Risk factors in patients surgically treated for peptic ulcer perforation

Retrospective study of 189 cases of acute perforated peptic ulcer: safety and efficacy of over-the-scope-clip based endoscopic closure

BACKGROUND

To compare the clinical outcomes in patients with acute perforated peptic ulcer (PPU) treated with over-the-scope clip (OTSC), non-surgical, and surgical interventions, and to explore the effectiveness and safety of OTSC closure.

METHODS

Hospital stay, antibiotic use, diet resumption time, and mortality rate were analyzed retrospectively. Binary Logistic regression analysis was used to identify the risk factors influencing PPU complicated with sepsis.

RESULTS

Patients were divided into three treatment groups: OTSC (n = 62), non-surgical (n = 72), and surgical (n = 55) groups. The median time (IQR) from symptom onset to admission was 9.0 (4-23) h. 88.71% (55/62) of the patients in In the OTSC group underwent OTSC closure within 24 h (median [IQR] time: 14.5 [7.00-30.25] h). The perforation diameters in the OTSC and surgical groups were 9.87 mm ± 5.97 mm and 8.55 mm ± 6.17 mm, respectively. The median (IQR) hospital stays in the OTSC (9.50 [7.00-12.25] days) and non-surgical group (9.00[7.00-13.00]days) were similar (p > 0.05), but shorter than that in surgical group (12.00[10.00-16.00]days), (p < 0.05). The median duration of antibiotic use was shorter in the OTSC group (7.00[3.00-10.00]) than in the non-surgical group (9.00[7.00-11.00]) and surgical group (11.00[9.00-13.00]) ( p < 0.05); and the time to resume oral feeding was shorter in the OTSC group (4.00[2.00-5.25]) than in the non-surgical group (7.00[6.13-9.00]) and surgical group (8.00[6.53-10.00]), respectively ( p < 0.05). No mortality difference among groups (p = 0.109) was found. Lower albumin level at admission, older age, and elevated creatinine levels were associated with increased sepsis risk, with OR(95%CI) of 0.826 (0.687-0.993), 1.077 (1.005-1.154), and 1.025 (1.006-1.043), respectively (all p < 0.05).

CONCLUSION

OTSC closure improves clinical outcomes of acute PPU patients without sepsis. Age, hypoalbuminemia, and baseline renal dysfunction increase the risk of sepsis, while mortality was associated with sepsis and multiorgan dysfunction.

Predictors of mortality in patients with isolated gastrointestinal perforation

Gastrointestinal (GI) perforation is common in the emergency department and has a high mortality rate. The present study aimed to identify risk factors for mortality in patients with GI perforation. The objective was to assess and prognosticate the surgical outcomes of patients, aiming to ascertain the efficacy of the procedure for individual patients. A retrospective cohort study of patients with GI perforation who underwent surgery in a public tertiary hospital in China from January 2012 to June 2022 was performed. Demographics, clinical characteristics, laboratory and imaging results, and outcomes were collected from electronic medical records. The primary outcome measure was in-hospital mortality, and patients were divided into survivor and non-survivor groups based on this measure. Univariate and multivariable logistic regression analyses were performed to obtain independent factors associated with mortality. A total of 529 patients with GI perforation were eligible for inclusion. The in-hospital mortality rate after emergency surgery was 10.59%. The median age of the patients was 60 years (interquartile range, 44-72 years). Multivariable logistic regression analysis indicated that age, shock on admission, elevated serum creatinine (sCr) and white blood cell (WBC) count <3.5x109 or >20x109 cells/l were predictors of in-hospital mortality. In conclusion, advanced age, shock on admission, elevated sCr levels and significantly abnormal WBC count are associated with higher in-hospital mortality following emergency laparotomy.

Association between Intraoperative Early Warning Score and Mortality and In-Hospital Stay in Lower Gastrointestinal Spontaneous Perforation

Background

Early warning scores (EWSs) can be easily calculated from physiological indices; however, the extent to which intraoperative EWSs and the corresponding changes are associated with patient prognosis is unknown. In this study, we investigated whether EWS and the corresponding time-related changes are associated with patient outcomes during the anesthetic management of lower gastrointestinal perforation.

Methods

This was a single-center, retrospective cohort study conducted at a tertiary emergency care center. Adult patients who underwent surgery for spontaneous lower gastrointestinal perforations between September 1, 2012, and December 31, 2019, were included. The National Early Warning Score (NEWS) and Modified Early Warning Score (MEWS) were calculated based on the intraoperative physiological indices, and the associations with in-hospital death and length of hospital stay were investigated.

