PROGNOSTIC SCORING SYSTEM ON

PEPTIC ULCER PERFORATION

Prof. Dr. P. Soetamto Wibowo, Sp.B-KBD – Dep/SMF I. Bedah FK. Unair/RSUD Dr. Soetomo Surabaya

The 1st Surabaya Gastrointestinal and Emergency Surgery (SuGIES) – Hotel Novotel Surabaya, 19 – 20 Mei 2017

Perforated Peptic Ulcer Management - Mortality

Author

Soetomo Gen. Hosp.

n=59 (2012)

Buck DL [1]

Denmark (7 Dept)

n=117 (2008-2009)

Wegdam HH [2]

Ghana

n=56 (2004-2008)

Age Median (range)

Male No (%)

59 yrs (31 – 72)

44 (74.6)

70 yrs (25 – 92)

57 (49.0)

42 yrs (20 – 100)

50 (89.3)

Laparotomi

Omental patch

Resection

Mortality

52/55 = 94.5 %

3/55 = 5.5 %

7 (11.9%)

108 (93 %)

8 (7 %)

20 (17 %)

56 (100 %)

-

6 (10.7 %)

Reoperation 6 (10.2%) 20 (17.1%)

[1] Buck DL, andersen MV, Moller MH, Accuracy of Clinical Prediction rule in peptic ulcer perforation : an observational study, Scand. J.

Gastroenterol, 2012; 47 : 28 – 35 2] Wegdam HH, Hillah AA, Modified open omental plugging of peptic ulcer perforation in a Municipal

Hospital in Ghana, Post graduate Medical J. Ghana, 2013; 2 (1) : 1 – 3

Influent of Age – Socio-geography – EGDT [1]

Perforated Peptic Ulcer (PPU → High risk mortality (3 – 40%) and Morbidity (20 – 50%) (1)

Soetomo General Hospital Surabaya Experience

2016 Emergency Digestive Surgery

Dr. Soetomo General Hospital – 2016

n %

Appendicitis 87 28.15

Peptic Ulcer Perforation 60 19.87

Colorectal Malignancy 57 18.87

Incarcerated Hernia 46 15.23

Intestinal Adhesion 14 4.64

Small Intestine Perforation 10 3.31

Diverticulitis 8 2.65

Intestinal Strangulation 7 2.32

Hepatobiliary pathology 7 2.32

Others 8 2.65

Dr. Iskak General Hospital Tulungagung Experience

2016

Emergency Digestive Surgery 580

n %

1 Acute appendicitis / perforation 110 51.89

2 General peritonitis (laparotomy) 44 20.75

3 Incarcerated hernia 32 15.09

4 Intestinal obstruction 19 8.96

5 Peptic Ulcer perforation 7 3.30

Total 212

Clinical Pathway (1)

PPU (+ Risk Factors)

Peritonitis

Sepsis

Mortality / Morbidity

SURGERY

ED

(1) Moller MH, Adamsen S, Thornsen RW et al. Preoperative prognostic factors for mortality in peptic ulcer perforation :

a systematic review. Scandinavian J. Gastroenterology 2010; 45 (7-*) : 785 – 805

(2) Soreide K. et al. Perforated Peptic Ulcer . Lancet 2015; 386 (10.000) : 12 88 - 1298

− 5 x bleeding PU (2)

OR 12.2 (95% CI 9.8 – 14.9)

Scoring system PPU - Risk Factors (1)

Prognostic PPU

50 Risk Factors (37 identified) (1)

Univariate logistic regression analysis (p≤ 0,25)

Multivariate logistic regression Analysis (OR – CI 95%)

