Skip to main content

Advertisement

SpringerLink
Log in

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

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

Data availability

This study is based in part on data from the National Health Insurance Research Database (NHIRD), provided by the National Health Insurance Administration of the Ministry of Health and Welfare and managed by the National Health Research Institutes (registration number NHIRD-103-246). The data utilized in this study cannot be made available in the manuscript, supplemental files, or in a public repository due to the “Personal Information Protection Act” executed by Taiwan’s government, which took effect in 2012. Requests for data can be sent as a formal proposal to the NHIRD (http://nhird.nhri.org.tw) or via email to nhird@nhri.org.tw.

References

  1. Welch CE, Rodkey GV, von Ryll GP (1986) A thousand operations for ulcer disease. Ann Surg 204:454–467

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Lau JY, Sung J, Hill C, Henderson C, Howden CW, Metz DC (2011) Systematic review of the epidemiology of complicated peptic ulcer disease: incidence, recurrence, risk factors and mortality. Digestion 84:102–113

    Article  PubMed  Google Scholar 

  3. Soreide K, Thorsen K, Harrison EM, Bingener J, Moller MH, Ohene-Yeboah M, Soreide JA (2015) Perforated peptic ulcer. Lancet 386:1288–1298

    Article  PubMed  PubMed Central  Google Scholar 

  4. Lee CW, Sarosi GA Jr (2011) Emergency ulcer surgery. Surg Clin North Am 91:1001–1013

    Article  PubMed  Google Scholar 

  5. Moller MH, Adamsen S, Thomsen RW, Moller AM, Peptic Ulcer Perforation trial group (2011) Multicentre trial of a perioperative protocol to reduce mortality in patients with peptic ulcer perforation. Br J Surg 98:802–810

    Article  CAS  PubMed  Google Scholar 

  6. Kim JM, Jeong SH, Lee YJ, Park ST, Choi SK, Hong SC, Jung EJ, Ju YT, Jeong CY, Ha WS (2012) Analysis of risk factors for postoperative morbidity in perforated peptic ulcer. J Gastric Cancer 12:26–35

    Article  PubMed  PubMed Central  Google Scholar 

  7. Moller MH, Engebjerg MC, Adamsen S, Bendix J, Thomsen RW (2012) The peptic ulcer perforation (PULP) score: a predictor of mortality following peptic ulcer perforation A cohort study. Acta Anaesthesiol Scand 56:655–662

    Article  CAS  PubMed  Google Scholar 

  8. Crofts TJ, Park KG, Steele RJ, Chung SS, Li AK (1989) A randomized trial of non-operative treatment for perforated peptic ulcer. N Engl J Med 320:970–973

    Article  CAS  PubMed  Google Scholar 

  9. Tarasconi A, Coccolini F, Biffl WL, Tomasoni M, Ansaloni L, Picetti E, Molfino S, Shelat V, Cimbanassi S, Weber DG, Abu-Zidan FM, Campanile FC, Di Saverio S, Baiocchi GL, Casella C, Kelly MD, Kirkpatrick AW, Leppaniemi A, Moore EE, Peitzman A, Fraga GP, Ceresoli M, Maier RV, Wani I, Pattonieri V, Perrone G, Velmahos G, Sugrue M, Sartelli M, Kluger Y, Catena F (2020) Perforated and bleeding peptic ulcer: WSES guidelines. World J Emerg Surg 15:3

    Article  PubMed  PubMed Central  Google Scholar 

  10. Oida T, Kano H, Mimatsu K, Kawasaki A, Kuboi Y, Fukino N, Kida K, Amano S (2012) Percutaneous drainage in conservative therapy for perforated gastroduodenal ulcers. Hepatogastroenterology 59:168–170

    PubMed  Google Scholar 

  11. Songne B, Jean F, Foulatier O, Khalil H, Scotte M (2004) Non operative treatment for perforated peptic ulcer: results of a prospective study. Ann Chir 129:578–582

