Archives of Academic Emergency Medicine. 2022; 10(1): e86 OR I G I N A L RE S E A RC H Predictors of Postoperative Outcome in Emergency La- parotomy for Perforation Peritonitis; a Retrospective Cross-sectional Study Ankit Rai1, Farhanul Huda1∗, Praveen Kumar2, Lena Elizabath David1, Chezhian S1, Somprakas Basu1, Sudhir Singh1 1. Department of General Surgery, All India Institute of Medical Sciences, Rishikesh, India. 2. Department of Surgery, Himalayan Institute of Medical Sciences, Dehradun, India. Received: August 2022; Accepted: September 2022; Published online: 31 October 2022 Abstract: Introduction: Hollow viscus perforation is a significant cause of surgical mortality. Various attempts have been made to identify high-risk patients preoperatively and optimize and manage such patients more aggressively. This study aimed to evaluate the predictors of outcome in patients undergoing emergency laparotomy for per- foration peritonitis. Methods: This retrospective cross-sectional study was conducted on perforation peritonitis cases admitted to the Department of General Surgery, All India Institute of Medical Sciences, Rishikesh, India. The association between preoperative patient variables with postoperative complications, anastomotic leaks, need for intensive care unit (ICU) admission, and 30-day mortality were evaluated. Results: Tachycardia at the time of admission (t = 2.443, p = 0.020), hypotension (χ2 = 18.214, p = <0.001), lower haemoglobin (t = -4.134, p = <0.001), higher blood urea nitrogen levels (W = 1967.000, p = 0.012), International Normalised Ratio (INR) ≥ 1.5 (χ2 = 17.340, p = <0.001), the mean albumin level 2.89 ± 0.77 g/dL (t = -2.348, p = 0.027), and delay in surgery (χ2 = 28.423, p = 0.008) were significant associate factors of mortality. The association between need for ICU admission and higher pulse rate on admission (W = 2782.500, p = 0.011), lower systolic blood pressure (W = 1627.500, p = 0.029), higher blood urea nitrogen (W = 2299.000, p = 0.030) and serum creatinine levels (W = 2192.500, p = 0.045), preoperative coagulopathy (χ2 = 6.773, p = 0.017), hypoalbuminemia (t = -2.515, p = 0.016), and delay in surgery (χ2 = 17.780, p = 0.016) was significant. Conclusion: Based on the results of this study, hypotension, azotaemia, coagulopathy, and delay in surgery, increase the risk of postoperative mortality of patients undergoing emergency laparotomy for perforation peritonitis. Tachycardia, hypotension, azotaemia, hypoalbuminemia, and pre-operative coagulopathy were good predictors of need for ICU admission. Shock at presentation, deranged renal function and coagulopathy were associated with an increased risk of postoperative complications. Keywords: Emergencies; intestinal perforation; mortality; peritonitis Cite this article as: Rai A, Huda F, Kumar P, David LE, Chezhian S, Basu S, Singh S. Predictors of Postoperative Outcome in Emer- gency Laparotomy for Perforation Peritonitis; a Retrospective Cross-sectional Study. Arch Acad Emerg Med. 2022; 10(1): e86. https://doi.org/10.22037/aaem.v10i1.1827. 1. Introduction Gastrointestinal tract perforation is one of the most com- mon surgical emergencies worldwide. Peritonitis and the re- sultant sepsis and systemic complications due to the perfo- ∗Corresponding Author: Farhanul Huda, Department of General Surgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand-249203, In- dia. Email: farhanul1973huda@gmail.com, Tel: +91-9997533211, ORCID: https://orcid.org/0000-0002-1309-1832. ration are still responsible for significant mortality despite the advent of newer antibiotics, safer operative and anaes- thetic techniques, and an improved understanding of pre- and postoperative management (1). Rapid source control through surgical exploration and prudent antimicrobial ther- apy is fundamental for treating intra-abdominal sepsis due to perforation (2). Billing et al. proposed early prognostic assessment of pa- tients with perforation peritonitis to allow triaging of patients for a more aggressive therapeutic approach (3). Several