Hollow viscous perforation, characterized by a disruption in the continuity of the bowel wall, is a severe complication arising from various underlying conditions. Common etiologies include infection, inflammation, malignancy, ischemia, obstruction, trauma, and medical instrumentation. Early detection and immediate intervention are crucial to mitigating the morbidity and potential mortality associated with peritonitis and its systemic consequences due to the leakage of intestinal contents¹.

A comprehensive history and thorough physical examination play a pivotal role in determining the cause of perforation. During the initial assessment, vital signs must be promptly evaluated, as they may reveal indications of Systemic Inflammatory Response Syndrome (SIRS) or septic shock, necessitating urgent resuscitation and intervention.

Several imaging techniques and laboratory tests are valuable in identifying both the presence and cause of a hollow viscous perforation. In most cases, surgical intervention is required. Regardless of whether a patient undergoes operative or nonoperative management, the initial approach involves bowel rest, intravenous fluid resuscitation, broad-spectrum antibiotic therapy, and regular abdominal examinations².

Surgical management typically involves resection or repair of the perforated site, with or without drainage and diversion. The prognosis following surgery is significantly influenced by preexisting comorbidities, one of the most common being diabetes mellitus.

Symptoms such as postprandial fullness, nausea, bloating, abdominal pain, diarrhea, and constipation are characteristic of diabetes-related GI dysfunction. Early identification and appropriate management of these complications are crucial in enhancing diabetic care and overall patient well-being.

Abdominal surgeries frequently result in transient hyperglycemia and reduced peripheral insulin sensitivity in the perioperative period3. Although large-scale randomized trials have reported inconsistent findings regarding the survival benefits of strict glycemic control in critically ill patients4, stress-induced hyperglycemia is a well-recognized contributor to increased morbidity in hospitalized individuals. Data from the Surgical Care and Outcomes Assessment Program indicate that diabetes correlates with poorer outcomes in conventional colorectal surgeries, including a twofold increase in infection risk and elevated rates of in-hospital mortality and reoperation. Patients with Type 2 Diabetes Mellitus, especially those requiring insulin therapy, face higher postoperative morbidity risks. Perioperative glucose levels exceeding 180 mg/dL have been associated with greater susceptibility to infections, increased reoperations, prolonged hospital stays, and higher mortality rates.5

Given the inherent risks of preexisting hyperglycemia, diabetic patients undergoing colorectal surgery are particularly vulnerable to complications. Reports suggest that diabetes is present in 10–30% of patients undergoing such procedures6.

Aim: To study the various prognostic factors affecting patients with hollow viscous perforation in diabetics versus non diabetics.

Objective: To compare the prognostic factors in patients with hollow viscous perforation in diabetics versus non diabetics.

This prospective, observational study was conducted under the Department of Surgery in a tertiary care hospital. Prior approval of Institutional Ethics Committee (IEC) was taken before start of the study. A written signed informed consent was taken from all the patients prior to their enrolment in the study. Department of Surgery in a tertiary care hospital for a period of18 months on 60 patients (30 in the DM Group and 30 in the Non-DM Group) Patients diagnosed with hollow viscous perforation and planned for surgical management and meeting the inclusion and exclusion criteria

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Inclusion Criteria:

1. Patients with hollow viscous perforation.
2. Patients undergoing surgical management for the hollow viscous perforation.
3. Patients aged 18 to 65 years and of either gender.
4. Patients giving consent for taking part in the study. 44

Exclusion Criteria

1. Patients below 18 years of age or more than 65 years of age.
2. Pregnant patients.
3. Patients who were managed conservatively
4. Patients who do not consent to participate in the study

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METHOD OF DATA COLLECTION: All patients having hollow viscous perforation and planned for surgical management during the study period were included in the study, provided they met the inclusion and exclusion criteria as above. A written informed consent was taken from all the patients who were to be included in the study. Once consent was given, the patients were included in the study. A total of 60 patients were included in the study. Demographic details were recorded. Detailed history of present illness along with personal and past history were taken from the all the patients and recorded. General and systemic examinations were meticulously performed. All patients then underwent pre-anesthetic checkup and pre operative blood investigations. The surgical site was prepared inside the theatre by painting and draping with betadine scrub, spirit and betadine solution respectively. All the surgical procedures were performed as per standard guidelines. Postoperatively, the requirement of Intensive Care Unit (ICU) stay, duration of hospital stay and the final outcome in the form of discharge/death was noted. Any complications during the post- operative period were noted.

