Risk stratification and nonoperative management of duodenal perforation: the role of the POMPP score and CT imaging in a retrospective cohort

Risk stratification and nonoperative management of duodenal perforation: the role of the POMPP score and CT imaging in a retrospective cohort | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Risk stratification and nonoperative management of duodenal perforation: the role of the POMPP score and CT imaging in a retrospective cohort Bingwen Liu, Mengyao Zou, Xueming Yang, Xiang Ma, Lijian Xu, Fei Zhou, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8668268/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Duodenal perforation is a heterogeneous and potentially life-threatening surgical emergency, with increasingly complex etiologies and management strategies in recent years. In previous studies and guidelines comparing nonoperative management (NOM) and surgical treatment, gastric and duodenal perforations have often been investigated together as upper gastrointestinal perforations, whereas evidence focusing specifically on duodenal perforation remains limited. This study aimed to identify risk factors for severe complications in duodenal perforation, to compare the predictive performance of different risk scoring systems, to explore differences among perforation sites within the duodenum, and to evaluate conditions under which NOM may be considered. Methods A retrospective study was conducted on patients diagnosed with duodenal perforation between January 2021 and May 2025. Clinical characteristics were compared among patients with different outcomes, treatment strategies, and perforation locations. Representative cases were also described. Results Age, POMPP score, sex, albumin, D-dimer, urea, C-reactive protein, creatinine and hemoglobin were associated with the occurrence of severe complications (Clavien–Dindo classification ≥ IV). The POMPP score demonstrated superior predictive performance compared with the Boey score. When comparing patients managed with NOM and those undergoing surgery, significant differences were observed only in CT findings, specifically extensive extraluminal air and suprapelvic fluid collections, whereas other clinical characteristics and clinical outcomes were comparable between the two groups. In addition, patients with perforations at the D2/D3 segments required longer durations of somatostatin use, acid-suppressive therapy, antibiotic treatment, and hospital stay than those with D1 perforations. Conclusion The management of duodenal perforation should be individualized based on patient risk factors, perforation characteristics, and disease progression. Hypoalbuminemia, advanced age, female sex, anemia, and elevated C-reactive protein, creatinine, urea, and D-dimer levels are associated with a higher risk of severe complications. The POMPP shows promise as a reliable tool for identifying low-risk patients. Compared with D1 perforations, D2/D3 perforations require longer treatment durations. In clinically stable, low-risk patients, the absence of extensive extraluminal air or suprapelvic fluid collections on CT may support the selection of NOM. Duodenal perforation Peptic ulcer perforation Nonoperative management Conservative treatment Risk factors Anatomical segment-based differences Clavien-Dindo classification POMPP Boey score Figures Figure 1 Figure 2 Figure 3 Background Duodenal perforation is a life-threatening emergency with diverse etiologies, and its reported mortality ranges from 8% to 25%( 1 ). With the widespread use of proton pump inhibitors (PPIs) and the successful eradication of Helicobacter pylori , the incidence of ulcer-related duodenal perforation has declined( 2 , 3 ). However, the increasing aging population and the growing use of nonsteroidal anti-inflammatory drugs (NSAIDs) and endoscopic interventions have contributed to greater complexity in the etiology and management of duodenal perforation( 4 – 10 ). Given the high mortality associated with duodenal perforation, identifying relevant risk factors and establishing reliable risk prediction systems are crucial for recognizing high-risk patients and guiding clinical decision-making( 11 , 12 ). Previous studies have reported multiple risk factors for upper gastrointestinal perforation, and several scoring systems have been developed; however, their predictive performance and practicality remain controversial( 5 , 13 – 16 ). Surgery is traditionally the most common treatment for duodenal perforation, but operative management itself carries the risk of postoperative complications( 1 , 17 ). In 1989, Croft et al. conducted a prospective randomized clinical trial demonstrating the feasibility of nonoperative management (NOM) for upper gastrointestinal perforation( 18 ). Since then, numerous retrospective studies and several guidelines have explored the indications for NOM( 11 , 12 , 17 , 19 , 20 ). Moreover, with advances in endoscopic techniques, the incidence of endoscopy-related perforations has increased, and endoscopic repair of duodenal perforation has been increasingly adopted in clinical practice( 6 – 9 ). Most previous studies and guidelines comparing surgical management and NOM have examined gastric and duodenal perforations collectively as “upper gastrointestinal perforation,” whereas research focusing exclusively on duodenal perforation remains limited( 11 , 12 , 19 ). In addition, the duodenum consists of four anatomical segments, and differences in perforation characteristics across these segments warrant further investigation( 21 , 22 ). Therefore, this study aims to retrospectively analyze the risk factors, treatment strategies, and anatomical variations in duodenal perforation, supplemented by representative case analyses, to provide additional clinical evidence for optimizing management strategies in patients with duodenal perforation. Methods Ethics Statements This study was approved by the Medical Ethics Committee of the Second Affiliated Hospital of Nanjing Medical University (Approval No. 2025-KY-465-01). Patients This study retrospectively reviewed 60 consecutive patients diagnosed with duodenal perforation at the Second Affiliated Hospital of Nanjing Medical University between January 2021 and May 2025. The diagnosis was confirmed by imaging, endoscopy, or intraoperative findings. Using a standardized data extraction form, we retrospectively collected comprehensive patient information, including demographic data, laboratory results, computed tomography (CT) findings, and treatment-related variables. Each patient was assessed for risk stratification using both the POMPP (Practical scoring system of mortality in patients with perforated peptic ulcer) and Boey scoring systems( 5 , 23 ). Severe complications were defined as those classified as Clavien–Dindo classification ≥ IV, including life-threatening events requiring ICU management or resulting in death( 24 ). Extensive extraluminal air was defined as either an extensive distribution of free air or extensive mottled extraluminal air bubbles. Suprapelvic fluid collections was defined as intraperitoneal or retroperitoneal fluid accumulation, excluding pelvic fluid. CT images were independently reviewed by two experienced radiologists who were blinded to clinical outcomes. In this study, NOM included nil by mouth, intravenous hydration, parenteral nutrition, nasogastric decompression, somatostatin and acid-suppressive therapy, and intravenous antibiotics. In addition, one patient underwent placement of a nasojejunal feeding tube under digital subtraction angiography (DSA), and one patient received endoscopic closure, which eventually failed. When comparing operative and nonoperative management, we attempted to identify differences in the patients’ clinical characteristics at admission in order to explore the general conditions under which nonoperative treatment may be selected. However, two patients—one who developed a perforation due to failed ERCP stone extraction and required emergency surgery, and another with a fish bone penetrating the anterior wall of the third portion of the duodenum—were considered unavoidable surgical cases and were excluded from the comparative analysis of treatment modalities to avoid confounding by indication( 10 , 25 ). A total of 58 patients were ultimately included in the comparison of treatment modalities (Table 3 ). Study Outcomes When analyzing different treatment modalities and perforation locations, we defined severe complications (Clavien–Dindo classification ≥ IV) as the primary outcome. Secondary outcomes were the duration (in days) of the following: total parenteral nutrition, nasogastric decompression, somatostatin use, acid-suppressive therapy, and antibiotic therapy, as well as the total length of hospital stay. Inclusion and exclusion criteria Inclusion criteria ( 1 ) confirmed diagnosis of duodenal perforation;( 2 ) availability of complete medical records;( 3 ) age ≥ 18 years. Exclusion criteria ( 1 ) unclear perforation site;( 2 ) incomplete clinical data;( 3 ) perforation secondary to malignant disease. Statistical analysis Data were imported into Microsoft Excel for data management. Continuous variables are presented as median with interquartile range (IQR), and categorical variables as counts and percentages. Statistical analyses were performed using SPSS software (IBM Corp., version 27.0). Continuous variables and ordinal variables between groups were compared using the Mann–Whitney U test, while categorical variables were analyzed using Fisher’s exact test. Receiver operating characteristic (ROC) curve analysis and visualization were conducted using the pROC (v1.18.0) and ggplot2 (v3.4.0) packages in R (v4.5.2). All statistical tests were two-sided, and a p-value < 0.05 was considered statistically significant. Multivariable analysis was not performed due to the limited sample size and the potential risk of model overfitting. Results Clinical Characteristics of the Patients As shown in Table 1 , among the 60 patients included in this study, 55 (91%) had ulcer-related perforations. A total of 40 patients (67%) underwent surgical management. One patient developed a perforation during endoscopic submucosal dissection (ESD); endoscopic closure was attempted but failed, as confirmed by CT the following day, and the patient subsequently underwent surgery. This case was also the only instance of endoscopic repair of duodenal perforation in our cohort. Twenty patients (33%) were managed with NOM. Regarding the anatomical location of perforation, 43 cases (72%) occurred in the first portion of the duodenum (D1), 14 (23%) in the second portion (D2), and 3 (5%) in the third portion (D3). No perforations in the fourth portion (D4) were identified in this study. Factors Associated with Severe Complications (Clavien-Dindo classification ≥ IV) Univariable analyses demonstrated that a wide range of factors across patient demographics and laboratory parameters were significantly associated with severe complications (Clavien–Dindo classification ≥ IV) ( Table 2 ). Advanced age, higher POMPP score, and female sex emerged as significant patient-related risk factors. Hypoalbuminemia, elevated D-dimer, urea, CRP, and creatinine levels, as well as lower hemoglobin, were also identified as significant laboratory risk factors, whereas CT findings showed no significant differences between groups. Notably, the Boey score—although commonly used in gastrointestinal perforation—showed no significant difference between the two groups in this study. In contrast, ROC analysis showed that the POMPP had measurable predictive ability for severe complications (Fig. 1 ) (AUC = 0.778, 95% CI 0.658–0.898; SE = 0.061; p < 0.001). The sensitivity and specificity for POMPP score exceeding 0 point were 88.0% and 65.7% respectively. Comparison of Clinical Characteristics and Outcomes Between NOM and Surgery Comparison of clinical characteristics and outcomes between the two groups (Table 3 ) showed no significant differences in demographics, clinical presentation, or laboratory parameters. CT findings demonstrated that extensive extraluminal air and suprapelvic fluid collections were detected more frequently in the surgical group than in the NOM group. No significant differences were observed in clinical outcomes between the two groups. However, the overall medical costs were significantly lower in the NOM group. Comparison of Clinical Characteristics and Outcomes Between D1 and D2/D3 Perforation Patients were divided into two groups according to the anatomical location of the duodenal perforation (Table 4 ). No significant differences in clinical characteristics were observed between the groups. Regarding clinical outcomes, the two groups did not differ significantly in the primary outcome (Clavien–Dindo classification ≥ IV). However, for secondary outcomes, the D2/D3 group had longer durations of somatostatin use, acid-suppression therapy, and antibiotic treatment, as well as a longer hospital stay. Representative cases Two representative