scor- ing systems have since been developed to enable general and This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem A. Rai et al. 2 prognostic evaluation of patients with perforation peritonitis (2, 4). Bohen et al. did an anatomical classification of intra- abdominal infections into three groups (group I- appendici- tis and perforated duodenal ulcer; group II- peritonitis from all other intra-abdominal organs, not following surgery; and group III- postoperative peritonitis) and showed a difference in outcomes between them (4). The Acute Physiology and Chronic Health Evaluation (APACHE) system, on the other hand, is a non-specific physiologic scoring system that has been validated for risk stratification and has also been used in several studies for intra-abdominal infections (5). Meakins and associates proposed an approach for the study and clin- ical management of intra-abdominal infections that com- bined functional and anatomical components (6). Singh et al. did a prospective analysis of 84 patients with perforation peritonitis and identified laboratory indices, delay in presen- tation, and surgery as good predictors of postoperative mor- tality (7). Most of these scoring systems are exhaustive and challenging to use in emergency departments. This study aimed to evaluate the predictive factors of postop- erative outcome in patients undergoing emergency laparo- tomy for perforation peritonitis. 2. Methods 2.1. Study design and settings A retrospective cross-sectional study was conducted in the Department of General Surgery at the All India Institute of Medical Sciences, Rishikesh, a government-run medical uni- versity and tertiary-care hospital in Northern India. The study period was from 01st July 2017 to 01st July 2020. The as- sociation between preoperative patient variables with post- operative complications, anastomotic leaks, need for inten- sive care unit (ICU) admission, and mortality were studied. Approval was obtained from the Institute’s Ethics Commit- tee before the study (AIIMS/IEC/20/741). The transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) statement was adhered to while reporting this study (8). 2.2. Participants All adult patients admitted to General Surgery department with the diagnosis of peritonitis due to perforation of the gas- trointestinal (GI) tract were included on the basis of clinical findings, pneumoperitoneum on chest X-ray, or Abdominal computed tomography (CT). All cases of primary peritoni- tis, perforations due to corrosive intake, trauma, postoper- ative peritonitis due to anastomosis leakage, pregnant pa- tients, and patients whose records were not available were excluded. 2.3. Data collection Patient data were retrospectively collected from the elec- tronic health records (EHR) of the hospital database. Pa- tient details such as demographic information (age, gen- der, co-morbidities/addictions), symptoms at the time of presentation (pain abdomen, vomiting, fever, ileus), vital signs at the time of presentation (heart rate, blood pres- sure), and preoperative blood parameters (haemoglobin, to- tal leucocyte count, serum creatinine, blood urea, Interna- tional Normalised Ratio (INR), serum albumin) were col- lected. The type of management (operative/non-operative), delay in surgery, and the anatomical site of perforation were also recorded. 2.4. Outcomes Postoperatively, data regarding complications (using the Clavein-Dindo classification)(9), anastomotic leaks, need for ICU admission, and 30-day postoperative mortality were col- lected. 