Factors Affecting Mortality and Morbidity in Patients With Peptic Ulcer Perforation

Belma Kocer; Suleyman Surmeli; Cem Solak; Bulent Unal; Betul Bozkurt; Osman Yildirim; Mete Dolapci; Omer Cengiz

Disclosures

J Gastroenterol Hepatol. 2007;22(4):565-570. 

In This Article

Abstract and Introduction

Abstract

Background and Aim: With the introduction of H2 receptor antagonists and proton pump inhibitors, the incidence of elective surgery for peptic ulcer (PU) diseases has decreased, although complications of PU such as perforation and bleeding have remained fairly constant. The purpose of this study was to identify the risk factors that predict morbidity and mortality in patients with perforated PU.
Methods: The records of 269 patients who were operated on for perforated PU were reviewed retrospectively. The following factors were analyzed in terms of morbidity and mortality: age >65 years; gender; associated medical illness; chronic ingestion of non-steroidal anti-inflammatory drugs, aspirin, corticosteroids or immunosuppressants; alcohol ingestion and smoking habits; American Society of Anesthesiologist (ASA) status; season; delayed operation; site of ulcer perforation; and shock on admission and type of operation.
Results: There were 30 female (11.16%) and 239 male (88.84%) patients. Seventy-one (26.4%) patients had associated diseases. Simple closure was performed in 257 (95.5%) patients; 12 patients (4.5%) underwent definitive operations. A total of 108 postoperative complications were present in 65 (24.2%) patients. Twenty-three patients died (8.55%). Multivariate analysis showed that only age, ASA score, treatment delay, presence of shock and definitive operation were independent predictors of mortality. Significant risk factors that led to morbidity were ASA status, time of surgery, season, presence of shock and type of surgery. There was a significant difference concerning morbidity and mortality between simple closure of the perforation and definitive surgery.
Conclusions: Age, delayed surgery, presence of shock, ASA risk and definitive surgery are factors significantly associated with fatal outcomes in patients undergoing emergency surgery for perforated PU. Therefore, proper resuscitation from shock, improving ASA grade, decreasing delay and reserving definitive surgery for selected patients is needed to improve overall results.

Introduction

With the introduction of H2 receptor antagonists and proton pump inhibitors, the incidence of elective surgery for peptic ulcer (PU) diseases has decreased;[1,2,3] however, complications of PU, such as perforation and bleeding, have remained fairly constant[1,4] or increased.[2] The characteristics of perforated PU disease appear to be changing. Recently, it has been reported that there has been a relative increase in peptic ulcer perforation (PUP) in the elderly, especially in women.[3,5,6] History of using non-steroidal anti-inflammatory drugs (NSAIDs) among PU patients has increased.[7,8] Surgical treatment of perforated PU has been changing in most hospitals over recent years. With the introduction of H2 blockers and proton pump inhibitors as an effective medical treatment after surgery, simple closure has become the preferred option for many surgeons.[5,9] The rate of complications and mortality has not declined during recent decades.[6] Mortality was reported to vary between 4 and 30%[2,6,9,10,11,12] and morbidity was reported as 25-89%.[6,8,13,14] Delayed treatment, older age, presence of shock on admission, concomitant diseases and American Society of Anesthesiologist (ASA) status have been cited as the main risk factors for complication and mortality.[8,9,10,13,15,16] A delay of more than 24 h increased lethality seven- to eight-fold and the complication rate three-fold.[17] The main factor which could be changed to improve prognosis of PUP is delay in diagnosis. The purpose of the present study was to identify the risk factors affecting postoperative complications and the mortality of PUP.

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