cases are presented to illustrate the clinical course of duodenal perforation under different management strategies: Case 1 describes successful NOM of a D2 perforation in a 62-year-old man (POMPP score = 0) with a 10-year history of upper gastrointestinal ulcer disease, who remained clinically stable and recovered without severe complications (Fig. 2 ) . Case 2 illustrates delayed Stapfer type I perforation following ESD in a 64-year-old man (POMPP score = 0), in whom initial endoscopic closure failed and surgical repair was required (Fig. 3 ) . Both patients recovered uneventfully without ICU admission, 30-day readmission, or additional invasive procedures. Discussion Duodenal perforations arise from peptic ulceration, inflammation, neoplasia, trauma, foreign bodies, and iatrogenic causes. The condition is heterogeneous and potentially life-threatening, and no universally applicable treatment exists. Clinical decision-making therefore depends on a comprehensive assessment of patient risk, perforation characteristics, and disease progression( 1 , 11 , 26 ). Consistent with prior reports, we identified hypoalbuminemia, advanced age, female sex, anemia, elevated CRP, increased serum creatinine and urea, and coagulation disturbance as factors associated with severe complications (Clavien–Dindo classification ≥ IV)( 11 , 16 , 19 , 27 ). Notably, in this study, among coagulation parameters, only D-dimer—rather than PT—was associated with severe complications. In contrast, WBC count and hyperbilirubinemia were not associated with severe complications in our cohort. Severe sepsis–related immunosuppression and blunted inflammatory responses in older patients may explain the lack of WBC association( 28 ). Although bilirubin elevation may reflect sepsis or hepatic dysfunction, prognosis is primarily determined by control of the underlying insult, and transient cholestasis may not independently predict survival( 29 , 30 ). Among existing scoring systems, the ASA score is limited by its subjectivity and lack of specificity for gastrointestinal perforations, and the Peptic Ulcer Perforation (PULP) score is often difficult to apply due to its complexity. The Boey score is practical but its predictive performance has been inconsistent across studies. The World Society of Emergency Surgery (WSES) proposed the POMPP (Practical scoring system of mortality in patients with perforated peptic ulcer), claiming improved prognostic accuracy, although cohort-based validation remains limited( 5 ). In this study, the Boey score—which includes medical illness, preoperative shock, and perforation duration > 24 h—performed poorly. Several reasons may account for this: elderly patients might have reduced pain perception, retroperitoneal perforations may delay symptom onset, and the true onset time is often underestimated( 1 , 31 ). Additionally, the Boey score, developed more than 30 years ago, does not incorporate age, despite the increasing incidence of PPU complications in the population of advanced age due to prolonging mean lifetime and increased use of NSAIDs in the advanced ages. Moreover, the original Boey score predicts mortality, whereas our outcome measure was severe complications( 5 ). In contrast, the POMPP score demonstrated better performance. Its components—age > 65, albumin ≤ 1.5 g/dL, and BUN > 45 mg/dL (urea > 16.1 mmol/L)—are objective, independent on patient recall, and simple to apply. Despite its moderate specificity, the high sensitivity of the POMPP score may be clinically meaningful, as patients considered for NOM require careful risk stratification to avoid overlooking severe complications. In this setting, prioritizing sensitivity over specificity may be justified, given that false-positive results can be addressed through closer monitoring, whereas false-negative results may delay necessary surgical intervention. Nonetheless, risk assessment should not rely solely on POMPP, but should integrate clinical presentation and other risk factors. Regarding management, most studies and guidelines have grouped gastric and duodenal perforations as “upper gastrointestinal perforations.” However, differences in anatomical structure and intraluminal biochemistry support evaluating duodenal perforations separately( 21 , 22 ). Although NOM avoids operative trauma and postoperative complications, its indications remain controversial( 11 , 12 ). Since Croft et al.’s 1989 study, improvements in CT imaging, antibiotics, PPIs, and somatostatin have stimulated growing discussion regarding NOM in selected patients( 1 , 16 , 18 , 26 , 32 ). NOM is generally appropriate when the perforation is presumed sealed and risk is low, whereas unsealed perforations cause ongoing leakage and infection. Delayed surgery carries inherent risks and is conceptually inconsistent with NOM. For low-risk patients, surgery following failed NOM has a higher likelihood of success compared with high-risk patients( 11 , 12 ). Manifest clinical symptoms remain the primary indication for surgical intervention in duodenal perforation; however, they may appear late, particularly in retroperitoneal cases. With advances in CT imaging, CT has therefore become increasingly important for early detection and for informing clinical decision-making. Intestinal wall discontinuity on CT has the most direct diagnostic evidence but limited sensitivity and should be interpreted alongside clinical and laboratory findings( 1 , 26 , 32 , 33 ). In addition, although some studies have advocated the use of oral or rectal contrast agents before CT, the reported sensitivity of contrast extravasation is limited. Moreover, in patients with paralytic ileus, oral contrast administration may delay CT acquisition due to slow intestinal transit( 11 , 33 , 34 ). Therefore, oral contrast agents were not routinely administered in our institution. Notably, upper gastrointestinal contrast examination was performed in only one patient in this cohort, which corresponded to the representative Case 1 . This examination was conducted at a late stage of NOM to confirm complete closure of the perforation and to evaluate ulcer-related cicatricial stricture, rather than for initial diagnosis or treatment selection. In this study, the only significant differences between NOM and surgical groups were CT findings. Extensive extraluminal air was more common in the surgical group. According to WSES guidelines, pneumoperitoneum extent is independently associated with NOM failure. Extensive extraluminal air often correlates with unsealed perforations, larger defects, or longer duration, yet its assessment remains subjective and lacks standardized criteria( 11 , 33 ).Pelvic fluid was deliberately excluded when assessing CT fluid collections because small pelvic fluid volumes may be physiologic( 35 , 36 ). The absence of fluid above the pelvis may indicate spontaneous perforation sealing. We hypothesize that, in D1 perforations, small leaks may self-seal via fibrin deposition, omental coverage, or adherence beneath the liver, any minor leaked fluid tends to settle in the pelvis due to gravity( 37 ); for D2/D3 perforations (typically retroperitoneal, with leaked fluid not tracking into the pelvis), a rapidly self-sealed perforation may leave only minimal leaked fluid, which—because the retroperitoneal space contains loose adipose tissue—does not appear as a fluid collection on CT but only as fat stranding. Retroperitoneal fluid on CT likely reflects a larger leak, associated with retropancreatic infection requiring extensive retropancreatic drainage( 9 , 38 , 39 ).Previous studies support this interpretation. In a 2021 study, patients with NOM success had no upper-quadrant ascites( 19 ). In a 2022 study of retroperitoneal perforations, the single patient with a retroperitoneal abscess on CT had markedly poorer outcomes with NOM than those with covered perforations( 17 ). In our work, Case 1 was clinically stable with no extensive extraluminal air or fluid collections, supporting NOM and ultimately achieving success. Patient assessment should not rely solely on the initial evaluation. Even patients suitable for NOM require close monitoring of symptoms and laboratory dynamics. Repeat CT or emergent surgery should be performed when indicated. WSES “5R” principles provide a useful management framework( 11 ). In this study, NOM and surgical groups had comparable clinical characteristics except CT findings, and clinical outcomes did not differ. In patients with minimal symptoms, the absence of extensive extraluminal air or suprapelvic fluid collections may serve as an imaging criterion supporting NOM—particularly relevant in resource-limited settings. Our study also found that, with comparable clinical characteristics, patients with D2/D3 perforations had longer treatment durations and hospital stay. We hypothesize that this is firstly attributable to the looser retroperitoneal tissue and intercompartmental communications with lack of omental coverage at D2/D3, which make infection control more difficult; secondly, because pancreatic juice and bile jointly enter the lumen at the ampulla in D2, intraluminal digestive enzyme and bile exposure is greater at D2/D3, increasing local autodigestive injury and delaying healing; and thirdly, although operative rates were similar between groups, procedures addressing D2/D3 perforations were more complex and associated with greater surgical trauma( 17 , 39 , 40 ). However, severe complication rates did not differ, indicating perforation location alone may not reliably predict prognosis. The increasing incidence of endoscopy-related perforations warrants discussion. Most of these perforations occur in the D2/D3 region, and many are immediately recognized visually during the procedure( 7 , 41 , 42 ). Compared with postoperative leaks or ulcer-related perforations, the surrounding tissue in acute iatrogenic perforations is generally cleaner and healthier, facilitating endoscopic clip closure and subsequent healing( 43 ). The American Gastroenterological Association (AGA) reports that early type I perforations < 13 mm can be closed with clips with an 88–100% success rate. Type II perforations with asymptomatic retroperitoneal air may be managed with NOM, and a covered self-expanding metal stent (SEMS) across the ampulla can effectively seal the defect. However, clinicians should remain vigilant for retroperitoneal abscess or peritonitis; patients with worsening abdominal pain or systemic inflammatory response require prompt surgical intervention( 41 ). In this study, all four endoscopy-related perforations ultimately underwent surgery. One ERCP-related perforation required emergency conversion, while three others showed extensive air or retroperitoneal fluid on CT the following day. Case 2 exemplifies this: the perforation was < 13 mm and the predicted risk was low (POMPP score = 0), making initial endoscopic repair reasonable. However, due to a large mucosal defect, delayed perforation occurred. Fortunately, because the failure was identified promptly and surgery was performed, the outcome was acceptable. For type I perforations following ESD/EMR with extensive muscular exposure, treatment selection should be guided by overall patient risk and perforation characteristics. Endoscopic closure may be attempted in selected cases; however, technical difficulty or subsequent clinical or radiological deterioration should prompt early conversion to surgical management. Ongoing enzymatic injury to the exposed muscular layer may predispose patients to delayed perforation, underscoring the need for close monitoring and repeat CT when indicated. Findings such as free or retroperitoneal air or fluid are indicative of endoscopic treatment failure and warrant timely surgical intervention( 7 , 41 ). This study has limitations. It is retrospective, and some treatment details were unavailable. Some NOM perforations might have been excluded due to uncertain duodenal origin on imaging, which could have resulted in selection bias. Additionally, this is a single-center study with a small sample size, and only univariate analysis were performed. Larger multi-center studies are needed to refine management strategies. Conclusion The management of duodenal perforation should be individualized based on patient risk factors, perforation characteristics, and disease progression. Hypoalbuminemia, advanced age, female sex, anemia, and elevated C-reactive protein, creatinine, urea, and D-dimer levels are associated with a higher risk of severe complications. The POMPP shows promise as a reliable tool for identifying low-risk patients. Compared with D1 perforations, D2/D3 perforations require longer treatment durations. In clinically stable, low-risk patients, the absence of extensive extraluminal air or suprapelvic fluid collections on CT may support the selection of NOM. Abbreviations CT Computed tomography NOM Nonoperative management CRP C-reactive protein POMPP Practical scoring system of mortality in patients with perforated peptic ulcer PULP Peptic Ulcer Perforation WBC White blood cell Hb Hemoglobin PT Prothrombin time AST Aspartate aminotransferase PLT Platelet count PPIs Proton pump inhibitors NSAIDs Nonsteroidal anti-inflammatory drugs DSA Digital subtraction angiography ERCP Endoscopic Retrograde Cholangiopancreatography D1 First portion of the duodenum D2 Second portion of the duodenum D3 Third portion of the duodenum D4 Fourth portion of the duodenum ICU Intensive Care Unit AGA American Gastroenterological Association SEMS Self-expanding metal stent WSES World Society of Emergency Surgery ASA American Society of Anesthesiologists ESD Endoscopic Submucosal Dissection EMR Endoscopic Mucosal Resection TPN Total parenteral nutrition PPU Perforated peptic ulcer Declarations Ethics approval : This study was approved by the Medical Ethics Committee of the Second Affiliated Hospital of Nanjing Medical University (Approval No. 2025-KY-465-01). Consent to participate : The Authors state that informed consent was obtained from all subjects and/or their legal guardians. Clinical trial number not applicable. Consent for publication : Not applicable. Competing interests : The authors declare no competing interests. Funding: This work was supported by the Jiangsu Provincial “333 High-level Talents Training Project” (Grant No. BRA2020393). Author Contribution Jian Shen and Fei Zhou conceived and designed the study. Bingwen Liu, Mengyao Zou, and Xueming Yang collected and validated the data. Xiang Ma and Lijian Xu contributed to the preparation of Figures 1–3. Bingwen Liu performed the data analysis and drafted the manuscript. All authors critically revised the manuscript and approved the final version. Acknowledgements: Not applicable. 