2.5. Statistical analysis The sample size was based on a study by Jhobta et al., who re- ported 10% mortality in patients with perforation peritonitis (10). It was calculated according to the formula by Lemeshow et al., (11). With a precision (δ) of 0.05 (5%), and type I error (α) at 0.05 (5%), z was taken as 1.96. Based on the above for- mula, the required sample size was calculated as, N = [1.962 x 0.10 x (1-0.10)] / 0.052 = 138.29 ≈ 139. Thus, with a 95% con- fidence interval, the minimum sample size required for the study was 139. Statistical analysis was done using the SPSS statistics package v23 (IBM Corp., USA)(12). We tried to explore the association between the preoperative patient variables with the postop- erative outcomes, as mentioned above. Group comparisons for continuously distributed data were made using the inde- pendent sample t-test. For non-normally distributed data, an appropriate non-parametric test, such as the Wilcoxon test, was used. Chi-squared test was used for group comparisons of categorical data. In case the expected frequency in the contingency tables was found to be <5 for >25% of the cells, Fisher’s exact test was used instead. Linear correlation be- tween the variables was explored using Pearson’s and Spear- man’s correlation for normally and non-normally distributed data, respectively. Statistical significance was kept at p<0.05. 3. Results 3.1. Baseline characteristics of studied cases One hundred eighty-three consecutive cases of perforation peritonitis with the mean age of 42.61 ± 15.99 (Range: 18-85) years presenting during our study period were included in This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2022; 10(1): e86 the study (80.5% male). 13% of patients had some comorbid- ity such as diabetes mellitus, hypertension, tuberculosis, etc. Most of the patients also had some form of addiction, with smoking (52.4%), and alcohol intake (20.5%) being common. 3.2. Associated factors of outcomes I. Postoperative anastomotic leaks Participants in the age group 41-50 years had the highest pro- portion of leaks (χ2 = 16.846, p = 0.026). Among the present- ing symptoms, ileus was significantly associated with anas- tomotic leaks (χ2 = 4.941, p = 0.043). The site of perforation was also associated with postoperative leaks (χ2 = 41.051, p = 0.045), with duodenum, caecum or ascending colon perfora- tions contributing to the majority of leaks. Table 1 shows the associated factors of postoperative anastomotic leak of stud- ied cases. II. Postoperative complications Vomiting as a presenting complaint was a predictor of post- operative complications (p = 0.005). The duration of ileus at presentation also predicted delayed complications (p = 0.027). Shock (systolic blood pressure (SBP) < 100 mmHg) on admission correlated with poor prognosis (p = 0.013). Among the blood parameters, raised serum creatinine (p = 0.043) and coagulopathy (INR > 1.5) (p = 0.017) predicted postoperative complications. Table 2 shows the association between differ- ent grades of Clavien-Dindo postoperative complications (9) and preoperative variables. III. ICU admission Table 3 summarizes the association between need for ICU admission and preoperative parameters. Patients who re- quired ICU admission had a higher pulse rate on admission (W = 2782.500, p = 0.011). The median (interquartile range; IQR) of systolic BP in the ICU admission group was 103 (90- 120) mmHg. There was a significant difference in systolic BP (W = 1627.500, p = 0.029) between groups, with the me- dian systolic BP being highest in the group that did not re- quire ICU admission. Subgroup analysis revealed a signif- icant difference between the groups, SBP < 100 and SBP ≥ 100 (χ2 = 12.194, p = <0.001). Deranged renal function was significantly associated with ICU admission, with both blood urea (W = 2299.000, p = 0.030) and serum creatinine levels significantly elevated (W = 2192.500, p = 0.045). Preopera- tive coagulopathy also predicted ICU admission (χ2 = 6.773, p = 0.017). Hypoalbuminemia was also a strong predictor of ICU admission (t = -2.515, p = 0.016), with 2.17 times higher chance of admission in those with albumin <2.5g/dL (95% CI= 0.79-5.94). The reason for delay in surgery was also a sig- nificant predictor of ICU admission (χ2 = 17.780, p = 0.016). IV. Postoperative mortality Table 4 summarizes the association between 30-day mortal- ity and preoperative parameters. Tachycardia at the time of admission was associated with higher postoperative mortal- ity (t = 2.443, p = 0.020). However, on