Results

A total of 101 patients were analyzed. The median age was 70 years, and there were 11 cases of in-hospital death (mortality rate: 10.9%). There was a significant association between the intraoperative maximum NEWS and in-hospital death (odds ratio (OR): 1.60, 95% confidence interval (CI): 1.10-2.32, p=0.013) and change from initial to maximum NEWS (OR: 1.60, 95% CI: 1.07-2.40, p=0.023) in the crude analysis. However, when adjustments were made for confounding factors, no statistically significant associations were found. Other intraoperative EWS values and changes were not significantly associated with the investigated outcomes. The preoperative sepsis-related organ failure assessment score and the intraoperative base excess value were significantly associated with in-hospital death.

Conclusions

No clear association was observed between EWSs and corresponding changes and in-hospital death in cases of lower gastrointestinal perforation. The preoperative sepsis-related organ failure assessment score and intraoperative base excess value were significantly associated with in-hospital death.

Risk Factors for Mortality in Emergently Admitted Patients with Acute Gastric Ulcer: An Analysis of 15,538 Patients in National Inpatient Sample, 2005-2014

Background: Patients admitted emergently with a primary diagnosis of acute gastric ulcer have significant complications including morbidity and mortality. The objective of this study was to assess the risk factors of mortality including the role of surgery in gastric ulcers. Methods: Adult (18−64-year-old) and elderly (≥65-year-old) patients admitted emergently with hemorrhagic and/or perforated gastric ulcers, were analyzed using the National Inpatient Sample database, 2005−2014. Demographics, various clinical data, and associated comorbidities were collected. A stratified analysis was combined with a multivariable logistic regression model to assess predictors of mortality. Results: Our study analyzed a total of 15,538 patients, split independently into two age groups: 6338 adult patients and 9200 elderly patients. The mean age (SD) was 50.42 (10.65) in adult males vs. 51.10 (10.35) in adult females (p < 0.05). The mean age (SD) was 76.72 (7.50) in elderly males vs. 79.03 (7.80) in elderly females (p < 0.001). The percentage of total deceased adults was 1.9% and the percentage of total deceased elderly was 3.7%, a difference by a factor of 1.94. Out of 3283 adult patients who underwent surgery, 32.1% had perforated non-hemorrhagic ulcers vs. 1.8% in the non-surgical counterparts (p < 0.001). In the 4181 elderly surgical patients, 18.1% had perforated non-hemorrhagic ulcers vs. 1.2% in the non-surgical counterparts (p < 0.001). In adult patients managed surgically, 2.6% were deceased, while in elderly patients managed surgically, 5.5% were deceased. The mortality of non-surgical counterparts in both age groups were lower (p < 0.001). The multivariable logistic regression model for adult patients electing surgery found delayed surgery, frailty, and the presence of perforations to be the main risk factors for mortality. In the regression model for elderly surgical patients, delayed surgery, frailty, presence of perforations, the male sex, and age were the main risk factors for mortality. In contrast, the regression model for adult patients with no surgery found hospital length of stay to be the main risk factor for mortality, whereas invasive diagnostic procedures were protective. In elderly non-surgical patients, hospital length of stay, presence of perforations, age, and frailty were the main risk factors for mortality, while invasive diagnostic procedures were protective. The following comorbidities were associated with gastric ulcers: alcohol abuse, deficiency anemias, chronic blood loss, chronic heart failure, chronic pulmonary disease, hypertension, fluid/electrolyte disorders, uncomplicated diabetes, and renal failure. Conclusions: The odds of mortality in emergently admitted geriatric patients with acute gastric ulcer was two times that in adult patients. Surgery was a protective factor for patients admitted emergently with gastric perforated non-hemorrhagic ulcers.

Laparoscopic distal gastric and D1 resection for large perforated duodenal bulb peptic ulcer, with intracorporeal antecolic gastrojejunal anastomosis

BACKGROUND

Peptic ulcer perforation is a common surgical emergency and a major cause of death especially in elderly patients, despite the fact of the presence of effective drug treatments and an increased understanding of its etiology. Giant duodenal perforations, in particular, pose a significant challenge and there is scarce data regarding their optimal management. Laparoscopic surgery is advocated in the surgical treatment of perforated duodenal ulcer disease, in experienced hands.