    Article  CAS  PubMed  Google Scholar 

  12. Tanaka R, Kosugi S, Sakamoto K, Yajima K, Ishikawa T, Kanda T, Wakai T (2013) Treatment for perforated gastric ulcer: a multi-institutional retrospective review. J Gastrointest Surg 17:2074–2081

    Article  PubMed  Google Scholar 

  13. Bucher P, Oulhaci W, Morel P, Ris F, Huber O (2007) Results of conservative treatment for perforated gastroduodenal ulcers in patients not eligible for surgical repair. Swiss Med Wkly 137:337–340

    CAS  PubMed  Google Scholar 

  14. Lay PL, Huang HH, Chang WK, Hsieh TY, Huang TY, Lin HH (2016) Outcome of nonsurgical intervention in patients with perforated peptic ulcers. Am J Emerg Med 34:1556–1560

    Article  PubMed  Google Scholar 

  15. Alizadeh N, Buhler L, Huber O, Morel P (1997) Conservative treatment of gastroduodenal peptic ulcer perforations: indications and results. Schweiz Med Wochenschr Suppl 89:17S-19S

    CAS  PubMed  Google Scholar 

  16. Bergamaschi R, Marvik R, Johnsen G, Thoresen JE, Ystgaard B, Myrvold HE (1999) Open vs laparoscopic repair of perforated peptic ulcer. Surg Endosc 13:679–682

    Article  CAS  PubMed  Google Scholar 

  17. Bertleff MJ, Lange JF (2010) Laparoscopic correction of perforated peptic ulcer: first choice? A review of literature. Surg Endosc 24:1231–1239

    Article  PubMed  Google Scholar 

  18. Leusink A, Markar SR, Wiggins T, Mackenzie H, Faiz O, Hanna GB (2018) Laparoscopic surgery for perforated peptic ulcer: an English national population-based cohort study. Surg Endosc 32:3783–3788

    Article  PubMed  Google Scholar 

  19. Lohsiriwat V, Prapasrivorakul S, Lohsiriwat D (2009) Perforated peptic ulcer: clinical presentation, surgical outcomes, and the accuracy of the Boey scoring system in predicting postoperative morbidity and mortality. World J Surg 33:80–85

    Article  PubMed  Google Scholar 

  20. Agarwal A, Jain S, Meena LN, Jain SA, Agarwal L (2015) Validation of Boey’s score in predicting morbidity and mortality in peptic perforation peritonitis in Northwestern India. Trop Gastroenterol 36:256–260

    Article  PubMed  Google Scholar 

  21. Huang KW, Luo JC, Leu HB, Lin HC, Lee FY, Chan WL, Lin SJ, Chen JW, Chang FY (2012) Chronic obstructive pulmonary disease: an independent risk factor for peptic ulcer bleeding: a nationwide population-based study. Aliment Pharmacol Ther 35:796–802

    Article  PubMed  Google Scholar 

  22. Johnston LE, Grimm JC, Magruder JT, Shah AS (2016) Development of a transplantation risk index in patients with mechanical circulatory support: a decision support tool. JACC Heart failure 4:277–286

    Article  PubMed  Google Scholar 

  23. Charlson M, Szatrowski TP, Peterson J, Gold J (1994) Validation of a combined comorbidity index. J Clin Epidemiol 47:1245–1251

    Article  CAS  PubMed  Google Scholar 

  24. Austin PC, Lee DS, D’Agostino RB, Fine JP (2016) Developing points-based risk-scoring systems in the presence of competing risks. Stat Med 35:4056–4072

    Article  PubMed  PubMed Central  Google Scholar 

  25. Lin SW, Chen CY, Su YC, Wu KT, Yu PC, Yen YC, Chen JH (2022) Mortality prediction model before surgery for acute mesenteric infarction: a population-based study. J Clin Med. https://doi.org/10.3390/jcm11195937