subgroup analysis, no difference was observed between the groups, pulse rate (PR) < 100 and PR ≥ 100 (χ2 = 3.722, p = 0.054). Hypotension was also associated with increased postoperative mortality (χ2 = 18.214, p = <0.001) with 4.55 times higher risk of mortality in the group with systolic BP ≤ 100 mmHg (95% CI = 2.19 - 9.22). Diastolic BP was also significantly associated with postoper- ative mortality (W = 988.500, p = <0.001). The haemoglobin (Hb) in the postoperative mortality group was significantly lower (t = -4.134, p = <0.001). However, no difference in the group Hb ≤ 8 g/dL and Hb > 8g/dL (χ2 = 4.925, p = 0.061) was evident on subgroup analysis. On the other hand, blood urea levels influenced postoperative mortality (W = 1967.000, p = 0.012). INR ≥ 1.5 was also associated with higher mortality (χ2 = 17.340, p = <0.001). The mean (standard deviation; SD) of albumin level in mortality group was 2.89 (0.77) g/dL and was significantly associated with postoperative mortality (t = -2.348, p = 0.027). No difference was evident on subgroup analysis between the groups, albumin ≤ 2.5 g/dL and > 2.5 g/dL (χ2 = 3.685, p = 0.089). There was a significant difference in mortality due to surgery delay (χ2 = 28.423, p = 0.008). Delay due to initial resuscita- tion led to the highest rate of mortality. 4. Discussion Based on the results of this study, hypotension, azotaemia, coagulopathy, and delay in surgery increase the risk of post- operative mortality of patients undergoing emergency la- parotomy for perforation peritonitis. Tachycardia, hypoten- sion, azotemia, hypoalbuminemia, and preoperative coag- ulopathy were good predictors of ICU admission. Shock at presentation, deranged renal function and coagulopathy were associated with an increased risk of postoperative com- plications. Generalised peritonitis is a common surgical emergency. It is one of the leading causes of death in non-trauma surgical patients, with a mortality as high as 20% (2, 3). Even with the advancement in diagnostic and therapeutic aspects over the years, a significant number of lives are being lost to this ill- ness. Several modifiable and non-modifiable factors can influence the clinical outcome in patients with perforation peritonitis. Attempts must be made to identify and optimize the high- risk patient preoperatively, while simultaneously preparing for emergency surgery. Multiple studies have tried to identify the factors that can influence the clinical outcome in these patients. Certain factors and lab parameters can be used to predict the outcome, and several scoring systems have been devised using them, such as the Acute Physiology and Chronic Health Evaluation (APACHE) score, the Simplified Acute Physiology Score (SAPS), the Boey Score, the Multi- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem A. Rai et al. 4 Organ Failure (MOF) Score, and the Mannheim Peritonitis Index (MPI) (2, 7). These scores are not simple to use and are time-consuming. Preoperative functional status is also being used for predicting the postoperative outcome (13). It is, thus, more relevant to identify simple patient parameters that can predict postoperative complications and mortality. Anastomotic leak is one of the major complications following bowel repair or anastomosis. The UK Surgical Infection Study Group defined an enteric leak as "leakage of luminal con- tents from a surgical join between two hollow viscera" (14). Several factors have been linked to anastomotic leaks such as, malnutrition, steroids, tobacco use, leukocytosis, cardio- vascular disease, alcohol use, lower GI anastomoses, subop- timal anastomotic blood supply, operative time of more than 2 hours, bowel obstruction, perioperative blood transfusion, and intra-operative septic conditions not conducive to a pri- mary anastomosis (15, 16). We report the highest rate of anastomotic leaks between 41-50 years of age (χ2 = 16.846, p = 0.026). Mcdermott et al. found that the mean age group was 60 years and that age did not correlate with postoper- ative leakage (17). We found