Surgeons' Perspectives on Intraoperative Biopsy in Perforated Gastric Ulcers: A Nationwide Survey from Türkiye

Objective: Intraoperative biopsy in perforated gastric ulcers has traditionally been widely used to exclude the risk of malignancy. However, despite accumulating evidence in recent years indicating a low incidence of malignancy, it remains unclear to what extent this approach has been adopted by surgeons. This study aims to evaluate the attitudes of general surgeons in Türkiye toward intraoperative biopsy in perforated gastric ulcers and to identify the factors influencing this decision. Materials and Methods: A descriptive, cross-sectional, nationwide survey was conducted among actively practicing general surgeons in Türkiye. A total of 361 surgeons were included. The structured questionnaire addressed demographic data, biopsy practices in perforated gastric ulcers, preferred surgical approaches, and postoperative endoscopy planning. Multivariable logistic regression analysis was performed to determine factors associated with routine intraoperative biopsy. Results: The mean age of participants was 41.4 ± 10.3 years, and the mean duration of surgical experience was 12.8 ± 9.7 years. Only 34.07% of surgeons correctly estimated the current malignancy risk (<5%) in perforated gastric ulcers; 115 participants (28.3%) did not provide a quantitative estimate. Among respondents, 54.57% reported performing routine intraoperative biopsy, 41.55% reported performing selective biopsy, and 3.88% reported performing no biopsy. Surgeons performing routine biopsy were older (42.6 ± 10.1 vs. 39.8 ± 10.1 years, p = 0.01) and more experienced (14.3 ± 9.7 vs. 11.0 ± 9.2 years, p = 0.002). In multivariable logistic regression, age (OR 1.02, 95% CI 0.95-1.10, p = 0.608), surgical experience (OR 1.01, 95% CI 0.93-1.09, p = 0.820), and perceived malignancy risk (OR 1.02, 95% CI 0.99-1.05, p = 0.116) were not independent predictors of routine biopsy. Postoperative endoscopy was recommended by 87.53% of participants. Conclusions: Routine intraoperative biopsy for perforated gastric ulcers remains widely practiced in Türkiye despite the low malignancy rates reported in the contemporary literature. Surgeons' biopsy decisions are largely influenced by perceived malignancy risk, experience, and traditional clinical approaches. These findings suggest that an evidence-based strategy relying on selective biopsy and planned postoperative endoscopy, rather than routine intraoperative biopsy, should be more effectively integrated into clinical practice.