Global 30-day morbidity and mortality of surgery for perforated peptic ulcer - GRACE study

Background Perforated peptic ulcer (PPU) is a surgical emergency with a mortality rate of 16-30% and a morbidity rate of 20-50%. All studies reporting on the outcome of surgery for PPU are either local or national. Most of these are based on small cohort sizes. A few larger studies have been reported, but still limited to a single nation, accounting for the wide variations in the literature. There is a lack of global, multicenter data on this topic. We aimed to assess the global 30-day morbidity and mortality of surgery for PPU and the factors influencing it. Methods We conducted a global observational cohort study of patients who underwent surgery for PPU between 01/01/2022 and 30/06/2022. Adults (≥18 years) who underwent surgery for PPU and those who had a PPU in a bypassed stomach after bariatric surgery were included. We excluded patients with underlying gastric cancer, and those treated conservatively. Patients were divided into subgroups to study the influence of some variables. These were age (≤50 and >50 years), time from onset of symptoms to hospital presentation (≤24 and >24 hours), and surgical technique (open, laparoscopic, and laparoscopic converted to open). Results This is the first global study on this topic and included 1864 patients from 162 centers across 52 countries. Mean age was 49.7 ± 17 years, and males represented 78.3%. The mean hospital stay was 10 ± 9.2 days and the 30-day reoperation rate was 5.4%. The 30-day morbidity rate was 48.5% and mortality rate was 9.3%. On multivariate analysis, age >50 years, presentation >24 hours, female gender, shock on admission, and acute kidney injury were significantly associated with 30-day morbidity. 30-day mortality was significantly associated with age >50 years, female gender, acute kidney injury, and shock on admission. Conclusions Surgery for PPU carries high 30-day morbidity and mortality globally. Age > 50 years old, female gender, acute kidney injury, and signs of shock upon admission are independent factors that can increase the likelihood of 30-day mortality. Laparoscopic surgery appears to be underutilized despite lower morbidity and mortality rates.