preoperative ileus to be sig- nificantly associated with anastomotic leaks (χ2 = 4.941, p = 0.043). Peter et al. observed similar findings in patients undergoing colorectal resection (15). Multiple studies have shown that those with lower GI anastomoses are more prone to leaks than those having anastomoses in the upper GI tract, especially after emergency surgery (16, 18). We found the site of perforation to be associated with anastomotic leaks (χ2 = 41.051, p = 0.045). However, most leaks in our patients oc- curred following duodenal, caecal, and colonic perforations, in that order. In another study, Gupta et al. observed that the size of the duodenal perforation determines the risk of post- operative leak (19). We report hypotension at the time of ad- mission as an important predictor of postoperative mortality (χ2 = 18.214, p = 0.001) with 4.55 times higher risk in those with systolic BP ≤ 100 mmHg (95% CI = 2.19 - 9.22). Dias- tolic BP was also significantly associated with postoperative mortality (W = 988.500, p =0.001). Singh et al. also found that shock could predict poor postoperative outcomes, which is in line with our findings (7). In a study by Wesselink et al., the authors observed that intraoperative mean arterial pressure (MAP) less than 60-65mm Hg was associated with poor sur- gical outcomes (20). We conclude that deranged renal function and hypoalbu- minemia are important predictors of postoperative compli- cations. This is in concordance with studies conducted pre- viously (3, 21). Presence of coagulopathy (INR >5) was also related to postoperative mortality (t = -2.348, p = 0.027). This could be a result of sepsis-induced disseminated intravas- cular coagulopathy (DIC). In a single-centre analysis, Naka- mura et al. found that preoperative DIC score is a prognostic factor for colonic perforation associated with peritonitis (22). Moreover, patients with deranged kidney function, hypoal- buminemia, and deranged INR were more likely to require ICU admission post-surgery. However, the other important causes of raised creatinine in these patients, such as urinary tract obstruction (stones, neoplasms, prostatic hyperplasia), diabetes, and nephrotoxic drug intake, must also be kept in mind. It seems that preoperative variables such as tachycardia, hy- potension, deranged renal function, coagulopathy, and hy- poalbuminemia are strong predictors of poor prognosis in patients with perforation peritonitis. Identifying one or more of these high-risk predictors calls for a more aggressive re- suscitation with rapid source control for a favourable patient outcome. 5. Limitation This study was a retrospective one, and data collection was record-based. A larger prospective study is, thus, required to generate more substantial evidence. This study was con- ducted at a tertiary-care referral centre, thus receiving the sickest patients from the state and outside. Moreover, there was a significant delay in the presentation of patients due to the arduous Himalayan terrain. All of these could poten- tially cause a systematic error in favour of the most critical patients, which may not be the case at other centres, and thus, result in an overestimation in our findings. Age, and pre-existing systemic illnesses, are specific confounders that must also be individually matched for to generate more de- cisive evidence. The role of inflammatory markers such as C-reactive protein and procalcitonin in severity assessment in patients with perforation peritonitis and abdominal sep- sis is well known (23, 24). However, due to the high costs of these tests and non-affordability by the majority of our pa- tients, they could not be included in the present study. 6. Conclusion Based on the results of this study, hypotension, azotaemia, coagulopathy, and delay in surgery increase the risk of post- operative mortality of patients undergoing emergency la- parotomy for perforation peritonitis. Tachycardia, hypoten- sion, azotaemia, hypoalbuminemia, and pre-operative co- agulopathy were good predictors of ICU admission. Shock at presentation, deranged renal function, and coagulopathy were associated with an increased risk of postoperative com- plications. 