Scoring System

(1) Moller MH, Adamsen S, Thornsen RW et al. Preoperative prognostic factors for mortality in peptic ulcer perforation : a

systematic review. Scandinavian J. Gastroenterology 2010; 45 (7-*) : 785 - 805

ROC p<0.05

Prognostic Factors of PPU

(1) Moller MH, Adamsen S, Thornsen RW et al. Preoperative prognostic factors for mortality in peptic ulcer perforation : a

systematic review. Scandinavian J. Gastroenterology 2010; 45 (7-*) : 785 - 805

Preoperative Scoring System for prediction of PPU

PPU SCORE ORIGIN OUTCOME

Boey Hongkong 1987 30 day mortality

Hacettepe Turkey 1992 30 day mortality

Jabalpur India 2003 30 day mortality

PULP Denmark 2012 30 day mortality

POMPP (2) Turkey 2015 30 day mortality

PmPUPG (3) Surabaya 2016 30 day + morbidity

Prognostic → Scoring Systems (1)

(1) Thorsen K, Soreide JA, Soreide K. Scoring Systems for outcome prediction in patient with perforated peptic ulcer. Scandinavian

J.Trauma Resuscitation and emergency Med. 2013; 21 : 25 (2) Menekse E, Kocer B, Topcu R, et al. A practical scoring system to

predict mortality in patients with perforated peptic ulcer. W.J. Emergency Surg. 2015; 10 : 7 (3) Lestari WB. Prognostic Scoring

system of morbidity for patients with peptic ulcer perforation. Final paper for surgical training 2017.

Preoperative Scoring System for prediction of

Peptic Ulcer Perforation (PPU) (1)

GENERAL SCORING OUTCOME

ASA (American Society of

Anesthesiologist)

1941 Preoperative Risk

Charlson Comorbidity Index 1987 1 year mortality

Manheim Peritonitis Index (MPI) 2002 Prediction of surgical outcome

Apache II 1985 Prediction outcome ICU

SAPS II 1993 Prediction outcome ICU

MPM II 1993 Prediction outcome ICU

POSSUM 1991 Prediction of Surgical mortality

(1) Thorsen K, Soreide JA, Soreide K. Scoring Systems for outcome prediction in patient with perforated peptic ulcer. Scandinavian

J.Trauma Resuscitation and emergency Med. 2013; 21 : 25

Perforated Peptic UlcerBoey Score [1]

Most well known prediction rule in PPU [2]

1. Concomitant severe medical illness

2. Preoperative shock

3. Duration of perforation more than 24 hours

Boey

Score

Mortality

[1] [3]

0 0 % -

1 10 % 8 %

2 45.5 % 33 %

3 100 % 38 %

[1] Boey J, Choi SK, Poon A, Algoratnam TI, Risk Stratification in perforated duodenal ulcer. A postoperative validation of

Predictive Factors, Ann. Surg. 1987; 205 : 22-26 [2] Thorsen K, Soreide JA, Soreide K, et al Scoring systems for outcome prediction in

patients with perforated peptic ulcer, Scandinavian J. Trauma, Resuscitation and Emergency Medicine 2013; 21 : 25. [3] Lui FY , Davis

KA, Gastrodudenal perforation. Maximal or Minimal intervention ? Scandinavian J. Surg. 2010; 99 : 77-77

High Score > 1

Perforated Peptic UlcerASA Score [1] “Subjective”

Most common used surgical prognostic prediction

world wide [2]

1. Normal health

2. Mild systemic disease

3. Severe systemic disease

4. Severe systemic disease that is constant threat to

life

5. Patient survival is not expected without surgery

[1] Saklad M, Grading of patients for surgical procedures, Anesthesiology 1941; 2 : 281 – 4

[2] Thorsen K, Soreide JA, Soreide K, et al Scoring systems for outcome prediction in patients with perforated peptic

ulcer, Scandinavian J. Trauma, Resuscitation and Emergency Medicine 2013; 21 : 25.

High Score > 3

Perforated Peptic UlcerPeptic Ulcer Perforation (PULP) Score [1]

Assignment of points according to the Peptic Ulcer Perforation Score

Variables Points

Age > 65 years 3

Co-morbid active malignant disease (AROS) 1

Co-morbid Liver Chirhostic 2

Steroid use 1

Shock on admission * 1

Time from perforation to admission . 24 hours 1

Serum Creatinine > 1.5 mg.dl 2

ASA score 2

3

4

5

1

3

5

7

Total PULP Score 0 – 18

* Shock on admission = blood pressure , 100 mmHg

and heart beat rate > 100/min

[1] Moller MH, Engebjerg MC, adamsen S et al. The Peptic Ulcer Perforation (PULP) Score: A Predictor Mortality following

pepetic ulcer perforation. A Cohort study, Acta Anaesthesiiol. Scand. 2012; 56(5) : 655 – 62.