METHODS

Herein we present an 84-year-old man with past medical history of type II diabetes mellitus and hypertension who was admitted to our Department due to epigastric pain and diffuse peritonitis. CT scan revealed the presence of a significant amount of free air and fluid in the upper abdomen secondary to a duodenal perforation.

RESULTS

The patient was taken immediately to the theater for an urgent laparoscopy. Methylene blue via the NG tube better defined the extent of the duodenal perforation which was not amenable to a primary repair. Consequently, a decision was made for a laparoscopic pancreas-sparing, ampulla preserving gastroduodenectomy with intracorporeal Billroth II gastrojejunal anastomosis. The postoperative period was uneventful and the patient was discharged on the 13th postoperative day. Histopathology revealed a large benign duodenal ulcer.

CONCLUSIONS

Although the incidence of peptic ulcer disease is decreasing, it appears that the incidence of complications is rising. Laparoscopic approach, especially when performed by laparoscopic surgery experts, could be a treatment option for difficult duodenal ulcer perforations with less pain, shorter hospital stay and reduced morbidity.

The prognostic value of surgical delay in patients undergoing major emergency abdominal surgery: a systematic review and meta-analysis

BACKGROUND

Mortality following major emergency abdominal surgery is high. Surgical delay is regarded as an important modifiable prognostic factor. Current care-bundles aim at reducing surgical delay, most often using a six-hour cut-off. We aimed to investigate the evidence supporting the in-hospital delay cutoffs currently used.

METHODS

MEDLINE, EMBASE and the Cochrane Library were searched. We included studies assessing in-hospital surgical delay in major emergency abdominal surgery patients. Studies were only included if they performed adjusted analysis. Surgical delay beyond six hours was the primary cutfrom interest. The primary outcome was mortality at longest follow-up. Meta-analyses were conducted if possible.

RESULTS

Eleven observational studies were included with 16,772 participants. Two studies evaluated delay in unselected major emergency abdominal surgery patients. Three studies applied a six-hour cutoff, but only a study on acute mesenteric ischemia showed an association between delay and mortality. Meta-analysis showed no association with mortality at this cutoff. An association was seen between hourly delay and mortality risk estimate, 1.02 (95% confidence interval [CI], 1.00 - 1.03), and on subgroup analysis of hourly delay in perforated peptic ulcer patients, risk estimate, 1.02 (95% CI, 1.0 - 1.03). All risk estimates had a very low Grading of Recommendations Assessment, Development, and Evaluation score.

CONCLUSION

Little evidence supports a six-hour cutoff in unselected major emergency abdominal surgical patients. We found an association between hourly delay and increased mortality; however, evidence supporting this was primarily in patients undergoing surgery for perforated peptic ulcer. This review is limited by the quality of the individual studies.

Perforation on the superior side of duodenum is a risk factor of laparoscopic primary repair for duodenal ulcer perforation

Purpose

Primary repair is the standard surgical method for treating duodenal ulcer perforations, with very good results usually anticipated because of the simplicity of the associated surgical techniques. Therefore, this study aimed to analyze the risk factors that affect laparoscopic primary repair outcomes for duodenal ulcer perforation.

Methods

Between June 2010 and June 2020, 124 patients who underwent laparoscopic primary repair for duodenal ulcer perforations were reviewed. Early surgical outcomes were evaluated and risk factors for postoperative complications were assessed.

Results

All surgeries were performed laparoscopically without open conversion. Multivariate analysis showed that the elderly (over 70 years), and perforations that needed more than 2 stitches for closure were risk factors for overall postoperative complications. Perforations that needed more than 2 stitches and perforations on the superior side of the duodenum were major risk factors for severe postoperative complications. Severe postoperative complications occurred in 6 of the patients, and 1 of them died of multiorgan failure.

Conclusion

Based on our results, we suggest that laparoscopic primary repair can be safely performed in duodenal ulcer perforation. However, more careful surgery and postoperative care are needed to improve the surgical outcomes of patients who need more than 2 stitches to close their perforation or who have perforations on the superior side of the duodenum.

Validation of prognostic scoring systems for predicting 30-day mortality in perforated peptic ulcer disease

Objectives

Perforations in Peptic Ulcer Disease are known to cause considerable morbidity and mortality. The objective of this study was to compare efficacy of known clinical parameters and three existing scoring systems in predicting 30-day mortality and determining mortality risk stratification based on risk factors.

