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

Perforated peptic ulcer

Worldwide perforated peptic ulcer disease is the leading cause of mortality after abdominal emergency surgery Rapid clinical assessment, proper diagnostics, and timely decision-making are vital in handling patients with suspected or identified perforated peptic ulcer CT has high diagnostic sensitivity, whereas perforation is only evident on three-quarters of plain abdominal X-rays Delay in surgical intervention increases mortality risk Simple closure of the perforated ulcer is still the preferred method of surgery Laparoscopic surgery is the preferred approach in experienced hands

Should Empiric Anti-Fungals Be Administered Routinely for All Patients with Perforated Peptic Ulcers? A Critical Review of the Existing Literature

A perforated peptic ulcer (PPU) is a surgical emergency with a high mortality rate. PPUs cause secondary peritonitis due to bacterial and fungal peritoneal contamination. Surgery is the main treatment modality and patient's comorbidites impacts perioperative morbidity and surgical outcomes. Even after surgery, resuscitation efforts should continue. While empiric antibiotics are recommended, the role of empiric anti-fungal treatment is unclear due to a lack of scientific evidence. This literature review demonstrated a paucity of studies evaluating the role of empiric anti-fungals in PPUs, and with conflicting results. Studies were heterogeneous in terms of patient demographics and underlying surgical pathology (PPUs vs. any gastrointestinal perforation), type of anti-fungal agent, timing of administration and duration of use. Other considerations include the need to differentiate between fungal colonization vs. invasive fungal infection. Despite positive fungal isolates from fluid culture, it is important for clinical judgement to identify the right group of patients for anti-fungal administration. Biochemistry investigations including new fungal biomarkers may help to guide management. Multidisciplinary discussions may help in decision making for this conundrum. Moving forward, further research may be conducted to select the right group of patients who may benefit from empiric anti-fungal use.

Factors influencing outcome in patients with perforated peptic ulcer disease at a South African tertiary hospital

BACKGROUND

Perforated peptic ulcer (PPU) is associated with significant morbidity and mortality, particularly in low to middle income countries. This study aimed to scrutinise the clinical course of patients diagnosed with PPU and identify modifiable factors to improve outcomes.

METHODS

A retrospective review of the hybrid electronic medical record (HEMR) database at Grey's Hospital was performed. All patients diagnosed with PPU between January 2013 and December 2020 were entered into the study. The variables collected include age, ethnicity, comorbid profile, Boey score, type of surgery performed and complications. These factors were analysed to determine the factors responsible for morbidity and mortality.

RESULTS

One hundred and ninety four patients were diagnosed with PPU during the study period. Six patients were treated non-operatively, all of whom survived. In the surgically treated group, omental patch repair was performed in 159 (84.5%) patients, and primary closure in 26 (13.8%) patients. The leak rate was 32% in the cohort that underwent relaparotomy and the overall mortality was 14%. There was no significant relationship between the type of repair performed and outcome. All patients had a Boey score of 1 or more. The following factors were found to increase the probability of in-hospital mortality: age > 40 years (OR: 8.49, 95% CI 2.46-29.29 p < 0.01), female gender (OR: 2.509, CI 0.98-6.37, p = 0.048), need for relaparotomy (OR: 0.398, CI 0.17-0.91, p = 0.027) and Boey score > 1 (OR: 46.437, CI 6.13-350.28, p < 0.01). A Boey score > 1 was the only variable that increased the likelihood of finding a leaking repair at relaparotomy (p < 0.01).

CONCLUSION

The Boey score was a significant predictor of mortality and leak rate in our patients with PPU. Adding age as a variable may improve the ability to predict mortality in our setting, while the impact of gender and ethnicity needs further investigation.

Risk Factors for Postoperative Morbidity, Suture Insufficiency, Re-Surgery and Mortality in Patients with Gastroduodenal Perforation

(1) Background: The aim of the present study was to identify risk factors associated with postoperative morbidity, suture/anastomotic insufficiency, re-surgery, and mortality in patients undergoing surgery for gastroduodenal perforation. (2) Methods: A retrospective analysis of 273 adult patients who received surgical treatment for gastroduodenal perforation from January 2006 to June 2021 at the University Hospital Erlangen was performed. The patient demographics and preoperative, intraoperative, and postoperative parameters were collected and compared among the different outcome groups (in-hospital morbidity, suture/anastomotic insufficiency, re-surgery, and 90-day mortality). (3) Results: In-hospital morbidity, suture/anastomotic insufficiency, need for re-surgery, and 90-day mortality occurred in 71%, 10%, 26%, and 25% of patients, respectively. The independent risk factors for morbidity were a significantly reduced general condition, a lower preoperative hemoglobin level, and a higher preoperative creatinine level. The independent risk factors for suture/anastomotic insufficiency could be identified as an intake of preoperative steroids and a perforation localization in the proximal stomach or duodenum. The four parameters were independent risk factors for the need for re-surgery: a significantly reduced general condition, a perforation localization in the proximal stomach, a higher preoperative creatinine level, and a higher preoperative CRP level. An age over 66 years and a higher preoperative CRP level were independent risk factors for 90-day mortality. (4) Conclusions: Our study could identify relevant risk factors for the postoperative outcome of patients undergoing surgical treatment for gastroduodenal perforation. Patients exhibiting the identified risk factors should receive heightened attention in the postoperative period and may potentially benefit from personalized and tailored therapy.

Predicting in-hospital mortality risk for perforated peptic ulcer surgery: the PPUMS scoring system and the benefit of laparoscopic surgery: a population-based study

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.

Sarcopenia provides extra value outside the PULP score for predicting mortality in older patients with perforated peptic ulcers

BACKGROUND

Perforated peptic ulcer (PPU) remains challenging surgically due to its high mortality, especially in older individuals. Computed tomography (CT)-measured skeletal muscle mass is a effective predictor of the surgical outcomes in older patients with abdominal emergencies. The purpose of this study is to assess whether a low CT-measured skeletal muscle mass can provide extra value in predicting PPU mortality.

METHODS

This retrospective study enrolled older (aged ≥ 65 years) patients who underwent PPU surgery. Cross-sectional skeletal muscle areas and densities were measured by CT at L3 and patient-height adjusted to obtain the L3 skeletal muscle gauge (SMG). Thirty-day mortality was determined with univariate, multivariate and Kaplan-Meier analysis.

RESULTS

From 2011 to 2016, 141 older patients were included; 54.8% had sarcopenia. They were further categorized into the PULP score ≤ 7 (n=64) or PULP score > 7 group (n=82). In the former, there was no significant difference in 30-day mortality between sarcopenic (2.9%) and nonsarcopenic patients (0%; p=1.000). However, in the PULP score > 7 group, sarcopenic patients had a significantly higher 30-day mortality (25.5% vs. 3.2%, p=0.009) and serious complication rate (37.3% vs. 12.9%, p=0.017) than nonsarcopenic patients. Multivariate analysis showed that sarcopenia was an independent risk factor for 30-day mortality in patients in the PULP score > 7 group (OR: 11.05, CI: 1.03-118.7).

CONCLUSION

CT scans can diagnose PPU and provide physiological measurements. Sarcopenia, defined as a low CT-measured SMG, provides extra value in predicting mortality in older PPU patients.

Are admission laboratory values in isolation meaningful for predicting surgical outcome in patients with perforated peptic ulcers?

Background

The study aimed to calculate the predictive value of admission laboratory values in patients with perforated peptic ulcers.

Methods

A retrospective, cohort analytical, observational study was performed, including patients with surgically confirmed perforated peptic ulcers over a 5-year period. Demographic data and admission laboratory values were collected from hospital electronic databases. Outcomes measured were in-hospital mortality, intensive care unit (ICU) admission and length of stay. The significance of categorical variables was calculated by chi-square and Fisher's exact test. Logistic regression analysis was performed to determine univariately statistically significant variables.