High Score > 6

ROC Curve analysis (AUC) of POMPP, PULP,

BOEY and ASA Scoring System (1)

(1) Menekse E, Kocer B, Topcu R, et al. A practical scoring system to predict mortality in patients with perforated peptic ulcer. W.J. Emergency

Surg. 2015; 10 : 7

ROC : Receiver Operating Curve

AUC : Area Under the Curve

POMPP (Turkey) Point

Age > 65 years 1

BUN > 45 mg/dL 1

Albumin > 1.5 g/L 1

High Score > 1

PmPUPG (Prognostic Morbidity Peptic Ulcer

Perforated and Gastric

33 Risk Factors – Morbidity

Univariate regression analysis (p < 0.05)

9 Risk Factors

Multivariate regression analysis (p < 0.05)

4 Risk Factors : Points

BUN > 27.3 mg/dl 3

Albumin ≤ 3.08 g/dl 2

Natrium ≤ 139.1 7

Time from perforation – surgery > 24 hrs 7

Total Score 0 - 19

Prognostic Value of Morbidity in Gastric Peptic Ulcer Perforation

Surabaya Experience – Retrospective Cohort 2011 – 2015

WINDIARTI BUDI LESTARI, dr – n = 84

Low Risk Score : 0 – 12

High Risk Score : 13 – 19

Morbidity Rate : 73.8%

PmPUPG – Surabaya Experience (2017)

Scoring

SystemAUC SE 95% CI

Boey .630 068 498 – 762

PULP .698 069 563 – 833

POMPP .564 070 426 – 702

Jabalpur .674 068 541 – 806

PmPUPG .895 042 813 – 977

Comparison of ROC analysis of BOEY, PULP.POMPP, Jabalpur - PmPUPG

AUC > 80 Good60 – 80 Moderate

< 60 Poor

Scoring accuracy of mortality prediction in PPU patients.

Meta analysis

Scoring

system

Mishra

Mortality Rate 10.7%

India

n = 140

1999 - 2001

Lohsiriwat

Mortality Rate 9.0%

Thailand

n = 152

2001 - 2006

Moller

Mortality Rate 27.0%

Denmark

n = 2668

2003 – 2009

Menekse (2)

Mortality Rate 10,1%

Turkey

n = 227

2002 - 2010

ASA − 0.91 0.78 0.91

BOEY 0.85 0.86 0.70 0.92

Jabalpur 0.92 − − −

PULP − − 0.83 0.96

POMPP − − − 0.93

(1) Thorsen K, Soreide JA, Soreide K. Scoring Systems for outcome prediction in patient with perforated peptic ulcer. Scandinavian J.Trauma

Resuscitation and emergency Med. 2013; 21 : 25 ( 2) Menekse E, Kocer B, Topcu R, et al. A practical scoring system to predict mortality in

patients with perforated peptic ulcer. W.J. Emergency Surg. 2015; 10 : 7

Area under the ROC Curve (AUC)

AUC : > 0.80 Good, 0.60 – 0.80 Moderate, < 0.60 Poor

Comparing AUC Value → Limitation (1)

1. Different inclusion criteria : Time perforation → admission/surgery

2. Socio demographic

▪ Sex (WEST vs EAST)

▪ Age – co existing disease

▪ Site of perforation

▪ NSAID / steroid / jamu

3. Number of patient and ratio of outcome (% mortality)

Large sample size → higher power and reliability (PULP) – Mortality 27%

4. Timing of collection

5. Positive Predictive Value (PPV) Boey Score – ASA Score 24% →

→ Predict Mortality POORLY (2)

(1) Thorsen K, soreide JA, Soreide K. Scoring systems for outcome of prediction in patients with perforated peptic ulcer. Scandinavian

J.Trauma Resuscitation and Emergency Medicine 2013; 21 : 25 (2) Buck DL, Vester , andersen M, Moller MH. Accuracy of clinical

prediction rule in peptic ulcer perforation : an abrevational study. Scandinavian J.Gastroenterology 2012; 47 : 28 – 35

Problem of PPU Scoring System ?