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Clinical outcomes of iatrogenic upper gastrointestinal endoscopic perforation: a 10-year study. BMC Gastroenterol. 2019;19(1):218. Tables Table 1. Clinical Characteristics and Outcomes of the Patients Variables Total (n=60) Demographics Age, years 64.00（26.75） Sex，male，n (%) 41（68%） Etiology of Perforation Ulcer, n (%) 55（91%） Post-ESD/ERCP, n (%) 4（7%） Foreign body(fish bone), n (%) 1（2%） Treatment Surgery, n (%) 40（67%） — Simple closure, n (%) 29（73%） — Gastric resection, n (%) 4（10%） — Other, n (%) 7（17%） Non-operative management（NOM）, n (%) 20（33%） Site of Perforation First part（D1）, n (%) 43（72%） Second part（D2）, n (%) 14（23%） Third part（D3）, n (%) 3（5%） Outcomes Days of total parenteral nutrition (TPN） 7.00（5.00） Days of nasogastric decompression 7.00（7.00） Days of somatostatin use 5.00（8.00） Days of acid-suppressive therapy 12.00（7.00） Duration of antibiotic therapy, days 11.00（9.00） Length of hospital stay, days 13.00（11.00） Severe complications (Clavien-Dindo classification ≥IV), n (%) 25（42%） Table 2. Factors Associated with Severe Complications (Clavien-Dindo classification ≥ IV) Variables Clavien-Dindo classification P-value ＜ IV（n=35） ≥ IV（n=25） Age, years 58.00（28.00） 76.00（24.00） 0.001 Prothrombin time (PT), s 13.70（3.10） 14.50（5.90） 0.615 D-dimer, mg/L, 1.66（2.20） 4.78（7.36） ＜ 0.001 Aspartate aminotransferase (AST), U/L 18.40（9.20） 18.50（6.00） 0.389 Urea, mmol/L 5.76（2.79） 10.10（12.10） 0.001 Albumin, g/L 42.90（6.80） 29.20（9.50） ＜ 0.001 Total bilirubin, μmol/L 11.20（4.90） 13.50（29.70） 0.152 Serum creatinine, μmol/L 75.00（30.60） 97.00（185.00） 0.030 White blood cell count (WBC), ×10⁹/L 11.68（5.04） 10.90（8.85） 0.928 Hemoglobin (Hb), g/L 138.00（39.00） 113.00（37.00） 0.030 Platelet count (PLT), ×10⁹/L 212.00（74.00） 196.00（122.00） 0.284 C-reactive protein (CRP), mg/L 3.98（90.81） 96.86（172.97） 0.001 POMPP score 0（1） 1（0） ＜ 0.001 Boey score 1（1） 1（1） 0.169 Sex, male, n (%) 28（80%） 13（52%） 0.027 Vomiting, n (%) 13（37%） 9（36%） 1.000 Underwent surgery, n (%) 22（63%） 18（72%） 0.581 Perforation site: First part（D1）, n (%) 23（66%） 20（80%） 0.260 Extensive extraluminal air, n (%) 21（60%） 16（64%） 1.000 Suprapelvic fluid collections, n (%) 17（49%） 16 (64%) 0.305 Table 3. Comparison of Clinical Characteristics and Outcomes Between NOM and Surgery Variables Treatment P-value Non-operative management（n=20） Surgery（n=38） Clinical Characteristics Age, years 67.50（29.00） 64.00（26.00） 0.386 Sex, male, n (%) 12（60%） 29（76%） 0.233 Prothrombin time (PT), s 14.40（2.30） 13.80（4.40） 0.647 D-dimer, mg/L 3.20（6.49） 2.40（4.19） 0.288 Aspartate aminotransferase (AST), U/L 18.40（11.50） 18.60（7.50） 0.896 Urea, mmol/L 5.76（8.36） 6.95（5.08） 0.395 Albumin, g/L 38.50（14.10） 39.30（12.98） 0.418 Total bilirubin, μmol/L 10.80（6.30） 13.25（12.50） 0.487 Serum creatinine, μmol/L 79.00（117.00） 79.80（42.30） 0.870 White blood cell count (WBC), ×10⁹/L 11.68（4.58） 11.19（7.80） 0.987 Hemoglobin (Hb), g/L 122.00（37.00） 130.50（48.00） 0.477 Platelet count (PLT), ×10⁹/L 201.00（76.00） 211.50（95.00） 0.390 C-reactive protein (CRP), mg/L 51.15（131.01） 18.72（112.03） 0.435 POMPP score 1.0（1.0） 0.5（1.0） 0.215 Boey score 1.0（1.0） 1.0（1.0） 0.666 Perforation site: First part（D1）, n (%) 14（70%） 29（76%） 0.754 Extensive extraluminal air, n (%) 7（35%） 29（76%） 0.004 Suprapelvic fluid collections, n (%) 6（30%） 26（68%） 0.007 Outcomes Days of total parenteral nutrition (TPN） 6.00（5.00） 7.00（5.00） 0.087 Days of nasogastric decompression 7.00（8.00） 7.00（7.00） 0.412 Days of somatostatin use 6.00（9.00） 4.00（8.00） 0.261 Days of acid-suppressive therapy 11.00（12.00） 11.50（6.00） 0.398 Duration of antibiotic therapy, days 10.00（11.00） 10.00（8.00） 0.600 Length of hospital stay, days 13.00（12.00） 13.00（10.00） 0.555 Clavien-Dindo classification ≥IV，n(%) 7（35%） 18（47%） 0.414 Other Total expenses（RMB） 20244.30（16114.98） 48757.05（52276.875） ＜ 0.001 Table 4. Comparison of Clinical Characteristics and Outcomes Between D1 and D2/D3 Perforation Variables Site of perforation P-value D1（n=43） D2/D3(n=17) Clinical Characteristics Age, years 66.00（31.00） 64.00（25.00） 0.321 Prothrombin time (PT), s 13.70（6.10） 14.30（2.90） 0.560 D-dimer, mg/L 2.49（2.84） 2.97（7.32） 0.762 Aspartate aminotransferase (AST), U/L 18.40（7.80） 20.40（7.90） 0.290 Urea, mmol/L 7.06（7.71） 5.90（3.02） 0.549 Albumin, g/L 38.50（11.60） 78.24（15.95） 0.922 Total bilirubin, μmol/L 11.00（8.30） 13.95（15.70） 0.234 Serum creatinine, μmol/L 80.00（63.00） 77.25（34.90） 0.806 White blood cell count (WBC), ×10⁹/L 11.47（7.71） 12.05（5.34） 0.889 Hemoglobin (Hb), g/L 129.00（49.00） 121.50（36.00） 0.676 Platelet count (PLT), ×10⁹/L 210.00（90.00） 198.00（95.00） 0.294 C-reactive protein (CRP), mg/L 18.89（133.24） 50.83（151.77） 0.669 POMPP score 1（1） 0（1） 0.086 Boey score 1（1） 1（1） 0.561 Sex, male, n (%) 31（72%） 10（59%） 0.365 Vomiting, n (%) 14（33%） 8（47%） 0.376 Underwent surgery, n (%) 29（67%） 11（65%） 1.000 Extensive extraluminal air, n (%) 26（60%） 11（65%） 0.763 Suprapelvic fluid collections, n (%) 24（59%） 9（53%） 1.000 Outcomes Days of total parenteral nutrition (TPN） 7.00（5.00） 6.00（6.00） 0.581 Days of nasogastric decompression 7.00（4.00） 10.50（13.00） 0.110 Days of somatostatin use 4.00（7.00） 8.50（12.00） 0.003 Days of acid-suppressive therapy 11.00（7.00） 14.50（9.00） 0.042 Duration of antibiotic therapy, days 10.00（8.00） 15.00（21.00） 0.004 Length of hospital stay, days 13.00（9.00） 20.50（23.00） 0.001 Clavien-Dindo classification≥IV，n(%) 20（47%） 5（29%） 0.260 Additional Declarations No competing interests reported. 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(\u003cstrong\u003eb\u003c/strong\u003e) shows the perforation following ESD. (\u003cstrong\u003ec\u003c/strong\u003e) shows extensive muscular layer exposure. (\u003cstrong\u003ed\u003c/strong\u003e) red arrow indicates discontinuity of the bowel wall; green arrow indicates extensive extraluminal air and titanium clips; yellow arrow indicates subcutaneous emphysema. (\u003cstrong\u003ee\u003c/strong\u003e) arrow indicates a retroperitoneal abscess. (\u003cstrong\u003ef\u003c/strong\u003e) arrow indicates a titanium clip.\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8668268/v1/f6a99c750887fd50400e0f11.jpg"},{"id":106726979,"identity":"9331ffae-5073-4b4d-8c40-9d5fa7563d4b","added_by":"auto","created_at":"2026-04-12 18:37:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2285011,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8668268/v1/e49f8a06-6a34-45c4-b856-0ea79455c7fb.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Risk stratification and nonoperative management of duodenal perforation: the role of the POMPP score and CT imaging in a retrospective cohort","fulltext":[{"header":"Background","content":"\u003cp\u003eDuodenal perforation is a life-threatening emergency with diverse etiologies, and its reported mortality ranges from 8% to 25%(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). With the widespread use of proton pump inhibitors (PPIs) and the successful eradication of \u003cem\u003eHelicobacter pylori\u003c/em\u003e, the incidence of ulcer-related duodenal perforation has declined(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). However, the increasing aging population and the growing use of nonsteroidal anti-inflammatory drugs (NSAIDs) and endoscopic interventions have contributed to greater complexity in the etiology and management of duodenal perforation(\u003cspan additionalcitationids=\"CR5 CR6 CR7 CR8 CR9\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGiven the high mortality associated with duodenal perforation, identifying relevant risk factors and establishing reliable risk prediction systems are crucial for recognizing high-risk patients and guiding clinical decision-making(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Previous studies have reported multiple risk factors for upper gastrointestinal perforation, and several scoring systems have been developed; however, their predictive performance and practicality remain controversial(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSurgery is traditionally the most common treatment for duodenal perforation, but operative management itself carries the risk of postoperative complications(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). In 1989, Croft et al. conducted a prospective randomized clinical trial demonstrating the feasibility of nonoperative management (NOM) for upper gastrointestinal perforation(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Since then, numerous retrospective studies and several guidelines have explored the indications for NOM(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Moreover, with advances in endoscopic techniques, the incidence of endoscopy-related perforations has increased, and endoscopic repair of duodenal perforation has been increasingly adopted in clinical practice(\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMost previous studies and guidelines comparing surgical management and NOM have examined gastric and duodenal perforations collectively as \u0026ldquo;upper gastrointestinal perforation,\u0026rdquo; whereas research focusing exclusively on duodenal perforation remains limited(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In addition, the duodenum consists of four anatomical segments, and differences in perforation characteristics across these segments warrant further investigation(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTherefore, this study aims to retrospectively analyze the risk factors, treatment strategies, and anatomical variations in duodenal perforation, supplemented by representative case analyses, to provide additional clinical evidence for optimizing management strategies in patients with duodenal perforation.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003eEthics Statements\u003c/h2\u003e\n\u003cp\u003eThis study was approved by the Medical Ethics Committee of the Second Affiliated Hospital of Nanjing Medical University (Approval No. 2025-KY-465-01).\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003ePatients\u003c/h3\u003e\n\u003cp\u003eThis study retrospectively reviewed 60 consecutive patients diagnosed with duodenal perforation at the Second Affiliated Hospital of Nanjing Medical University between January 2021 and May 2025. The diagnosis was confirmed by imaging, endoscopy, or intraoperative findings.\u003c/p\u003e\n\u003cp\u003eUsing a standardized data extraction form, we retrospectively collected comprehensive patient information, including demographic data, laboratory results, computed tomography (CT) findings, and treatment-related variables. Each patient was assessed for risk stratification using both the POMPP (Practical scoring system of mortality in patients with perforated peptic ulcer) and Boey scoring systems(\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e). Severe complications were defined as those classified as Clavien\u0026ndash;Dindo classification\u0026thinsp;\u0026ge;\u0026thinsp;IV, including life-threatening events requiring ICU management or resulting in death(\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e). Extensive extraluminal air was defined as either an extensive distribution of free air or extensive mottled extraluminal air bubbles. Suprapelvic fluid collections was defined as intraperitoneal or retroperitoneal fluid accumulation, excluding pelvic fluid. CT images were independently reviewed by two experienced radiologists who were blinded to clinical outcomes.