Material and Methods

This was a prospective observational study of 190 patients operated for perforated peptic ulcer over a period of 14 months at a 1500 bed tertiary care university hospital in Western India.

Results

The mortality rate observed was 18.95%. Elderly population, raised serum creatinine, time delay to surgery > 24 hours, preoperative shock and pre-existing medical illness were identified as risk factors for poor postoperative prognosis. The Area under curve for mortality prediction was 0.590 for ASA, 0.745 for Boey and 0.804 for PULP score. Mortality was best anticipated by a combination of raised serum creatinine levels, preoperative shock and delayed surgery by multivariate logistic regression analysis.

Conclusion

Poor outcome was significantly higher in the elderly, patients with raised serum creatinine, preoperative shock, pre-existing medical illness and when the time delay to surgery was > 24 hours. In spite of the Boey score being more practical in application, PULP score proved to be a more precise indicator of mortality. A larger study inclusive of other Mortality Risk Prediction Models would help formulate a more accurate and population specific scoring system.

Perioperative risk factors for in-hospital mortality after emergency gastrointestinal surgery

Few studies have evaluated the risk factors for in-hospital mortality in critically ill surgical patients who have undergone emergency gastrointestinal (GI) surgery. The aim of this study was to identify the risk factors associated with in-hospital mortality in critically ill surgical patients after emergency GI surgery.The medical records of 362 critically ill surgical patients who underwent emergency GI surgery, admitted to intensive care unit between January 2007 and December 2011, were reviewed retrospectively. Perioperative biochemical and clinical parameters of survivors and nonsurvivors were compared. Logistic regression multivariate analysis was performed to identify the independent risk factors of mortality.The in-hospital mortality rate was 15.2% (55 patients). Multivariate analyses revealed cancer-related perforation (odds ratio [OR] 16.671, 95% confidence interval [CI] 2.629-105.721, P = 0.003), preoperative anemia (hemoglobin <10 g/dL; OR 6.976, 95% CI 1.376-35.360, P = 0.019), and preoperative hypoalbuminemia (albumin <2.7 g/dL; OR 9.954, 95% CI 1.603-61.811, P = 0.014) were independent risk factors of in-hospital mortality after emergency GI surgery.The findings of this study suggest that in critically ill patients undergoing emergency GI surgery, cancer-related peritonitis, preoperative anemia, and preoperative hypoalbuminemia are associated with in-hospital mortality. Recognizing risk factors at an early stage could aid risk stratification and the provision of optimal perioperative care.

Scoring Systems for Outcome Prediction of Patients with Perforation Peritonitis

INTRODUCTION

Peritonitis continues to be one of the major infectious problems confronting a surgeon. Mannheim Peritonitis Index (MPI), Physiological and Operative Severity Score for en Umeration of Mortality (POSSUM) and Morbidity and sepsis score of Stoner and Elebute have been devised for risk assessment and for prediction of postoperative outcome.

AIM

The aim of this study was to find the accuracy of these scores in predicting outcome in terms of mortality in patients undergoing exploratory laprotomy for perforation peritonitis.

MATERIALS AND METHODS

The prospective study was carried out in 100 diagnosed cases of perforation at our centre in a single unit over a period of 21 months from December 2012 to August 2014. Study was conducted on all cases of peritonitis albeit primary, tertiary, iatrogenic and those with age less than 12 years were excluded from the study. All the relevant data were collected and three scores were computed from one set of data from the patient. The main outcome measure was survival of the patient. The Receiver Operator Characteristics (ROC) curves were obtained for the three scores. Area Under the Curves (AUC) was calculated. Sensitivity and specificity were calculated at a cut off point obtained from the ROC curves.

RESULTS

POSSUM had an AUC of 0.99, sepsis score had an AUC of 0.98 and MPI had an AUC of 0.95. The cut off point score of 51 for POSSUM had an accuracy of 93.8 and positive predictive value of 70.5, the score of 29 for MPI had an accuracy of 82.8 and positive predictive value of 46 and the score of 22 for sepsis score had an accuracy of 95.9 and positive predictive value of 86.67.

CONCLUSION

POSSUM score was found to be superior in prediction of mortality as compared to sepsis score of Stoner and Elebute and MPI. POSSUM and MPI over predicted mortality in some cases. None of these scores are strictly preoperative.

