With the advances that are being made in many areas of medicine, the surgeon must be familiar with infectious diseases of the peritoneal cavity which has increased in severity and complexity. In addition to the surgical management of secondary peritonitis from gastrointestinal perforation, the practicing surgeon may be called in to manage patient with cirrhosis with infected ascitic fluid as well as patient undergoing peritoneal dialysis with infected dialysis fluid. In addition, there is increasing recognition of a group of patients with persistent intra-abdominal sepsis or tertiary peritonitis in whom infection is associated with multiple system organ failure and general depression of immune system.1 Peritonitis continues to be one of the major infectious problems confronting the surgeons. Despite the many advances in anti-microbial agents and supportive care, the mortality rate of diffuse suppurative peritonitis remains unacceptably high.2 Its causes vary from the one requiring immediate surgical intervention to that requiring conservative management. Its accurate diagnosis and management are a challenge to every surgeon.

The complex nature of surgical infections, the multifaceted aspects of treatment, and the increasing complexity of ICU support make evaluation of new diagnostic and therapeutic advances in this field very difficult. Scoring systems that provide objective descriptions of the patient’s conditions at specific points in the disease process aid our understanding of these problems. This is important in determining the course; the disease is taking in a particular patient, whether the line of management taken is appropriate or need to be changed.3

The management of peritonitis patients has taken a new turn with the understanding of patho physiologic basis of the disease, the concept of sepsis syndrome and multi- organ failure. The current trend is to recognize these at the earliest and institute aggressive therapy. When the patient has already gone into multi-organ failure, the outlook appears dismal whatever the line of management is. It is here that conservative line of management, as well as newer modalities of treatment such as programmed relaparotomy, immuno modulation is being tried. Although these newer modalities may be useful are expensive. Hence, proper clinical monitoring with optimum number of investigations remain the corner stone of emergency surgery and also for the better use of above methods.

AIM

To compare POSSUM, MPI SCORE and Sepsis Score of STONER and ELEBUTE in predicting outcome in terms of mortality and morbidity in patients undergoing exploratory laparotomy for perforation peritonitis due to hollow viscous perforation.

Prospective observational study of total 150 cases of perforation peritonitis admitted in General surgical wardswere included in the study after applying inclusion and exclusion criteria and getting informed written consent and approved by the institute of ethical committee, at tertiary care hospital from May 2019-May 2020 to assess the utility of MPI,4 POSSUM5 and SEPSIS SCORE OF STONER AND ELEBUTE6 in case of perforation peritonitis.

All patients with primary peritonitis (spontaneous bacterial peritonitis),with tertiary peritonitis-Patients with peritonitis due to anastomotic dehiscence or leak, Patients with acute appendicitis (without perforation), age <12 years were excluded from study.

After the relevant data were collected in printed proforma sheets containing the requisite variables necessary, they were entered into online score calculators (www.SFAR.org and www.riskpredicton.org.uk). The calculated scores were tabulated and analysed using statistical software SPSS.

The patients with age ranging from 18-86 years were studied. Maximum number of patients were <50 years of age- 78 patients. 43 (28.66%) patients were female and 107 (71.33%) were male.

In our study 24 patients died with crude mortality of 16%. Among the 24 patients who succumbed, 18 died in the age group > 50 years and 6 in <50 years age group. In this study, there was appreciable difference, statistical significance (P value<0.004) found among various age groups.Amongst the mortality, there were 15 (62.5%) males and 9(37.5%) females.In our study <50 years of age having better outcome with 48% discharged and 4% died. In our study >50 years of age having poor outcome with 36% discharged and12% died.

We observed duration of more than 24 hours to be associated with significant mortality in patients with peritonitis. In our study 68 (45.33%) patients had free bowel content i.e. leading to diffuse peritonitis, 45(30%) had local pus with localised peritonitis and 37(24.66%) patients had serous soiling. Among them free bowel content had highest mortality 66.7% followed by serous soiling 20.8%.In our study 113 (75.33%) patients had pus as exudate, 34(22.66%) patients had fecal exudate, 3(2.4%) patient had clear exudates. Mortality rate was higher with fecal exudate (12%).

