Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (34 page)
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Authors: Simon Paterson-Brown MBBS MPhil MS FRCS
As mentioned previously, the size of the bleeding artery is a critical determinant in the success of endoscopic treatment. In an ex vivo model, a vessel size of 2 mm could be consistently sealed by a 3.2-mm contact thermal device. In clinical studies that examined factors that might predict failure of endoscopic treatment, ulcer size greater than 2 cm, ulcers on the lesser curvature and ulcers on the superior or posterior wall of bulbar duodenum were consistently identified as major risk factors for recurrent bleeding.
23
These ulcers erode into large artery complexes such as the left gastric and the gastroduodenal artery, which are usually sizeable. Consideration should therefore be given to prophylactic measures against recurrent bleeding in these ulcers judged endoscopically to be at significant risk of re-bleeding.
Many endoscopists re-scope their patients the next morning and re-treat ulcers with remaining stigmata of bleeding. In a pooled analysis on the role of second-look endoscopy,
38
the authors found a modest 6.2% reduction in the absolute risk of re-bleeding (number needed to treat (NNT) to reduce one episode of recurrent bleeding). The NNT for reduction of surgery and surgery was 58 and 97, respectively. A subsequent meta-analysis and a third meta-analysis carried out for an international consensus conference confirmed that routine second-look endoscopy did reduce the incidence of re-bleeding. The findings were strongest in studies including a high proportion of high-risk ulcers. However, in many of these trials, adrenaline injection alone was used. The role of second-look endoscopy following dual therapy or mechanical therapy remains unclear. In addition, adjuvant treatment with PPI therapy following endoscopic haemostasis can be expected to reduce the benefit of second-look endoscopy even further. With aggressive first endoscopic treatment, the risk of complications, especially perforation, with second treatment is substantial. There may, however, be a role for second-look endoscopy in selected high-risk patients, although this would require further studies and the most recent international consensus guidelines did not recommend this approach on the basis of the available evidence.
23
Second-look endoscopy is not indicated as a routine if primary optimum endoscopic haemostasis has been performed.
23
Acid suppression
It has been shown in an in vitro study that platelet aggregation is dependent on plasma pH. It is thought that a pH of 6 is critical for clot stability and an intragastric pH above 4 inactivates stomach pepsin, preventing the digestion of clots.
13
To raise intragastric pH consistently above 6, a high-dose PPI given intravenously is required. The antisecretory effect of histamine receptor antagonists, due to tolerance, is less reliable than PPIs. In a study from the Hong Kong group,
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a 3-day course of high-dose omeprazole infusion given after endoscopic therapy to bleeding ulcers reduced the rate of recurrent bleeding from 22.5% to 6.7% at day 30. The majority of recurrent bleeding occurred within the first 3 days of endoscopic treatment. This trial demonstrated the importance of early endoscopic triage, selecting only the high-risk ulcers for aggressive endoscopic treatment followed by profound acid suppression. In a Cochrane systematic review of 24 controlled trials and 4373 patients,
40
PPI treatment was shown to reduce re-bleeding (pooled rate of 10.6% vs. 17.3%, OR 0.49, 95% CI 0.37–0.65) as well as surgery (pooled rate of 6.1% vs. 9.3%, OR 0.61, 95% CI 0.48–0.78) when compared with placebo or histamine-2 receptor antagonist. There was no evidence of an effect on all-cause mortality, although when the analysis was confined to patients with high-risk stigmata (active bleeding or visible vessels) there was an associated reduction in mortality with PPI therapy. A multicentre study randomised 767 patients from 91 hospitals in 16 countries to intravenous esomeprazole or placebo following successful endoscopic haemostasis.
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Esomeprazole was associated with significant reductions in re-bleeding and endoscopic re-intervention rates and non-significant reductions in mortality and the need for surgery.
High-dose intravenous PPI therapy (80 mg omeprazole followed by 8 mg/h for 72 h) is recommended for patients with active bleeding or visible vessels at the time of endoscopy.
40
The first UK audit revealed a mortality of 24% in those patients (251 of 2071, 12%) who required surgery for bleeding peptic ulcers.
1
However, in 78% of these patients, no previous attempt at endoscopic haemostasis had been made. In the most recent UK audit,
3
surgery was required in only 1.9% of patients but mortality remained high in this group (30%). The high mortality is probably related to an aged population, with the mean age at 68, and the high incidence of comorbidity. In some patients with severe comorbid illnesses and bleeding peptic ulcer, gastrointestinal haemorrhage is an agonal event. Bleeding ulcers that fail endostasis are typically ‘difficult’ ulcers – larger chronic ulcers that erode into major arterial complexes. The decline in elective ulcer surgery also means the atrophy of surgical techniques in dealing with these ulcers. Ideally, a specialist team with an experienced upper gastrointestinal surgeon should be involved in managing these patients.
Although emergency ulcer surgery has diminished significantly, it has an important gatekeeping role in the management algorithm. The clear indication for surgery is loosely defined as ‘failure of endoscopic treatment’. In a patient with massive bleeding that cannot be controlled by endoscopy, immediate surgery should obviously follow. Similarly, in a patient with bleeding controlled at endoscopy, most clinicians would adopt a non-operative approach. However, the difficulty lies in deciding the exact role of surgery in ulcers judged to have a high risk of recurrent bleeding (e.g. > 2 cm and at difficult locations), in whom endoscopic haemostasis has been initially successful. Increasingly, angiographic embolisation is replacing emergency surgery in these circumstances.