\u003c/p\u003e\n\u003cp\u003eIn this study, NOM included nil by mouth, intravenous hydration, parenteral nutrition, nasogastric decompression, somatostatin and acid-suppressive therapy, and intravenous antibiotics. In addition, one patient underwent placement of a nasojejunal feeding tube under digital subtraction angiography (DSA), and one patient received endoscopic closure, which eventually failed.\u003c/p\u003e\n\u003cp\u003eWhen comparing operative and nonoperative management, we attempted to identify differences in the patients\u0026rsquo; clinical characteristics at admission in order to explore the general conditions under which nonoperative treatment may be selected. However, two patients\u0026mdash;one who developed a perforation due to failed ERCP stone extraction and required emergency surgery, and another with a fish bone penetrating the anterior wall of the third portion of the duodenum\u0026mdash;were considered unavoidable surgical cases and were excluded from the comparative analysis of treatment modalities to avoid confounding by indication(\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e). A total of 58 patients were ultimately included in the comparison of treatment modalities (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ch3\u003eStudy Outcomes\u003c/h3\u003e\n\u003cp\u003eWhen analyzing different treatment modalities and perforation locations, we defined severe complications (Clavien\u0026ndash;Dindo classification\u0026thinsp;\u0026ge;\u0026thinsp;IV) as the primary outcome. Secondary outcomes were the duration (in days) of the following: total parenteral nutrition, nasogastric decompression, somatostatin use, acid-suppressive therapy, and antibiotic therapy, as well as the total length of hospital stay.\u003c/p\u003e\n\u003ch3\u003eInclusion and exclusion criteria\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e) confirmed diagnosis of duodenal perforation;(\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e) availability of complete medical records;(\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e) age\u0026thinsp;\u0026ge;\u0026thinsp;18 years.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e) unclear perforation site;(\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e) incomplete clinical data;(\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e) perforation secondary to malignant disease.\u003c/p\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n\u003ch2\u003eStatistical analysis\u003c/h2\u003e\n\u003cp\u003eData were imported into Microsoft Excel for data management. Continuous variables are presented as median with interquartile range (IQR), and categorical variables as counts and percentages. Statistical analyses were performed using SPSS software (IBM Corp., version 27.0). Continuous variables and ordinal variables between groups were compared using the Mann\u0026ndash;Whitney U test, while categorical variables were analyzed using Fisher\u0026rsquo;s exact test.\u003c/p\u003e\n\u003cp\u003eReceiver operating characteristic (ROC) curve analysis and visualization were conducted using the pROC (v1.18.0) and ggplot2 (v3.4.0) packages in R (v4.5.2). All statistical tests were two-sided, and a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. Multivariable analysis was not performed due to the limited sample size and the potential risk of model overfitting.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n\u003ch2\u003eClinical Characteristics of the Patients\u003c/h2\u003e\n\u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e, among the 60 patients included in this study, 55 (91%) had ulcer-related perforations. A total of 40 patients (67%) underwent surgical management. One patient developed a perforation during endoscopic submucosal dissection (ESD); endoscopic closure was attempted but failed, as confirmed by CT the following day, and the patient subsequently underwent surgery. This case was also the only instance of endoscopic repair of duodenal perforation in our cohort. Twenty patients (33%) were managed with NOM. Regarding the anatomical location of perforation, 43 cases (72%) occurred in the first portion of the duodenum (D1), 14 (23%) in the second portion (D2), and 3 (5%) in the third portion (D3). No perforations in the fourth portion (D4) were identified in this study.\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eFactors Associated with Severe Complications (Clavien-Dindo classification\u0026thinsp;\u0026ge;\u0026thinsp;IV)\u003c/h3\u003e\n\u003cp\u003eUnivariable analyses demonstrated that a wide range of factors across patient demographics and laboratory parameters were significantly associated with severe complications (Clavien\u0026ndash;Dindo classification\u0026thinsp;\u0026ge;\u0026thinsp;IV) (\u003cstrong\u003eTable\u0026nbsp;2\u003c/strong\u003e). Advanced age, higher POMPP score, and female sex emerged as significant patient-related risk factors. Hypoalbuminemia, elevated D-dimer, urea, CRP, and creatinine levels, as well as lower hemoglobin, were also identified as significant laboratory risk factors, whereas CT findings showed no significant differences between groups.\u003c/p\u003e\n\u003cp\u003eNotably, the Boey score\u0026mdash;although commonly used in gastrointestinal perforation\u0026mdash;showed no significant difference between the two groups in this study. In contrast, ROC analysis showed that the POMPP had measurable predictive ability for severe complications (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e) (AUC\u0026thinsp;=\u0026thinsp;0.778, 95% CI 0.658\u0026ndash;0.898; SE\u0026thinsp;=\u0026thinsp;0.061; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The sensitivity and specificity for POMPP score exceeding 0 point were 88.0% and 65.7% respectively.\u003c/p\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n\u003ch2\u003eComparison of Clinical Characteristics and Outcomes Between NOM and Surgery\u003c/h2\u003e\n\u003cp\u003eComparison of clinical characteristics and outcomes between the two groups (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e) showed no significant differences in demographics, clinical presentation, or laboratory parameters. CT findings demonstrated that extensive extraluminal air and suprapelvic fluid collections were detected more frequently in the surgical group than in the NOM group. No significant differences were observed in clinical outcomes between the two groups. However, the overall medical costs were significantly lower in the NOM group.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n\u003ch2\u003eComparison of Clinical Characteristics and Outcomes Between D1 and D2/D3 Perforation\u003c/h2\u003e\n\u003cp\u003ePatients were divided into two groups according to the anatomical location of the duodenal perforation (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). No significant differences in clinical characteristics were observed between the groups. Regarding clinical outcomes, the two groups did not differ significantly in the primary outcome (Clavien\u0026ndash;Dindo classification\u0026thinsp;\u0026ge;\u0026thinsp;IV). However, for secondary outcomes, the D2/D3 group had longer durations of somatostatin use, acid-suppression therapy, and antibiotic treatment, as well as a longer hospital stay.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n\u003ch2\u003eRepresentative cases\u003c/h2\u003e\n\u003cp\u003eTwo representative cases are presented to illustrate the clinical course of duodenal perforation under different management strategies:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase 1\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003edescribes successful NOM of a D2 perforation in a 62-year-old man (POMPP score\u0026thinsp;=\u0026thinsp;0) with a 10-year history of upper gastrointestinal ulcer disease, who remained clinically stable and recovered without severe complications (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e. \u003cstrong\u003eCase\u003c/strong\u003e \u003cspan class=\"InternalRef\"\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/span\u003e illustrates delayed Stapfer type I perforation following ESD in a 64-year-old man (POMPP score\u0026thinsp;=\u0026thinsp;0), in whom initial endoscopic closure failed and surgical repair was required (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e. Both patients recovered uneventfully without ICU admission, 30-day readmission, or additional invasive procedures.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eDuodenal perforations arise from peptic ulceration, inflammation, neoplasia, trauma, foreign bodies, and iatrogenic causes. The condition is heterogeneous and potentially life-threatening, and no universally applicable treatment exists. Clinical decision-making therefore depends on a comprehensive assessment of patient risk, perforation characteristics, and disease progression(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eConsistent with prior reports, we identified hypoalbuminemia, advanced age, female sex, anemia, elevated CRP, increased serum creatinine and urea, and coagulation disturbance as factors associated with severe complications (Clavien\u0026ndash;Dindo classification\u0026thinsp;\u0026ge;\u0026thinsp;IV)(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Notably, in this study, among coagulation parameters, only D-dimer\u0026mdash;rather than PT\u0026mdash;was associated with severe complications. In contrast, WBC count and hyperbilirubinemia were not associated with severe complications in our cohort. Severe sepsis\u0026ndash;related immunosuppression and blunted inflammatory responses in older patients may explain the lack of WBC association(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Although bilirubin elevation may reflect sepsis or hepatic dysfunction, prognosis is primarily determined by control of the underlying insult, and transient cholestasis may not independently predict survival(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAmong existing scoring systems, the ASA score is limited by its subjectivity and lack of specificity for gastrointestinal perforations, and the Peptic Ulcer Perforation (PULP) score is often difficult to apply due to its complexity. The Boey score is practical but its predictive performance has been inconsistent across studies. The World Society of Emergency Surgery (WSES) proposed the POMPP (Practical scoring system of mortality in patients with perforated peptic ulcer), claiming improved prognostic accuracy, although cohort-based validation remains limited(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In this study, the Boey score\u0026mdash;which includes medical illness, preoperative shock, and perforation duration\u0026thinsp;\u0026gt;\u0026thinsp;24 h\u0026mdash;performed poorly. Several reasons may account for this: elderly patients might have reduced pain perception, retroperitoneal perforations may delay symptom onset, and the true onset time is often underestimated(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Additionally, the Boey score, developed more than 30 years ago, does not incorporate age, despite the increasing incidence of PPU complications in the population of advanced age due to prolonging mean lifetime and increased use of NSAIDs in the advanced ages. Moreover, the original Boey score predicts mortality, whereas our outcome measure was severe complications(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn contrast, the POMPP score demonstrated better performance. Its components\u0026mdash;age\u0026thinsp;\u0026gt;\u0026thinsp;65, albumin\u0026thinsp;\u0026le;\u0026thinsp;1.5 g/dL, and BUN\u0026thinsp;\u0026gt;\u0026thinsp;45 mg/dL (urea\u0026thinsp;\u0026gt;\u0026thinsp;16.1 mmol/L)\u0026mdash;are objective, independent on patient recall, and simple to apply. Despite its moderate specificity, the high sensitivity of the POMPP score may be clinically meaningful, as patients considered for NOM require careful risk stratification to avoid overlooking severe complications. In this setting, prioritizing sensitivity over specificity may be justified, given that false-positive results can be addressed through closer monitoring, whereas false-negative results may delay necessary surgical intervention. Nonetheless, risk assessment should not rely solely on POMPP, but should integrate clinical presentation and other risk factors.\u003c/p\u003e \u003cp\u003eRegarding management, most studies and guidelines have grouped gastric and duodenal perforations as \u0026ldquo;upper gastrointestinal perforations.\u0026rdquo; However, differences in anatomical structure and intraluminal biochemistry support evaluating duodenal perforations separately(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Although NOM avoids operative trauma and postoperative complications, its indications remain controversial(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Since Croft et al.