SURGICAL MANAGEMENT OF UPPER GASTROINTESTINAL

HEMORRHAGE

Jeffrey S. Bender, MD, FACSUniversity of Oklahoma

College of Medicine

Objectives

• Follow the changing patterns of the disease

• Outline the current scope of the problem

• Diagnostic and non-operative modalities

• Future management

UGI Hemorrhage

• Approximately 30% decline in rate over last 15 years

• 150,000 admissions per year

• Over $1,000,000,000 annually

• Associated with NSAID use

UGI Hemorrhage

• Mortality rate 8-10%

• >65 now comprise over 30%

• Peptic ulcer still most common cause

• Surgery now plays an adjunctive role

UGI Hemorrhage: 1985

• 40 y.o. man with known or suspected PUD

• Often significant co-morbidities (drugs, ETOH, etc.)

• Hematemesis and hypotension

• NGT placed and volume resuscitated

• EGD reveals 1.5 cm DU with visible vessel

• 6 units PRBC transfused

• OR: oversewing and vagotomy and pyloroplasty

• Discharged home POD#4; F/U:?; uninsured:?

UGI Hemorrhage: 1985

• 48 y.o. female s/p Roux-en-Y gastric bypass with subsequent revision

• One day h/o abdominal pain

• CT scan: pneumoperitoneum

• OR: perforated DU: Graham patch

UGI Hemorrhage: 2005

• POD #2: intermittent BRBPR

• Volume resuscitated

• Intermittently hypotensive

• Nuclear medicine: tagged RBC scan

UGI Hemorrhage: 2005

• Suspected bleed from transverse colon

• Bleeding continues

• Arteriogram performed X 2

UGI Hemorrhage: 2005

• Occluded celiac axis

• Retrograde flow via inferior pancreatico-duodenal artery

• Fills hepatic, left gastric, splenic arteries

• Unable to embolize 2nd branch of IPDA

UGI Hemorrhage: 2005

• OR: duodenotomy with bleeding point third portion oversewn

• 20 units PRBC

• Fascia left open with vac sponge closure

• Fascia closed POD #4

UGI Hemorrhage: 2005

• Prolonged ICU course (30 days)

• Transferred to rehab center day #45

• Insurance: “pre-existing condition”

UGI Hemorrhage: 2005

• Personal experience

• 27 gastric resections

• 17 vagotomies

• 95th percentile

UGI Hemorrhage: 1985

• OU experience (15 chiefs, 2002-2005)

• 49 resections (3.3/resident)

• 26 operations for perforation(1.7/resident)

• 6 vagotomies (0.4/resident)

• 2 laparoscopic resections

UGI Hemorrhage: 2005

• 10 articles in 5 major journals

• “Management of Giant Duodenal Ulcer”

• “Risks of Surgery for UGI Hemorrhage: 1972 vs. 1982”

• “Improvements in the Diagnosis and Management of Aortoenteric Fistula”

UGI Hemorrhage: 1985: Literature

• “Changing Patterns of Gastrointestinal Bleeding”

• “Recurrence After Parietal Cell Vagotomy”

• “Esophageal Transection Fails…Variceal Bleeding”

• “Topical Prostaglandin E2 in…UGI Hemorrhage”

UGI Hemorrhage: 1985: Literature

• Only 3 references in same 5 journals

• “Rupture of Splenic Artery Pseudoaneurysms”

• “Modified Sugiura Procedure”

• “Effectiveness of Gastric Devascularization and Splenectomy…Gastric Varices”

UGI Hemorrhage: 2000’s: Literature

• “Celiac Axis Ligation…Unmanageable UGI Hemorrhage”

• Arterial Embolization for Dieulafoy Bleeding”

UGI Hemorrhage: 2005: Literature

• Mostly gastroduodenal ulcers

• Protocol: resuscitation, early endoscopy and operation

• 66 patients, 1986-1990

• No deathsBender, et al.Am Surg 1994

UGI Hemorrhage: 1980’s

• Therapeutic endoscopy

• Discovery of the role of h. pylori

• Better acid suppression drugs

• Liver transplant

• Interventional radiology

UGI Hemorrhage: 1990What Changed?

Helicobacter Pylori

• First reported 1983 in mucosal biopsies of patients with active gastritis

• Initially debated about role in ulcer disease

• Abundant producer of urase

• Elicits robust inflammatory response

Pharmacologic Therapy

• Oral antacids have no effect on bleeding

• H2- receptor antagonists have had 27 RCT’s on over 2500 patients

• Marginal improvement in surgery and death

• Still widely used

Collins, et al.

NEJM, 1985

Proton Pump Inhibitors

• Appear to be effective at high doses

• Especially so with high risk patients

• Effects clouded by use of therapeutic endoscopy

Endoscopic Therapy

• Widely accepted as most effective method

• Not only controls ulcer bleeding but prevents rebleeding

• Decreases need for surgery

• Only meta analysis shows decrease in deaths

Cook, et al.Gastroenterology, 1992

Thermal Therapy

• Laser (Argon and Nd: YAG)

• Monopolar electrocoagulation

• Bipolar or mulitpolar electrocoagulation

• Heater probe

Injection Therapy

• Epinephrine (1:10,000)

• Saline

• Absolute alcohol

• Water

• Sclerosing agents

Which Endoscopic Therapy?

• Injection, laser, multi- / bipolar and heater probe equivalent

• Latter three most common (simplest)

• Combination therapy not been shown more effective

• Rebleed rates 15-20%

• Lack of standardized definitions, especially in stigmata

• Complications: rebleeding, 20%; perforation, 1%

• Costs not defined

• Role of repeat endoscopy: planned vs. rebleeding

Endoscopic Therapy - Questions

Future Endoscopic Therapies

• Cryotherapy

• Clips

• Argon plasma coagulation

• Sewing

Adjunctive Therapies

• Prokinetic agents

• Octreotide

• Dedicated units

• ? Earlier surgery

Second Look Endoscopy

• Patients at high risk of rebleeding can be identified

• Age, site, size, co-existent disease

• Baylor Bleeding Score

Endoscopic vs. Operative Treatment• 55 patients (of 61) with arterial bleeding or

visible vessel > 2 mm

• Repeated endoscopy in 24 hrs (32) or early operation (23)

• Gastric resection in 79%

• Rebleed: 48% endoscopy vs. 11% operation (p=0.002)

• 22% required operation in endoscopy group

• Mortality: 6% endoscopy vs. 7% operation

• No subgroup or intent-to-treat analysis

• Early 1990’sImhof, et al.Langenbecks Arch Surg, 2003

Endoscopic vs. Operative Treatment

“Modern” Management ofUGI Hemorrhage

• Resuscitation

• High dose proton pump inhibitors

• Early endoscopy with therapeutic intervention

• Repeat endoscopy in 2 hours for high risk patients

• Concomitant decision by surgery and gastroenterology regarding operation

• Most deaths still due to repeated episodes of shock

“Modern” Management ofUGI Hemorrhage

Operation for UGI Hemorrhage

• Likely to become even less frequent

• Therefore operative mortality will likely increase

• No need to do a curative ulcer operation

• Control hemorrhage only

Future Directions

• Further risk stratification

• Define role of angiography

• Earlier operation for those at higher risk