prognostic scoring system on peptic ulcer...
TRANSCRIPT
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