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


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

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During the past few decades the incidence of perforations has declined in the young age groups and among men, but has risen among elderly people.[6,18,19,20] In our study, PUP was still common in younger patients. Smoking among young people is common in Turkey, which may explain our higher incidence of perforation in young males. Male patients had PUP frequently at younger ages, while female patients had PUP most commonly in the fourth to sixth decades. In fact, an absolute increase has been reported in elderly women in different studies.[5,6,21] We found that female sex was associated with a higher mortality rate than males. The higher mortality rate among women might be due to the older age of women than men. The mortality rate among the elderly patients undergoing surgery for perforated PU is as high as 12-47%.[15,21,22,23,24] In this study, patients older than 65 years had a higher mortality rate when compared to younger patients (37.7% vs 1.4%). Associated medical diseases and diagnostic delay may account for the higher morbidity and mortality rates in the elderly patients in our study.

Risk of postoperative death and complications are closely related to the duration of perforation.[6,8,10,11,15,17,21] Thirty percent of patients were admitted to our surgical department with a perforated ulcer that had been present for more than 24 h. Elderly patients were commonly admitted to the hospital more than 24 h after the perforation had occurred. A delay of more than 24 h increased lethality 6.5 times and the complication rate 3.4 times in our study. Most of our patients came from rural areas and they were referred to us from smaller hospitals. The present study is in agreement with previous ones and reveals the importance of early surgical intervention to improve survival rates.[3,15,17,22]

The incidence of NSAID use (9%) was low in the present study. The reason for this low percentage in comparison with other studies may be due to the low mean age of our patients. Strong association between ulcer perforation and smoking was reported in several studies.[25,26] Smoking is a causal factor for ulcer perforation.[25] The risk was increased by a factor of 10 in smokers among both men and women. Smoking prevalence of 84% and 86% have been reported among patients with duodenal ulcer perforations,[27,28] and smokers have a three-fold higher mortality rate from PU than non-smokers.[29] However, smokers had a lower mortality rate in this study because most elderly patients who had higher mortality were non-smokers.

Duodenal and pyloric ulcers show seasonal variations. More perforation occurred in early summer (May, June, July) and early winter (November, December).[6,30] Several studies[31,32] show increased perforation rates in early summer and decreased rates during late summer. In our study, incidence of PUP was the same in all seasons. Sonnenberg et al. confirmed that the highest mortality was seen in January and the lowest mortality was seen in July.[33] Although the mortality rate was higher in winter in this study, the ratio of elderly patients with late admission was higher in winter. In addition, the 81% of patients with preshock were admitted to the hospital in winter and therefore season was not an independent predictor of mortality.

ASA scores served as valuable predictors of mortality in the management of perforated PU. High ASA score (ASA III; IV) increased the mortality.[13,16] Each increase in ASA score increased morbidity 2 times and mortality 4.5 times in our patients.

The choice of surgical procedure in emergency is still debated. Even though simple closure has proved to be safe, some authors have suggested that definitive surgery decreases the recurrence rate without increasing the operative morbidity and mortality.[34,35,36] However, some studies show no difference in mortality between the non-definitive and definitive procedure.[15,37,38,39,40] Most surgeons choose simple closure instead of a definitive procedure due to higher risk in patients with perforated PU. The mortality and morbidity rates of gastric resection were also significantly increased in elderly patients with perforated gastric ulcers, as shown in our study.[41] Simple closure is an adequate surgical treatment for PUP in the elderly.[5,14,21] Boey et al. found a mortality rate of 7.8% in 2558 PUP patients with simple closure.[34] The discovery of the role of Helicobacter pylori in PU and successful treatment against H. pylori provides the choice of simple closure combined with treatment against H. pylori.[9,11,42] Open or laparoscopic primary suture of perforated peptic ulcer is increasingly advocated as the optimal surgical treatment in recent years.[11,43,44,45] Gastric resection is usually reserved for giant ulcers when it is not safe to perform a simple closure alone.[40] With non-definitive surgery, we also avoided the late consequences of vagotomy or gastrectomy. We preferred the simple closure in most of our patients. Although higher risk patients were also treated with simple closure, mortality and morbidity rates of patients who had undergone simple closure were lower than patients who had definitive procedures.

The mortality and morbidity of PU disease have not decreased after the introduction of H2 receptor antagonists and despite many advances in pre- and postoperative care.[2,6] During the past few decades, patients have become older and had more coexisting medical diseases and use of NSAIDs has increased. Mortality rates varied between 4 and 30% in different studies.[2,6,9,10,11,12] Our mortality rate was 8.6% (n = 23) and morbidity rate was 24.2% (n = 65), with respiratory failure and wound infections being the most common cause of morbidity. We believe that such low mortality rates in our series could be explained by the low mean age of the patients which were treated with the preferred simple closure.

In conclusion, we defined the risk factors for morbidity and mortality of PUP. Increased ASA scores, delay of more than 24 h, presence of shock, and definitive surgery increased the morbidity and mortality of PUP. We found that simple closure is safe with few side-effects and should be combined with treatment against H. pylori and should be chosen instead of an acid reducing operation. In order to improve prognosis of patients with PUP, diagnosis and treatment should not be delayed and the associated medical diseases should be treated. Elderly patients have obscure clinical symptoms, often leading to an initial wrong diagnosis. Therefore, the possibility of PUP in elderly patients with abdominal pain should be kept in mind.

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