Assessment of PULP score in predicting 30-day perforated duodenal ulcer morbidity, and comparison of its performance with Boey and ASA, a retrospective study

A comparative analysis of Charlson's weighted index of comorbidity and perforated peptic ulcer scores in predicting postoperative mortality and high comprehensive complication index

BACKGROUND

Limited data exists on Charlson's weighted index of comorbidity (WIC) predictability for postoperative outcomes following perforated peptic ulcer (PPU) surgery. This study assesses the utility of WIC and other predictive scores in forecasting both postoperative mortality and morbidity in PPU.

MATERIALS & METHODS

Patients with PPUs operated between 2018 and 2021 in a Malaysian tertiary referral center were included. Clinical data were retrospectively analyzed for association with mortality and morbidity measured with the Comprehensive Complication Index (CCI). Predictability of WIC and other predictors were examined using area under receiver-operator characteristic (ROC) curve (AUC).

RESULTS

Among 110 patients included, 18 died (16.4%) and 36 (32.7%) had significant morbidity postoperatively (High CCI, ≥26.2). Both mortality and high CCI were associated with age >65 years, female sex, comorbidities (diabetes mellitus, hypertension, and renal disease), and American Society of Anesthesiologist score >2. Most patients who died had renal dysfunction, metabolic acidosis, lactate >2 mmol/L upon presentation preoperatively. While surgery >24 h after presentation correlated with mortality and high CCI, the benefit of earlier surgery <6 h or <12 h was not demonstrated. WIC (AUC, 0.89; 95% CI, 0.81-0.99) showed similar predictability to Peptic Ulcer Perforation (PULP) (AUC, 0.97; 95% CI, 0.93-1.00) for mortality. PULP effectively predicted high CCI (AUC, 0.83; 95% CI, 0.73-0.93; p < 0.001).

CONCLUSION

WIC is valuable in predicting mortality, highlighting the importance of comorbidity in risk assessment. PULP score was effective in predicting both mortality and high CCI. Early identification of patients with high perioperative risk will facilitate patients' triage for escalated care, leading to a better outcome.

Analysis of risk factors for duodenal leak after repair of a duodenal perforation

BACKGROUND

Repairing of a duodenal perforation is a well accepted procedure, but clinically, approximately 4% of patients develop duodenal leaks after perforation repair, increasing the risk of death. We retrospectively analyzed clinical data from 168 patients at our hospital to explore risk factors for duodenal leak after perforation repair and developed a nomogram for predicting postoperative duodenal leak.

METHODS

This retrospective case-control study totalled 168 patients undergoing repair of a duodenal perforation with omentopexy at the General Surgery Department, Dongnan Hospital of Xiamen University, from January 2012 to January 2022. The patients were divided into the non-leak group and the leak group. Risk factors were evaluated by analyzing the patient's sex, shock, diameter and anatomic position of the ulcer, use of NSAIDS and Glucocorticoid, history of drinking, diabetes, chronic diseases, age, time of onset of symptoms and lab tests.

RESULT

One hundred fifty-six patients (92.9%) who did not develop leaks after repair of a duodenal perforation were included in the non-leak group, and 12 (7.1%) developed leaks were included in the leak group. In univariate analysis, there were significant differences between the two groups referring to age, shock, NSAIDs, albumin, and perforation size (P < 0.05). The area under the ROC curve for perforation diameter was 0.737, the p-value was 0.006, the optimal cutoff point was 11.5, sensitivity was 58.3%, and specificity was 93.6%, the positive predictive value is 41.1%, and the negative predictive value is 98.0%. In the internal validation of the performance of the nomogram, the C-index and AUC of the model were 0.896(95%CI 0.81-0.98), demonstrating that the nomogram model was well calibrated.

CONCLUSION

The study discussed the risk factors for postoperative duodenal leak in patients undergoing repair of a duodenal perforation, and a nomogram was constructed to predict the leak. Future prospective studies with large sample sizes and multiple centres are needed to further elucidate the risk of duodenal leak after repair of a duodenal perforation.