\u0026rsquo;s 1989 study, improvements in CT imaging, antibiotics, PPIs, and somatostatin have stimulated growing discussion regarding NOM in selected patients(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNOM is generally appropriate when the perforation is presumed sealed and risk is low, whereas unsealed perforations cause ongoing leakage and infection. Delayed surgery carries inherent risks and is conceptually inconsistent with NOM. For low-risk patients, surgery following failed NOM has a higher likelihood of success compared with high-risk patients(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Manifest clinical symptoms remain the primary indication for surgical intervention in duodenal perforation; however, they may appear late, particularly in retroperitoneal cases. With advances in CT imaging, CT has therefore become increasingly important for early detection and for informing clinical decision-making. Intestinal wall discontinuity on CT has the most direct diagnostic evidence but limited sensitivity and should be interpreted alongside clinical and laboratory findings(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). In addition, although some studies have advocated the use of oral or rectal contrast agents before CT, the reported sensitivity of contrast extravasation is limited. Moreover, in patients with paralytic ileus, oral contrast administration may delay CT acquisition due to slow intestinal transit(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Therefore, oral contrast agents were not routinely administered in our institution. Notably, upper gastrointestinal contrast examination was performed in only one patient in this cohort, which corresponded to the representative \u003cb\u003eCase\u003c/b\u003e\u003cspan refid=\"FPar3\" class=\"InternalRef\"\u003e\u003cb\u003e1\u003c/b\u003e\u003c/span\u003e. This examination was conducted at a late stage of NOM to confirm complete closure of the perforation and to evaluate ulcer-related cicatricial stricture, rather than for initial diagnosis or treatment selection.\u003c/p\u003e \u003cp\u003eIn this study, the only significant differences between NOM and surgical groups were CT findings. Extensive extraluminal air was more common in the surgical group. According to WSES guidelines, pneumoperitoneum extent is independently associated with NOM failure. Extensive extraluminal air often correlates with unsealed perforations, larger defects, or longer duration, yet its assessment remains subjective and lacks standardized criteria(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).Pelvic fluid was deliberately excluded when assessing CT fluid collections because small pelvic fluid volumes may be physiologic(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). The absence of fluid above the pelvis may indicate spontaneous perforation sealing. We hypothesize that, in D1 perforations, small leaks may self-seal via fibrin deposition, omental coverage, or adherence beneath the liver, any minor leaked fluid tends to settle in the pelvis due to gravity(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e); for D2/D3 perforations (typically retroperitoneal, with leaked fluid not tracking into the pelvis), a rapidly self-sealed perforation may leave only minimal leaked fluid, which\u0026mdash;because the retroperitoneal space contains loose adipose tissue\u0026mdash;does not appear as a fluid collection on CT but only as fat stranding. Retroperitoneal fluid on CT likely reflects a larger leak, associated with retropancreatic infection requiring extensive retropancreatic drainage(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e).Previous studies support this interpretation. In a 2021 study, patients with NOM success had no upper-quadrant ascites(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In a 2022 study of retroperitoneal perforations, the single patient with a retroperitoneal abscess on CT had markedly poorer outcomes with NOM than those with covered perforations(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). In our work, \u003cb\u003eCase\u003c/b\u003e\u003cspan refid=\"FPar3\" class=\"InternalRef\"\u003e\u003cb\u003e1\u003c/b\u003e\u003c/span\u003e was clinically stable with no extensive extraluminal air or fluid collections, supporting NOM and ultimately achieving success.\u003c/p\u003e \u003cp\u003ePatient assessment should not rely solely on the initial evaluation. Even patients suitable for NOM require close monitoring of symptoms and laboratory dynamics. Repeat CT or emergent surgery should be performed when indicated. WSES \u0026ldquo;5R\u0026rdquo; principles provide a useful management framework(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn this study, NOM and surgical groups had comparable clinical characteristics except CT findings, and clinical outcomes did not differ. In patients with minimal symptoms, the absence of extensive extraluminal air or suprapelvic fluid collections may serve as an imaging criterion supporting NOM\u0026mdash;particularly relevant in resource-limited settings.\u003c/p\u003e \u003cp\u003eOur study also found that, with comparable clinical characteristics, patients with D2/D3 perforations had longer treatment durations and hospital stay. We hypothesize that this is firstly attributable to the looser retroperitoneal tissue and intercompartmental communications with lack of omental coverage at D2/D3, which make infection control more difficult; secondly, because pancreatic juice and bile jointly enter the lumen at the ampulla in D2, intraluminal digestive enzyme and bile exposure is greater at D2/D3, increasing local autodigestive injury and delaying healing; and thirdly, although operative rates were similar between groups, procedures addressing D2/D3 perforations were more complex and associated with greater surgical trauma(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). However, severe complication rates did not differ, indicating perforation location alone may not reliably predict prognosis.\u003c/p\u003e \u003cp\u003eThe increasing incidence of endoscopy-related perforations warrants discussion. Most of these perforations occur in the D2/D3 region, and many are immediately recognized visually during the procedure(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Compared with postoperative leaks or ulcer-related perforations, the surrounding tissue in acute iatrogenic perforations is generally cleaner and healthier, facilitating endoscopic clip closure and subsequent healing(\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). The American Gastroenterological Association (AGA) reports that early type I perforations\u0026thinsp;\u0026lt;\u0026thinsp;13 mm can be closed with clips with an 88\u0026ndash;100% success rate. Type II perforations with asymptomatic retroperitoneal air may be managed with NOM, and a covered self-expanding metal stent (SEMS) across the ampulla can effectively seal the defect. However, clinicians should remain vigilant for retroperitoneal abscess or peritonitis; patients with worsening abdominal pain or systemic inflammatory response require prompt surgical intervention(\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn this study, all four endoscopy-related perforations ultimately underwent surgery. One ERCP-related perforation required emergency conversion, while three others showed extensive air or retroperitoneal fluid on CT the following day.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCase 2\u003c/strong\u003e \u003cp\u003eexemplifies this: the perforation was \u0026lt;\u0026thinsp;13 mm and the predicted risk was low (POMPP score\u0026thinsp;=\u0026thinsp;0), making initial endoscopic repair reasonable. However, due to a large mucosal defect, delayed perforation occurred. Fortunately, because the failure was identified promptly and surgery was performed, the outcome was acceptable.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eFor type I perforations following ESD/EMR with extensive muscular exposure, treatment selection should be guided by overall patient risk and perforation characteristics. Endoscopic closure may be attempted in selected cases; however, technical difficulty or subsequent clinical or radiological deterioration should prompt early conversion to surgical management. Ongoing enzymatic injury to the exposed muscular layer may predispose patients to delayed perforation, underscoring the need for close monitoring and repeat CT when indicated. Findings such as free or retroperitoneal air or fluid are indicative of endoscopic treatment failure and warrant timely surgical intervention(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study has limitations. It is retrospective, and some treatment details were unavailable. Some NOM perforations might have been excluded due to uncertain duodenal origin on imaging, which could have resulted in selection bias. Additionally, this is a single-center study with a small sample size, and only univariate analysis were performed. Larger multi-center studies are needed to refine management strategies.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe management of duodenal perforation should be individualized based on patient risk factors, perforation characteristics, and disease progression. Hypoalbuminemia, advanced age, female sex, anemia, and elevated C-reactive protein, creatinine, urea, and D-dimer levels are associated with a higher risk of severe complications. The POMPP shows promise as a reliable tool for identifying low-risk patients. Compared with D1 perforations, D2/D3 perforations require longer treatment durations. In clinically stable, low-risk patients, the absence of extensive extraluminal air or suprapelvic fluid collections on CT may support the selection of NOM.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCT Computed tomography\u003c/p\u003e\u003cp\u003eNOM Nonoperative management\u003c/p\u003e\u003cp\u003eCRP C-reactive protein\u003c/p\u003e\u003cp\u003ePOMPP Practical scoring system of mortality in patients with perforated peptic ulcer\u003c/p\u003e\u003cp\u003ePULP Peptic Ulcer Perforation\u003c/p\u003e\u003cp\u003eWBC White blood cell\u003c/p\u003e\u003cp\u003eHb Hemoglobin\u003c/p\u003e\u003cp\u003ePT Prothrombin time\u003c/p\u003e\u003cp\u003eAST Aspartate aminotransferase\u003c/p\u003e\u003cp\u003ePLT Platelet count\u003c/p\u003e\u003cp\u003ePPIs Proton pump inhibitors\u003c/p\u003e\u003cp\u003eNSAIDs Nonsteroidal anti-inflammatory drugs\u003c/p\u003e\u003cp\u003eDSA Digital subtraction angiography\u003c/p\u003e\u003cp\u003eERCP Endoscopic Retrograde Cholangiopancreatography\u003c/p\u003e\u003cp\u003eD1 First portion of the duodenum\u003c/p\u003e\u003cp\u003eD2 Second portion of the duodenum\u003c/p\u003e\u003cp\u003eD3 Third portion of the duodenum\u003c/p\u003e\u003cp\u003eD4 Fourth portion of the duodenum\u003c/p\u003e\u003cp\u003eICU Intensive Care Unit\u003c/p\u003e\u003cp\u003eAGA American Gastroenterological Association\u003c/p\u003e\u003cp\u003eSEMS Self-expanding metal stent\u003c/p\u003e\u003cp\u003eWSES World Society of Emergency Surgery\u003c/p\u003e\u003cp\u003eASA American Society of Anesthesiologists\u003c/p\u003e\u003cp\u003eESD Endoscopic Submucosal Dissection\u003c/p\u003e\u003cp\u003eEMR Endoscopic Mucosal Resection\u003c/p\u003e\u003cp\u003eTPN Total parenteral nutrition\u003c/p\u003e\u003cp\u003ePPU Perforated peptic ulcer\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003e \u003cb\u003eEthics approval\u003c/b\u003e:\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eThis study was approved by the Medical Ethics Committee of the Second Affiliated Hospital of Nanjing Medical University (Approval No. 2025-KY-465-01).\u003c/p\u003e \u003cp\u003e\u003c/p\u003e \u003cp\u003e \u003cstrong\u003e \u003cb\u003eConsent to participate\u003c/b\u003e:\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eThe Authors state that informed consent was obtained from all subjects and/or their legal guardians.\u003c/p\u003e \u003cp\u003e\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eClinical trial number\u003c/strong\u003e \u003c/p\u003e\u003cp\u003enot applicable.\u003c/p\u003e \u003cp\u003e\u003c/p\u003e \u003cp\u003e \u003cstrong\u003e \u003cb\u003eConsent for publication\u003c/b\u003e:\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eNot applicable.\u003c/p\u003e \u003cp\u003e\u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003ch2\u003e \u003cb\u003eCompeting interests\u003c/b\u003e:\u003c/h2\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003cp\u003e\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis work was supported by the Jiangsu Provincial “333 High-level Talents Training Project” (Grant No. BRA2020393).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJian Shen and Fei Zhou conceived and designed the study. Bingwen Liu, Mengyao Zou, and Xueming Yang collected and validated the data. Xiang Ma and Lijian Xu contributed to the preparation of Figures 1–3. Bingwen Liu performed the data analysis and drafted the manuscript. All authors critically revised the manuscript and approved the final version.