Objective. Mortality and morbidity following perforated peptic ulcer (PPU) is substantial and probably related to the development of sepsis. During the last three decades a large number of preoperative prognostic factors in patients with PPU have been examined. The aim of this systematic review was to summarize available evidence on these prognostic factors. Material and methods. MEDLINE (January 1966 to June 2009), EMBASE (January 1980 to June 2009), and the Cochrane Library (Issue 3, 2009) were screened for studies reporting preoperative prognostic factors for mortality in patients with PPU. The methodological quality of the included studies was assessed. Summary relative risks with 95% confidence intervals for the identified prognostic factors were calculated and presented as Forest plots. Results. Fifty prognostic studies with 37 prognostic factors comprising a total of 29,782 patients were included in the review. The overall methodological quality was acceptable, yet only two-thirds of the st...

Preoperative prognostic factors for mortality in peptic ulcer perforation: a systematic review.

Background: Patients with perforated peptic ulcer (PPU) often present with acute, severe illness that carries a high risk for morbidity and mortality. Mortality ranges from 3-40% and several prognostic scoring systems have been suggested. The aim of this study was to review the available scoring systems for PPU patients, and to assert if there is evidence to prefer one to the other. Material and methods: We searched PubMed for the mesh terms “perforated peptic ulcer”, “scoring systems”, “risk factors”, ”outcome prediction”, “mortality”, ”morbidity” and the combinations of these terms. In addition to relevant scores introduced in the past (e.g. Boey score), we included recent studies published between January 2000 and December 2012) that reported on scoring systems for prediction of morbidity and mortality in PPU patients. Results: A total of ten different scoring systems used to predict outcome in PPU patients were identified; the Boey score, the Hacettepe score, the Jabalpur score the peptic ulcer perforation (PULP) score, the ASA score, the Charlson comorbidity index, the sepsis score, the Mannheim Peritonitis Index (MPI), the Acute physiology and chronic health evaluation II (APACHE II), the simplified acute physiology score II (SAPS II), the Mortality probability models II (MPM II), the Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity physical sub-score (POSSUM-phys score). Only four of the scores were specifically constructed for PPU patients. In five studies the accuracy of outcome prediction of different scoring systems was evaluated by receiver operating characteristics curve (ROC) analysis, and the corresponding area under the curve (AUC) among studies compared. Considerable variation in performance both between different scores and between different studies was found, with the lowest and highest AUC reported between 0.63 and 0.98, respectively. Conclusion: While the Boey score and the ASA score are most commonly used to predict outcome for PPU patients, considerable variations in accuracy for outcome prediction were shown. Other scoring systems are hampered by a lack of validation or by their complexity that precludes routine clinical use. While the PULP score seems promising it needs external validation before widespread use.

https://link.springer.com/content/pdf/10.1186%2F1757-7241-21-25.pdf

Scoring systems for outcome prediction in patients with perforated peptic ulcer

Acute perforated peptic ulcer: On clinical experience in an urban tertiary hospital in south east Nigeria

Background/Aims: To establish the efficacy of two-port appendectomy as an alternative to standard laparoscopic and open appendectomy in the management of acute appendicitis. Materials and Methods : Of the 151 patients included in the study, 47 patients were in the open group, 61 in two-port and 43 patients were included in the three-port group. Only patients with uncomplicated acute appendicitis were included in the study. Patients with complicated appendicitis like perforated appendix, appendicular lump and appendicular abscess were excluded from the study. Patients converted to open procedure after initial diagnosis and patients with other pathology in addition to appendicitis were also excluded. Patients with recurrent appendicitis and chronic appendicitis were excluded. The total number of excluded cases was 50. Data were compared with cases of open and three-port appendectomy. Results: The mean operative time was 43.94, 35.74, and 59.65 min (SD: 18.91, 11.06, 19.29) for open, two-port, and three-port appendectomy groups respectively. Mean length of stay in days was 3.02, 1.93, and 2.26 (SD: 1.27, 1.04, 1.09) for open, two-port, and three-port appendectomy groups respectively. Surgical site infection was significantly lower (P = 0.03) in laparoscopy group as compared to that in open appendectomy group. Seven patients (4.63%) developed surgical site infection, 5 (10.63%) in the open and 2 (1.92%) in the laparoscopy group. Surgical site infection was 1.63% and 2.32% in two-port and three-port appendectomy groups respectively. Conclusions: For uncomplicated appendicitis, the two-port appendectomy technique significantly reduces operative time as well as length of hospital stay. It also reduces surgical site infection as compared to open appendectomy group.

A retrospective study of two-port appendectomy and its comparison with open appendectomy and three-port appendectomy.

