Outcomes of bailout tube duodenostomy in management of hostile nonsalvageable perforated duodenal ulcer: a systematic review and meta-analysis.

INTRODUCTION: This study aimed to evaluate outcomes of tube duodenostomy in the management of hostile nonsalvageable perforated duodenal ulcer. METHODS: PRISMA statement standards were followed to conduct a systematic review with proportion meta-analysis. All studies with a minimum sample size of five patients reporting outcomes of tube duodenostomy in the management of hostile nonsalvageable perforated duodenal ulcer were included. Hostile nonsalvageable perforated duodenal ulcer was defined as ulcers associated with at least two of the following features: size ≥1.5cm; delayed presentation (≥72h); reoperation after failure of the primary repair; ulcers with friable and necrotic margins; haemodynamic instability. RESULTS: Six eligible studies including 116 patients were identified. Mean patient age was 48.4 years (95% confidence interval (CI), 43.2-53.5) and 73.4% (95% CI 54.7-92.1) were male. Mean defect size was 19.0mm (95% CI 17.2-20.8). Technical success was achieved in 97.9% (95% CI 0.95-1.00). Risk of 30-day mortality was 4.9% (95% 1.1-8.8). Risk of return to theatre due to leak was 2.6% (95% CI 0.0-6.0) and mean length of hospital stay was 18.0 days (95% CI 14.5-21.5). The likelihood of being discharged home was 95.1% (95% 91.2-98.9). GRADE certainty was moderate. CONCLUSIONS: Bailout tube duodenostomy is a safe strategy with favourable outcomes in the management of hostile nonsalvageable perforated duodenal ulcer (moderate certainty). Although comparative evidence is lacking, it may be considered as an alternative to bypass surgery, which is associated with longer operative time and high risks of morbidity in the presence of peritoneal contamination, sepsis and haemodynamic instability.