Anesthetic management for patients with perforation peritonitis

Perforation peritonitis is a common surgical emergency. Anesthesia in patients with perforation peritonitis can be challenging. Delayed presentations, old age, hemodynamic instability, presence of sepsis and organ dysfunction are some of the predictors of poor outcome in such patients. Pre-operative optimization can reduce intraoperative and post-operative morbidity and mortality, but surgery should not be unnecessarily delayed. Intensive care in critical care settings may be essential.

Scoring systems for outcome prediction in patients with perforated peptic ulcer

Background

Patients with perforated peptic ulcer (PPU) often present with acute, severe illness that carries a high risk for morbidity and mortality. Mortality ranges from 3-40% and several prognostic scoring systems have been suggested. The aim of this study was to review the available scoring systems for PPU patients, and to assert if there is evidence to prefer one to the other.

Material and methods

We searched PubMed for the mesh terms “perforated peptic ulcer”, “scoring systems”, “risk factors”, ”outcome prediction”, “mortality”, ”morbidity” and the combinations of these terms. In addition to relevant scores introduced in the past (e.g. Boey score), we included recent studies published between January 2000 and December 2012) that reported on scoring systems for prediction of morbidity and mortality in PPU patients.

Results

A total of ten different scoring systems used to predict outcome in PPU patients were identified; the Boey score, the Hacettepe score, the Jabalpur score the peptic ulcer perforation (PULP) score, the ASA score, the Charlson comorbidity index, the sepsis score, the Mannheim Peritonitis Index (MPI), the Acute physiology and chronic health evaluation II (APACHE II), the simplified acute physiology score II (SAPS II), the Mortality probability models II (MPM II), the Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity physical sub-score (POSSUM-phys score). Only four of the scores were specifically constructed for PPU patients. In five studies the accuracy of outcome prediction of different scoring systems was evaluated by receiver operating characteristics curve (ROC) analysis, and the corresponding area under the curve (AUC) among studies compared. Considerable variation in performance both between different scores and between different studies was found, with the lowest and highest AUC reported between 0.63 and 0.98, respectively.

Conclusion

While the Boey score and the ASA score are most commonly used to predict outcome for PPU patients, considerable variations in accuracy for outcome prediction were shown. Other scoring systems are hampered by a lack of validation or by their complexity that precludes routine clinical use. While the PULP score seems promising it needs external validation before widespread use.

Quality-of-care initiative in patients treated surgically for perforated peptic ulcer

BACKGROUND

Mortality and morbidity are considerable after treatment for perforated peptic ulcer (PPU). Since 2003, a Danish nationwide quality-of-care (QOC) improvement initiative has focused on reducing preoperative delay, and improving perioperative monitoring and care for patients with PPU. The present study reports the results of this initiative.

METHODS

This was a nationwide cohort study based on prospectively collected data, involving all hospitals caring for patients with PPU in Denmark. Details of patients treated surgically for PPU between September 2004 and August 2011 were reported to the Danish Clinical Register of Emergency Surgery. Changes in baseline patient characteristics and in seven QOC indicators are presented, including relative risks (RRs) for achievement of the indicators.

RESULTS

The study included 2989 patients. An increasing number fulfilled the following four QOC indicators in 2010-2011 compared with the first 2 years of monitoring: preoperative delay no more than 6 h (59·0 versus 54·0 per cent; P = 0·030), daily monitoring of bodyweight (48·0 versus 29·0 per cent; P < 0·001), daily monitoring of fluid balance (79·0 versus 74·0 per cent; P = 0·010) and daily monitoring of vital signs (80·0 versus 68·0 per cent; P < 0·001). A lower proportion of patients had discontinuation of routine prophylactic antibiotics (82·0 versus 90·0 per cent; P < 0·001). Adjusted 30-day mortality decreased non-significantly from 2005-2006 to 2010-2011 (adjusted RR 0·87, 95 per cent confidence interval 0·76 to 1·00), whereas the rate of reoperative surgery remained unchanged (adjusted RR 0·98, 0·78 to 1·23).

CONCLUSION

This nationwide quality improvement initiative was associated with reduced preoperative delay and improved perioperative monitoring in patients with PPU. A non-significant improvement was seen in 30-day mortality.