\u003c/p\u003e\u003ch2\u003eAcknowledgements:\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analyzed during the current study are not publicly available due to patient privacy and ethical restrictions, but are available from the corresponding author, Jian Shen, on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAnsari D, Tor\u0026eacute;n W, Lindberg S, Pyrh\u0026ouml;nen HS, Andersson R. Diagnosis and management of duodenal perforations: a narrative review. Scand J Gastroenterol. 2019;54(8):939\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMalmi H, Kautiainen H, Virta LJ, F\u0026auml;rkkil\u0026auml; N, Koskenpato J, F\u0026auml;rkkil\u0026auml; MA. Incidence and complications of peptic ulcer disease requiring hospitalisation have markedly decreased in Finland. Aliment Pharmacol Ther. 2014;39(5):496\u0026ndash;506.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXie X, Ren K, Zhou Z, Dang C, Zhang H. The global, regional and national burden of peptic ulcer disease from 1990 to 2019: a population-based study. BMC Gastroenterol. 2022;22(1):58.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eS\u0026oslash;reide K, Thorsen K, Harrison EM, Bingener J, M\u0026oslash;ller MH, Ohene-Yeboah M, et al. Perforated peptic ulcer. Lancet (London England). 2015;386(10000):1288\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMenekse E, Kocer B, Topcu R, Olmez A, Tez M, Kayaalp C. A practical scoring system to predict mortality in patients with perforated peptic ulcer. World J Emerg surgery: WJES. 2015;10:7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChevallay M, Lorenz F, Bichard P, Frossard JL, Schmidt T, Goeser T, et al. Outcome of endoscopic vacuum therapy for duodenal perforation. Surg Endosc. 2023;37(3):1846\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChenevas-Paule Q, Palen A, Giovannini M, Ewald J, Ratone JP, Caillol F, et al. Stapfer I and II duodenal perforations after endoscopic procedures: how surgical delay impacts outcomes. Surg Endosc. 2024;38(11):6614\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu C, Deng S, Chen Z, Tang H. Successful intervention of an impacted basket and duodenal perforation secondary to endoscopic retrograde cholangiopancreatography. Asian J Surg. 2023;46(10):4513\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiao YS, Li YY, Cheng BW, Zhan YF, Zeng S, Zhou XJ, et al. Clinical analysis of 45 cases of perforation were identified during endoscopic retrograde cholangiopancreatography procedure. Front Med. 2022;9:1039954.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStapfer M, Selby RR, Stain SC, Katkhouda N, Parekh D, Jabbour N, et al. Management of duodenal perforation after endoscopic retrograde cholangiopancreatography and sphincterotomy. Ann Surg. 2000;232(2):191\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTarasconi A, Coccolini F, Biffl WL, Tomasoni M, Ansaloni L, Picetti E, et al. Perforated and bleeding peptic ulcer: WSES guidelines. World J Emerg surgery: WJES. 2020;15:3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSatoh K, Yoshino J, Akamatsu T, Itoh T, Kato M, Kamada T, et al. Evidence-based clinical practice guidelines for peptic ulcer disease 2015. J Gastroenterol. 2016;51(3):177\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu J, Zhou S, Wang S, Xue X. Analysis of risk factors for duodenal leak after repair of a duodenal perforation. BMC Surg. 2023;23(1):116.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThorsen K, S\u0026oslash;reide JA, S\u0026oslash;reide K. What is the best predictor of mortality in perforated peptic ulcer disease? A population-based, multivariable regression analysis including three clinical scoring systems. J Gastrointest surgery: official J Soc Surg Aliment Tract. 2014;18(7):1261\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSivaram P, Sreekumar A. 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N Engl J Med. 1989;320(15):970\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSugase T, Michiura T, Urabe S, Sasaki K, Hayashi N, Yamabe K. Optimal treatment and complications of patients with the perforated upper gastrointestinal tract. Surg Today. 2021;51(9):1446\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDonovan AJ, Berne TV, Donovan JA. Perforated duodenal ulcer: an alternative therapeutic plan. Archives of surgery (Chicago, Ill: 1960). 1998;133(11):1166-71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAndroulakis J, Colborn GL, Skandalakis PN, Skandalakis LJ, Skandalakis JE. Embryologic and anatomic basis of duodenal surgery. Surg Clin North Am. 2000;80(1):171\u0026ndash;99.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNyumura Y, Tsuboi K, Suzuki T, Kajimoto T, Tanishima Y, Yano F, et al. Pathophysiology and surgical outcomes of patients with fungal peritonitis from upper gastrointestinal tract perforation: a retrospective study. Surg Today. 2024;54(11):1345\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoey J, Choi SK, Poon A, Alagaratnam TT. Risk stratification in perforated duodenal ulcers. A prospective validation of predictive factors. Ann Surg. 1987;205(1):22\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250(2):187\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang R, He J, Chen Z, Wen K. Migration of fish bones into abdominal para-aortic tissue from the duodenum after leading to duodenal perforation: a case report. BMC Gastroenterol. 2021;21(1):82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShin D, Rahimi H, Haroon S, Merritt A, Vemula A, Noronha A, et al. Imaging of Gastrointestinal Tract Perforation. Radiol Clin North Am. 2020;58(1):19\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEnns R, Eloubeidi MA, Mergener K, Jowell PS, Branch MS, Pappas TM, et al. ERCP-related perforations: risk factors and management. Endoscopy. 2002;34(4):293\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHotchkiss RS, Monneret G, Payen D. Sepsis-induced immunosuppression: from cellular dysfunctions to immunotherapy. Nat Rev Immunol. 2013;13(12):862\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChand N, Sanyal AJ. Sepsis-induced cholestasis. Hepatology (Baltimore MD). 2007;45(1):230\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang D, Yin Y, Yao Y. Advances in sepsis-associated liver dysfunction. Burns trauma. 2014;2(3):97\u0026ndash;105.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRagsdale L, Southerland L. Acute abdominal pain in the older adult. Emerg Med Clin North Am. 2011;29(2):429\u0026ndash;48. x.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCelik H, Kamar MA, Altay C, Basara Akin I, Secil M. Accuracy of specific free air distributions in predicting the localization of gastrointestinal perforations. Emerg Radiol. 2022;29(1):99\u0026ndash;105.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim HC, Yang DM, Kim SW, Park SJ. Gastrointestinal tract perforation: evaluation of MDCT according to perforation site and elapsed time. Eur Radiol. 2014;24(6):1386\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBecker CD, Mentha G, Terrier F. Blunt abdominal trauma in adults: role of CT in the diagnosis and management of visceral injuries. Part 1: liver and spleen. Eur Radiol. 1998;8(4):553\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavis JA, Gosink BB. Fluid in the female pelvis: cyclic patterns. J ultrasound medicine: official J Am Inst Ultrasound Med. 1986;5(2):75\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrown SE, Dubbins PA. Detection of free intraperitoneal fluid in healthy young men. J ultrasound medicine: official J Am Inst Ultrasound Med. 2012;31(10):1527\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDonovan AJ, Vinson TL, Maulsby GO, Gewin JR. Selective treatment of duodenal ulcer with perforation. Ann Surg. 1979;189(5):627\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePerchoc A, Le Gall G, Malgras B. Biliary peritonitis after endoscopic retrograde cholangiopancreatography. J Visc Surg. 2021;158(6):532\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDodds WJ, Darweesh RM, Lawson TL, Stewart ET, Foley WD, Kishk SM, et al. The retroperitoneal spaces revisited. AJR Am J Roentgenol. 1986;147(6):1155\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeyers MA. Radiological features of the spread and localization of extraperitoneal gas and their relationship to its source. An anatomical approach. Radiology. 1974;111(1):17\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee JH, Kedia P, Stavropoulos SN, Carr-Locke D. AGA Clinical Practice Update on Endoscopic Management of Perforations in Gastrointestinal Tract: Expert Review. Clin Gastroenterol hepatology: official Clin Pract J Am Gastroenterological Association. 2021;19(11):2252\u0026ndash;e612.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFujihara S, Mori H, Kobara H, Nishiyama N, Matsunaga T, Ayaki M, et al. Management of a large mucosal defect after duodenal endoscopic resection. World J Gastroenterol. 2016;22(29):6595\u0026ndash;609.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKang DH, Ryu DG, Choi CW, Kim HW, Park SB, Kim SJ, et al. Clinical outcomes of iatrogenic upper gastrointestinal endoscopic perforation: a 10-year study. BMC Gastroenterol. 2019;19(1):218.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"672\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1. Clinical Characteristics and Outcomes of the Patients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.381%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.619%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal (n=60)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.381%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDemographics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.619%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.381%;\"\u003e\n \u003cp\u003eAge, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.619%;\"\u003e\n \u003cp\u003e64.00（26.75）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.381%;\"\u003e\n \u003cp\u003eSex，male，n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.619%;\"\u003e\n \u003cp\u003e41（68%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.381%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEtiology of Perforation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.619%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.381%;\"\u003e\n \u003cp\u003eUlcer, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.619%;\"\u003e\n \u003cp\u003e55（91%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.381%;\"\u003e\n \u003cp\u003ePost-ESD/ERCP, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.619%;\"\u003e\n \u003cp\u003e4（7%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.381%;\"\u003e\n \u003cp\u003eForeign body(fish bone), n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.619%;\"\u003e\n \u003cp\u003e1（2%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.381%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTreatment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.619%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.381%;\"\u003e\n \u003cp\u003eSurgery, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.619%;\"\u003e\n \u003cp\u003e40（67%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.381%;\"\u003e\n \u003cp\u003e\u0026emsp;\u0026mdash; Simple closure, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.619%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;29（73%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.381%;\"\u003e\n \u003cp\u003e\u0026emsp;\u0026mdash; Gastric resection, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.619%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;4（10%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.381%;\"\u003e\n \u003cp\u003e\u0026emsp;\u0026mdash; Other, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.619%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;7（17%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.381%;\"\u003e\n \u003cp\u003eNon-operative management（NOM）, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.619%;\"\u003e\n \u003cp\u003e20（33%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.381%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSite of Perforation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.619%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.381%;\"\u003e\n \u003cp\u003eFirst part（D1）, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.619%;\"\u003e\n \u003cp\u003e43（72%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.381%;\"\u003e\n \u003cp\u003eSecond part（D2）, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.619%;\"\u003e\n \u003cp\u003e14（23%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.381%;\"\u003e\n \u003cp\u003eThird part（D3）, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.619%;\"\u003e\n \u003cp\u003e3（5%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.381%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.619%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.381%;\"\u003e\n \u003cp\u003eDays of total parenteral nutrition (TPN）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.619%;\"\u003e\n \u003cp\u003e7.00（5.