Statistical analysis

All the data was recorded in excel and analyzed. Statistical Analysis: The data was analyzed using statistical software (IBM SPSS, IBM Corporation, Armonk, NY, USA). Descriptive statistics: The Numerical/ Continuous data were expressed as Mean ± Standard Deviation and the Categorical data were expressed as Percentages. Analytical statistics: The Numerical/Continuous data were analyzed by the ‘Unpaired t test’ and the Categorical data were analyzed by the Chi square test (Fischer’s exact test was used when more than 20% of the cells had value less than 5). P value of less than 0.05 was considered as “statistically significant” and indicated by “*” in the Tables. Bar charts, pie diagrams and scatter charts were used for the presentation of the data as applicable.

Table 1: Demographic Characteristics of the Study Population in the Two Groups.

The DM group had a significantly older mean age (48.23 ± 11.91 years) compared to the NON-DM group (38.50 ± 11.60 years; P = 0.002). The 46–55 and 56–65 age groups were more prevalent in DM, while 36–45 was dominant in NON-DM. Gender distribution showed a male preponderance in both groups (60% DM, 70% NON-DM), with no significant difference (P = 0.417).

Table 2: Clinical Signs and Perforation Characteristics

Guarding with diffuse tenderness was the most common sign in both groups (56.67% DM, 76.67% NON-DM), but tense abdomen with guarding and rigidity was exclusive to DM (40%; P = 0.001). Time of presentation and number of perforations showed no significant differences (P = 0.247 and 0.723, respectively). Gastric and ileal perforations predominated in both groups, with no significant variation (P = 0.569).

Table 3: General Examination and Laboratory Findings

DM patients had a significantly higher pulse rate (114.80 vs. 104.80; P = 0.017) and lower SpO2 (95.17% vs. 97.70%; P = 0.011) than NON-DM. Blood pressure was similar (P > 0.05). Laboratory findings showed lower albumin (2.69 vs. 3.56; P < 0.001), higher RBS (212.83 vs. 132.53; P < 0.001), and higher HbA1c (9.75 vs. 5.01; P < 0.001) in DM, with other characterics s comparable (P > 0.05).

Table 4: Surgical and Postoperative Outcomes

Modified Graham’s patch was common in NON-DM (56.67%), while DM had more varied surgeries (P = 0.071). Surgery duration was similar (P = 0.391). ICU stay (66.67% DM vs. 40% NON-DM; P = 0.038), higher antibiotic use (73.33% DM vs. 40% NON-DM; P = 0.009), and complications (70% DM vs. 26.67% NON-DM; P = 0.003) were significantly higher in DM.

Table 5: Histopathology and Mortality

TB was the most common finding in DM (50%) vs. chronic inflammation in NON-DM (40%; P = 0.015). Mortality occurred only in DM (16.67% vs. 0% NON-DM; P = 0.020), indicating a significant difference.

Demographic and Clinical Characteristics

The study revealed that patients with DM were significantly older than those without DM, with a mean age of 48.23 ± 11.91 years compared to 38.50 ± 11.60 years (P = 0.002). This age disparity may reflect the higher prevalence of DM in older populations and could contribute to poorer outcomes, as age is a known risk factor for postoperative complications. The demographic data, summarized in Table 1, also showed a male preponderance in both groups, with no significant difference in gender distribution (P = 0.417).

Clinically, while guarding with diffuse tenderness was the most common sign in both groups, a tense abdomen with guarding and rigidity was exclusively observed in DM patients (40% vs. 0%, P = 0.001). This suggests that DM may be associated with more severe presentations of hollow viscous perforation, possibly due to delayed presentation or altered physiological responses, such as microvascular complications or impaired immune function.

Laboratory and Physiological Parameters

Laboratory investigations, detailed in Table 3, showed that DM patients had lower albumin levels (2.69 ± 0.51 g/dL vs. 3.56 ± 0.54 g/dL, P < 0.001), indicating poorer nutritional status or increased systemic inflammation, both of which can adversely affect surgical outcomes. Additionally, higher random blood sugar (212.83 ± 59.68 mg/dL vs. 132.53 ± 32.85 mg/dL, P < 0.001) and HbA1c levels (9.75 ± 1.72% vs. 5.01 ± 0.42%, P < 0.001) in DM patients confirm the presence of hyperglycemia, which is known to impair immune function, wound healing, and overall recovery. Physiologically, DM patients presented with a higher pulse rate (114.80 ± 15.46 vs. 104.80 ± 16.09, P = 0.017) and lower SpO2 (95.17% ± 4.50 vs. 97.70% ± 2.65, P = 0.011), indicating increased cardiovascular stress and potential respiratory compromise, which may be exacerbated by the underlying DM and the perforation itself.