7. Declarations 7.1. Acknowledgments We acknowledge the support of faculty and residents of the Department of General Surgery, All India Institute of Medical This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 5 Archives of Academic Emergency Medicine. 2022; 10(1): e86 Sciences, Rishikesh (India). 7.2. Funding and support Nil. 7.3. Conflict of interest The authors declare that they have no conflict of interest. 7.4. Authors’ contribution Dr. Somprakas Basu, Dr. Farhanul Huda, Dr. Praveen Kumar conceptualised the study; Dr. Ankit Rai, Dr. Lena Elizabath David, Dr. Chezhian S did the data collection; Dr. Ankit Rai, and Dr. Lena Elizabath David did the data analysis; Dr. Ankit Rai, Dr. Lena Elizabath David, Dr. Chezhian S prepared the first manuscript; Dr. Somprakas Basu, Dr. Farhanul Huda, Dr. Sudhir Singh, Dr. Praveen Kumar, Dr. Ankit Rai, Dr. Lena Elizabath David, Dr. Chezhian S reviewed the manuscript; Dr. Somprakas Basu, Dr. Farhanul Huda, Dr. Praveen Kumar supervised the study at all stages. 7.5. Data availability The data used and/or analyzed in the study are available with the corresponding author and can be provided on request. 7.6. Ethical considerations This study was approved by the Institute Ethics Committee of the All India Institute of Medical Sciences, Rishikesh (AI- IMS/IEC/20/741). 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This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 7 Archives of Academic Emergency Medicine. 2022; 10(1): e86 Table 1: Associated factors of postoperative anastomotic leak in the studied patients Parameters Anastomotic Leak P Present (n = 7) Absent (n = 178) Age ( Years) Mean ± SD 50.14 ± 6.31 42.31 ± 16.19 0.133 41-50 Years 5 (14.7) 29 (85.3) 0.026 51-60 Years 2 (7.1) 26 (92.9) Gender Male 7 (4.7) 142 (95.3) 0.349 Female 0 (0.0) 36 (100.0) Co-Morbidities Addiction 6 (4.9) 116 (95.1) 0.426 Symptoms Pain 7 (3.8) 176 (96.2) 1.000 Vomiting 3 (3.4) 85 (96.6) 1.000 Fever 4 (8.5) 43 (91.5) 0.073 Ileus 7 (6.4) 102 (93.6) 0.043 Duration of symptoms (days) Pain 4.43 ± 2.82 7.35 ± 18.24 0.591 Vomiting 4.00 ± 2.00 3.66 ± 3.69 0.329 Fever 3.75 ± 2.06 9.84 ± 17.45 0.589 Ileus 2.71 ± 1.60 2.74 ± 1.85 0.924 Vital signs Systolic BP (mmHg) 113.57 ± 21.63 109.76 ± 18.31 0.635 Pulse Rate (bpm) 111.57 ± 19.23 104.74 ± 17.30 0.342 Investigations Haemoglobin (g/dL) 11.38 ± 2.23 12.66 ± 3.17 0.403 TLC (/cu.mm) 9663.3 ± 3447.4 12408.4 ± 9243.02 0.727 Platelet Count (/cu.mm) 187.67 ± 56.89 1471.42 ± 9188.72 0.384 Blood Urea (mg/dL) 80.60 ± 64.35 59.33 ± 45.46 0.269 Serum Creatinine (mg/dL) 1.63 ± 1.82 1.29 ± 0.90 0.604 INR 1.21 ± 0.11 1.41 ± 0.55 0.492 Serum Albumin (g/dL) 3.00 ± 0.43 3.29 ± 0.84 0.334 Delay in surgery Yes 6 (5.7) 99 (94.3) 0.251 Site of perforation Gastric (Type I) 1 (20.0) 4 (80.0) 0.045 Gastric (Type III) 4 (5.9) 64 (94.1) Duodenum* 1 (100.0) 0 (0.0) Jejunum 1 (33.3) 2 (66.7) Management Operative 7 (4.7) 141 (95.3) 1.000 Non-operative 0 (0.0) 18 (100.0) Data are presented as mean ± standard deviation (SD) or frequency (%). BP: Blood Pressure; INR: International Normalised Ratio; TLC: Total Leucocyte Count. *: duodenum, caecum, and ascending colon. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem A. Rai et al. 8 Table 2: Association between different grades of Clavien-Dindo postoperative complications and preoperative variables Parameters Post-operative complications based on Clavien-Dindo Grade P I (n =1) II (n = 21) IIIa (n=15) IIIb (n=7) IVa (n=23) IVb (n = 4) V (n = 15) Age ( Years) Mean ± SD 42.00 ± 0 35.81 ± 10.97 39.93 ± 15.81 43.57 ± 14.66 44.04 ± 16.83 51.75 ± 11.00 50.07 ± 18.80 0.199 Gender Male 1 (1.4) 14 (20.3) 12 (17.4) 7 (10.1) 20 (29.0) 4 (5.8) 11 (15.9) 0.448 Female 0 (0.0) 7 (41.2) 3 (17.6) 0 (0.0) 3 (17.6) 0 (0.0) 4 (23.5) Co-Morbidity Addiction 1 (1.9) 14 (25.9) 8 (14.8) 2 (3.7) 15 (27.8) 2 (3.7) 12 (22.2) 0.307 Symptom Pain 1 (1.2) 21 (24.7) 15 (17.6) 6 (7.1) 23 (27.1) 