Results

In total, 188 patients met the inclusion criteria. The median age was 46 (range 15-87) years with a male predominance of 71.3 % (n = 134). The median length of hospital stay was 7 (range 1-94) days and 31.4 % (n = 59) of patients were admitted to the ICU. Post-operative in-hospital mortality was 25.0 % (n = 47). Predicting the categorical outcome of in-hospital mortality, abnormal haemoglobin, platelet count, urea, creatinine and potassium levels were all found to be statistically significant in the univariate analysis. Age (odds ratio [OR] 1.03), haemoglobin (OR 4.36) and creatinine (OR 7.76) levels were significant in the multivariate analysis.

Conclusions

Mortality rate among patients with perforated peptic ulcer disease is still substantial. Admission laboratory values showed statistical significance as outcome indicators and were valuable to assist in predicting the prognosis. An abnormally high serum creatinine level was the strongest single predictor of both mortality and ICU admission.

Key message

Initial laboratory findings of patients admitted for perforated peptic ulcer showed that an abnormally high serum creatinine level was the strongest single predictor of both mortality and ICU admission.

Risk factors and prognoses of invasive Candida infection in surgical critical ill patients with perforated peptic ulcer

BACKGROUND

The risk of invasive Candida infection (ICI) is high in patients with perforated peptic ulcer (PPU) who received laparotomy or laparoscopic surgery, but the risk factors and predictors of morbidity outcomes remain uncertain. This study aims to identify the risk factors of ICI in surgical critically ill PPU patients and to evaluate the impact on patient's outcomes.

METHODS

This is a single-center, retrospective study, with a total of 170 surgical critically ill PPU patients. Thirty-seven patients were ICI present and 133 were ICI absent subjects. The differences in pulmonary complications according to invasive candidiasis were determined by the Mann-Whitney U test. Evaluation of predictors contributing to ICI and 90-day mortality was conducted by using multivariate logistic regression analysis.

RESULTS

Candida albicans was the primary pathogen of ICI (74.29%). The infected patients had higher incidence of bacteremia (p < 0.001), longer intensive care unit (p < 0.001) and hospital (p < 0.001) stay, longer ventilator duration (p < 0.001) and increased hospital mortality (p = 0.02). In the multivariate analysis, serum lactate level measured at hospital admission was independently associated with the occurrence of ICI (p = 0.03). Liver cirrhosis (p = 0.03) and Sequential Organ Failure Assessment (SOFA) score (p = 0.007) were independently associated with the 90-day mortality.

CONCLUSIONS

Blood lactate level measured at hospital admission could be a predictor of ICI and the surgical critically ill PPU patients with liver cirrhosis and higher SOFA score are associated with poor outcomes.

Analysis of Surgical Mortalities Using the Fishbone Model for Quality Improvement in Surgical Disciplines

BACKGROUND

The healthcare industry is complex and prone to the occurrence of preventable patient safety incidents. Most serious patient safety events in surgery are preventable.

AIM

This study was conducted to determine the rate of occurrence of preventable mortalities and to use the fishbone model to establish the main contributing factors.

METHODS

We reviewed the records of patients who died following admission to the surgical wards. Data regarding their demography, diagnosis, acuity, comorbidities, categorization of death and contributing factors were extracted from the Research Electronic Data Capture (REDCap) database. Factors which contributed to preventable and potentially preventable mortalities were collated. The fishbone model was used for root cause analysis. The study received prior ethical clearance (M190122).

RESULTS

Records of 859 mortalities were found, of which 65.7% (564/859) were males. The median age of the patients who died was 49 years (IQR: 33-64 years). The median length of hospital stay before death was three days (IQR: 1-11 days). Twenty-four percent (24.1%) of the deaths were from gastrointestinal (GIT) emergencies, 18.4% followed head injury and 17.0% from GIT cancers. Overall, 5.4% of the mortalities were preventable, and 41.1% were considered potentially preventable. The error of judgment and training issues accounted for 46% of mortalities.

CONCLUSION

Most surgical mortalities involve males, and around 46% are either potentially preventable or preventable. The majority of the mortality were associated with GIT emergencies, head injury and advanced malignancies of the GIT. The leading contributing factors to preventable and potentially preventable mortalities were the error of judgment, inadequate training and shortage of resources.

Outcomes of Nonoperative Treatment for Gastroduodenal Ulcer Perforation: a Nationwide Study of 14,918 Inpatients in Japan

BACKGROUND

Gastroduodenal ulcer perforation is a common abdominal emergency that may be curable without surgical repair in non-elderly patients with localized and stable symptoms. However, the outcomes of nonoperative approaches have rarely been described.

METHODS

Using a Japanese national inpatient database, we identified 14,918 patients with gastroduodenal ulcer perforation who were hospitalized and received nonoperative treatment from July 2010 to March 2017. We categorized these patients into three groups according to age: 18 to 64 years (young group, n=8407), 65 to 74 years (old group, n=2616), and ≥75 years (old-old group, n=3895). We investigated the characteristics, treatments, and outcomes in each group.

RESULTS

Most of the patients were men (71%), and the median patient age was 62 years (interquartile range, 47-75 years). The old and old-old groups had more comorbidities than the young group. Whereas most patients were administered proton pump inhibitors and various antibiotics (96% and 90%, respectively), only 58% of patients underwent gastric tube placement. Surgical repair >3 days after admission was performed in 7.1% of all patients (6.3% vs. 7.9% vs. 5.5%, P<0.001). The old and old-old groups showed higher mortality (1.4% vs. 8.3% vs. 18%, P<0.001) and morbidity (6.6% vs. 15% vs. 17%, P<0.001) than the young group. The median length of stay was almost 2 weeks (13 vs. 17 vs. 20 days, P<0.001).

DISCUSSION

Unlike previous studies, many patients aged >65 years received nonoperative treatment in this nationwide cohort. Our findings provide useful information for clinicians and patients hospitalized for gastric ulcer perforation.

Low serum albumin may predict poor efficacy in patients with perforated peptic ulcer treated nonoperatively

BACKGROUND

Nonoperative management (NOM) is a promising therapeutic modality for patients with perforated peptic ulcer (PPU). However, the risk factors for poor efficacy and adverse events of NOM are a concern.

AIM

To investigate the factors predictive of poor efficacy and adverse events in patients with PPU treated by NOM.

METHODS

This retrospective case-control study enrolled 272 patients who were diagnosed with PPU and initially managed nonoperatively from January 2014 to December 2018. Of these 272 patients, 50 converted to emergency surgery due to a lack of improvement (surgical group) and 222 patients were included in the NOM group. The clinical data of these patients were collected. Baseline patient characteristics and adverse outcomes were compared between the two groups. Logistic regression analysis and receiver operating characteristic curve analyses were conducted to investigate the factors predictive of poor efficacy of NOM and adverse outcomes in patients with PPU.

RESULTS

Adverse outcomes were observed in 71 patients (32.0%). Multivariate analyses revealed that low serum albumin level was an independent predictor for poor efficacy of NOM and adverse outcomes in patients with PPU.

CONCLUSION

Low serum albumin level may be used as an indicator to help predict the poor efficacy of NOM and adverse outcomes, and can be used for risk stratification in patients with PPU.

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.

Evaluation of clinical factors and three scoring systems for predicting mortality in perforated peptic ulcer patients, a retrospective study

Background/objective

Early identification of mortality risk in perforated peptic ulcer (PPU) patients is important for triage and risk stratification. This study aimed to compare clinical and laboratory factors and three scoring systems to predict mortality in PPU patients.

Methods

Retrospective data on PPU patients at M. Djamil Hospital who underwent emergency laparotomy repair surgery were collected from December 2018 to May 2021. The data included demographics, clinical characteristics, and three scoring systems. Data analysis used bivariate, multivariate, and ROC analysis.