Surgical Outcomes and Complications

Surgical management, as outlined in Table 4, was similar between the two groups, with no significant differences in the type or duration of surgery (P = 0.071 and P = 0.391, respectively). However, postoperative outcomes were markedly worse for DM patients. They required more frequent ICU admissions (66.67% vs. 40%, P = 0.038), higher doses of antibiotics (73.33% vs. 40%, P = 0.009), and experienced a higher rate of complications, particularly wound dehiscence (46.67% vs. 13.33%) and burst abdomen (23.33% vs. 6.67%), with an overall complication rate of 70% compared to 26.67% in non-DM patients (P = 0.003). These findings are consistent with previous studies. For instance, Lin C.S. et al.7., reported longer hospital stays and higher medical expenditures in DM patients undergoing surgery, while Zhang X. et al.9. , found a higher incidence of postoperative complications, including infections and wound healing disorders, in DM patients across various surgical procedures. Additionally, Gysling S. et al.8., noted a 10% longer hospital stay and higher mortality in DM patients undergoing colorectal surgery, further supporting the adverse impact of DM on surgical outcomes.

Perforation Characteristics and Histopathological Findings

The characteristics of perforation, , showed no significant differences in time of presentation (68.80 ± 29.72 hours in DM vs. 58.40 ± 38.56 hours in non-DM, P = 0.247) or number of perforations (1.13 ± 0.35 in DM vs. 1.17 ± 0.38 in non-DM, P = 0.723). Gastric and ileal perforations were predominant in both groups, with no significant variation in site distribution (P = 0.569). However, histopathological examination, as shown in Table 5, revealed significant differences between the groups (P = 0.015). Tuberculosis (TB) was more common in DM patients (50% vs. 26.67%), while chronic inflammation was more prevalent in non-DM patients (6.67% vs. 40%). The higher incidence of TB in DM patients may reflect their increased susceptibility to infections, including TB, which could contribute to the etiology of perforation in this population. This finding is particularly noteworthy, as it suggests an infectious component that may be more pronounced in DM patients, potentially due to impaired immune responses.

Mortality and Prognosis

Mortality was also significantly higher in DM patients (16.67% vs. 0%, P = 0.020), highlighting the lethal combination of DM and hollow viscous perforation. This aligns with findings from Zhang X. et al.9., who reported an increased risk of mortality in DM patients post-major surgery (Odds Ratio: 1.606 [1.178, 2.191]), and Gysling S. et al.8., who observed higher mortality rates in DM patients undergoing colorectal surgery (367.8 vs. 212.3 per 1000 person-years). The increased mortality in DM patients may be attributed to hyperglycemia-induced immune dysfunction, including compromised polymorphonuclear phagocytosis, neutrophil chemotaxis, and altered cytokine production, which can lead to increased infection rates and complications.

Implications for Clinical Practice and Future Research

The findings of this study underscore the significant impact of DM on the prognosis of hollow viscous perforation. DM patients present with more severe clinical signs, altered physiological and laboratory parameters, and experience higher rates of postoperative complications and mortality. These outcomes are likely influenced by multiple factors, including hyperglycemia, impaired immune function, and microvascular complications associated with DM. Clinically, these results emphasize the need for aggressive perioperative management in DM patients, including strict glycemic control, nutritional optimization, and vigilant monitoring for infections and wound healing issues. Additionally, the higher prevalence of TB in DM patients suggests that screening for and managing infectious diseases should be a priority in this population.

This study concludes that diabetes mellitus significantly worsens the prognosis of patients with hollow viscus perforation, leading to higher rates of postoperative complications, greater resource utilization, and increased mortality. These findings advocate for heightened clinical vigilance and specialized care strategies for diabetic patients undergoing surgery for this condition. Future research with larger sample sizes and multicenter designs could further validate these results and explore specific interventions to improve outcomes in this high-risk population.

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