Lack of validation in external Cohorts → hampers generalizability (1,2)

(1) Soreide K. et al. Perforated Peptic Ulcer . Lancet 2015; 386 (10.000) : 12 88 - 1298

(2) Thorsen K, soreide JA, Soreide K. Scoring systems for outcome of prediction in patients with perforated peptic ulcer.

Scandinavian J.Trauma Resuscitation and Emergency Medicine 2013; 21 : 25

Post operative score is better

than preoperative score (1)

Thorsen K, soreide JA, Soreide K. Scoring systems for outcome of prediction in patients with perforated peptic ulcer. Scandinavian

J.Trauma Resuscitation and Emergency Medicine 2013; 21 : 25

How to improve OutcomeEGDT - Early Goal Directed Therapy (1,2,3,4)

Preoperative Care Outcome

(1)Kehlet H. Wilmore DW. Evidence Based Surgical Care and the Evolution of Fast Track Surgery. Ann Surg 2008; 248 : 189 – 198 (2) Moller MH, Thornsen RW,

Moller AM et al. Multicenter trial of a preoperative protocol to reduce morltality in patients with peptic ulcer perforastion. Br.J.Surg 2011; 98; : 802 – 810 (3)

Soreide K. et al. Perforated Peptic Ulcer . Lancet 2015; 386 (10.000) : 12 88 – 1298 (4) Rhodes A et al. Surviving sepsis Campaign International Guidelines

for management of sepsis and septic shock : 2016.

SEPSIS

Surviving Sepsis

Campaign

Multimodality and multidisciplinary evidence

based preoperative care protocol

INTERVENTION

GROUP

CONTROL

n = 117

2008 – 2009

(+ PULP)

n = 510

2003 – 2007

Mortality 17.1% 27.1%

RR 0.63 (CI 95% 0.42 – 0.95

Reduction of 37% mortality

Moller MH (Denmark)(1) − Fast Track Surgery

7 center 2008 – 2009 → n = 117 (intervention group)

FOCUS – CONSISTENCY – PROFESSIONAL

TEAM APPROACH

Moller MH, Thornsen RW, Moller AM et al. Multicenter trial of a preoperative protocol to reduce morltality in patients with peptic

ulcer perforastion. Br.J.Surg 2011; 98; : 802 – 810

Post Operative Score

Clavien Dindo Classification (2004) (1)

Quality Assessment → Performance

It’s not about what happen to you It’s about how you response to what happen to you

Grading Complications based on

The Therapy used to treat the Complication

(1) Dindo D. Demartines N. Clavien PA. Classification of Surgical Complications. A New Proposal with evaluation in a cohort of

6336 patients and results of survey. Ann. Surg. 2004; 240 (2) : 2015 – 213.

Conclusion :

Simple, reproducible, flexible and aplicable

Mentula PJ, Leppaniemi AK. Applicability of the Clavien Dindo Classification to emergency surgical procedure. A

retrospective Cohort studiyon 444 consecutive patients . Patients Safety Surgery 2014; 8 : 31.

Clavien Dindo Classification

Mentula PJ, Leppaniemi AK. Applicability of the Clavien Dindo Classification to emergency surgical procedure. A retrospective

Cohort studiyon 444 consecutive patients . Patients Safety Surgery 2014; 8 : 31.

Conclusion

1. No scoring system was ideal

2. Boey score and ASA score are the most commonly

applied

3. Pulp score seems promising validation is

recommended

4. EGDT is more important to improve performance

5. Clavien Dindo Classification for postoperative

complications appears reliable tool for quality

assessment in surgery

6. Novel Technique