el periodo enero de 2002-marzo de 2012&#46; Se analizaron datos demogr&#225;ficos&#44; tiempo operatorio&#44; complicaciones y estancia hospitalaria&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se incluy&#243; a 112 pacientes &#40;mediana&#44; 49 a&#241;os&#41;&#44; 60 en el grupo laparosc&#243;pico y 52 en el grupo abierto&#46; Los pacientes operados por v&#237;a laparosc&#243;pica eran significativamente m&#225;s j&#243;venes y ten&#237;an un mayor consumo de tabaco&#44; alcohol y cannabis&#46; La mediana de duraci&#243;n de los s&#237;ntomas agudos fue menor en los pacientes del grupo laparosc&#243;pico &#40;6&#160;h&#41; en comparaci&#243;n con los del grupo abierto &#40;12&#160;h&#41;&#46; La mediana del tiempo operatorio fue significativamente mayor en los pacientes del grupo laparosc&#243;pico &#40;104&#44;5 vs&#46; 76&#160;min&#59; p&#160;&#61;&#160;0&#44;025&#41;&#46; El porcentaje de conversi&#243;n a cirug&#237;a abierta fue del 25&#37;&#46; La morbilidad fue similar en ambos grupos&#44; pero 3 pacientes fallecieron en el grupo abierto&#46; La mediana de estancia hospitalaria fue significativamente menor en el grupo laparosc&#243;pico &#40;6 vs&#46; 8 d&#237;as&#59; p&#160;&#61;&#160;0&#44;041&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusi&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El abordaje por v&#237;a laparosc&#243;pica es una t&#233;cnica segura y comparable a la cirug&#237;a abierta en el tratamiento de la UPP&#44; con la que el paciente se beneficia de una estancia hospitalaria m&#225;s corta&#46;</p>"
      ]
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objective</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">To analyse the outcomes of laparoscopic versus open repair for perforated peptic ulcers &#40;PPU&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">All patients undergoing PPU repair between January 2002 and March 2012 were included in the study&#46; Demographic characteristics&#44; operation time&#44; complications&#44; and length of hospital stay were evaluated&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Two hundred and twelve patients &#40;median age&#44; 49 years&#41; were included&#44; 60 in the laparoscopic group and 52 in the open group&#46; Patients operated laparoscopically were significantly younger and had a higher consumption of tobacco&#44; alcohol and cannabis&#46; Median acute symptoms time was shorter in the laparoscopic group &#40;6<span class="elsevierStyleHsp" style=""></span>h&#41; compared to the open group &#40;12<span class="elsevierStyleHsp" style=""></span>h&#59; <span class="elsevierStyleItalic">P</span>&#61;&#46;025&#41; Symptoms time was shorter in the laparoscopic group&#46; Median operating time was significantly longer in the laparoscopic group &#40;104&#46;5<span class="elsevierStyleHsp" style=""></span>min vs&#46; 76<span class="elsevierStyleHsp" style=""></span>min&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;025&#41;&#46; The percentage of conversion to open repair was 25&#37;&#46; There was no difference in morbidity between 2 groups&#44; but there were 3 deaths in the open group&#46; Median hospital stay was significantly shorter in patients treated laparoscopically when compared with the open group &#40;6 days vs&#46; 8 days&#59; <span class="elsevierStyleItalic">P</span>&#61;&#46;041&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Laparoscopic and open repair are equally safe in the management of PPU&#46; A shorter hospital stay can be achieved in the laparoscopic group&#46;</p>"
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Evidencia de aire libre</span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Radiolog&#237;a simple&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tomograf&#237;a computarizada&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No detectado en pruebas de imagen&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Clasificaci&#243;n ASA</span><a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a><span class="elsevierStyleItalic">&#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>II&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>III&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>IV&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;5&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Puntuaci&#243;n de Boey</span><a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a><span class="elsevierStyleItalic">&#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">37 &#40;33&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Tiempo diagn&#243;stico-quir&#243;fano &#40;minutos&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  """
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>G&#225;strica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Prepil&#243;rica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pil&#243;rica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Duodenal&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31 &#40;27&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Tama&#241;o de la perforaci&#243;n &#40;mm&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Conversi&#243;n a cirug&#237;a abierta &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Tipo de reparaci&#243;n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sutura simple&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61 &#40;54&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sutura simple &#43; epiploplastia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47 &#40;42&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Piloroplastia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;2&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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Información del artículo
ISSN: 0009739X
Idioma original: Español
DOI:10.1016/j.ciresp.2012.10.016
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