title: Surgical delay is a critical determinant of survival in perforated peptic ulcer.
abstract: BACKGROUND
  Morbidity and mortality following perforated peptic ulcer (PPU) remain substantial. Surgical delay is a well established negative prognostic factor, but evidence derives from studies with a high risk of bias. The aim of the present nationwide cohort study was to evaluate the adjusted effect of hourly surgical delay on survival after PPU.
  
  
  METHODS
  This was a cohort study including all Danish patients treated surgically for PPU between 1 February 2003 and 31 August 2009. Medically treated patients and those with a malignant ulcer were excluded. The associations between surgical delay and 30-day survival are presented as crude and adjusted relative risks (RRs) with 95 per cent confidence intervals (c.i.).
  
  
  RESULTS
  A total of 2668 patients were included. Their median age was 70·9 (range 16·2-104·2) years and 55·4 per cent (1478 of 2668) were female. Some 67·5 per cent of the patients (1800 of 2668) had at least one of six co-morbid diseases and 45·6 per cent had an American Society of Anesthesiologists fitness grade of III or more. A total of 708 patients (26·5 per cent) died within 30 days of surgery. Every hour of delay from admission to surgery was associated with an adjusted 2·4 per cent decreased probability of survival compared with the previous hour (adjusted RR 1·024, 95 per cent c.i. 1·011 to 1·037).
  
  
  CONCLUSIONS
  Limiting surgical delay in patients with PPU seems of paramount importance.
authors.affiliation: Department of Anaesthesiology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.
authors.forename: D L
authors.initials: DL
authors.lastname: Buck
authors.forename: M
authors.initials: M
authors.lastname: Vester-Andersen
authors.forename: M H
authors.initials: MH
authors.lastname: Møller
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D003718:Denmark / Q000453:epidemiology; D004381:Duodenal Ulcer / Q000401:mortality / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010439:Peptic Ulcer Perforation / Q000401:mortality / Q000601:surgery*; D012307:Risk Factors; D013276:Stomach Ulcer / Q000401:mortality / Q000601:surgery*; D061665:Time-to-Treatment; D016896:Treatment Outcome; D055815:Young Adult