Introduction: Laparoscopic appendectomy is a safe and feasible technique accepted by many surgeons as the gold standard approach for the treatment of acute appendicitis in children. Traditionally laparoscopic appendectomy requires the use of three ports. However, surgical techniques with fewer ports have been reported. Aim: To evaluate the efficacy of laparoscopic appendectomy in children according to the proposed 3-step protocol using one, two or three ports. Material and methods: A total of 100 children with the diagnosis of acute appendicitis underwent laparoscopic appen dectomy. Patients were treated according to the following protocol: transumbilical access with one 10 mm port using the laparoscope with working channel. The appendix was mobilized and delivered through the umbilical port and tied extracorporeally and removed. If the appendix was placed retrocecally or had adhesions, a second port was intro duced. The appendix was mobilized and finally retrieved from the abdominal cavity through the camera port, and resected extracorporeally. In the cases of very short and gangrenous appendix and immobile colon, a third port was introduced and totally intra-abdominal appendectomy was performed. Patients were evaluated regarding the dura tion of the operation, and operative and postoperative complications. Results: During the study period 100 children (58 males, 42 females) had laparoscopic appendectomy: 48 children by one-port technique (group I), 27 children by two-port technique (group II) and 25 children by three-port technique (group III). The mean operative time was 33 min (20-55 min) in group I, 39 min in group II (23-60 min), and 49 min (30-75 min) in group III. There were no intraoperative complications. Wound infections were recorded in 4 (8.3%) patients in group I, three (11.1%) in group II and four (16.0%) in group III. One patient in group III developed an abdominal abscess managed conservatively. Conclusions: One-port laparoscopic appendectomy is a feasible technique in children. It allows 48% of children to have the operation. The addition of a second port allows one to mobilize the appendix and perform extracorporeal resection in an additional 27% of cases. These approaches have shorter operative time compared to 3-port technique. Laparoscopic extracorporeal appendectomy, especially one-port, is found to be cost effective and have excellent cosmetic results.

https://www.termedia.pl/Journal/-42/pdf-20447-10?filename=One two or three.pdf

One, two or three port appendectomy - a rational approach.

Duodenal perforation is a common abdominal catastrophe with excellent outcome if prompt resuscitation and surgical repair of perforation are done. The aim of this study was to identify factors associated with death after surgery in patients with duodenal perforation. One hundred and forty-five patients who underwent Graham's patch repair for perforated duodenal ulcer between 14 April 2002 and 31 December 2004 were studied. The mean age was 45.99 years and 61 patients (42.07 %) were referrals. There were 124 (85.52 %) males and 21 (14.48 %) females. There were 10 deaths (6.9 %). The mean time delay was 2.46 days. It was 2.37 days in survivors, 3.7 days in non-survivors. The time delay was 3.25 days for females and 3.13 days for patients referred from another hospital. The mortality was significantly associated with time delay between perforation and operation (p<0.01), presence of co-morbid conditions (P<0.04), respiratory rate (p<0.02), raised blood urea (p<0.01) and serum creatinine (p<0.001), size of perforation (p<0.005), amount of peritoneal fluid (p=0.003) and requirement of postoperative intensive care unit support (p=0.003). Time delay between perforation and operation, preoperative blood urea and serum creatinine, size of perforation and amount of peritoneal fluid, presence of co-morbid conditions and need for post operative ICU support are the important predictors of outcome after emergency surgery for duodenal perforation.

Factors influencing mortality in perforated duodenal ulcer following emergency surgical repair

The time honoured surgical procedure open appendectomy seems to be on the decline, it may be replaced in the modern era by laparoscopic appendectomy (“in appendectomy”) performed with three trocars, or by the port exteriorization appendectomy (“out appendectomy”) which can be done with two ports or even one. These techniques combine the benefits of decreased tissue trauma and operative time in addition to other advantages of minimal invasion. We conducted this study to know the effectiveness of Port Exteriorization Appendectomy, to analyze its complications and to assess the conversion rate. A one year prospective study consisted of fifty cases; a combination of emergency and elective group. They were operated under general anaesthesia and different variables were documented. Mean operative time, conversion rate, hospital stay, complications and patient satisfaction. There were 27 females with the (F: M) ratio of 1.17:1. The operative time of 23.3 mins, conversion in 4 (8.0%) patients and 2.4 days of hospital stay contributed to 86.0% operative success rate. Surgical site infection was seen in 5 (10.0%) patients and one (2.0%) developed pelvic abscess. On analysis of the satisfaction level, 44(93.6%) were completely satisfied and one (2.1%) patient seemed disappointed with the technique for cosmesis though, 42 (89.3%) remained completely satisfied and 5(10.7%) didn’t like their scars. Port exteriorization appendectomy’s efficacy can be verified by 86.0% success rate, operative time of 23.3 mins, indoor stay of 2.4 days, and minimal undesirable sequlae. However, more authentic results could be obtained if this technique is compared to open or laparoscopic appendectomy in a well designed randomized controlled clinical trial.

/pdf/port-exteriorization-appendectomy-is-it-the-future-4eu74553h4.pdf

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Papers

Factors influencing mortality in perforated duodenal ulcer following emergency surgical repair

Port exteriorization appendectomy: is it the future?