Management of the difficult duodenal stump in penetrating duodenal ulcer disease: a comparative analysis of duodenojejunostomy with "classical" stump closure (Nissen-Bsteh)

BACKGROUND

Duodenal stump insufficiency after surgery for penetrating gastroduodenal ulcer is associated with substantial mortality. "Classical" technique of closing a difficult duodenal stump (Nissen-Bsteh) has, up to now, not been compared with duodenojejunostomy (DJ) in larger patient sets. This also refers to the potential benefit of a gastric and biliary diversion under such conditions. The aim of the present study was to compare classical duodenal closure (CC) with DJ and to evaluate the impact of gastric and biliary diversion on postoperative outcome after surgery for penetrating, high-risk duodenal ulcer in a matched control study.

METHODS

Out of 321 patients, treated for penetrating duodenal ulcer disease, the perioperative outcome of 62 DJ patients was compared with 62 patients undergoing CC matched for age, gender, biliary diversion, and the operating surgeon collective. A total of 70 patients, equally distributed between DJ and CC subsets, received temporary biliary diversion.

RESULTS

Overall perioperative mortality was 10.5%. However, DJ significantly reduced the mortality rate (4.8%) associated with penetrating duodenal ulcer compared to CC (16.1%, P < 0.04). The overall morbidity in DJ patients nearly equalled that in the CC group (P = 0.4). Differences in the prevalence of duodenal leakage rate between DJ (14.5%) and CC (29%) patients were of borderline significance (P = 0.05). Temporary biliary diversion was identified as a prognostic factor for closure consistency with lower duodenal leakage rates in both DJ (odds ratio 0.05, 95% confidence interval 0.005-0.42) and CC patients (odds ratio 0.2, 95% confidence interval 0.05-0.6). In contrast, gastric diversion performed in a subset of 35 DJ patients had no protective effect.

CONCLUSION

Duodenojejunostomy combined with temporary biliary diversion substantially improves perioperative outcome in management of penetrating duodenal ulcer.

The Peptic Ulcer Perforation (PULP) score: a predictor of mortality following peptic ulcer perforation. A cohort study

BACKGROUND

Accurate and early identification of high-risk surgical patients with perforated peptic ulcer (PPU) is important for triage and risk stratification. The objective of the present study was to develop a new and improved clinical rule to predict mortality in patients following surgical treatment for PPU.

METHODS

DESIGN

nationwide cohort study based on prospectively collected data.

SETTING

thirty-five hospitals in Denmark.

PATIENTS

a total of 2668 patients surgically treated for gastric or duodenal PPU between 1 February 2003 and 31 August 2009.

OUTCOME MEASURE

30-day mortality.

RESULTS

We derived a new clinical prediction rule for 30-day mortality and evaluated and compared its prognostic performance with the American Society of Anaesthesiologists (ASA) and Boey scores. A total of 708 patients (27%) died within 30 days of surgery. The Peptic Ulcer Perforation (PULP) score - comprised eight variables with an adjusted odds ratio of more than 1.28: 1) age > 65 years, 2) active malignant disease or AIDS, 3) liver cirrhosis, 4) steroid use, 5) time from perforation to admission > 24 h, 6) pre-operative shock, 7) serum creatinine > 130 μM, and 8) the four levels of the ASA score (from 2 to 5). The score predicted mortality well (area under receiver operating characteristics curve (AUC) 0.83). It performed considerably better than the Boey score (AUC 0.70) and better than the ASA score alone (AUC 0.78).

CONCLUSION

The PULP score accurately predicts 30-day mortality in patients operated for PPU and can assist in risk stratification and triage.

Accuracy of clinical prediction rules in peptic ulcer perforation: an observational study

OBJECTIVE

The aim of the present study was to compare the ability of four clinical prediction rules to predict adverse outcome in perforated peptic ulcer (PPU): the Boey score, the American Society of Anesthesiologists (ASA) score, the Acute Physiology and Chronic Health Evaluation (APACHE) II score, and the sepsis score.

DESIGN

an observational multicenter study.

PARTICIPANTS AND SETTINGS

a total of 117 patients surgically treated for PPU between 1 January 2008 and 31 December 2009 in seven gastrointestinal departments in Denmark were included. Pregnant and breastfeeding women, non-surgically treated patients, patients with malignant ulcers, and patients with perforation of other organs were excluded.

PRIMARY OUTCOME MEASURE

30-day mortality rate.

STATISTICAL ANALYSIS

the ability of four clinical prediction rules to distinguish survivors from non-survivors (discrimination ability) was evaluated by the area under the receiver operating characteristic curve (AUC), positive predictive values (PPVs), negative predictive values (NPVs), and adjusted relative risks.

