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Invited Response
January 2001

Predicting Mortality and Morbidity of Patients Operated on for Perforated Peptic Ulcers—Invited Response

Arch Surg. 2001;136(1):94. doi:10.1001/archsurg.136.1.94

Once again we have to emphasize that this nonrandomized retrospective study only aims at validating a risk scoring system that can be used to stratify patients operated on for perforated peptic ulcers—we do not aim to compare treatment outcomes of different operative techniques. Because of its nonrandomized nature, there was a general tendency to subject "ill" patients to open repair.

Leakage after simple repair accounted for 3 of 15 deaths; all 3 patients underwent reoperation and the leakage was confirmed. For the remaining 12 patients who died of multiorgan dysfunction as a result of sepsis, postmortem examination did not reveal any evidence of leakage.

The mortality and morbidity rates of patients with different Boey scores have been stated in the text. Concerning the APACHE II score, the median scores of survivors and nonsurvivors were 4 (range, 0-21) and 15 (range, 6-24), respectively. The median scores of those with and without complications were 7 (range, 0-21) and 4 (range, 0-24), respectively. The median ulcer perforation sizes of nonsurvivors were larger than those of survivors: 10 (range, 2-25) mm vs 5 (range, 1-80) mm. Similarly, median ulcer perforation size was larger in patients with morbidity: 8 (range, 2-80) mm vs 5 (range, 1-60) mm.

The use of median APACHE II score as the dividing score is to illustrate the importance of stratifying patients before comparing treatment outcome of various techniques. We have not advocated the use of "APACHE II score 5" in general. Even if we divided our patients into different subgroups according to their APACHE II score, individual procedures did not significantly influence the mortality and morbidity (see Article Table 1).

Although Drs Schein and Wise suggest that nonoperative treatment might be beneficial for high-risk patients, a previous randomized trial conducted at our institute demonstrated that high-risk patients were less likely to respond to a conservative approach.1

Crofts  TJPark  KGMSteele  RJCChung  SCSLi  AKC A randomized trial of nonoperative treatment for perforated peptic ulcer.  N Engl J Med. 1989;320970- 973Google ScholarCrossref