Clinical factors associated with gastrectomy selection and derivation of an exploratory prediction score for perforated gastric ulcer: a retrospective study

The operative choice between primary repair and gastrectomy for perforated gastric ulcer varies according to lesion- and patient-related factors; however, factors associated with gastrectomy selection are not well characterized. This study aimed to identify factors associated with gastrectomy selection and to derive an exploratory perioperative risk-stratification score, with postoperative outcomes evaluated in a secondary analysis. This single-center retrospective study included 273 consecutive patients who underwent surgery for perforated gastric ulcers (197 non-gastrectomy and 76 gastrectomy procedures). Ulcer size was assessed intraoperatively. Logistic regression was used to identify factors associated with gastrectomy selection. A parsimonious score based on ulcer size and history of peptic ulcer disease (PUD) was developed among 223 patients with documented ulcer size and internally validated using bootstrap resampling and repeated 10-fold cross-validation. Postoperative outcomes were compared using crude, covariate-adjusted, and overlap-weighted analyses. Ulcer size and history of PUD remained independently associated with gastrectomy selection (ulcer size: adjusted odds ratio [OR], 2.78; 95% confidence interval [CI], 1.97–3.92; p < 0.001; PUD history: adjusted OR, 4.21; 95% CI, 1.73–10.28; p = 0.002). The exploratory four-point score assigned 0–3 points according to ulcer size (< 1, 1–<2, 2–<3, or ≥ 3 cm) and 1 additional point for PUD history, and showed good discrimination (AUC, 0.853; bootstrap 95% CI, 0.797–0.902; repeated 10-fold cross-validated AUC, 0.830). At a cutoff of ≥ 2 points, sensitivity was 86.7% and specificity was 74.8%. Crude postoperative morbidity was greater in the gastrectomy group, but no between-group difference in postoperative outcome reached statistical significance after overlap weighting. Ulcer size and a history of PUD were independently associated with observed gastrectomy selection. The parsimonious score showed good discrimination and may provide a structured adjunct at operative assessment. It should be regarded as exploratory rather than an operative indication and requires external validation.