Results

A total 72 patients were included and mortality rate was 52.8%. Bivariate analysis showed a significant association between age (p = 0.029), onset of illness (p = 0.001), alteration of consciousness (p = <0.001), respiratory rate (p = 0.04), duration of surgery (p = 0.040), preoperative shock (p = 0.049), preoperative creatinine (p = <0.001), Boey's scores (p = 0.002), ASA (p = 0.001), and qSOFA scores (p = <0.001) with mortality in PPU patients. From multivariate analysis, the strongest clinical factors associated with mortality were alteration of consciousness (p = <0.001) and preoperative creatinine (p = 0.001). Receiver Operating Characteristic (ROC) analysis showed the area under the curve (AUC) of Boey's Score 0.73, ASA classification 0.69, qSOFA score 0.77, alteration of consciousness 0.74, and preoperative creatinine 0.78.

Conclusion

Preoperative creatinine and altered consciousness had the strongest association with mortality in PPU patients. The qSOFA score predicted mortality better than Boey's score and ASA classification. Preoperative creatinine was the best single predictor of mortality.

How long of a postponement in surgery can a blunt hollow viscus injury patient tolerate? A retrospective study from the National Trauma Data Bank

BACKGROUND

In the management of patients with blunt abdominal trauma, delayed diagnosis and treatment of hollow viscus injury can occur. We assessed the effect of the time to surgery on the outcomes of blunt hollow viscus injury patients.

METHODS

The National Trauma Data Bank was queried from 2012 to 2015 to identify patients with blunt hollow viscus injury for inclusion. Patients with unstable hemodynamics, concomitant intra-abdominal organ injuries, or other severe extra-abdominal injuries were excluded. Inverse probability of treatment weighting and multivariate logistic regression were used to evaluate the effect of the time to surgery on the outcomes.

RESULTS

In total, 2,997 patients with blunt hollow viscus injury were studied; the mean time to abdominal surgery was 6.7 hours. Twenty-two hours was selected as a cutoff value for further analyses because of an observed transition zone at that time in the distribution of mortality and severe sepsis rates. After adjustment, patients who underwent surgery within 22 hours had a significantly lower mortality rate (1.2% vs 4.2%), lower sepsis rate (0.9% vs 4.5%), shorter hospital length of stay (8.7 vs 12.0 days), and shorter intensive care unit length of stay (1.4 vs 3.3 days). In patients who underwent surgery within 22 hours, neither mortality nor sepsis were affected significantly by the time to surgery.

CONCLUSION

In the management of patients with blunt hollow viscus injury, early surgical treatment is needed. Patients with isolated blunt hollow viscus injury may have a poor outcome if they undergo abdominal surgery more than 22 hours after arrival in the emergency department.

Primary closure versus Graham patch omentopexy in perforated peptic ulcer: A systematic review and meta-analysis

BACKGROUND

There are different methods to repair a perforated peptic ulcer, the two most frequently used are the Graham patch omentopexy and the primary closure. Currently there is no high-level evidence to provide guidance of the optimal method of repair. The aim of this study is to compare the outcomes of the two methods so as to provide improved guidance for surgeons undertaking this repair.

METHODS

A systematic review and meta-analysis was conducted including any study that compared Graham patch omentopexy with primary closure in adults. Embase, Medline, Cochrane and Google's search engine were searched. The primary outcome was breakdown of the repair resulting in bile leak and the secondary outcomes were mortality, operation time, wound infection and time to start oral intake. The meta-analysis was conducted using Review Manager Software version 5:4. Outcome data were reported as odd ratios and weighted mean differences with their 95% confidence intervals.

RESULTS

Of the 229 studies identified, 6 were suitable for analysis, 4 were retrospective, one was a prospective cohort study and one was a randomized controlled trial. Meta-analysis showed no difference in occurrence of bile leak or mortality between primary closure and Graham patch omentopexy (OR 0.64; 95% (0.26-1.54) & 0.66; 95% (0.25-1.76) respectively). There was no difference in the rates of wound infection OR 0.65; 95% (0.4-1.05). The duration of the operation was shorter in the primary closure group by 5.6 min; 95% (-21 + 10.4).

CONCLUSION

There was no difference in the clinical outcomes between the two modes of repair.

A Fast and Reliable Method to Interpret Short-Term Mortality in Perforated Peptic Ulcer: Red Cell Distribution Width is Sensitive and Specific

Introduction

Peptic ulcer is an important health problem worldwide with a prevalence of around 5%. Peptic ulcer perforation is a potentially mortal complication of peptic ulcer disease. We aimed to investigate the potential use of red cell distribution width as a prognostic marker in peptic ulcer perforation.

Methods

The files, operation notes, biochemical and hematological parameters, and prognosis of patients who were operated for a peptic ulcer perforation were reviewed in a retrospective cohort study. The relation of red cell distribution width (RDW) to main outcome in-hospital mortality was assessed.

Results

The mean age of the 172 patients was 40 ± 17.89. There were 158 (92%) males and 14 (8%) females. The in-hospital mortality was 8.7% (15/172). The median RDW in the group with mortality was 15.00 (interquartile range (IQR): 14.30–17.20) compared with the median RDW in the group with no mortality as 13.2 (IQR: 12.80–14.00, p ≤ 0.001). Receiver operator characteristic curves were plotted for RDW to identify nonsurvivors and yielded a significant area under the curve as 0.812 (95% confidence interval: 0.682–0.942). The sensitivity and specificity of RDW at a cutoff value of 14.25% were calculated with an accuracy of 81.98 (95% confidence interval: 75.40–87.41) as 80.00 (51.91–95.67) and 82.17 (75.27–87.81), respectively.

Conclusion

Increased RDW may be of use to interpret mortality in patients with peptic ulcer perforation.

Primary percutaneous coronary intervention without stenting using excimer laser and manual thrombectomy in STEMI with duodenal ulcer perforation: a case report

Background

ST-segment elevation myocardial infarction (STEMI) and peptic ulcer perforation are both medical emergencies that require urgent intervention. In case that these time-sensitive medical emergencies present concomitantly, it remains unclear which one should be treated first.

Case summary

An 85-year-old man with melaena, epigastric pain, and severe anaemia was transferred to our emergency department and diagnosed as having inferior STEMI based on electrocardiogram. Emergency coronary angiography (CAG) revealed severe stenosis with thrombus in the proximal right coronary artery. Immediate oesophagogastroduodenoscopy and abdominal computed tomography detected the presence of duodenal ulcer perforation. Primary percutaneous coronary intervention (PCI) without stenting using excimer laser coronary angioplasty and manual thrombectomy was performed under intravascular ultrasound (IVUS) guidance to avoid dual antiplatelet therapy (DAPT). After successful PCI, the perforated viscus was surgically repaired with a laparoscopic omental patch. On Day 7, endoscopic haemostasis treated the oozing of blood from the duodenal ulcer. On Day 21, follow-up CAG and IVUS showed residual stenosis with organized thrombus in the culprit lesion, in which a drug-coated stent was directly implanted. He was discharged with a favourable clinical course on Day 23.

Discussion

We judged that PCI should take precedence over the surgical repair of perforated duodenal ulcer in our case since STEMI was an immediate life-threatening compared to the perforated viscus which had no active exsanguination. Excimer laser coronary angioplasty with manual thrombectomy might be an adequate option to avoid stent deployment and subsequent DAPT in such complex scenarios.

Potential use of peptic ulcer perforation (PULP) score as a conversion index of laparoscopic-perforated peptic ulcer (PPU) repair

BACKGROUND

Laparoscopic repair is a well-accepted treatment modality for perforated peptic ulcer (PPU). However, intraoperative conversion to laparotomy is still not uncommon. We aimed to identify preoperative factors strongly associated with conversion.

METHODS

A retrospective review of records of all PPU patients treated between January 2011 and July 2019 was performed. Patients were divided into three groups: laparoscopic repair (LR), conversion to laparotomy (CL), and primary laparotomy (PL). Patient demographics, operative findings, and outcomes were compared between the groups. Logistic regression analyses were performed, taking conversion as the outcome.