RESULTS

Median age (range) was 70 years (25-92 years), 51% of the patients were females, and 73% of the patients had at least one co-existing disease. The 30-day mortality proportion was 17% (20/117). The AUCs: the Boey score, 0.63; the sepsis score, 0.69; the ASA score, 0.73; and the APACHE II score, 0.76. Overall, the PPVs of all four prediction rules were low and the NPVs high.

CONCLUSIONS

The Boey score, the ASA score, the APACHE II score, and the sepsis score predict mortality poorly in patients with PPU.

Diagnostic indicators for peptic ulcer perforation at a tertiary care hospital in Thailand

Introduction

Limited data currently exists regarding the diagnostic indicators of peptic ulcer perforation for early detection among patients in Thailand. Delayed diagnosis and treatment for an ulcer can be life-threatening, resulting in shock or death.

Objective

To determine the diagnostic indicators of peptic ulcer perforation.

Material and methods

A cohort study was conducted in a tertiary care hospital in Thailand from 2005 to 2009. Peptic ulcer patients aged 15 years and over admitted to the surgical department were included. The diagnostic indicators used criteria of the patients’ final diagnoses and operations, coded according to the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, which included patient profiles, gender, age, coexisting illnesses, personal habits, signs and symptoms, laboratory investigations, radiological finding, and treatment role. Exponential risk regression analyses to obtain relative risk (RR) estimates for diagnostic indicators were analyzed using Stata^® statistical software package, version 11 (StataCorp LP, College Station, TX).

Results

The study included 1290 patients. Of these, 57% reported perforated peptic ulcer. Multivariate analysis showed five diagnostic indicators: signs and symptoms including intense abdominal pain (RR = 1.53, 95% confidence interval [CI] 1.14–2.06), tenderness (RR = 1.94, 95% CI 1.17–3.21), and guarding (RR = 1.52, 95% CI 1.05–2.20); X-ray with free air (RR = 2.80, 95% CI 2.08–3.77); and referral from other hospitals (RR = 1.37, 95% CI 1.03–1.82).

Conclusion

Five diagnostic indicators for peptic ulcer perforation monitoring were suggested from this study. Improving diagnostic indicators for medical care may improve the outcome of patients that have perforated peptic ulcer.

Emergency ulcer surgery

The rate of elective surgery for peptic ulcer disease has been declining steadily over the past 3 decades. During this same period, the rate of emergency ulcer surgery rose by 44%. This means that the gastrointestinal surgeon is likely to be called on to manage the emergent complications of peptic ulcer disease without substantial experience in elective peptic ulcer disease surgery. The goal of this review is to familiarize surgeons with our evolving understanding of the pathogenesis, epidemiology, presentation, and management of peptic ulcer disease in the emergency setting, with a focus on peptic ulcer disease-associated bleeding and perforation.

Preoperative predictors of mortality in adult patients with perforation peritonitis

INTRODUCTION

There is paucity of data from India regarding the etiology, prognostic indicators, morbidity, and mortality patterns of perforation peritonitis. The objective of our study was to evaluate the predictors of mortality, preoperatively, for risk stratification of the patients and institution of an early goal-directed therapy.

MATERIALS AND METHODS

Eighty-four consecutive patients presenting with perforation peritonitis, in the age group of 14-70 years scheduled for emergency laparotomy were studied prospectively. The parameters studied were age and sex of the patients, associated co-morbidities, duration of symptoms, delay in initiating surgical intervention, and preoperative biochemical parameters such as hemoglobin, random blood sugar, blood urea, serum creatinine, pH, base excess, and serum lactate levels. In-hospital mortality was taken as the outcome.

RESULTS

We encountered a mortality of 17.8% in our study. Multiple linear (enter) regression identified the age, duration of symptoms, preoperative blood sugar levels, blood urea, serum creatinine levels, Mannheim Peritonitis Index, and the delay in instituting surgical intervention as independent predictors of mortality. Hyperlactatemia, acidosis and base excess were not found to be associated with mortality.

CONCLUSION

Routine biochemical investigations, delay in presentation, and surgical intervention are good predictors of mortality. Recognizing such patients early may help the anesthesiologists in risk stratification and in providing an early goal-directed therapy.

Multicentre trial of a perioperative protocol to reduce mortality in patients with peptic ulcer perforation

BACKGROUND

Morbidity and mortality rates in patients with perforated peptic ulcer (PPU) remain substantial. The aim of the present study was to evaluate the effect of a multimodal and multidisciplinary perioperative care protocol on mortality in patients with PPU.

