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Huang YK, Wu KT, Su YS, Chen CY, Chen JH. Predicting in-hospital mortality risk for perforated peptic ulcer surgery: the PPUMS scoring system and the benefit of laparoscopic surgery: a population-based study. Surg Endosc 2023; 37:6834-6843. [PMID: 37308764 DOI: 10.1007/s00464-023-10180-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 05/30/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND The major treatment for perforated peptic ulcers (PPU) is surgery. It remains unclear which patient may not get benefit from surgery due to comorbidity. This study aimed to generate a scoring system by predicting mortality for patients with PPU who received non-operative management (NOM) and surgical treatment. METHOD We extracted the admission data of adult (≥ 18 years) patients with PPU disease from the NHIRD database. We randomly divided patients into 80% model derivation and 20% validation cohorts. Multivariate analysis with a logistic regression model was applied to generate the scoring system, PPUMS. We then apply the scoring system to the validation group. RESULT The PPUMS score ranged from 0 to 8 points, composite with age (< 45: 0 points, 45-65: 1 point, 65-80: 2 points, > 80: 3 points), and five comorbidities (congestive heart failure, severe liver disease, renal disease, history of malignancy, and obesity: 1 point each). The areas under ROC curve were 0.785 and 0.787 in the derivation and validation groups. The in-hospital mortality rates in the derivation group were 0.6% (0 points), 3.4% (1 point), 9.0% (2 points), 19.0% (3 points), 30.2% (4 points), and 45.9% when PPUMS > 4 point. Patients with PPUMS > 4 had a similar in-hospital mortality risk between the surgery group [laparotomy: odds ratio (OR) = 0.729, p = 0.320, laparoscopy: OR = 0.772, p = 0.697] and the non-surgery group. We identified similar results in the validation group. CONCLUSION PPUMS scoring system effectively predicts in-hospital mortality for perforated peptic ulcer patients. It factors in age and specific comorbidities is highly predictive and well-calibrated with a reliable AUC of 0.785-0.787. Surgery, no matter laparotomy or laparoscope, significantly reduced mortality for scores < = 4. However, patients with a score > 4 did not show this difference, calling for tailored approaches to treatment based on risk assessment. Further prospective validation is suggested.
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Affiliation(s)
- Yi-Kai Huang
- Bariatric and Metabolism International Surgery Center, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Kun-Ta Wu
- Bariatric and Metabolism International Surgery Center, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Yi-Shan Su
- Division of General Surgery, E-Da Hospital, Kaohsiung, Taiwan
| | - Chung-Yen Chen
- Division of General Surgery, E-Da Hospital, Kaohsiung, Taiwan
- Bariatric and Metabolism International Surgery Center, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Jian-Han Chen
- Division of General Surgery, E-Da Hospital, Kaohsiung, Taiwan.
- Bariatric and Metabolism International Surgery Center, E-Da Hospital, Kaohsiung, Taiwan.
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan.
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Guan F, Han W, Ni T, Zhao L, Zhang B, Li M, Luo X, Zhang L, Li X, Sun W, Zhang T. Risk of gastric ulcer contributed by genetic polymorphisms of PSCA: A case-control study based on Chinese Han population. Gene 2020; 757:144941. [PMID: 32640304 DOI: 10.1016/j.gene.2020.144941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 05/29/2020] [Accepted: 07/01/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Fanglin Guan
- College of Medicine and Forensics, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Wei Han
- College of Medicine and Forensics, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Tong Ni
- College of Medicine and Forensics, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Longrui Zhao
- College of Medicine and Forensics, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Bo Zhang
- School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, China
| | - Miao Li
- Department of Pathology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xiaoqin Luo
- Department of Nutrition and Food Safety, School of Public Health, Xi'an Jiaotong University, Xi'an, China
| | - Lei Zhang
- Department of Laboratory Medicine, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xiaoming Li
- Department of Emergency, Shaanxi People's Hospital, Xi'an, China
| | - Wei Sun
- Department of Digestion, Xi'an Central Hospital, Xi'an, China
| | - Tianxiao Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China.
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Abstract
Perforated peptic ulcers continue to be an important problem in surgical practice. In this study, risk factors for peptic ulcer perforation-associated mortality and morbidity were evaluated. This is a retrospective study of patients surgically treated for perforated peptic ulcer over a decade (March 1999–December 2014). Patient age, sex, complaints at presentation, time lapse between onset of complaints and presentation to the hospital, physical findings, comorbidities, laboratory and imaging findings, length of hospitalization, morbidity, and mortality were recorded. The Mannheim peritonitis index (MPI) and Acute Physiology and Chronic Health Evaluation (APACHE) II score were calculated and recorded for each patient on admission to the hospital. Of the 149 patients, mean age was 50.6 ± 19 years (range: 17–86). Of these, 129 (86.5%) were males and 20 (13.4%) females. At least 1 comorbidity was found in 42 (28.1%) of the patients. Complications developed in 36 (24.1%) of the patients during the postoperative period. The most frequent complication was wound site infection. There was mortality in 26 (17.4%) patients and the most frequent cause of mortality was sepsis. Variables that were found to have statistically significant effects on morbidity included age older than 60 years, presence of comorbidities, and MPI (P = 0.029, 0.013, and 0.013, respectively). In a multivariate analysis, age older than 60 years, presence of comorbidities, and MPI were independent risk factors that affected morbidity. In the multivariate logistic regression analysis, age older than 60 years [P = 0.006, odds ratio (OR) = 5.99, confidence interval (CI) = 0.95] and comorbidities (OR = 2.73, CI = 0.95) were independent risk factors that affected morbidity. MPI and APACHE II scoring were both predictive of mortality. Age older than 60, presentation time, and MPI were independent risk factors for mortality. Undelayed diagnosis and appropriate treatment are of the utmost importance when presenting with a perforated peptic ulcer. We believe close observation of high-risk patients during the postoperative period may decrease morbidity and mortality rates.