Perforated peptic ulcer (PPU) treatment: an Italian nationwide propensity score-matched cohort study investigating laparoscopic vs open approach

BACKGROUND

Perforated peptic ulcer (PPU) remain a surgical emergency accounting for 37% of all peptic ulcer-related deaths. Surgery remains the standard of care. The benefits of laparoscopic approach have been well-established even in the elderly. However, because of inconsistent results with specific regard to some technical aspects of such technique surgeons questioned the adoption of laparoscopic approach. This leads to choose the type of approach based on personal experience. The aim of our study was to critically appraise the use of the laparoscopic approach in PPU treatment comparing it with open procedure.

METHODS

A retrospective study with propensity score matching analysis of patients underwent surgical procedure for PPU was performed. Patients undergoing PPU repair were divided into: Laparoscopic approach (LapA) and Open approach (OpenA) groups and clinical-pathological features of patients in the both groups were compared.

RESULTS

A total of 453 patients underwent PPU simple repair. Among these, a LapA was adopted in 49% (222/453 patients). After propensity score matching, 172 patients were included in each group (the LapA and the OpenA). Analysis demonstrated increased operative times in the OpenA [OpenA: 96.4 ± 37.2 vs LapA 88.47 ± 33 min, p = 0.035], with shorter overall length of stay in the LapA group [OpenA 13 ± 12 vs LapA 10.3 ± 11.4 days p = 0.038]. There was no statistically significant difference in mortality [OpenA 26 (15.1%) vs LapA 18 (10.5%), p = 0.258]. Focusing on morbidity, the overall rate of 30-day postoperative morbidity was significantly lower in the LapA group [OpenA 67 patients (39.0%) vs LapA 37 patients (21.5%) p = 0.002]. When stratified using the Clavien-Dindo classification, the severity of postoperative complications was statistically different only for C-D 1-2.

CONCLUSIONS

Based on the present study, we can support that laparoscopic suturing of perforated peptic ulcers, apart from being a safe technique, could provide significant advantages in terms of postoperative complications and hospital stay.

New machine learning scoring system for predicting postoperative mortality in gastroduodenal ulcer perforation: A study using a Japanese nationwide inpatient database

BACKGROUND

Conventional prediction models for estimating risk of postoperative mortality in gastroduodenal ulcer perforation have suboptimal prediction ability. We aimed to develop and validate new machine learning models and an integer-based score for predicting the postoperative mortality.

METHODS

We retrospectively identified patients with gastroduodenal ulcer perforation who underwent surgical repair, using a nationwide Japanese inpatient database. In a derivation cohort from July 2010 to March 2016, we developed 2 machine learning-based models, Lasso and XGBoost, using 45 candidate predictors, and also developed an integer-based score for clinical use by including important variables in Lasso. In a validation cohort from April 2016 to March 2017, we measured the prediction performances of the models by computing area under the curve and comparing it to the conventional American Society of Anesthesiology risk score.

RESULTS

Of 25,886 patients, 1,176 (4.5%) died after surgical repair. For the validation cohort, Lasso and XGBoost had significantly higher prediction abilities than the American Society of Anesthesiology score (Lasso area under the curve = 0.84; 95% confidence interval 0.81-0.86; American Society of Anesthesiology score area under the curve = 0.70; 95% confidence interval 0.65-0.74, P < .001). The integer-based risk score, which had 13 factors, had a prediction ability similar to those of Lasso and XGBoost (area under the curve = 0.83; 95% confidence interval 0.81-0.86). According to the integer-based score, the mortalities were 0.1%, 2.3%, 9.3%, and 29.0% for the low (score, 0), moderate (1-2), high (3-4), and very high (≥5) score groups, respectively.

CONCLUSION

Machine learning models and the integer-based risk score performed well in predicting risk of postoperative mortality in gastroduodenal ulcer perforation. These models will help in decision making.