RESULTS

Of 822 patients, there were 236, 45, and 541 in the LR, CL, and PL groups, respectively. The conversion rate was 16%. Compared with those in the LR group, patients in the CL group were older (p < 0.001), had higher PULP scores (p < 0.001), had higher ASA scores (p < 0.001) and had hypertension (p = 0.003). PULP score was the only independent risk factor for conversion. The area under the curve (AUC) for the PULP score to predict conversion was 75.3%, with a best cut-off value of ≥ 4. The operative time was shorter for PL group patients than for CL group patients with PULP scores ≥ 4. For patients with PULP scores < 4, LR group patients had a shorter length of stay than PL group patients.

CONCLUSION

The PULP score may have utility in predicting and minimizing conversion for laparoscopic PPU repair. Laparoscopic repair is the procedure of choice for PPU patients with PULP scores < 4, while open surgery is recommended for those with PULP scores ≥ 4.

Survival curve identifies critical period for postoperative mortality in cardiac patients undergoing emergency general surgery

The number of non-cardiac major surgeries carried out has significantly increased in recent years to around 200 million procedures carried out annually. Approximately 30% of patients submitted to non-cardiac surgery present some form of cardiovascular comorbidity. In emergency situations, with less surgery planning time and greater clinical severity, the risks become even more significant. The aim of this study is to determine the incidence and clinical outcomes in patients with cardiovascular disease submitted to non-cardiac surgical procedures in a single cardiovascular referral center. This is a prospective cohort study of patients with cardiovascular disease submitted to non-cardiovascular surgery. All procedures were carried out by the same surgeon, between January 2006 and January 2018. 240 patients included were elderly, 154 were male (64%), 8 patients presented two diagnoses. Of the resulting 248 procedures carried out, 230 were emergency (92.8%). From the data obtained it was possible to estimate the day from which the occurrence of mortality is less probable in the postoperative phase. Our research evaluated the epidemiological profile of the surgeries and we were able to estimate the survival and delimit the period of greatest risk of mortality in these patients. The high rate of acute mesenteric ischemia was notable, a serious and frequently fatal condition.

Long-term mortality in the Intermediate care after emergency abdominal surgery (InCare) trial-A post-hoc follow-up study

BACKGROUND

Patients undergoing emergency abdominal surgery are at high risk of post-operative complications. Although post-operative treatment at an intermediate care unit may improve early outcome, there is a lack of studies on the long-term effects of such therapy. The aim of this study was to assess the long-term effect of intermediate care versus standard surgical ward care on mortality in the Intermediate Care After Emergency Abdominal Surgery (InCare) trial.

METHODS

We included adult patients undergoing emergency major laparoscopy or laparotomy with an Acute Physiology and Chronic Health Evaluation (APACHE) II score of 10 or more, who participated in the InCare trial from October 2010 to November 2012. In the InCare trial, patients were randomized to either post-operative intermediate care or standard surgical ward care. The primary outcome was time to death within 6 years after surgery. We assessed mortality with Coxregression analysis.

RESULTS

A total of 286 patients were included. The all-cause 6-year landmark mortality was 52.8% (76 of 144 patients) in the intermediate care group and 47.9% (68 of 142 patients) in the ward care group. There was no statistically significant difference in mortality risk between the two groups (hazard ratio 1.06 (95% confidence interval 0.76-1.47), P = .73).

CONCLUSION

We found no statistically significant difference in 6-year mortality between patients randomized to post-operative intermediate care or ward care after emergency abdominal surgery. However, we detected an absolute mortality risk reduction of 5% in favour of ward care, possibly due to random error.

[Comparison of laparoscopic and open suturing of perforated peptic ulcer complicated by advanced peritonitis]

AIM

To compare the results of open and laparoscopic interventions for PGDU complicated by advanced peritonitis.

MATERIAL AND METHODS

A retrospective analysis enrolled 172 patients with PGDU who underwent surgery for the period 2014-2016. The research was performed at the bases of the Department of Faculty-Based Surgery No. 1 of the Medical Faculty of the Pirogov Russian National Research Medical University. Further analysis enrolled 138 patients in accordance with inclusion and exclusion criteria (laparoscopic intervention - 116 patients, open surgery - 22). Propensity score matching (pseudorandomization) was applied after comparative analysis of patients' characteristics and treatment outcomes in order to ensure maximum comparability of both groups.

RESULTS

Length of hospital-stay (7.1 vs. 9.8 days), incidence of extra-abdominal complications (6.3%. vs. 41.2%) and adverse events Clavien-Dindo grade II (6.3% vs. 35.3%) were significantly lower after minimally invasive surgery (p<0.05).

CONCLUSION

Analysis of comparable groups of patients with PGDU complicated by peritonitis revealed that laparoscopic surgery is accompanied by significantly lower incidence of extra-abdominal postoperative complications and shorter hospital-stay compared with open surgery. Mortality and incidence of intra-abdominal postoperative complications were similar in both groups.

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.

Laparoscopic repair of perforated peptic ulcer is not prognostic factor for 30-day mortality (a nationwide prospective cohort study)

BACKGROUND

Laparoscopic surgery has become increasingly popular in treating perforated peptic ulcer (PPU). However, currently it is not recognized as a prognostic factor for mortality within this group of patients. The aim of this study was to investigate whether laparoscopic surgery was an independent mortality risk factor in patients treated surgically for perforated peptic ulcer.

MATERIALS AND METHODS

This was a Danish nationwide cohort study based on prospectively collected data of 1008 patients treated surgically for PPU between September 2011 and December 2015. A propensity score matching analysis, considering most of the known prognostic factors for mortality and baseline characteristics, was used to adjust mortality estimates in patients treated with open and laparoscopic surgery. The primary outcome was postoperative 30-day mortality.

RESULTS

The study population comprised 1008 patients; 507 were treated laparoscopically and 501 by open surgery. There was significantly higher mean age, and higher ASA scores, as well as other mortality risk factors in the open surgery group. The unadjusted 30-day mortality was significantly lower in patients undergoing laparoscopic surgery compared to open surgery (HR = 0.48, 95% CI: 0.36-0.65). After matching and weighting controls, the adjusted difference in mortality was reduced and was not significant (HR = 0.82, 95% CI: 0.59-1.15). The 30-day mortality was 13.1% for laparoscopy and 14.7% for the matched controls in the open surgery group.

CONCLUSIONS

Compared to open surgery, laparoscopic surgery in patients with PPU does not reduce short term mortality. More well powered randomized clinical trials are needed to investigate the role of laparoscopic surgery in treatment of patients with PPU.

Role of Empiric Anti-Fungal Therapy in the Treatment of Perforated Peptic Ulcer Disease: Review of the Evidence and Future Directions

Background: Peptic ulcer disease (PUD) affects four million people worldwide. Perforated peptic ulcer (PPU) occurs in less than 15% of cases but is associated with significant morbidity and mortality rates. Administration of antibiotics is standard treatment for gastrointestinal perforations, including PPU. Although fungal growth is common in peritoneal fluid cultures from patients with PPU, current data suggest empiric anti-fungal therapy fails to improve outcomes. To examine the role of anti-fungal agents in the treatment of PPU, the Surgical Infection Society hosted an Update Symposium at its 37^th Annual Meeting. Here, we provide a synopsis of the symposium's findings and a brief review of prospective and retrospective reports on the subject. Methods: A search of Pubmed/MEDLINE, EMBASE, and the Cochrane Library was performed between January 1, 2000, and November 1, 2018, comparing outcomes of PPU following empiric anti-fungal treatment versus no anti-fungal therapy. We used the search terms "perforated peptic ulcer," "gastroduodenal ulcer," "anti-fungal," and "perforated" or "perforation." Results: There are no randomized clinical trials comparing outcomes specifically for patients with PPU treated with or without empiric anti-fungal therapy. We identified one randomized multi-center trial evaluating outcomes for patients with intra-abdominal perforations, including PPU, that were treated with or without empiric anti-fungal therapy. We identified one single-center prospective series and three additional retrospective studies comparing outcomes for patients with PPU treated with or without empiric anti-fungal therapy. Conclusion: The current evidence reviewed here does not demonstrate efficacy of anti-fungal agents in improving outcomes in patients with PPU. As such, we caution against the routine use of empiric anti-fungal agents in these patients. Further studies should help identify specific subpopulations of patients who might derive benefit from anti-fungal therapy and help define appropriate treatment regimens and durations that minimize the risk of resistance, adverse events, and cost.

