D. J. Gross1, P. J. Chung1, M. C. Smith1, V. Roudnitsky2, A. E. Alfonso1, G. Sugiyama1 1SUNY Downstate Medical Center,Department Of Surgery,Brooklyn, NY, USA 2Kings County Hospital Center,Brooklyn, NY, USA
Introduction: Despite numerous advances in medical and surgical therapy, perforated gastroduodenal ulcers carry a high mortality rate. Patients with end stage renal disease (ESRD) represent a growing subset of surgical candidates, given their increasing life expectancy and prevalence in the general population. Furthermore, ESRD has been shown to be an independent predictor of morbidity and mortality in other emergency and elective operations. Using a large national database, we examined outcomes and risk factors for patients presenting with perforated gastroduodenal ulcers undergoing omentopexy.
Methods: Data was obtained from the Nationwide Inpatient Sample (NIS) from 2005 – 2012. We identified patients that had duodenal and gastroduodenal ulcers with perforation (532.10, 532.20, 532.50, 532.60, 533.10, 533.20, 533.50, 533.60) that underwent omentopexy (44.42, 54.74). We included only adults (≥18 years) and non-elective cases. We excluded patients that had diagnoses of gastric cancer (151), patients with acute kidney injury (584.5, 584.6, 584.7, 584.8, 584.9), those undergoing peritoneal dialysis (V56.2, V56.8, 54.98, 585.9), and patients with missing gender and race information. We identified patients with a diagnosis of end stage renal disease (585.6) and computed the Elixhauser-Van Walraven score to assess global comorbidity status. We then performed multiple imputation for remaining missing data. Multivariable logistic regression was performed using inpatient mortality as our primary outcome while adjusting for demographics, comorbidity status, hospital size, urban vs rural status, and geographical location, weekend status, and month of year, as well as ESRD status.
Results: A total of 6,521 patients were identified. Median age was 59.0 years. The majority were male (55.56%). There were 79 (1.21%) patients with ESRD, and 367 (5.63%) patients died during the same admission. Multivariable logistic regression showed that age (OR 2.71 [1.98-3.69 95% CI], p<0.0001), Elixhauser-Van Walraven score (OR 2.69 [2.37-3.05 95% CI], p<0.0001), and ESRD status (OR 3.88 [2.21-6.83 95% CI], p<0.0001) were independent risk factors for mortality. However, female gender (OR 0.77 [0.61-0.98 95% CI], p=0.0305), and obtaining care in the Midwest compared to the South, were independent predictors of decreased mortality (OR 0.58 [0.40-0.84 95% CI], p=0.0064).
Conclusion: In this large observational study, ESRD was strongly associated with mortality in patients undergoing omentopexy for perforated gastroduodenal ulcers. These results highlight the observation that patients with ESRD are an especially vulnerable population and require extra consideration and careful preoperative planning. Future studies are necessary to identify mitigating factors in these patients, and identify methods to help improve survival.