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.381%;\"\u003e\n \u003cp\u003eDays of nasogastric decompression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.619%;\"\u003e\n \u003cp\u003e7.00（7.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.381%;\"\u003e\n \u003cp\u003eDays of somatostatin use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.619%;\"\u003e\n \u003cp\u003e5.00（8.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.381%;\"\u003e\n \u003cp\u003eDays of acid-suppressive therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.619%;\"\u003e\n \u003cp\u003e12.00（7.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.381%;\"\u003e\n \u003cp\u003eDuration of antibiotic therapy, days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.619%;\"\u003e\n \u003cp\u003e11.00（9.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.381%;\"\u003e\n \u003cp\u003eLength of hospital stay, days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.619%;\"\u003e\n \u003cp\u003e13.00（11.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.381%;\"\u003e\n \u003cp\u003eSevere complications (Clavien-Dindo classification \u0026ge;IV), n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22.619%;\"\u003e\n \u003cp\u003e25（42%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"676\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 628px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2. Factors Associated with Severe Complications (Clavien-Dindo classification \u0026ge; IV)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 260px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 271px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Clavien-Dindo classification\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e＜\u003c/strong\u003e\u003cstrong\u003eIV（n=35）\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026ge;\u003c/strong\u003e\u003cstrong\u003eIV（n=25）\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 260px;\"\u003e\n \u003cp\u003eAge, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e58.00（28.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e76.00（24.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 260px;\"\u003e\n \u003cp\u003eProthrombin time (PT), s\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e13.70（3.10）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e14.50（5.90）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.615\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 260px;\"\u003e\n \u003cp\u003eD-dimer, mg/L,\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e1.66（2.20）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e4.78（7.36）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e＜\u003c/strong\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 260px;\"\u003e\n \u003cp\u003eAspartate aminotransferase (AST), U/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e18.40（9.20）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e18.50（6.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.389\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 260px;\"\u003e\n \u003cp\u003eUrea, mmol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e5.76（2.79）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e10.10（12.10）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 260px;\"\u003e\n \u003cp\u003eAlbumin, g/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e42.90（6.80）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e29.20（9.50）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e＜\u003c/strong\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 260px;\"\u003e\n \u003cp\u003eTotal bilirubin, \u0026mu;mol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e11.20（4.90）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e13.50（29.70）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.152\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 260px;\"\u003e\n \u003cp\u003eSerum creatinine, \u0026mu;mol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e75.00（30.60）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e97.00（185.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.030\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 260px;\"\u003e\n \u003cp\u003eWhite blood cell count (WBC), \u0026times;10⁹/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e11.68（5.04）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e10.90（8.85）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.928\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 260px;\"\u003e\n \u003cp\u003eHemoglobin (Hb), g/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e138.00（39.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e113.00（37.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.030\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 260px;\"\u003e\n \u003cp\u003ePlatelet count (PLT), \u0026times;10⁹/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e212.00（74.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e196.00（122.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.284\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 260px;\"\u003e\n \u003cp\u003eC-reactive protein (CRP), mg/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e3.98（90.81）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e96.86（172.97）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 260px;\"\u003e\n \u003cp\u003ePOMPP score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e0（1）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1（0）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e＜\u003c/strong\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 260px;\"\u003e\n \u003cp\u003eBoey score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e1（1）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1（1）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.169\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 260px;\"\u003e\n \u003cp\u003eSex, male, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e28（80%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e13（52%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.027\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 260px;\"\u003e\n \u003cp\u003eVomiting, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e13（37%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e9（36%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 260px;\"\u003e\n \u003cp\u003eUnderwent surgery, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e22（63%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e18（72%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.581\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 260px;\"\u003e\n \u003cp\u003ePerforation site: First part（D1）, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e23（66%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e20（80%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.260\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 260px;\"\u003e\n \u003cp\u003eExtensive extraluminal air, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e21（60%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e16（64%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 260px;\"\u003e\n \u003cp\u003eSuprapelvic fluid collections, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e17（49%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e16 (64%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e0.305\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"603\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 603px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3. Comparison of Clinical Characteristics and Outcomes Between NOM and Surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 343px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Treatment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-operative management（n=20）\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgery（n=38）\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical Characteristics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eAge, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e67.50（29.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e64.00（26.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.386\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eSex, male, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e12（60%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e29（76%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.233\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eProthrombin time (PT), s\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e14.40（2.30）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e13.80（4.40）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.647\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eD-dimer, mg/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e3.20（6.49）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e2.40（4.19）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.288\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eAspartate aminotransferase (AST), U/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e18.40（11.50）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e18.60（7.50）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.896\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eUrea, mmol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e5.76（8.36）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e6.95（5.08）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.395\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eAlbumin, g/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e38.50（14.10）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e39.30（12.98）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.418\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eTotal bilirubin, \u0026mu;mol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e10.80（6.30）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e13.25（12.50）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.487\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eSerum creatinine, \u0026mu;mol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e79.00（117.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e79.80（42.30）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.870\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eWhite blood cell count (WBC), \u0026times;10⁹/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e11.68（4.58）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e11.19（7.80）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.987\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eHemoglobin (Hb), g/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e122.00（37.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e130.50（48.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.477\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003ePlatelet count (PLT), \u0026times;10⁹/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e201.00（76.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e211.50（95.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.390\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eC-reactive protein (CRP), mg/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e51.15（131.01）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e18.72（112.03）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.435\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003ePOMPP score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e1.0（1.0）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.5（1.0）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.215\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eBoey score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e1.0（1.0）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e1.0（1.0）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.666\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003ePerforation site: First part（D1）, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e14（70%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e29（76%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.754\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eExtensive extraluminal air, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e7（35%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e29（76%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.004\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eSuprapelvic fluid collections, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e6（30%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e26（68%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.007\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eDays of total parenteral nutrition (TPN）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e6.00（5.