The DIFFMASK score for predicting difficult facemask ventilation: a cohort study of 46,804 patients

Facemask ventilation is an essential part of airway management. Correctly predicting difficulties in facemask ventilation may reduce the risk of morbidity and mortality among patients at risk. We aimed to develop and evaluate a weighted risk score for predicting difficult facemask ventilation during anaesthesia. We analysed a cohort of 46,804 adult patients who were assessed pre-operatively airway for 13 predictors of difficult airway management and subsequently underwent facemask ventilation during general anaesthesia. We developed the Difficult Facemask (DIFFMASK) score in two consecutive steps: first, a multivariate regression analysis was performed; and second, the regression coefficients of the adjusted regression model were converted into a clinically applicable weighted point score. The predictive accuracy of the DIFFMASK score was evaluated by assessment of receiver operating characteristic curves. The prevalence of difficult facemask ventilation was 1.06% (95%CI 0.97-1.16). Following conversion of regression coefficients into 0, 1, 2 or 3 points, the cumulated DIFFMASK score ranged from 0 to 18 points and the area under the receiver operating characteristic curve was 0.82. The Youden index indicated a sum score ≥ 5 as an optimal cut-off value for prediction of difficult facemask ventilation giving a sensitivity of 85% and specificity of 59%. The DIFFMASK score indicated that a score of 6-10 points represents a population of patients who may require heightened attention when facemask ventilation is planned, compared with those patients who are obviously at a high- or low risk of difficulties. The DIFFMASK score may be useful in a clinical context but external, prospective validation is needed.

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

Background

/aim: Scores commonly employed to risk stratify perforated peptic ulcer patients include ASA (American Society of Anesthesiologists), Boey and peptic ulcer perforation score (PULP). However, few studies assessed and compared the accuracy indices of these three scores in predicting post PPU repair 30-day morbidity. We assessed accuracy indices of PULP, and compared them to Boey and ASA in predicting post perforated duodenal (PDU) ulcer repair 30-day morbidity.

Methods

Retrospective chart review of all PDU patients (perforated duodenal ulcers only) at the largest two hospitals in Qatar (N = 152). Data included demographic, clinical, laboratory, operative, and post repair 30-day morbidity. Area under the Curve (AUC), sensitivity and specificity were computed for each of the 3 scores. Multivariate logistic regression assessed the accuracy indices of each score.

Results

All patients were males (M age 37.41 years). Post PDU repair 30-day morbidity was 10.5% (16 morbidities). Older age, higher ASA (≥3), Boey (≥1) or PULP (≥8) scores, shock on admission and preoperative comorbidities; and conversely, lower hemoglobin and albumin were all positively significantly associated with higher post PDU 30-day morbidity. PULP displayed the largest AUC (72%), and was the only score to significantly predict 30-day morbidity. The current study is the first to report the sensitivity and specificity of these three scores for post PDU repair 30-day morbidity; and first to assess accuracy indices for PULP in predicting post PDU repair 30-day morbidity.

Conclusion

PULP score had the largest AUC and was the only score to significantly predict post PDU repair 30-day morbidity.

•

The current study is the first to report the sensitivity and specificity of the three scoring systems (ASA, Boey and PULP) for post perforated duodenal ulcer repair 30-day morbidity.

•

It is also the first study to assess accuracy indices for PULP in predicting post perforated duodenal ulcer repair 30-day morbidity.

•

Compared with ASA and Boey, PULP score had the largest area under the curve and was the only score to significantly predict post perforated duodenal ulcer repair 30-day morbidity.

Laparoscopic versus open repair of perforated peptic ulcer: A retrospective cohort study

INTRODUCTION

Perforated peptic ulcer disease (PPU) is a condition subject to wide geographical variations in incidence. It remains a significant cause of morbidity and mortality, even in the era of Helicobacter pylori eradication and proton-pump inhibitor therapy. There is no clear consensus on whether laparoscopic or open approaches are superior, and with most studies in this area originating from Europe and Asia, Australian data addressing this issue are lacking.

METHODS

This retrospective cohort study included all patients who underwent surgery for PPU within a hospital network in Australia. Baseline variables and primary outcomes, including length of hospital stay, chest and abdominal complications, and mortality, were recorded. Secondary outcomes, including reasons for conversion, were also considered.

RESULTS

In total, 109 patients underwent operations for PPU between January 2011 and December 2015. There were no significant differences with regard to baseline comorbidities. There were no statistically significant differences in terms of median length of hospital stay or rates of chest and abdominal complications, but the operative time was 28.5 min longer (P = <0.001) in the laparoscopic group than in the open group.

CONCLUSION

Open operations were faster to perform than laparoscopic operations for repair of PPU. Despite increased experience treating many surgical diseases laparoscopically, this study did not find it to be superior in terms of length of hospital stay or complication rates.

Laparoscopy is an available alternative to open surgery in the treatment of perforated peptic ulcers: a retrospective multicenter study

Background

Perforated peptic ulcers (PPU) remain one of the most frequent causes of death. Their incidence are largely unchanged accounting for 2–4% of peptic ulcers and remain the second most frequent abdominal cause of perforation and of indication for gastric emergency surgery. The minimally invasive approach has been proposed to treat PPU however some concerns on the offered advantages remain.

Methods

Data on 184 consecutive patients undergoing surgery for PPU were collected. Likewise, perioperative data including shock at admission and interval between admission and surgery to evaluate the Boey’s score.

It was recorded the laparoscopic or open treatments, the type of surgical procedure, the length of the operation, the intensive care needed, and the length of hospital stay.

Post-operative morbidity and mortality relation with patient’s age, surgical technique and Boey’s score were evaluated.

Results

The relationship between laparoscopic or open treatment and the Boey’s score was statistically significant (p = 0.000) being the open technique used for the low-mid group in 41.1% and high score group in 100% and laparoscopy in 58.6% and 0%, respectively. Postoperative complications occurred in 9.7% of patients which were related to the patients’ Boey’s score, 4.7% in the low-mid score group and 21.4% in the high risk score group (p = 0.000). In contrast morbidity was not related to the chosen technique being 12.8% in open technique and 5.3% in laparoscopic one (p = 0.092, p > 0.05).

30-day post-operative mortality was 3.8% and occurred in the 0.8% of low-mid Boey’s score group and in the 10.7% of the high Boey’s score group (p = 0.001). In respect to the surgical technique it occurred in 6.4% of open procedures and in any case in the Lap one (p = 0.043). Finally, there was a statistically significant difference in morbidity and mortality between patients < 70 and > 70 years old (p = 0.000; p = 0.002).

Conclusions

Laparoscopy tends to be an alternative method to open surgery in the treatment of perforated peptic ulcer. Morbidity and mortality were essentially related to Boey’s score. In our series laparoscopy was not used in high risk Boey’s score patients and it will be interesting to evaluate its usefulness in high risk patients in large randomized controlled trials.

Short-term outcomes after emergency surgery for complicated peptic ulcer disease from the UK National Emergency Laparotomy Audit: a cohort study

OBJECTIVES

This study used national audit data to describe current management and outcomes of patients undergoing surgery for complications of peptic ulcer disease (PUD), including perforation and bleeding. It was also planned to explore factors associated with fatal outcome after surgery for perforated ulcers. These analyses were designed to provide a thorough understanding of current practice and identify potentially modifiable factors associated with outcome as targets for future quality improvement.