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Shibukawa N, Ouchi S, Wakamatsu S, Wakahara Y, Tatsumi N, Kaneko A. A Rare Case of Gastric Ulcer Penetrating the Pancreas that was Successfully Managed by Conservative Therapy. Intern Med 2017; 56:2277-2279. [PMID: 28794357 PMCID: PMC5635298 DOI: 10.2169/internalmedicine.8188-16] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
A 62-year-old woman was admitted to our hospital with septic shock due to left submandibular osteomyelitis and cellulitis. Her condition improved following tooth extraction, drainage, and the administration of antibiotics. However, on the 4th day of hospitalization, she went into hemorrhagic shock after defecating a massive tarry stool. Emergency esophagogastroduodenoscopy (EGD) was performed. We found a giant ulcer at the antral greater curvature of the stomach. Computed tomography (CT) revealed that the gastric ulcer had penetrated the pancreas. She had no signs of peritonitis and had a bad general condition. She was therefore managed solely by conservative therapy. She recovered within days.
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Affiliation(s)
| | - Shohei Ouchi
- Department of Gastroenterology, NTT West Osaka Hospital, Japan
| | - Shuji Wakamatsu
- Department of Gastroenterology, NTT West Osaka Hospital, Japan
| | - Yuhei Wakahara
- Department of Gastroenterology, NTT West Osaka Hospital, Japan
| | - Nobuyuki Tatsumi
- Department of Gastroenterology, NTT West Osaka Hospital, Japan
- Department of Gastroenterology, Japan Community Healthcare Organization Osaka Hospital, Japan
| | - Akira Kaneko
- Department of Gastroenterology, NTT West Osaka Hospital, Japan
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Abstract
Perforated peptic ulcer is a common emergency condition worldwide, with associated mortality rates of up to 30%. A scarcity of high-quality studies about the condition limits the knowledge base for clinical decision making, but a few published randomised trials are available. Although Helicobacter pylori and use of non-steroidal anti-inflammatory drugs are common causes, demographic differences in age, sex, perforation location, and underlying causes exist between countries, and mortality rates also vary. Clinical prediction rules are used, but accuracy varies with study population. Early surgery, either by laparoscopic or open repair, and proper sepsis management are essential for good outcome. Selected patients can be managed non-operatively or with novel endoscopic approaches, but validation of such methods in trials is needed. Quality of care, sepsis care bundles, and postoperative monitoring need further assessment. Adequate trials with low risk of bias are urgently needed to provide better evidence. We summarise the evidence for perforated peptic ulcer management and identify directions for future clinical research.
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Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Kenneth Thorsen
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Ewen M Harrison
- MRC Centre for Inflammation Research, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Morten H Møller
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Michael Ohene-Yeboah
- Department of Surgery, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Jon Arne Søreide
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Conservative treatment of idiopathic spontaneous pneumoperitoneum in a bedridden patient: a case report. Surg Case Rep 2015; 1:69. [PMID: 26366365 PMCID: PMC4560205 DOI: 10.1186/s40792-015-0073-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Accepted: 08/19/2015] [Indexed: 11/10/2022] Open
Abstract
Idiopathic spontaneous pneumoperitoneum is a rare condition that is characterized by intraperitoneal gas for which no clear etiology has been identified. We report here a case of idiopathic spontaneous pneumoperitoneum, which was successfully managed by conservative treatment. A 77-year-old woman who was bedridden with speech disability as a sequela of brain hemorrhage presented at our hospital with a 1-day history of abdominal distention. On physical examination, she had stable vital signs and slight epigastric tenderness on deep palpation without any other signs of peritonitis. A chest radiograph and computed tomography showed that a large amount of free gas extended into the upper abdominal cavity. Esophagogastroduodenoscopy revealed no perforation of the upper gastrointestinal tract. The patient was diagnosed with idiopathic spontaneous pneumoperitoneum, and conservative treatment was selected. The abdominal distension rapidly disappeared, and the patient resumed oral intake on the 5th hospital day without deterioration of symptoms. Knowledge of this rare disease and accurate diagnosis with findings of clinical imaging might contribute towards refraining from unnecessary laparotomy.
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