Joedd Biggs MD, Stephen Osterlind PhD, Erin Dalton, Linda Hanley RN, Jacob A Quick MD, Stephen L Barnes MD, Salman Ahmad MD
Salman Ahmad MD, FACS, Emergent Operation for Perforated Peptic Ulcer Disease
To evaluate perioperative clinical factors associated with morbidity and mortality in emergency operations for acute perforated peptic ulcer disease (PUD).
While the incidence of hospital admissions for PUD may have changed over the decades, peptic ulcer disease remains a significant cause for mortality, with perforation having a mortality of approximately 11-16%, and morbidity of approximately 30%.
We utilized the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to study demographic and perioperative variables that may be associated with morbidity and mortality after emergent surgical management of acute perforated PUD. We queried the ACS-NSQIP participant user files (PUF) from 2005 to 2013 and extracted only those cases with a postoperative diagnosis of peptic ulcer disease to include gastric and duodenal perforations. Our study population was then narrowed to emergency operations for perforated PUD. Demographic and perioperative factors were noted and compared for mortality. This study was considered exempt by our IRB as the database does not include any patient identifiers.
5666 cases were extracted between the years of 2005 and 2013 as our study population. There were 723 deaths yielding a 30-day mortality rate of 12.8%. Significant demographic differences between survivors and non-survivors included age (59.4 vs. 72.9, p<0.01), ASA class (2.94 vs. 3.82, p<0.01), female gender (46.5% vs. 55.1%, p<0.01) and white race (75% vs. 85.2%, p< 0.01). Average days from hospital admission to surgery were also significant between the groups (0.98 vs. 2.04, p<0.05). The most significant preoperative risk factors for death were preoperative serum albumin less than 3.5 g/dL (OR 6.88, 95% CI 5.45-8.70), disseminated cancer (OR 5.26, 95% CI 3.94-7.09), congestive heart failure (OR 4.9, 95% CI 3.58-6.67), renal failure (OR 4.33, 95% CI 3.25-5.78) and dialysis (OR 4.26, 95% CI 2.91-6.25). A MELD score greater than 30 increased the risk of death by 5.94 (95% CI 3.35-10.53. The most significant postoperative complications associated with mortality included renal failure (OR 12.22, 95% CI 8.90-16.81) and septic shock (OR 8.2, 95% CI 6.80-10.00). Bleeding requiring a transfusion increased the risk of death by 3.33 (95% CI 2.75-4.02). A multivariate logistic regression model for mortality controlling for age, gender and race predicted the highest risks from the preoperative conditions of disseminated cancer (OR 4.20, 95% CI 2.63-6.71), dialysis (OR 3.94, 95% CI 2.27-6.84), esophageal varices (OR 3.72, 95% CI 1.17-11.84), and a low serum albumin (OR 2.97, 95% CI 2.13-4.14) and the postoperative complications of comatose state (OR 5.85, 95% CI 1.87-18.18), septic shock (OR 5.67, 95% CI 4.06-7.93), acute renal failure (OR 4.35, 95% CI 2.61-7.25) and myocardial infarction (OR 4.00, 95% CI 2.00-8.00).
This is one of the largest databases of emergent operations for perforated PUD. According to the ACS-NSQIP database between 2005 and 2013 the mortality rate for emergent operations in perforated peptic ulcer disease was consistent with prior studies. In addition to expected post-operative complications, age and preexisting comorbidities contributed significantly to outcomes as did timing to operation which also increased the risk for post-operative complications. Our results emphasize the need for early operation, aggressive resuscitation to prevent renal failure, limiting blood loss and the need to transfuse and controlling perioperative infectious events to reduce the risk of sepsis.