Is Intraoperative Biopsy Necessary for Gastric Ulcer Perforation? A Systematic Review

Introduction: Gastric ulcer perforation is a life-threatening surgical emergency in which delay is poorly tolerated. In this setting a specimen is taken from ulcer margin to detect possible malignancy risk. The purpose of the present systematic review is to evaluate the need of intraoperative biopsy in gastric ulcer perforations using current biopsy-proven malignancy rates and its effect on complications. Methods: The review was carried out in line with the PRISMA guidelines and was registered (INPLASY202650135). Reports describing adults who operated on for a perforated gastric ulcer were considered. The principal endpoint was detection of malignancy. Malignancy proportions were combined within a random-effects model after Freeman-Tukey double-arcsine transformation, and statistical heterogeneity was quantified with the I² statistic. Results: Twelve reports were eligible for the review, amounting to 1122 patients. Of these, 953 individuals (64% men; average age 52 years) underwent sampling of the ulcer at operation. Twenty-seven patients had biopsy-proven malignancy on intraoperative histology; one additional patient had a false-negative intraoperative biopsy that was confirmed as malignant on postoperative endoscopy, so the biopsy-proven outcome was based on 27 events. The random-effects pooled proportion of biopsy-proven malignancy among patients with no previous gastric cancer diagnosis was 3.1% (95% CI 1.4-5.7%). There was substantial statistical heterogeneity between studies (I² = 72%; Cochran Q = 39.8, df = 11, p < 0.001). Sampling was omitted in 169 patients, and complications in patients with and without biopsy were contrasted in a single report only. In that single retrospective study, both total complications (46.4% vs. 11.8%, p = 0.007) and Clavien-Dindo grade ≥ III complications (34.5% vs. 5.9%, p = 0.017) occurred more often after biopsy since this signal derives from one single-centre comparison and may be confounded by ulcer complexity, so it ought to be treated as a hypothesis to be tested rather than as an established effect. Conclusions: The available evidence does not support the routine biopsy of all perforated gastric ulcers during surgery. However, as the evidence base is almost entirely retrospective and the included studies did not categorize lesions by size or appearance, a selective biopsy or intraoperative frozen section strategy may still be justified for large, chronic, mass-like, or otherwise suspicious ulcers, particularly in elderly patients.