    Article  PubMed  PubMed Central  Google Scholar 

  26. Bin-Taleb AK, Razzaq RA, Al-Kathiri ZO (2008) Management of perforated peptic ulcer in patients at a teaching hospital. Saudi Med J 29:245–250

    PubMed  Google Scholar 

  27. Blomgren LG (1997) Perforated peptic ulcer: long-term results after simple closure in the elderly. World J Surg 21:412–414

    Article  CAS  PubMed  Google Scholar 

  28. Daniel VT, Wiseman JT, Flahive J, Santry HP (2017) Predictors of mortality in the elderly after open repair for perforated peptic ulcer disease. J Surg Res 215:108–113

    Article  PubMed  PubMed Central  Google Scholar 

  29. Seow JG, Lim YR, Shelat VG (2017) Low serum albumin may predict the need for gastric resection in patients with perforated peptic ulcer. Eur J Trauma Emerg Surg 43:293–298

    Article  CAS  PubMed  Google Scholar 

  30. Sillakivi T, Lang A, Tein A, Peetsalu A (2000) Evaluation of risk factors for mortality in surgically treated perforated peptic ulcer. Hepatogastroenterology 47:1765–1768

    CAS  PubMed  Google Scholar 

  31. Bas G, Eryilmaz R, Okan I, Sahin M (2008) Risk factors of morbidity and mortality in patients with perforated peptic ulcer. Acta Chir Belg 108:424–427

    Article  CAS  PubMed  Google Scholar 

  32. Soreide K, Thorsen K, Soreide JA (2014) Strategies to improve the outcome of emergency surgery for perforated peptic ulcer. Br J Surg 101:e51-64

    Article  CAS  PubMed  Google Scholar 

  33. Knaus WA, Draper EA, Wagner DP, Zimmerman JE (1985) APACHE II: a severity of disease classification system. Crit Care Med 13:818–829

    Article  CAS  PubMed  Google Scholar 

  34. Le Gall JR, Lemeshow S, Saulnier F (1993) A new simplified acute physiology score (SAPS II) based on a European/North American multicenter study. JAMA 270:2957–2963

    Article  PubMed  Google Scholar 

  35. Lemeshow S, Teres D, Klar J, Avrunin JS, Gehlbach SH, Rapoport J (1993) Mortality probability models (MPM II) based on an international cohort of intensive care unit patients. JAMA 270:2478–2486

    Article  CAS  PubMed  Google Scholar 

  36. Li YT, Wang YC, Yang SF, Law YY, Shiu BH, Chen TA, Wu SC, Lu MC (2022) Risk factors and prognoses of invasive Candida infection in surgical critical ill patients with perforated peptic ulcer. J Microbiol Immunol Infect 55:740–748

    Article  CAS  PubMed  Google Scholar 

  37. Li CH, Bair MJ, Chang WH, Shih SC, Lin SC, Yeh CY (2009) Predictive model for length of hospital stay of patients surviving surgery for perforated peptic ulcer. J Formos Med Assoc 108:644–652

    Article  CAS  PubMed  Google Scholar 

  38. Copeland GP, Jones D, Walters M (1991) POSSUM: a scoring system for surgical audit. Br J Surg 78:355–360

    Article  CAS  PubMed  Google Scholar 

  39. Thorsen K, Soreide JA, Soreide K (2014) What is the best predictor of mortality in perforated peptic ulcer disease? A population-based, multivariable regression analysis including three clinical scoring systems. J Gastrointest Surg 18:1261–1268

    Article  PubMed  PubMed Central  Google Scholar 

  40. Bharadwaj S, Ginoya S, Tandon P, Gohel TD, Guirguis J, Vallabh H, Jevenn A, Hanouneh I (2016) Malnutrition: laboratory markers vs nutritional assessment. Gastroenterol Rep (Oxf) 4:272–280

    PubMed  Google Scholar 

  41. Soeters PB, Wolfe RR, Shenkin A (2019) Hypoalbuminemia: pathogenesis and clinical significance. JPEN J Parenter Enteral Nutr 43:181–193