DESIGN

National cohort study using National Emergency Laparotomy Audit (NELA) data.

SETTING

English and Welsh hospitals within the National Health Service.

PARTICIPANTS

Adult patients admitted as an emergency with perforated or bleeding PUD between December 2013 and November 2015.

INTERVENTIONS

Laparotomy for bleeding or perforated peptic ulcer.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was 60-day in-hospital mortality. Secondary outcomes included length of postoperative stay, readmission and reoperation rate.

RESULTS

2444 and 382 procedures were performed for perforated and bleeding ulcers, respectively. In-hospital 60-day mortality rates were 287/2444 (11.7%, 95% CI 10.5% to 13.1%) for perforations, and 68/382 (17.8%, 95% CI 14.1% to 22.0%) for bleeding. Median (IQR) 2-year institutional volume was 12 (7-17) and 2 (1-3) for perforation and bleeding, respectively. In the exploratory analysis, age, American Society of Anesthesiology score and preoperative systolic blood pressure were associated with mortality, with no association with time from admission to operation, surgeon grade or operative approach.

CONCLUSIONS

Patients undergoing surgery for complicated PUD face a high 60-day mortality risk. Exploratory analyses suggested fatal outcome was primarily associated with patient rather than provider care factors. Therefore, it may be challenging to reduce mortality rates further. NELA data provide important benchmarking for patient consent and has highlighted low institutional volume and high mortality rates after surgery for bleeding peptic ulcers as a target for future research and improvement.

Validation of the AAST EGS grading system for perforated peptic ulcer disease

INTRODUCTION

Perforated peptic ulcer disease (PPUD) including both duodenl and gastric ulcers is a severe disease and outcomes are influenced by comorbidities and physiology. We validated the AAST EGS grading system at two diverse centers (Mayo Clinic, USA and Pietermaritzburg, South Africa).

METHODS

Dual-center review of historic data (2010-2016) of adults with PPUD was performed. Preoperative, procedural, and postoperative data were abstracted. ASA, Boey, PULP and AAST EGS grades were generated. Comparative, multivariable, and pairwise analyses were performed.

RESULTS

There were 306 patients, 42% female with a mean (±SD) age of 56 ±20 years. Overall, the patints were categorized into the following AAST EGS grades: I (30, 10%), II (38, 12%), III (104, 34%), IV (76, 2e%), V (58, 18.9%). Initial management included: midline laparotomy (51%, n=157), laparoscopy (18%, n=58), laparoscopy converted to laparotomy (1%, n=3), and endoscopy (30%, n=88). Duration of stay increased with AAST EGS grade. In United States cohort, factors predictive for 30-day mortality included AAST EGS grade and patient comorbidity status. The AAST EGS grade was comparable to other scoring systems (Boey, PULP, and ASA).

CONCLUSIONS

Differences exist between centers for management of PPUD and their outcomes; however, the AAST EGS grade can be utilized to stratify thedisease severity of the patient and this demonstrates initial construct validity in a United States but not in a South African population.

Acute Myocardial Infarction with Simultaneous Gastric Perforation

Acute myocardial infarction and perforated peptic ulcer disease with associated peritonitis are both medical emergencies requiring urgent intervention. This patient presented with both emergencies simultaneously. Current literature is devoid of guidance as to which should be addressed initially. A multidisciplinary discussion was conducted leading to a unanimous decision for initiating percutaneous coronary intervention (PCI). After successful PCI, the patient was immediately taken to the operating room for laparoscopic repair of the perforated viscous. Subsequent to the operative repair, the patient became hemodynamically unstable and a repeat electrocardiogram demonstrated complete right coronary occlusion. Shock ensued and the patient died in the intensive care unit despite this plan of care. It is our opinion that this case reveals the need for expert panels to devise decision algorithms for concomitant presentations of life-threatening diseases.

[Perforated duodenal ulcer in high risk patients]

AIM

To improve the outcomes in patients with perforated duodenal ulcers.

MATERIAL AND METHODS

Cohort study included 456 patients with perforated duodenal ulcer. High risk of mortality was determined in 9% of patients (n=40) considering Boey diagnostic criteria (1982, 1987). There were 19 women and 21 men aged 59±2.8 years.

RESULTS

Perforated duodenal ulcer was followed by overall mortality near 3.8%. In high risk group this value was 17.5% (7 out of 40 patients) while expected mortality was 45.5-100% in these patients in view of Boey criteria. The main causes of death were multiple organ failure, pulmonary embolism and acute myocardial infarction.

CONCLUSION

Minimally invasive surgery including step-by-step procedures (mini-laparotomy, laparoscopy and navigation) are the key to improve the outcomes in patients with perforated duodenal ulcer.

Long-Term Mortality in Patients Operated for Perforated Peptic Ulcer: Factors Limiting Longevity are Dominated by Older Age, Comorbidity Burden and Severe Postoperative Complications

BACKGROUND

Perforated peptic ulcer (PPU) is a surgical emergency associated with high short-term mortality. However, studies on long-term outcomes are scarce. Our aim was to investigate long-term survival after surgery for PPU.

MATERIALS AND METHODS

A population-based, consecutive cohort of patients who underwent surgery for PPU between 2001 and 2014 was reviewed, and the long-term mortality was assessed. Survival was investigated by univariate analysis (log-rank test) and displayed using Kaplan-Meier survival curves. Multivariable analysis of risk factors for long-term mortality was assessed by Cox proportional hazards regression and reported as hazard ratio (HR) with 95 % confidence intervals (CI).

RESULTS

A total of 234 patients were available for the calculation of ninety-day, one-year and two-year mortality, and the results showed rates of 19.2 % (45/234), 22.6 % (53/234) and 24.8 % (58/234), respectively. At the end of follow-up, a total of 109 of the 234 patients (46.6 %) had died. Excluding 37 (15.2 %) patients who died within 30 days of surgery, 197 patients had long-term follow-up (median 57 months, range 1-168) of which 36 % (71/197) died during the follow-up period. In multivariable analyses, age >60 years (HR 3.95, 95 % CI 1.81-8.65), active cancer (HR 3.49, 95 % CI 1.73-7.04), hypoalbuminemia (HR 1.65, 95 % CI 0.99-2.73), pulmonary disease (HR 2.06, 95 % CI 1.14-3.71), cardiovascular disease (HR 1.67, 95 % CI 1.01-2.79) and severe postoperative complications (HR 1.76, 95 % CI 1.07-2.89) during the initial stay for PPU were all independently associated with an increased risk of long-term mortality. Cause of long-term mortality was most frequently (18 of 71; 25 %) attributed to new onset sepsis and/or multiorgan failure.

CONCLUSION

The long-term mortality after surgery for PPU is high. One in every three patients died during follow-up. Older age, comorbidity and severe postoperative complications were risk factors for long-term mortality.

Surgical Scales: Primary Closure versus Gastric Resection for Perforated Gastric Ulcer - A Surgical Debate

Perforated gastric ulcer is one of the most life-threatening complications of peptic ulcer disease with high morbidity and mortality rates. The surgical strategy for gastric perforation in contrast with duodenal perforations often requires consilium and intraoperative debates. The subject of the debate is a 59-year-old male patient who presented with perforated giant gastric ulcer complicated by generalized peritonitis and severe sepsis. The debate is based on a systematized table dividing all factors into three groups and putting them on surgical scales. Pathology-related factors influencing the decision-making are size and site of perforation, local tissue inflammation, signs of malignancy, simultaneous complications of peptic ulcer, peritonitis, and sepsis. Besides these factors, patient- and healthcare-related factors should also be considered.

Low serum albumin may predict the need for gastric resection in patients with perforated peptic ulcer

PURPOSE

Perforated peptic ulcer (PPU) is a common surgical emergency and treatment involves omental patch repair (PR). Gastric resection (GR) is reserved for difficult pathologies. We audit the outcomes of GR at our institution and evaluate the pre-operative factors predicting the need for GR.

