Can Risk Scoring Systems Guide the Selection of Laparoscopic Repair in Emergency Perforated Peptic Ulcer? A Retrospective Cohort Study

<title>Abstract</title> <p>Background: Perforated peptic ulcer (PPU) carries substantial morbidity and mortality and remains a true surgical emergency. Laparoscopic repair is now used more often, but whether it outperforms open surgery is debated, partly because patients selected for laparoscopy differ from those taken to open surgery. Whether clinical risk scores or inflammatory markers can guide this choice is also unclear. We examined whether three clinical scores (Boey, PULP, ASA) and inflammatory and nutritional indices (NLR, SII, PNI) could identify patients who benefit more from laparoscopic than open repair of PPU. Methods: We retrospectively reviewed 525 patients operated on for PPU at a tertiary referral center (2015–2025), grouped as laparoscopic (LG, n = 189) or open (OG, n = 336) repair. The primary endpoint was major postoperative complications (Clavien-Dindo ≥ III); secondary endpoints were 30-day mortality, ICU admission, and length of hospital stay. Logistic regression models with interaction terms tested whether the scores and markers modified the effect of surgical approach, and subgroup analyses were performed to generate hypotheses. Results: Laparoscopic patients were younger (39.3 vs. 49.8 years, p &lt; 0.001), a difference that itself suggests selection bias. They had fewer major complications (6.3% vs. 22.3%, p &lt; 0.001), lower 30-day mortality (2.6% vs. 14.6%, p &lt; 0.001), fewer ICU admissions (15.3% vs. 37.5%, p &lt; 0.001), and a shorter stay. This advantage was not independently significant after adjusting for age, sex, and severity scores (adjusted OR 0.94, 95% CI 0.37–2.40, p = 0.891), consistent with confounding by indication. None of the scores or markers showed a significant interaction with surgical approach (all p &gt; 0.05). Subgroup analyses suggested a larger laparoscopic benefit in low-risk patients (Boey 0–1, PULP &lt; 8, PNI ≥ 45, perforation ≤ 10 mm), though no significant interaction supported this. Conclusions: Unadjusted analyses favor laparoscopic repair, but this apparent benefit is primarily attributable to patient selection rather than the procedure itself. Although the prognostic scores and biomarkers evaluated show strong predictive validity, they do not guide the choice of surgical approach. More sophisticated, patient-specific decision-support tools remain an unmet need in the management of perforated peptic ulcer.</p>