Comparative Discrimination of Boey, PULP, and PPUMSs for Textbook Outcome Failure, Failure-to-Rescue, and 30-Day Mortality Following Perforated Peptic Ulcer Surgery

Background and Objectives: Early Textbook Outcome (Early TO), defined via the Naumann/BEACON Delphi process for non-traumatic emergency laparotomy, and Failure-to-Rescue (FTR) provide postoperative outcome frameworks beyond overall mortality. This study compared the discriminative performance of the mortality-oriented Boey, Peptic Ulcer Perforation (PULP), and Perforated Peptic Ulcer Mortality Score (PPUMS) scores for Early TO failure, FTR, and 30-day mortality in perforated peptic ulcer surgery. Materials and Methods: This retrospective, single-center cohort study included 128 consecutive adults undergoing emergency surgery for gastroduodenal peptic ulcer perforation (January 2015–February 2026). Boey, PULP, and PPUMSs were calculated from preoperative data. The primary outcome was Early TO failure (Naumann/BEACON criteria); secondary outcomes were FTR and 30-day mortality. FTR was assessed among patients with a documented Clavien–Dindo grade III/IV complication. Discriminative performance was quantified as the area under the receiver operating characteristic curve (AUC); correlated AUCs were compared using paired DeLong tests, with Holm adjustment for multiple comparisons within each outcome. Results: Early TO failure occurred in 47 patients (36.7%) and completely overlapped with Clavien–Dindo grade ≥ III postoperative morbidity; no additional patient was classified as Early TO failure solely by another Early TO component. The exploratory FTR analysis included 47 patients with a major postoperative complication, of whom 30 (63.8%) experienced FTR; 30-day mortality in the full cohort was 23.4%. PULP yielded the highest AUCs and Boey the lowest across outcomes: for Early TO failure, AUCs were 0.749 (95% CI, 0.660–0.838) for PULP, 0.703 (0.611–0.795) for PPUMS, and 0.587 (0.487–0.687) for Boey; corresponding AUCs were 0.832, 0.778, and 0.532 for FTR, and 0.851, 0.790, and 0.588 for 30-day mortality. After Holm adjustment, PULP outperformed Boey for all three outcomes, and PPUMS outperformed Boey for FTR and 30-day mortality; the PPUMS–Boey difference was not significant for Early TO failure (p = 0.057). PULP and PPUMS did not differ significantly for any outcome. Conclusions: PULP yielded numerically higher AUCs than PPUMS across all three analyses, although none of the PULP–PPUMS differences reached statistical significance; equivalence between the two scores cannot be inferred. In this cohort, Early TO failure completely overlapped with Clavien–Dindo grade ≥ III postoperative morbidity; therefore, its discriminative performance primarily reflected major postoperative morbidity rather than an independent composite outcome. FTR-specific findings should be considered exploratory and should not be interpreted as measures of institutional rescue capability. Prospective multicenter validation incorporating formal calibration and clinical utility assessment is required before direct clinical implementation.