METHODS

This was an externally controlled multicentre trial set in seven gastrointestinal departments in Denmark. Consecutive patients who underwent surgery for gastric or duodenal PPU between 1 January 2008 and 31 December 2009 were treated according to a multimodal and multidisciplinary evidence-based perioperative care protocol. The 30-day mortality rate in this group was compared with rates in historical and concurrent national controls.

RESULTS

The 30-day mortality rate following PPU was 17·1 per cent in the intervention group, compared with 27·0 per cent in the three control groups (P = 0·005). This corresponded to a relative risk of 0·63 (95 per cent confidence interval 0·41 to 0·97), a relative risk reduction of 37 (5 to 58) per cent and a number needed to treat of 10 (6 to 38).

CONCLUSION

The 30-day mortality rate in patients with PPU was reduced by more than one-third after the implementation of a multimodal and multidisciplinary perioperative care protocol, compared with conventional treatment.

REGISTRATION NUMBER

NCT00624169 (http://www.clinicaltrials.gov).

Trends in diagnosis and surgical management of patients with perforated peptic ulcer

INTRODUCTION

While the laparoscopic treatment of perforated peptic ulcers (PPU) has been shown to be feasible and safe, its implementation into routine clinical practice has been slow. Only a few studies have evaluated its overall utility. The aim of this study was to investigate changes in surgical management of PPU and associated outcomes.

MATERIAL AND METHODS

The study was a retrospective, single institution, population-based review of all patients undergoing surgery for PPU between 2003 and 2009. Patient demographics, diagnostic evaluation, management, and outcomes were evaluated.

RESULTS

Included were 114 patients with a median age of 67 years (range, 20-100). Women comprised 59% and were older (p < 0.001), had more comorbidities (p = 0.002), and had a higher Boey risk score (p = 0.036) compared to men. Perforation location was gastric/pyloric in 72% and duodenal in 28% of patients. Pneumoperitoneum was diagnosed by plain abdominal x-ray in 30 of 41 patients (75%) and by abdominal computerized tomography (CT) in 76 of 77 patients (98%; p < 0.001).Laparoscopic treatment was initiated in 48 patients (42%) and completed in 36 patients (75% of attempted cases). Laparoscopic treatment rate increased from 7% to 46% during the study period (p = 0.02). Median operation time was shorter in patients treated via laparotomy (70 min) compared to laparoscopy (82 min) and those converted from laparoscopy to laparotomy (105 min; p = 0.017). Postoperative complications occurred in 56 patients (49%). Overall 30-day postoperative mortality was 16%. No statistically significant differences were found in morbidity and mortality between open versus laparoscopic repair.

CONCLUSION

This study demonstrates an increased use of CT as the primary diagnostic tool for PPU and of laparoscopic repair in its surgical treatment. These changes in management are not associated with altered outcomes.

Preoperative prognostic factors for mortality in peptic ulcer perforation: a systematic review

OBJECTIVE

Mortality and morbidity following perforated peptic ulcer (PPU) is substantial and probably related to the development of sepsis. During the last three decades a large number of preoperative prognostic factors in patients with PPU have been examined. The aim of this systematic review was to summarize available evidence on these prognostic factors.

MATERIAL AND METHODS

MEDLINE (January 1966 to June 2009), EMBASE (January 1980 to June 2009), and the Cochrane Library (Issue 3, 2009) were screened for studies reporting preoperative prognostic factors for mortality in patients with PPU. The methodological quality of the included studies was assessed. Summary relative risks with 95% confidence intervals for the identified prognostic factors were calculated and presented as Forest plots.

RESULTS

Fifty prognostic studies with 37 prognostic factors comprising a total of 29,782 patients were included in the review. The overall methodological quality was acceptable, yet only two-thirds of the studies provided confounder adjusted estimates. The studies provided strong evidence for an association of older age, comorbidity, and use of NSAIDs or steroids with mortality. Shock upon admission, preoperative metabolic acidosis, tachycardia, acute renal failure, low serum albumin level, high American Society of Anaesthesiologists score, and preoperative delay >24 h were associated with poor prognosis.

CONCLUSIONS

In patients with PPU, a number of negative prognostic factors can be identified prior to surgery, and many of these seem to be related to presence of the sepsis syndrome.