The choice of surgical procedure for bleeding peptic ulcers, when required, has not been adequately examined in the era following routine eradication of
Helicobacter pylori
and high-dose PPI therapy. Many surgeons maintain that under-running of ulcers alone combined with acid suppression using high-dose PPI therapy is safer than definitive surgery by either gastric resection or vagotomy. Two randomised studies looking at the different surgical procedures used to control bleeding peptic ulcers have been reported,
42
,
43
but both predate the PPI and routine
H. pylori
eradication era and therefore their results must be interpreted with considerable caution. One of these was a multicentre study comparing minimal surgery (under-running the vessel or ulcer excision alone plus intravenous histamine receptor antagonist) versus definitive ulcer surgery (vagotomy and pyloroplasty or partial gastrectomy) in patients with gastric and duodenal ulcers.
42
The trial was terminated, however, because of the high rate of fatal re-bleeding in the minimal surgery group (6 of 62 vs. 0 of 67,
P
= 0.02).
The other trial was carried out by the French Association of Surgical Research and included only bleeding duodenal ulcers.
43
The patients in this trial were randomly assigned to either under-running plus vagotomy and drainage (58 patients) or partial gastrectomy (60 patients). Recurrent bleeding occurred in 10 of 58 patients (17%) after under-running and vagotomy. In the group assigned to partial gastrectomy, only two patients (3%) re-bled and both recovered without the need for further surgery. The rate of duodenal stump leak in the gastrectomy group was 8 in 60 (13%). When the results were analysed on an intention-to-treat basis, and those with duodenal leaks after re-operations for re-bleeding in the under-running and vagotomy group were included, duodenal leak rate was similar in both groups (7/58 vs. 8/60). The mortality in both groups was similar (22% after vagotomy and 23% after gastrectomy). In the era of PPI therapy, the role of vagotomy has disappeared. A proper ligation of the gastroduodenal artery complex including the right gastroepiploic and the transverse pancreatic branches is the key to avoid recurrent bleeding.
In a survey of UK surgeons reported in 2003, more than 80% of respondents rarely or never perform vagotomy for bleeding peptic ulcer.
44
Despite the absence of recent randomised evidence, surgeons have clearly adopted a more conservative approach based on the efficiency of PPI treatment and
H
.
pylori
eradication in the healing of peptic ulceration. With improvements in endoscopic therapy and the increasing age and comorbidity of patients, the risks of definitive ulcer surgery may outweigh any potential benefit from reduction in re-bleeding. For duodenal ulcer haemorrhage, longitudinal duodenotomy is carried out and control of bleeding achieved by digital pressure or by grasping the posterior duodenal wall in tissue forceps. If possible, preservation of the pylorus is preferred, but extension of the duodenotomy to include the pylorus may be required if access is difficult. Control of bleeding may be aided by mobilisation of the duodenum (Kocher's manoeuvre), allowing pressure to be applied posteriorly. In the majority of patients, simple under-running of the bleeding vessel can be achieved using 0 or 1/0 absorbable sutures above and below the bleeding point, ensuring deep enough tissue penetration to completely occlude the vessel. Due to the variation in anatomy of the gastroduodenal artery (
Fig. 7.5
), four or five sutures should be placed to ensure enduring haemostasis. The duodenotomy can then be closed longitudinally or converted into a formal pyloroplasty if the pylorus has been divided.
Figure 7.5
The anatomy of the gastroduodenal (GD) artery complex with confluence of several branches into the artery itself. RGE, right gastroepiploic artery; SPD, superior pancreatico-duodenal artery; TP, transverse pancreatic.
Reproduced from Berne CJ, Rosoff L. Peptic ulcer perforation of the gastroduodenal artery complex: clinical features and operative control. Ann Surg 1969; 169:141–4. With permission from Lippincott, Williams & Wilkins.
In cases of a massive duodenal ulcer, it may be necessary to exclude the ulcer, perform a distal gastrectomy and close the distal duodenum. This can be a challenging procedure in an elderly, unstable patient, particularly where duodenal thickening and scarring prevent safe stump closure. In this situation it may be better to anticipate a controlled duodenal fistula by closing the duodenal stump around a Foley catheter rather than attempting more complex closures, such as with the Billroth I reconstruction.
In the case of surgery for a bleeding gastric ulcer, the common scenario is for the ulcer to be located high on the lesser curve of stomach. Anterior gastrotomy, identification of the bleeding site and simple under-running of the ulcer (with biopsy of the ulcer edge) is the procedure of choice, and is also suitable for rare cases of Mallory–Weiss tear or a Dieulafoy lesion that does not respond to endoscopic management. In the rare case of a distal gastric ulcer that does not respond to endoscopic therapy, there may occasionally be a case for ulcer excision or even distal gastrectomy, but it is difficult to justify such a course of action in the hands of a non-specialist surgeon, and simple under-running should be the aim in the majority of patients.
The choice of operation in patients with bleeding peptic ulcers who have failed endoscopic treatment should involve, where possible, simple under-running of the bleeding ulcer, without either vagotomy or gastric resection. Biopsies should be taken from the edge of a gastric ulcer.