Early Risk Stratification for In-Hospital Mortality in Patients Undergoing Emergency Surgery for Perforated Peptic Ulcer: A 27-Year Retrospective Cohort Study

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Background/Objectives: Perforated peptic ulcer (PPU) is a serious clinical condition requiring emergency surgery and continues to carry a significant risk of mortality. This study evaluated factors associated with in-hospital mortality and the discriminatory performance of admission parameters. Methods: We retrospectively studied 385 adults who underwent emergency surgery for PPU between January 1999 and December 2025. Survivors and non-survivors were compared using nonparametric tests for continuous variables. A multivariable logistic regression model included 265 complete cases (40 deaths), and selected admission variables were evaluated using receiver operating characteristic (ROC) analysis. Results: In-hospital mortality occurred in 49 patients (12.7%). Non-survivors were older (median 76.50 vs. 55.00 years; p < 0.001) and had lower hemoglobin (12.30 vs. 14.90; p < 0.001) and higher BUN levels (36.00 vs. 21.00; p < 0.001). Time from symptom onset to admission did not differ significantly between groups (median 24 vs. 16 h; p = 0.471). After adjustment, ASA class remained associated with mortality (adjusted OR 5.404; 95% CI 2.640–11.064; p < 0.001), whereas BUN did not (adjusted OR 1.010; 95% CI 0.988–1.032; p = 0.378). ROC AUC values were 0.801 for ASA, 0.788 for age, and 0.749 for BUN. Conclusions: ASA class was independently associated with in-hospital mortality in this cohort. Although BUN showed discrimination in ROC analysis, its adjusted association was not statistically significant. Findings and exploratory cut-offs require external validation.