Risk Factors for Mortality Following Gastroduodenal Perforations: H. Pylori is alive and well in the USA!

Author(s):
Lamis El Kabab; Yen-Hong Kuo; Eric Klein; Niamh McGowan; David Pechman; Andrew Bates; Dominick Gadaleta; John Davis

Background:

Upper gastrointestinal perforation is a life-threatening disease. Recent research suggests that up to 10% of acute care surgery patients have gasstroduodenal disease requiring surgery. Limited data is available regarding the risk of mortality and morbidity rates in the United States.

Hypothesis:

With the advances in the understanding of the etiology of peptic ulcer disease and numerous medications to block acid production one might expect a decrease in the incidence and severity of complications of ulcer disease.

Methods:

The National Surgical Quality Improvement Program (NSQIP) database from 2015 to 2019 was queried for risk factors for mortality. Healthcare Cost and Utilization Project (HCUP) data from 1993 to 2014 was used to calculate the national trends in the incidence of gastrodudenal perforations over time.

Results:

Total of 4,754 patients were identified in the NSQIP database, 2322 patients had a gastric perforation, and 2432 patients had a duodenal perforation. HCUP data demonstrated a slight decrease of both gastric perforations (5600 down to 5535 cases) and duodenal perforatins (8680 down to 6370 cases) from 1993-2014.

The six most common risk factors for mortality following a gastric perforation in decreasing orders were septic shock (OR, 5.3, 95% CI 3.2-8.7, p<0.001), ascites (OR, 3.8, 95% CI 2.0-7.4, p <0.001), post-surgical wound infections (OR, 3.8, 95%CI 2.1-6.9, p<0.001) ventilator dependency (OR,3.8, 95% CI 2.0-6.8, p<0.001), dyspnea at rest (OR, 3.5, 95% CI 1.4-8.8, p=0.007) and disseminated cancer (OR, 3.3, 95% CI 1.8-6, p<0.001).

The six most common risk factors for mortality following  a duodenal perforation in decreasing orders were septic shock (OR, 12.8, 95% CI 7.4-22.0, p<0.001), disseminated cancer (OR, 6.9, 95% CI 3.6-13.2, p<0.001), ventilator dependency (OR,2.9, 95% CI 1.4-6.0, p=0.005), ascites (OR, 2.7, 95% CI 1.3-5.2, p=0.005), weight loss (OR,2.5,95% CI 1.6-4.0, p<0.003) and history of COPD (OR,2.5,95% CI 1.6-4.0, p<0.001).

Conclusions:

Despite significant advances in our understanding of peptic ulcer disease there has been almost no change in the incidence of perforation over the past two decades. Septic shock was the single greatest risk factor for death following both gastric and duodenal perforations. Further lomgitudinal prospective research is needed to make an impact on this surgical disease.