METHODS

This is a single-institution, retrospective study of patients with PPU who underwent surgery from 2004 to 2012. Demographics, clinical presentation and intra-operative findings were studied to identify factors predicting the need for GR in PPU. An audit of clinical outcomes and mortality for all patients with GR is reported.

RESULTS

537 (89.6 %) patients underwent PR and 62 (10.4 %) patients GR. Old age (p < 0.0001), female sex (p = 0.0123), non-steroidal anti-inflammatory drugs (NSAIDs) usage (p = 0.0008), previous history of peptic ulcer disease (PUD) (p = 0.0159), low hemoglobin (p < 0.0001), low serum albumin (p < 0.0001), high serum creatinine (p = 0.0030), high urea (p = 0.0006) and large ulcer size (p < 0.0001) predict the need for GR. On multivariate analysis only low serum albumin (OR 5.57, 95 % CI 1.56-19.84, p = 0.008) predicted the need for GR. The presence of Helicobacter pylori infection was protective against GR (OR 0.25, 95 %CI 0.14-0.44, p < 0.0001). Morbidity and mortality of GR was 27.7 and 24.2 %, respectively.

CONCLUSION

GR is needed in one in ten cases of PPU. Low serum albumin predicted the need for GR on multivariate analysis. Morbidity and mortality of GR remains high.

Management of intra-abdominal infections: recommendations by the WSES 2016 consensus conference

This paper reports on the consensus conference on the management of intra-abdominal infections (IAIs) which was held on July 23, 2016, in Dublin, Ireland, as a part of the annual World Society of Emergency Surgery (WSES) meeting. This document covers all aspects of the management of IAIs. The Grading of Recommendations Assessment, Development and Evaluation recommendation is used, and this document represents the executive summary of the consensus conference findings.

Simplified Mortality Score for the Intensive Care Unit (SMS-ICU): protocol for the development and validation of a bedside clinical prediction rule

INTRODUCTION

Mortality prediction scores are widely used in intensive care units (ICUs) and in research, but their predictive value deteriorates as scores age. Existing mortality prediction scores are imprecise and complex, which increases the risk of missing data and decreases the applicability bedside in daily clinical practice. We propose the development and validation of a new, simple and updated clinical prediction rule: the Simplified Mortality Score for use in the Intensive Care Unit (SMS-ICU).

METHODS AND ANALYSIS

During the first phase of the study, we will develop and internally validate a clinical prediction rule that predicts 90-day mortality on ICU admission. The development sample will comprise 4247 adult critically ill patients acutely admitted to the ICU, enrolled in 5 contemporary high-quality ICU studies/trials. The score will be developed using binary logistic regression analysis with backward stepwise elimination of candidate variables, and subsequently be converted into a point-based clinical prediction rule. The general performance, discrimination and calibration of the score will be evaluated, and the score will be internally validated using bootstrapping. During the second phase of the study, the score will be externally validated in a fully independent sample consisting of 3350 patients included in the ongoing Stress Ulcer Prophylaxis in the Intensive Care Unit trial. We will compare the performance of the SMS-ICU to that of existing scores.

ETHICS AND DISSEMINATION

We will use data from patients enrolled in studies/trials already approved by the relevant ethical committees and this study requires no further permissions. The results will be reported in accordance with the Transparent Reporting of multivariate prediction models for Individual Prognosis Or Diagnosis (TRIPOD) statement, and submitted to a peer-reviewed journal.

Triple tube drainage for “difficult” gastroduodenal perforations: A prospective study

AIM

To prospectively study the outcome of difficult gastroduodenal perforations (GDPs) treated by triple tube drainage (TTD) in order to standardize the procedure.

METHODS

Patients presenting to a single surgical unit of a tertiary hospital with difficult GDPs (large, unfavourable local and systemic factors) were treated with TTD (gastrostomy, duodenostomy and feeding jejunostomy). Postoperative parameters were observed like time to return of bowel sounds, time to start enteral feeds, time to start oral feeds, daily output of all drains, time to clamping/removal of all drains, time for skin to heal, complications, hospital stay, and, mortality. Descriptive statistics were used.

RESULTS

Between December 2013 and April 2015, 20 patients undergoing TTD for GDP were included, with mean age of 44.6 ± 19.8 years and male:female ratio of 17:3. Mean pre-operative APACHE II scores were 10.85 ± 3.55; most GDPs were prepyloric (9/20; 45%) or proximal duodenal (8/20; 40%) and mean size was 1.83 ± 0.59 cm (largest 2.5 cm). Median times of resumption of enteral feeding, removal of gastrostomy, removal of duodenostomy, removal of feeding jejunostomy and oral feeding were 4 d (4-5 IQR), 13 (12-16.5 IQR), 16 (16.25-22.25 IQR), 18 (16.5-24 IQR) and 12 d (10.75-18.5 IQR) respectively. Median hospital stay was 22 d (19-26 IQR) while mortality was 4/20 (20%).

CONCLUSION

TTD for difficult GDP is feasible, easy in the emergency, and patients recover in two-three weeks. It obviates the need for technically demanding and riskier procedures.

Association between ulcer site and outcome in complicated peptic ulcer disease: a Danish nationwide cohort study

OBJECTIVE

Mortality rates in complicated peptic ulcer disease are high. This study aimed to examine the prognostic importance of ulcer site in patients with peptic ulcer bleeding (PUB) and perforated peptic ulcer (PPU).

DESIGN

a nationwide cohort study with prospective and consecutive data collection.

POPULATION

all patients treated for PUB and PPU at Danish hospitals between 2003 and 2014.

DATA

demographic and clinical data reported to the Danish Clinical Registry of Emergency Surgery.

OUTCOME MEASURES

90- and 30-d mortality and re-intervention.

STATISTICS

the crude and adjusted association between ulcer site (gastric and duodenal) and the outcome measures of interest were assessed by binary logistic regression analysis.

RESULTS

Some 20,059 patients with PUB and 4273 patients with PPU were included; 90-d mortality was 15.3% for PUB and 29.8% for PPU; 30-d mortality was 10.2% and 24.7%, respectively. Duodenal bleeding ulcer, as compared to gastric ulcer (GU), was associated with a significantly increased risk of all-cause mortality within 90 and 30 d, and with re-intervention: adjusted odds ratio (OR) 1.47 (95% confidence interval 1.30-1.67); p < 0.001, OR 1.60 (1.43-1.77); p < 0.001, and OR 1.86 (1.68-2.06); p < 0.001, respectively. There was no difference in outcomes between gastric and duodenal ulcers (DUs) in PPU patients: adjusted OR 0.99 (0.84-1.16); p = 0.698, OR 0.93 (0.78 to 1.10); p = 0.409, and OR 0.97 (0.80-1.19); p = 0.799, respectively.

CONCLUSIONS

DU site is a significant predictor of death and re-intervention in patients with PUB, as compared to GU site. This does not seem to be the case for patients with PPU.

Risk factors for reintervention after surgery for perforated gastroduodenal ulcer

Background

Perforated gastroduodenal ulcer carries a high mortality rate. Need for reintervention after surgical repair is associated with worse outcome, but knowledge on risk factors for reintervention is limited. The aim was to identify prognostic risk factors for reintervention after perforated gastroduodenal ulcer in a nationwide cohort.

Methods

All patients treated surgically for perforated gastroduodenal ulcer in Denmark between 2003 and 2014 were included using data from the Danish Clinical Register of Emergency Surgery. Potential risk factors for reintervention were assessed, and their crude and adjusted associations calculated by the competing risks subdistribution hazards approach.