In our study patients with organ failure at the time of presentation having outcome with 20.66% discharged and 14.66% died. Patients without multi system organ failure at the time of presentation having outcome with 63.33% discharged and 1.3% died. In correlation of multi system organ failure with incidence of mortality p value in our study was <0.000 which is statistically significant.

In our study the malignancy was present in 6 (4%) patients and 144(96%) patients were not diagnosed with malignancy.

In our study 42(28%) patients underwent exploratory laparotomy with primary repair in peptic perforation peritonitis, 6(4%) patients underwent exploratory laparotomy with primary repair in ileal /colonic perforation, 22(14.67%) patients underwent appendicectomy, 23(15.33%) patients underwent exploratory laparotomy with resection anastomosis (RA) and 57(38%) patients underwent exploratory laparotomy with diversion stoma. Most common procedure performed was exploratory laparotomy with diversion stoma (57) followed by exploratory laparotomy with primary repair in peptic perforation (42) followed by exploratory laparotomy with resection anastomosis (RA) (23).

In our study 49 (32.67%) patients had ileal perforation, 42(28%) had peptic perforation, 33(22%) had colonic perforation and 26(17.33%) patients had appendicular perforation. The most common site of perforation was ileal (49) followed by peptic (42) and colon (33).

ROC analysis was done to identify the best cut off for MPI. The cut off that we got was 27 for which the sensitivity and specificity was calculated to be 91.70% and 88.90% respectively. (Area under Curve= 94%)

ROC analysis was done to identify the best cut off for SEPSIS SCORE OF STONER AND ELBUTE. The cut off obtained was 24.50 at which the sensitivity and specificity was calculated to be 100% and 100% respectively. (Area under curve=100%).

ROC analysis was done to identify the best cut off for POSSUM. The cut off was found out to be 47.50 at which the sensitivity and specificity was calculated to be 91.70% and 90.50% respectively. (Area Under Curve=94.4%).

Table 1: Outcome of patients according to Age

Table 2: Showing correlation of risk factors with incidence of mortality

Receiver operator characteristic curves were used to calculate the discriminatory ability of each of the scores. It is a graph plotted between sensitivity and 1- specificity. The area under the curve (AUC) for each of the scores was calculated for different cut off points and the cut off at which maximum AUC was obtained was chosen.

               Table 3: AUC & CUT off for various scoring systems

SEPSIS SCORE OF STONER AND ELEBUTE had the maximum area under the curve followed by POSSUM and MPI. Sepsis Score of Stoner and Elebute is a perfect test that has the capability to predict with maximum accuracy the subset of patients that are going to die from perforation peritonitis. POSSUM comes a close second with an area of 94.4% and MPI is third with a score of 94%.

The optimal cut off point for MPI was calculated to be 27. ROC studies reveal that the cut off for Sepsis score of Stoner and Elebute should be fixed at 24.50 for maximum results. POSSUM was found to have a cutoff of 47.

     Table 4: Comparison of sensitivity and specificity of MPI, POSSUM and Sepsis score of Stoner and Elebute

All three scores have very good sensitivity and specificity for predicting mortality in patients of perforation peritonitis undergoing surgical management of the underlying condition.

If ease of calculation of scores is taken into consideration, Mannheim peritonitis index with few variables needed for calculation which can be obtained in a short period of time and very little intra operative details seem easier to calculate as compared to  POSSUM score with two components physiological and operative severity with various variable in each of them and Sepsis score of Stoner and Elebute has four components local effects of tissue infection ,secondary effects of sepsis, laboratory data and pyrexia score were tedious to calculate.

According to our study MPI, POSSUM score and SEPSIS SCORE OF STONER AND ELEBUTE are good prognostic scoring systems and should be used routinely to identify the patients with high mortality. Although Sepsis Score of Stoner and Elebute has very high sensitivity and specificity among these scoring systems we recommend MPI scoring system for routine use for predicting the adverse outcome and mortality, as it has few variables and easy calculation as compared to other two scores.

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