Abstract and Background
Abstract
Background: With dwindling rates of postoperative mortality in perforated peptic ulcer that is attributable to H2-receptor blocker usage, there is a need to shift the focus towards the prevention of postoperative morbidity. Further, the simultaneous contribution of several putative clinical predictors to this postoperative morbidity is not fully appreciated. Our objective was to assess the predictors of the risk, rate and number of postoperative complications in surgically treated patients of perforated peptic ulcer.
Methods: In a prospective cohort study of 96 subjects presenting as perforated peptic ulcer and treated using Graham's omentoplatsy patch or gastrojejunostomy (with total truncal vagotomy), we assessed the association of clinical predictors with three domains of postoperative complications: the risk of developing a complication, the rate of developing the first complication and the risk of developing higher number of complications. We used multiple regression methods – logistic regression, Cox proportional hazards regression and Poisson regression, respectively – to examine the association of the predictors with these three domains.
Results: We observed that the risk of developing a postoperative complication was significantly influenced by the presence of a concomitant medical illness [odds ratio (OR) = 8.9, p = 0.001], abdominal distension (3.8, 0.048) and a need of blood transfusion (OR = 8.2, p = 0.027). Using Poisson regression, it was observed that the risk for a higher number of complications was influenced by the same three factors [relative risk (RR) = 2.6, p = 0.015; RR = 4.6, p < 0.001; and RR = 2.4, p = 0.002; respectively]. However, the rate of development of complications was influenced by a history suggestive of shock [relative hazards (RH) = 3.4, p = 0.002] and A blood group (RH = 4.7, p = 0.04).
Conclusion: Abdominal distension, presence of a concomitant medical illness and a history suggestive of shock at the time of admission warrant a closer and alacritous postoperative management in patients of perforated peptic ulcer.
Background
Surgical emergency due to a perforated peptic ulcer – whether treated laparoscopically or by open repair – is associated with a significant postoperative morbidity and mortality. Therefore, risk-stratification of these subjects provides surgeons with an important tool to plan the management. However, a generalized use of the currently popular risk-stratification strategies in patients of perforated peptic ulcer suffers from one or more of the following three limitations. First, most of the available strategies are better predictors of postoperative mortality than morbidity. Nonetheless, the use of H2-receptor blockers has significantly reduced the postoperative mortality. Consequently, it is now imperative and appropriate to recognize the determinants of the postoperative morbidity. Second, the studies that assess the association of clinical predictors with postoperative morbidity have examined only one domain of postoperative complication – the risk of developing a complication. There exist subtly distinct but additional other domains of the complications namely the rate of development of a complication and the number of complications that simultaneously or sequentially develop in a given patient. Arguably, the predictors that influence the risk of developing a complication may be different from the ones that can potentially influence these other domains of complications. Third, the isolated effect of a predictor is unlikely to be the same as the concurrent and concomitant effect of the same predictor in a multiple regression context with potentially better model fits resulting from multiple rather than single variable analyses. Considering these three critical issues, we conducted a prospective cohort study of the determinants of postoperative complications in subjects presenting as perforated peptic ulcer.