Results

A total of 4086 patients underwent surgery for perforated gastroduodenal ulcer during the study interval. Median age was 71·1 (i.q.r. 59·6–81·0) years and the overall 90-day mortality rate was 30·8 per cent (1258 of 4086). Independent risk factors for reintervention were: male sex (adjusted hazard ratio (HR) 1·46, 95 per cent c.i. 1·20 to 1·78), in-hospital perforation (adjusted HR 1·36, 1·11 to 1·68), high BMI (adjusted HR 1·49, 1·10 to 2·01), high ASA physical status grade (adjusted HR 1·54, 1·23 to 1·94), shock on admission (adjusted HR 1·40, 1·13 to 1·74), surgical delay (adjusted HR 1·07, 1·02 to 1·14) and other co-morbidity (adjusted HR 1·24, 1·02 to 1·51). Preadmission use of steroids (adjusted HR 0·59, 0·41 to 0·84) and age above 70 years (adjusted HR 0·72, 0·59 to 0·89) were associated with a reduced risk of reoperation.

Conclusion

Obese men with coexisting diseases and high disease severity who have surgery for gastroduodenal perforation are at increased risk of reoperation.

Which cause of diffuse peritonitis is the deadliest in the tropics? A retrospective analysis of 305 cases from the South-West Region of Cameroon

Background

Acute diffuse peritonitis is a common surgical emergency worldwide and a major contributor to non-trauma related death toll. Its causes vary widely and are correlated with mortality. Community acquired peritonitis seems to play a major role and is frequently related to hollow viscus perforation. Data on the outcome of peritonitis in the tropics are scarce. The aim of this study is to analyze the impact of tropic latitude causes of diffuse peritonitis on morbidity and mortality.

Methods

We retrospectively reviewed the records of 305 patients operated on for a diffuse peritonitis in two regional hospitals in the South-West Region of Cameroon over a 7 years period. The contributions of various causes of peritonitis to morbidity and mortality were analyzed.

Results

The diagnosis of diffuse peritonitis was suggested on clinical ground only in more than 93 % of cases. The most common causes of diffuse peritonitis included peptic ulcer perforation (n = 69), complications of acute appendicitis (n = 53) and spontaneous perforations of the terminal ileum (n = 43). A total of 142 complications were recorded in 96 patients (31.5 % complication rate). The most common complications included wound dehiscence, sepsis, prolonged paralytic ileus and multi-organ failure. Patients with typhoid perforation of the terminal ileum carried a significantly higher risk of developing a complication (p = 0.002). The overall mortality rate was 15.1 %. The most common cause of death was septic shock. Differential analysis of mortality of various causes of peritonitis indicated that the highest contributors to death toll were typhoid perforation of terminal ileum (34.7 % of deaths), post-operative peritonitis (19.5 %) and peptic ulcer perforation (15.2 %).

Conclusion

The diagnosis of diffuse peritonitis can still rely on clinical assessment alone in the absence of sophisticated imaging tools. Peptic ulcer and typhoid perforations are still major contributors to death toll. Patients presenting with these conditions require specific attention and prevention policies must be reinforced.

Clinical patterns of presentation and attenuated inflammatory response in octo- and nonagenarians with perforated gastroduodenal ulcers

BACKGROUND

Perforated gastrodudenal ulcer (PGDU) is an operative emergency with high mortality rates. The growing elderly population increasingly presents with need for geriatric acute operative care. Current knowledge of age-specific characteristics in presentation, diagnosis, and outcome for PGDU in the elderly is scarce.

METHODS

We reviewed a consecutive, population-based cohort of patients with PGDU, octa- and nonagenarians were compared with younger patients for variation in patterns of presentation and outcomes. Patterns and outcomes observed included 30-day mortality, serious complications (Clavien-Dindo 3 and 4), and duration of stay.

RESULTS

Of the 244 patients, 127 were women (52%); median age was 68 years; and 59 patients (24.2%) were ≥80 years. Two thirds had gastric ulcers (n = 168; 67.2%). On admission, hemoglobin levels, white blood cell count, and serum levels of C-reactive protein, bilirubin, and albumin differed significantly between the age groups. Diagnosis, treatment, and the occurrence of severe complications did not differ with age. The median hours of delay to definitive treatment did not differ significantly for all ages, but patients ≥80 years had a greater proportion (44.1% compared with 25.8%) of delay >12 hours (odds ratio 2.26, 95% confidence interval 1.22-4.17; P = .008). Overall mortality was 38 (15.6%); no deaths occurred in patients <55 years. Over one half of deaths occurred in those ≥80 years (odds ratio 4.76, 2.30-9.83; P < .001). Duration of hospital stay was significantly greater in elderly survivors, and fewer were discharged within a week.

CONCLUSION

Octa- and nonagenarians with PGDU present with fewer signs of peritonitis and have an attenuated inflammatory response. The very elderly have twice the risk of long delays to definitive treatment and almost 5 times increased risk of mortality.

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.

Postoperative Morbidity and Mortality of Perforated Peptic Ulcer: Retrospective Cohort Study of Risk Factors among Black Africans in Côte d'Ivoire

Introduction. Surgical treatment of perforated peptic ulcer (PPU) is a challenge for surgeons in Africa. Aim. To determine risk factors of postoperative complications or mortality among black Ivoirian patients with PPU. Methods. All 161 patients (median age = 34 years, 90.7 male) operated on for PPU in the visceral and general surgery unit were enrolled in a retrospective cohort study. Variables were studied with Kaplan Meier and Cox proportional hazard models. Results. Among 161 patients operated on for PPU, 36 (27.5%) experienced complications and 31 (19.3%) died. Follow-up results were the incidence of complications and mortality of 6.4 (95% CI: 4.9–8.0) per 100 person-days and 3.0 (95% CI: 1.9–4.0) per 100 person-days for incidence of mortality. In multivariate analysis, risk factors of postoperative complications or mortality were comorbidities (HR = 2.1, P = 0.03), tachycardia (pulse rate > 100/minutes) (HR = 2.4, P = 0.02), purulent intra-abdominal fluid collection (HR = 2.1, P = 0.04), hyponatremia (median value ≤ 134 mEq/L) (HR = 2.3, P = 0.01), delayed time of hospital admission > 72 hours (HR = 2.6, P < 0.0001), and delayed time of surgical intervention between 24 and 48 hours (HR = 3.8, P < 0.0001). Conclusion. The delayed hospital admission or surgical intervention and hyponatremia may be considered as additional risk of postoperative complications or mortality in Black African patients with PPU.

Assessing the risk: Scoring systems for outcome prediction in emergency laparotomies

Emergency laparotomy is the commonest emergency surgical procedure in most hospitals and includes over 400 diverse surgical procedures. Despite the evolution of medicine and surgical practices, the mortality in patients needing emergency laparotomy remains abnormally high. Although surgical risk assessment first started with the ASA Physical Status score in 1941, efforts to find an ideal scoring system that accurately estimates the risk of mortality, continues till today. While many scoring systems have been developed, no single scoring system has been validated across multiple centers and geographical locations. While some scoring systems can predict the risk merely based upon preoperative findings and parameters, some rely on intra-operative assessment and histopathology reports to accurately stratify the risk of mortality. Although most scoring systems can potentially be used to compare risk-adjusted mortality across hospitals and amongst surgeons, only those which are based on preoperative findings can be used for risk prognostication and identify high-risk patients before surgery for an aggressive treatment. The recognition of the fact, that in the absence of outcome data in these patients, it would be impossible to evaluate the impact of quality improvement initiatives on risk-adjusted mortality, hospital groups and surgical societies have got together and started to pool data and analyze it. Appropriate scoring systems for emergency laparotomies would help in risk prognostication, risk-adjusted audit and assess the impact of quality improvement initiative in patient care across hospitals. Large multi-centric studies across varied geographic locations and surgical practices need to assess and validate the ideal and most apt scoring system for emergency laparotomies. While APACHE-II and P-POSSUM continue to be the most commonly used scoring system in emergency laparotomies,studies need to compare them in their ability to predict mortality and explore if either has a higher sensitivity and specificity than the other.