4 (4.7) 15 (17.6) 1.000 Vomiting 1 (2.6) 16 (42.1) 6 (15.8) 1 (2.6) 7 (18.4) 3 (7.9) 4 (10.5) 0.005 Fever 1 (3.6) 6 (21.4) 8 (28.6) 3 (10.7) 4 (14.3) 1 (3.6) 5 (17.9) 0.177 Ileus 1 (1.8) 11 (19.3) 8 (14.0) 5 (8.8) 18 (31.6) 3 (5.3) 11 (19.3) 0.422 Duration of symptoms (Days) Pain 2.00 ± 0 3.38 ± 1.75 16.40 ± 37.16 3.83 ± 3.25 4.22 ± 2.68 4.50 ± 1.29 13.87 ± 30.92 0.054 Vomiting 2.00 ± 0 2.69 ± 1.40 5.67 ± 3.50 1.00 ± 0 4.43 ± 3.87 4.33 ± 1.53 4.50 ± 3.79 0.186 Fever 2.00 ± 0 7.33 ± 6.25 5.62 ± 4.96 4.00 ± 1.73 4.25 ± 3.86 6.00 ± 0 10.00 ± 9.90 0.950 Ileus 2.00 ± 0 2.27 ± 1.42 4.50 ± 2.98 1.20 ± 0.45 3.28 ± 1.96 3.67 ± 2.08 2.36 ± 1.29 0.027 Vital signs Pulse Rate (BPM) Mean ± SD 128.0 ± 0 107.6± 19.12 106.00 ± 11.50 115.5 ± 25.7 106.3 ± 16.1 110.2 ± 16.8 112.07 ± 17.1 0.758 Systolic BP (mmHg) Mean ± SD 128.0 ±0 109.50 ± 16.4 114.20 ± 20.8 118.4 ± 11.7 114.78 ± 10.43 110.5 ± 30.44 100.5 ± 23.06 0.167 <100 0 (0.0) 5 (29.4) 2 (11.8) 0 (0.0) 1 (5.9) 2 (11.8) 7 (41.2) 0.013 ≥100 1 (1.5) 15 (22.1) 13 (19.1) 7 (10.3) 22 (32.4) 2 (2.9) 8 (11.8) Diastolic BP (mmHg) Mean ± SD 70.00 ± 0 75.95 ± 11.27 76.27 ± 23.89 78.43 ± 8.83 69.30 ± 9.45 70.00 ± 14.14 61.87 ± 13.45 0.051 Investigations Haemoglobin (g/dL) - 12.64 ± 3.15 11.65 ± 2.76 11.55 ± 3.66 12.36 ± 3.17 12.95 ± 2.52 9.34 ± 2.83 0.059 TLC (/cu.mm) - 12395.1±7774.4 18355.6±11001.3 8580.0±6869.9 10847.4±7975.3 7480.6±5304.0 13102.5±15258.4 0.089 Platelet Count (/cu.mm) - 282.05 ± 155.89 263.85 ± 244.21 280.29 ± 232.78 231.32 ± 105.79 202.67 ± 160.75 5508.55 ± 17409.69 0.597 Blood Urea (mg/dL) - 51.38 ± 27.00 61.41 ± 51.76 48.57 ± 20.75 80.47 ± 62.90 170.82 ± 97.71 76.00 ± 47.52 0.103 Cr (mg/dL) Mean ± SD - 1.21 ± 0.65 1.10 ± 0.53 0.78 ± 0.29 1.54 ± 1.37 3.09 ± 1.39 1.66 ± 1.20 0.058 ≤2 mg/dL 0 (0.0) 16 (26.2) 14 (23.0) 7 (11.5) 15 (24.6) 1 (1.6) 8 (13.1) 0.043 >2 mg/dL 0 (0.0) 3 (20.0) 1 (6.7) 0 (0.0) 4 (26.7) 3 (20.0) 4 (26.7) INR Mean ± SD - 1.40 ± 0.35 1.38 ± 0.20 1.23 ± 0.09 1.55 ± 0.81 1.25 ± 0.22 1.80 ± 0.50 0.154 ≤1.5 0 (0.0) 10 (25.0) 10 (25.0) 5 (12.5) 11 (27.5) 2 (5.0) 2 (5.0) 0.017 >1.5 0 (0.0) 6 (28.6) 3 (14.3) 0 (0.0) 4 (19.0) 0 (0.0) 8 (38.1) Serum Albumin (g/dL) - 3.38 ± 0.89 3.18 ± 0.73 2.61 ± 0.38 2.95 ± 0.83 3.10 ± 0.46 2.86 ± 0.84 0.081 Imaging 0.761 Delay in Surgery 1 (1.8) 15 (27.3) 9 (16.4) 3 (5.5) 14 (25.5) 3 (5.5) 10 (18.2) 0.879 Site of Perforation 0.367 Management Operative 1 (1.2) 21 (25.6) 13 (15.9) 7 (8.5) 21 (25.6) 4 (4.9) 15 (18.3) 0.682 Non-operative 0 (0.0) 0 (0.0) 1 (50.0) 0 (0.0) 1 (50.0) 0 (0.0) 0 (0.0) Data are presented as mean ± standard deviation (SD) or frequency (%). BP: Blood Pressure; Cr: Creatinine; INR: International Normalised Ratio; TLC: Total Leucocyte Count; BPM: Beat Per Minute. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 9 Archives of Academic Emergency Medicine. 2022; 10(1): e86 Table 3: Association between need for ICU admission and preoperative parameters Parameters Need for ICU admission P Yes (n = 32) No (n = 138) Age ( Years) Mean ± SD 46.59 ± 17.33 41.62 ± 15.51 0.141 Gender Male 28 (20.0) 112 (80.0) Female 4 (13.3) 26 (86.7) Co-Morbidity Addiction 23 (20.4) 90 (79.6) 0.472 Symptom Pain 32 (18.9) 137 (81.1) 1.000 Vomiting 12 (15.4) 66 (84.6) 0.275 Fever 9 (20.5) 35 (79.5) 0.765 Ileus 21 (21.0) 79 (79.0) 0.409 Duration of symptoms (days) Pain 9.81 ± 24.18 6.91 ± 17.08 0.575 Vomiting 2.83 ± 1.40 3.70 ± 3.85 0.723 Fever 5.00 ± 6.00 10.86 ± 19.03 0.317 Ileus 2.67 ± 1.32 2.77 ± 2.00 0.693 Pulse Rate (BPM) Mean ± SD 111.41 ± 15.69 102.87 ± 16.72 0.011 <100 6 (9.8) 55 (90.2) 0.020 ≥100 26 (24.5) 80 (75.5) Systolic BP (mmHg) Mean ± SD 105.09 ± 22.42 112.01 ± 16.00 0.029 <100 12 (42.9) 16 (57.1) <0.001 ≥100 20 (14.4) 119 (85.6) Diastolic BP (mmHg) Mean ± SD 64.53 ± 13.75 72.67 ± 12.23 0.001 Laboratory Haemoglobin (g/dL) 12.26 ± 2.96 12.69 ± 3.27 0.505 TLC (/cu.mm) 11794.44 ± 9330.32 12709.10 ± 9307.87 0.406 Platelet Count (/cu.mm) 2390.15 ± 11114.30 968.27 ± 8028.70 0.224 Blood Urea (mg/dL) 77.87 ± 61.75 54.17 ± 40.04 0.030 Serum Creatinine (mg/dL) Mean ± SD 1.70 ± 1.19 1.18 ± 0.84 0.045 ≤2 