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e7.00（5.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.087\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eDays of nasogastric decompression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e7.00（8.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e7.00（7.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.412\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eDays of somatostatin use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e6.00（9.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e4.00（8.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.261\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eDays of acid-suppressive therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e11.00（12.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e11.50（6.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.398\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eDuration of antibiotic therapy, days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e10.00（11.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e10.00（8.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.600\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eLength of hospital stay, days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e13.00（12.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e13.00（10.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.555\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eClavien-Dindo classification \u0026ge;IV，n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e7（35%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e18（47%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.414\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOther\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eTotal expenses（RMB）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e20244.30（16114.98）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e48757.05（52276.875）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e＜\u003c/strong\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"677\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 677px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 4. Comparison of Clinical Characteristics and Outcomes Between D1 and D2/D3 Perforation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Site of perforation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eD1（n=43）\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;D2/D3(n=17)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical Characteristics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eAge, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e66.00（31.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e64.00（25.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e0.321\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eProthrombin time (PT), s\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e13.70（6.10）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e14.30（2.90）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e0.560\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eD-dimer, mg/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e2.49（2.84）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e2.97（7.32）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e0.762\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eAspartate aminotransferase (AST), U/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e18.40（7.80）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e20.40（7.90）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e0.290\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eUrea, mmol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e7.06（7.71）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e5.90（3.02）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e0.549\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eAlbumin, g/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e38.50（11.60）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e78.24（15.95）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e0.922\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eTotal bilirubin, \u0026mu;mol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e11.00（8.30）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e13.95（15.70）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e0.234\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eSerum creatinine, \u0026mu;mol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e80.00（63.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e77.25（34.90）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e0.806\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eWhite blood cell count (WBC), \u0026times;10⁹/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e11.47（7.71）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e12.05（5.34）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e0.889\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eHemoglobin (Hb), g/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e129.00（49.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e121.50（36.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e0.676\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003ePlatelet count (PLT), \u0026times;10⁹/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e210.00（90.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e198.00（95.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e0.294\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eC-reactive protein (CRP), mg/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e18.89（133.24）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e50.83（151.77）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e0.669\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003ePOMPP score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e1（1）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e0（1）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e0.086\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eBoey score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e1（1）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e1（1）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e0.561\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eSex, male, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e31（72%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e10（59%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e0.365\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eVomiting, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e14（33%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e8（47%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e0.376\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eUnderwent surgery, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e29（67%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e11（65%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eExtensive extraluminal air, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e26（60%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e11（65%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e0.763\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eSuprapelvic fluid collections, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e24（59%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e9（53%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eDays of total parenteral nutrition (TPN）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e7.00（5.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e6.00（6.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e0.581\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eDays of nasogastric decompression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e7.00（4.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e10.50（13.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e0.110\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eDays of somatostatin use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e4.00（7.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e8.50（12.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.003\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eDays of acid-suppressive therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e11.00（7.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e14.50（9.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.042\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eDuration of antibiotic therapy, days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e10.00（8.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e15.00（21.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.004\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eLength of hospital stay, days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e13.00（9.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e20.50（23.00）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eClavien-Dindo classification\u0026ge;IV，n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e20（47%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e5（29%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e0.260\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Duodenal perforation, Peptic ulcer perforation, Nonoperative management, Conservative treatment, Risk factors, Anatomical segment-based differences, Clavien-Dindo classification, POMPP, Boey score","lastPublishedDoi":"10.21203/rs.3.rs-8668268/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8668268/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDuodenal perforation is a heterogeneous and potentially life-threatening surgical emergency, with increasingly complex etiologies and management strategies in recent years. In previous studies and guidelines comparing nonoperative management (NOM) and surgical treatment, gastric and duodenal perforations have often been investigated together as upper gastrointestinal perforations, whereas evidence focusing specifically on duodenal perforation remains limited. This study aimed to identify risk factors for severe complications in duodenal perforation, to compare the predictive performance of different risk scoring systems, to explore differences among perforation sites within the duodenum, and to evaluate conditions under which NOM may be considered.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective study was conducted on patients diagnosed with duodenal perforation between January 2021 and May 2025. Clinical characteristics were compared among patients with different outcomes, treatment strategies, and perforation locations. Representative cases were also described.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAge, POMPP score, sex, albumin, D-dimer, urea, C-reactive protein, creatinine and hemoglobin were associated with the occurrence of severe complications (Clavien\u0026ndash;Dindo classification\u0026thinsp;\u0026ge;\u0026thinsp;IV). The POMPP score demonstrated superior predictive performance compared with the Boey score. When comparing patients managed with NOM and those undergoing surgery, significant differences were observed only in CT findings, specifically extensive extraluminal air and suprapelvic fluid collections, whereas other clinical characteristics and clinical outcomes were comparable between the two groups. In addition, patients with perforations at the D2/D3 segments required longer durations of somatostatin use, acid-suppressive therapy, antibiotic treatment, and hospital stay than those with D1 perforations.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe management of duodenal perforation should be individualized based on patient risk factors, perforation characteristics, and disease progression. Hypoalbuminemia, advanced age, female sex, anemia, and elevated C-reactive protein, creatinine, urea, and D-dimer levels are associated with a higher risk of severe complications. The POMPP shows promise as a reliable tool for identifying low-risk patients. Compared with D1 perforations, D2/D3 perforations require longer treatment durations. In clinically stable, low-risk patients, the absence of extensive extraluminal air or suprapelvic fluid collections on CT may support the selection of NOM.\u003c/p\u003e","manuscriptTitle":"Risk stratification and nonoperative management of duodenal perforation: the role of the POMPP score and CT imaging in a retrospective cohort","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-12 16:11:52","doi":"10.21203/rs.3.rs-8668268/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"08ca225c-a480-45ac-93cb-f009416077e6","owner":[],"postedDate":"February 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-09T19:24:25+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-12 16:11:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8668268","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8668268","identity":"rs-8668268","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}