Intraoperative biopsy in peptic ulcer perforation: Is it necessary? A comprehensive analysis of prognostic factors for mortality and ICU admission

INTRODUCTION: The necessity of routine intraoperative biopsy during emergency surgery for peptic ulcer perforation (PUP) remains controversial when malignancy is not suspected. This study evaluated the diagnostic yield of intraoperative biopsy and identified prognostic factors for mortality and intensive care unit (ICU) admission.
METHODS: This retrospective single-center cohort included 77 adults undergoing emergency laparotomy for PUP, excluding tumor perforations and cases with radiological suspicion of malignancy. Clinical, laboratory, and perioperative variables, including Boey and PULP scores, were analyzed. Outcomes were compared between patients with and without intraoperative biopsy, and according to mortality and ICU admission. Postoperative endoscopy at one month was used for secondary malignancy screening
RESULTS: Intraoperative biopsy was performed in 58.4% of patients, detecting malignancy in only one case (1.3%). No malignancy was found on postoperative endoscopy in patients without intraoperative suspicion. Overall mortality was 11.7% and was significantly associated with advanced age, delayed presentation, larger perforation size, comorbidity, higher Boey and PULP scores, elevated creatinine, and hypoalbuminemia. ICU admission (84.4%) showed similar associations. Intraoperative biopsy had no significant impact on mortality or ICU requirement.
DISCUSSION AND CONCLUSION: Routine intraoperative biopsy provides minimal diagnostic benefit in the absence of macroscopic suspicion of malignancy. A selective approach, guided by intraoperative findings and supported by early postoperative endoscopy, appears safe and sufficient. Prognosis is mainly determined by patient-related and physiological factors, perforation severity, and established risk scores.

Keywords: Biopsy, emergency surgery, gastric malignancy, intraoperative peptic ulcer perforation