Considerations of Surgeons for Intraoperative Biopsy in the Setting of Gastric Ulcer Perforation

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 aimed 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: This descriptive, cross-sectional survey study was conducted among actively practicing general surgeons across Türkiye. A total of 361 surgeons were included. The survey included 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 24.2% of surgeons correctly estimated the current malignancy risk (<5%) in perforated gastric ulcers; 102 participants did not provide a quantitative estimate. Among respondents, 52.9% reported performing routine biopsy, 42.9% selective biopsy, and 4.2% no biopsy. In multivariable analysis, age, surgical experience, and perceived malignancy risk were associated with routine biopsy; however, these relationships did not reach independent statistical significance. The vast majority of participants (87.0%) recommended postoperative endoscopy. Conclusion: In Türkiye, intraoperative biopsy in perforated gastric ulcers continues to be widely practiced despite the low malignancy rates reported in 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.