Platelet to Lymphocyte Ratio Associated with Prolonged Hospital Length of Stay Postpeptic Ulcer Perforation Repair: An Observational Descriptive Analysis

BACKGROUND

The predictive role of platelet to lymphocyte ratio (P/LR) in patients with perforated peptic ulcer (PPU) is not well-studied. We aimed to investigate the association between the P/LR ratio and the hospital length of stay (HLOS) for surgically treated PPU.

METHOD

This is a retrospective observational study for surgically treated adult cases of PPU at Hamad Medical Corporation during the period from January 2012 to August 2017. Patients were categorized into two groups based on their HLOS (I week). The receiver operating characteristic (ROC) curve was plotted to determine the cutoff value for lymphocyte count, neutrophil to lymphocyte ratio, and P/LR ratio for predicting the prolonged hospitalization.

RESULTS

One hundred and fifty-two patients were included in the study. The majority were young males. The mean age was 38.3 ± 12.7 years. Perforated duodenal ulcer (139 patients) exceeded perforated gastric ulcer (13 patients). The HLOS > 1 week was observed in 14.5% of cases. Older age (p = 0.01), higher preoperative WBC (p = 0.03), lower lymphocyte count (p = 0.01), and higher P/LR ratio (p = 0.005) were evident in the HLOS > 1 week group. The optimal cutoff value of P/LR was 311.2 with AUC 0.702 and negative predictive value of 93% for the prediction of prolonged hospitalization. Two patients died with a mean P/LR ratio of 640.8 ± 135.5 vs. 336.6 ± 258.9 in the survivors.

CONCLUSION

High preoperative P/LR value predicts prolonged HLOS in patients with repaired perforated peptic ulcer. Further larger multicenter studies are needed to support the study findings.

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Laparoscopic Repair of Perforated Peptic Ulcer in the Elderly: An Interim Analysis of the FRAILESEL Italian Multicenter Prospective Cohort Study

INTRODUCTION

The number of elderly patients requiring emergency surgical intervention has increased dramatically. Perforated peptic ulcer (PPU) complications, such as perforation, have remained relatively stable and associated morbidity remains between 10% and 20%. Advances in perioperative care have greatly improved the outcomes of laparoscopic emergency surgery, allowing increasing numbers of patients, even the elderly, to undergo safe repair. The aim of this study was to evaluate the feasibility, safety, and outcome of laparoscopic gastric repair in the elderly using the database of the FRAILESEL (Frailty and Emergency Surgery in the Elderly) study.

MATERIALS AND METHODS

This is a retrospective analysis carried out on data of the FRAILESEL study. Data on all the elderly patients who underwent emergency abdominal surgery for PPU from January 2017 to December 2017 at 36 Italian surgical departments were analyzed. Patients who underwent PPU repair were further divided into a laparoscopic gastroduodenal repair (LGR) cohort and an open gastroduodenal repair (OGR) cohort, and the clinicopathologic features of the patients in both the groups were compared.

RESULTS

Sixty-seven patients fulfilled the inclusion criteria. Thirty-three patients (47.8%) underwent LGR. The LGR patients had less blood loss and shorter postoperative stay, even if the difference was not statistically significant. The mean operative time was significantively higher in the OGR (OGR 96.5±27.7 vs. LGR 78.6±16.3 P=0.000). The rate of death after laparoscopic surgery was similar to the rate of the open surgery. Multivariate analysis indicated that only age (P=0.018), admission haemoblogbin (Hb) level (P=0.006), platelet count (P=0.16), lactate level (P=0.47), and Mannheim Peritonitis Index (P=0.18) were independent variables associated with the risk of overall mortality.

CONCLUSIONS

LGR is safe and feasible in elderly patients with PPU and it is associated with better perioperative outcomes. However, patient selection and preoperative frailty evaluation in the elderly population are the key to achieving better outcomes.