20 (15.2) 112 (84.8) 0.032 >2 8 (36.4) 14 (63.6) INR Mean ± SD 1.69 ± 0.75 1.30 ± 0.31 0.018 ≤1.5 10 (10.9) 82 (89.1) 0.017 >1.5 9 (31.0) 20 (69.0) Serum Albumin (g/dL) Mean ± SD 2.94 ± 0.79 3.37 ± 0.84 0.016 <2.5 g/dL 7 (30.4) 16 (69.6) 0.149 ≥2.5 g/dL 20 (16.8) 99 (83.2) Delay in Surgery Yes 18 (17.1) 87 (82.9) 0.572 Hours 14.78 ± 12.12 12.67 ± 22.15 0.191 Reason for the delay Unavailability of OT slot 14 (14.7) 81 (85.3) Unavailability of ICU/ventilator 0 (0.0) 1 (100.0) Delay in diagnosis 0 (0.0) 3 (100.0) Initial Resuscitation 3 (100.0) 0 (0.0) 0.016 Left against medical advice 0 (0.0) 0 (0.0) Non-operative management 1 (50.0) 1 (50.0) Delay in CT scan 0 (0.0) 1 (100.0) Impending Perforation 0 (0.0) 1 (100.0) This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem A. Rai et al. 10 Table 3: Association between need for ICU admission and preoperative parameters Parameters Need for ICU admission P Yes (n = 32) No (n = 138) Management Operative 29 (19.6) 119 (80.4) 0.531 Non-operative 2 (11.1) 16 (88.9) Data are presented as mean ± standard deviation (SD) or frequency (%). BP: Blood Pressure; INR: International Normalised Ratio; TLC: Total Leukocyte Count; ICU: Intensive Care Unit; CT: Computed Tomography; OT: Operation Theatre; BPM: Beat Per Minute. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 11 Archives of Academic Emergency Medicine. 2022; 10(1): e86 Table 4: Association between postoperative 30-day mortality and preoperative parameters Parameters Mortality P Present (n = 23) Absent (n=162) Age ( Years) Mean ± SD 49.00 ± 18.51 41.70 ± 15.45 0.072 Gender Male 17 (11.4) 132 (88.6) 0.403 Female 6 (16.7) 30 (83.3) Co-Morbidity Addiction 14 (11.5) 108 (88.5) 0.583 Symptom Pain 23 (12.6) 160 (87.4) 1.000 Vomiting 9 (10.2) 79 (89.8) 0.358 Fever 7 (14.9) 40 (85.1) 0.577 Ileus 15 (13.8) 94 (86.2) 0.555 Duration of symptoms (Days) Pain 14.43 ± 29.99 6.21 ± 15.29 0.534 Vomiting 3.44 ± 2.65 3.70 ± 3.75 0.657 Fever 7.86 ± 8.88 9.57 ± 17.87 0.844 Ileus 2.40 ± 1.12 2.79 ± 1.91 0.706 Pulse Rate (BPM) Mean ± SD 112.43 ± 15.33 103.92 ± 17.42 0.020 <100 4 (6.2) 60 (93.8) 0.054 ≥100 19 (16.2) 98 (83.8) Systolic BP (mmHg) Mean ± SD 98.26 ± 22.49 111.60 ± 17.15 0.002 <100 12 (34.3) 23 (65.7) <0.001 ≥100 11 (7.5) 135 (92.5) Diastolic BP (mmHg) Mean ± SD 61.70 ± 12.04 72.08 ± 12.96 <0.001 Laboratory data Haemoglobin (g/dL) Mean ± SD 10.17 ± 2.62 12.94 ± 3.09 <0.001 <8 g/dL 3 (33.3) 6 (66.7) 0.061 ≥8 g/dL 15 (9.6) 141 (90.4) TLC (/cu.mm) 14282.7± 14684.3 12135.6 ± 8356.3 0.648 Platelet Count (/cu.mm) 3464.1 ± 13610.6 1197.4 ± 8415.4 0.165 Blood Urea nitrogen (mg/dL) 91.61 ± 68.97 55.63 ± 40.37 0.012 Serum Creatinine (mg/dL) Mean ± SD 1.78 ± 1.22 1.24 ± 0.87 0.063 ≤2 mg/dL 14 (10.1) 125 (89.9) 0.094 >2 mg/dL 6 (23.1) 20 (76.9) INR Mean ± SD 1.91 ± 0.80 1.35 ± 0.47 0.002 ≤1.5 4 (4.2) 92 (95.8) <0.001 >1.5 10 (30.3) 23 (69.7) Serum Albumin (g/dL) 2.89 ± 0.77 3.34 ± 0.83 0.027 Mean ± SD 0.089 <2.5 g/d L 6 (24.0) 19 (76.0) ≥2.5 g/dL 13 (10.2) 115 (89.8) Reason for the delay Unavailability of OT slot 9 (9.5) 86 (90.5) Unavailability of ICU/ventilator 0 (0.0) 12 (100.0) Delay in diagnosis 1 (33.3) 2 (66.7) 0.008 Initial Resuscitation 3 (100.0) 0 (0.0) Left against medical advice 0 (0.0) 2 (100.0) Non-operative management 0 (0.0) 2 (100.0) Delay in investigations (CT) 0 (0.0) 1 (100.0) Impending Perforation 0 (0.0) 1 (100.0) This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem A. Rai et al. 12 Table 4: Association between postoperative 30-day mortality and preoperative parameters Parameters Mortality P Present (n = 23) Absent (n=162) Management Operative 20 (13.5) 128 (86.5) 1.000 Non-operative 2 (11.1) 16 (88.9) Data are presented as mean ± standard deviation (SD) or frequency (%). BP: Blood Pressure; INR: International Normalised Ratio; TLC: Total Leukocyte Count; ICU: Intensive Care Unit; CT: Computed Tomography; OT: Operation Theatre; BPM: Beat Per Minute. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem Introduction Methods Results Discussion Limitation Conclusion Declarations References