    Article  CAS  PubMed  Google Scholar 

  42. Andersen CJ, Murphy KE, Fernandez ML (2016) Impact of obesity and metabolic syndrome on immunity. Adv Nutr 7:66–75

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  43. Wang HE, Griffin R, Judd S, Shapiro NI, Safford MM (2013) Obesity and risk of sepsis: a population-based cohort study. Obesity (Silver Spring) 21:E762-769

    Article  CAS  PubMed  Google Scholar 

  44. Winfield RD, Reese S, Bochicchio K, Mazuski JE, Bochicchio GV (2016) Obesity and the risk for surgical site infection in abdominal surgery. Am Surg 82:331–336

    Article  PubMed  Google Scholar 

  45. Kaspersen KA, Pedersen OB, Petersen MS, Hjalgrim H, Rostgaard K, Moller BK, Juul-Sorensen C, Kotze S, Dinh KM, Erikstrup LT, Sorensen E, Thorner LW, Burgdorf KS, Ullum H, Erikstrup C (2015) Obesity and risk of infection: results from the Danish Blood Donor Study. Epidemiology 26:580–589

    Article  PubMed  Google Scholar 

  46. Carbone F, La Rocca C, De Candia P, Procaccini C, Colamatteo A, Micillo T, De Rosa V, Matarese G (2016) Metabolic control of immune tolerance in health and autoimmunity. Semin Immunol 28:491–504

    Article  CAS  PubMed  Google Scholar 

  47. Naylor C, Petri WA Jr (2016) Leptin regulation of immune responses. Trends Mol Med 22:88–98

    Article  CAS  PubMed  Google Scholar 

  48. Thorsen K, Glomsaker TB, von Meer A, Soreide K, Soreide JA (2011) Trends in diagnosis and surgical management of patients with perforated peptic ulcer. J Gastrointest Surg 15:1329–1335

    Article  PubMed  PubMed Central  Google Scholar 

  49. Siow SL, Mahendran HA, Wong CM, Hardin M, Luk TL (2018) Laparoscopic versus open repair of perforated peptic ulcer: Improving outcomes utilizing a standardized technique. Asian J Surg 41:136–142

    Article  PubMed  Google Scholar 

  50. Tan S, Wu G, Zhuang Q, Xi Q, Meng Q, Jiang Y, Han Y, Yu C, Yu Z, Li N (2016) Laparoscopic versus open repair for perforated peptic ulcer: a meta analysis of randomized controlled trials. Int J Surg 33:124–132

    Article  PubMed  Google Scholar 

  51. Rahman MM, Islam MS, Flora S, Akhter SF, Hossain S, Karim F (2007) Mortality in perforated peptic ulcer patients after selective management of stratified poor risk cases. World J Surg 31:2341–2344

    Article  PubMed  Google Scholar 

  52. Gouta EL, Dougaz W, Khalfallah M, Bouasker I, Dziri C (2018) Management of perforated duodenal peptic ulcer treated by suture. Tunis Med 96:424–429

    PubMed  Google Scholar 

  53. Alemrajabi M, Safari S, Tizmaghz A, Alemrajabi F, Shabestanipour G (2016) Laparoscopic repair of perforated peptic ulcer: outcome and associated morbidity and mortality. Electron Physician 8:2543–2545

    Article  PubMed  PubMed Central  Google Scholar 

  54. Manco G, Caramaschi S, Rolando G, Malagoli M, Zanelli G, Reggiani Bonetti L, Rossi A (2020) Primary laparoscopic approach to repair perforated peptic ulcer. A retrospective cohort study. Minerva Chir. https://doi.org/10.23736/S0026-4733.20.08287-5

    Article  PubMed  Google Scholar 

  55. Zimmermann M, Hoffmann M, Laubert T, Jung C, Bruch HP, Schloericke E (2015) Conversion of laparoscopic surgery for perforated peptic ulcer: a single-center study. Surg Today 45:1421–1428

