Operation or not? An In-hospital Mortality Risk Index in treating perforated peptic ulcer: A population-based study in Asia

Abstract

The major treatment for perforated peptic ulcers (PPU) is surgery, and several scoring systems have been reported to predict morbidity and mortality after surgery. However, it remains unclear which patient should receive nonoperative management instead of surgery. This study aimed to generate a scoring system for surgeons to identify patients with PPU who may be too weak to undergo surgery and without any survival benefit. We extracted the admission data of adult (≥ 18 years) patients with PPU disease from the NHIRD database. They were randomly divided into an 80% model derivation cohort and a 20% validation cohort. Multivariate analysis with a logistic regression model was applied to generate the scoring system, PPUMS. The scoring system was then applied to the validation group. 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). In the derivation group, patients with PPUMS > 4 had a 45.9% in-hospital mortality rate and similar in-hospital mortality risk in the operation group [traditional laparotomy: odds ratio (OR) = 0.729, p = 0.320, laparoscopy: OR = 0.772, p = 0.697] and the non-operation group. In the validation group, patients with PPUMS > 4 points had a 36.9% mortality rate and similar mortality risk in the operation group (traditional laparotomy: OR = 0.353, p = 0.093, laparoscopy: no applicable) and non-operation group. PPUMS is a good predictor of mortality risk in patients with PPU and with various underlying diseases or comorbidities. Surgical management is suggested for patients with PPU with PPUMS ≤ 4 points because of lower mortality risk. However, in patients with PPUMS > 4 points, surgery may have limited benefit due to the high mortality rate compared to nonoperative treatment.