Acute Physiology and Chronic Health Evaluation II score as a tool to guide management strategies in ileal perforation

Abstract

Background: Perforation peritonitis is the common surgical emergency. Despite advances in surgical techniques, antimicrobial therapy, and intensive care support, management of peritonitis continues to be highly demanding due to associated morbidity and mortality. Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring system is the best available method for risk stratification in critically ill patients. Materials and Methods : This study was conducted in the 60 patients, who were admitted from causality and surgical outpatient department with a proven diagnosis of ileal perforation peritonitis. The patients were scored using by APACHE II into either of the two groups, Group A: <10 score. Group B: ≥10 score. Patients were operated for primary closure or ileostomy formation and were divided into two groups of 30 each depending on the surgical management. Group I (n = 30): These patients were managed by primary repair of the perforation with or without resection-anastomosis. Group II (n = 30): These patients were managed by ileostomy formation with closure/resection of the perforation. The outcome was assessed by postoperative complications and duration of hospital stay as related to APACHE II score. Results : Typhoid accounted for 38.3% of ileal perforations, Tuberculosis 15%, trauma 5% and nonspecific 41.6%. The majority of the perforations were single (90%), of size <1 cm (81.66%), and located within 60 cm of terminal ileum (95%). Simple closure of perforation with or without resection anastomosis was statistically significantly (P < 0.005) more done in patients with APACHE II score <10 whereas frequency of ileostomy was statistically significantly (P < 0.005) more done in patients with APACHE II score ≥10. As the APACHE II score increases the percentage of complication rate and hence hospital stay also increases, 12.97 ± 3.50 days in patients with APACHE II <10 score and 20.96 ± 5.09 days in patients with APACHE II ≥10 score (P < 0.001). Conclusion: Enteric fever is the most common cause of perforation peritonitis. Higher APACHE II scores in secondary peritonitis correlated significantly with the higher mortality and morbidity of the patients.