    Article  PubMed  Google Scholar 

  56. Lau H (2004) Laparoscopic repair of perforated peptic ulcer: a meta-analysis. Surg Endosc 18:1013–1021

    Article  CAS  PubMed  Google Scholar 

  57. Vaidya BB, Garg CP, Shah JB (2009) Laparoscopic repair of perforated peptic ulcer with delayed presentation. J Laparoendosc Adv Surg Tech A 19:153–156

    Article  PubMed  Google Scholar 

  58. Guadagni S, Cengeli I, Galatioto C, Furbetta N, Piero VL, Zocco G, Seccia M (2014) Laparoscopic repair of perforated peptic ulcer: single-center results. Surg Endosc 28:2302–2308

    Article  PubMed  Google Scholar 

  59. Zogovic S, Bojesen AB, Andos S, Mortensen FV (2019) Laparoscopic repair of perforated peptic ulcer is not prognostic factor for 30-day mortality (a nationwide prospective cohort study). Int J Surg 72:47–54

    Article  PubMed  Google Scholar 

  60. Smith RS, Sundaramurthy SR, Croagh D (2019) Laparoscopic versus open repair of perforated peptic ulcer: a retrospective cohort study. Asian J Endosc Surg 12:139–144

    Article  PubMed  Google Scholar 

  61. Karabulut K, Dincer M, Liman RK, Usta S (2019) Non-operative management of perforated peptic ulcer: a single-center experience. Ulus Travma Acil Cerrahi Derg 25:585–588

    PubMed  Google Scholar 

Download references

Acknowledgements

The authors would like to thank Dr. Yaw-Sen Chen, Division of General Surgery, E-Da Hospital, and Dr. Chao-Ming Hung, Division of General Surgery, E-Da Cancer Hospital for their assistance. We are grateful to the grant support of E-Da Hospital, Taiwan, and IRB (EDAHI-109-001, EDAHI-110-003, EDAHC-111-007, EDAHP-112-005, EDAHC-112-001).

Author information

Author notes

  1. Chung-Yen Chen and Jian-Han Chen have contributed equally to this work.

Authors and Affiliations

  1. Division of General Surgery, E-Da Hospital, Kaohsiung, Taiwan

    Yi-Shan Su, Chung-Yen Chen & Jian-Han Chen

  2. Bariatric and Metabolism International Surgery Center, E-Da Hospital, Kaohsiung, Taiwan

    Yi-Kai Huang, Kun-Ta Wu, Chung-Yen Chen & Jian-Han Chen

  3. School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan

    Yi-Kai Huang, Kun-Ta Wu, Chung-Yen Chen & Jian-Han Chen

Authors
  1. Yi-Kai Huang
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Kun-Ta Wu
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Yi-Shan Su
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Chung-Yen Chen
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jian-Han Chen
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

JHC, YKH, CYC, KTW: conceptualization; JHC, CYC: methodology; JHC: software; JHC, CYC: validation; JHC, YKH, KTW: formal analysis; JHC: resources; JHC: data curation; YKH, YSS: writing (original draft); JHC, YKH, KTW: preparing tables and figures and visualization; YKH, JHC: project administration.

Corresponding author

Correspondence to Jian-Han Chen.

Ethics declarations

Disclosures

Yi-Kai Huang, Kun-Ta Wu, Yi-Shan Su, Chung-Yen Chen and Jian-Han Chen declare no competing interests and nothing to disclose.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Huang, YK., Wu, KT., Su, YS. et al. Predicting in-hospital mortality risk for perforated peptic ulcer surgery: the PPUMS scoring system and the benefit of laparoscopic surgery: a population-based study. Surg Endosc 37, 6834–6843 (2023). https://doi.org/10.1007/s00464-023-10180-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-023-10180-0

Keywords

Search

Navigation