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But, whatever you do, remember that old and chronically ill patients poorly tolerate
repeatedepisodesofbleeding;donotmessaroundwiththem.Asaroughguide,when
thetransfusionrequirementexceeds4units ofbloodina patientover65yearsofage,
consider surgery (or angiography). Yes, we know it is a rough guide but surgical
decisionsarerough.
Angiographictransarterialmanagement?
Asmentionedabove,insomecenterstherapeuticarteriographyisthe
next stop for patients failing endoscopic hemostasis. Not surprisingly,
assessingtheresultsofvariousmanagementoptionsinsuchpatientsis
difficult,butitseemsthatembolizationisassociatedwithahigherrateof
rebleedingthansurgery,andischemiccomplicationsatthetargetorgans
arenotuncommon.Ofcourse,aseverythinginlife,itdepends—inthis
case on your local expertise. We would consider this option as an
alternative to an operation in special circumstances — for example, a
bleedingDUwhentheriskofoperativeinterventionwouldbeprohibitive
(e.g.aftermyocardialinfarction)orUGIBfromapseudoaneurysmofthe
splenicarteryassociatedwithchronicoracutepancreatitis.Butagain,in
some‘high-tech’centersangiotherapyhasbecomethedefault—notthe
alternativetreatment.
Sopractically,thesedaysweare,sorrytosay,‘allowedtooperate’
onlyon patientswho‘have failedeverything’:they bled andbled—
neededlotsofblood;theyhavebeenendoscoped,injected,clippedover
and over again;lost more blood, and then dispatched for angiography.
We are operatingon a smaller number of patients who are sicker and
withmoredemandingsurgicalpathology—nowonderthatpostoperative
mortalityandmorbidityinsuchpatientsremainshigh.Butthisistypical
ofmodernmedicine:twostepsforward,oneback—likeafrogina
well.
Notin our center. Havingexpert angiographers available atall times, notonly do weoperate
muchless,butveryrarelydoweseemortalityanymorefrompepticbleeding(Iamnottalking
aboutvaricesandend-stageliverfailure).Icertainlydon’tmissoperatingonthe‘bleeders’with
theassociatedM&MthatIstillremember.Danny
Operativemanagement
So finally, you decided to take the (optimally resuscitated, we hope)
patienttotheOR.Considerrepeatingtheendoscopy!
ItiscrucialthatyouknowtheexactlocationintheUGItractfromwhere
thepatientisbleeding.Iftheinitialendoscopywasnotdonebyyou,orin
your presence; play it again Sam! In an anesthetized patient it will not
takeyou morethan5 minutesto insertandremove theendoscope.Do
not trust blindly the 2-day-old endoscopy report that the “source of
hemorrhage appeared to be in the duodenum”. This could lead you to
startwithanunnecessaryduodenotomywhilethesourcelieshighinthe
stomach.Oyveyizmir…
Exploration
Through a midline upper abdominal incision! No laparoscopy is
advisedin suchpatients, exceptin specialcircumstances (e.g.bleeding
gastric GIST). A paraxyphoid extension and forceful upward sternal
retractionletsyoudealwithanythingintheforegut.Inobesepatientswith
a wide costal angle, however, a transverse chevron-type incision may
take a few more minutes but affords a more comfortable exposure. In
addition, a generous reverse-Trendelenburg tilt of the patient will
bringtheupperstomachalmostintoyournose.
Start by searching for external visual or palpable features of chronic
ulceration.Thelatterareinvariablyassociatedwithserosalinflammatory
changes.Lookfor evidenceofchroniculcersfrom theduodenumto the
gastriccardia.Duodenal‘Kocherization’(TheodorKocherisperhapsthe
only surgeon in history to have his name used as a verb) will be
necessary to reveal the now almost extinct post-bulbar ulcer in the
second portion of the duodenum. Occasionally, a posterior or lesser
curvature gastriculcer will become palpable only through the lesser
sac. Acute superficial mucosal lesions are unfortunately not
identifiable from the outside, although a Mallory-Weiss lesion may be
naturally ‘tattooed’ by the blood with bluish serosal staining at the
gastroesophagealjunction.
The finding of a chronic ulcer in accordance with the pre-operative
endoscopicfindingtellsyouwherethetroubleis;butwhatistobedone
in the absenceof any external evidence ofpathology? Yes, a rare
situationbutplausible.Youhaveafewoptions:
•
Proceed according to the endoscopist’s findings — if you trust
them…buttheywillnotalwaysbecorrect.
•
Surgicalexploration.
•
Intra-operativeendoscopy.
Intra-operativeendoscopy
Having endoscopically visualized, with your own eyes, an actively
bleeding DU, you should not have any doubts. A doubtful endoscopic
report,however, may promote a negative duodenotomy, extendingit—
piecemeal — proximally, until the high gastric lesion is found. All that
was needed was a small gastrotomy and suture ligation of the
lesion; instead you are left with a very long, messy and
unnecessaryduodenogastrotomytorepair.Toobviatesuchamini-
disaster we would unscrub for a moment and shove in an
endoscope. On rare occasions, when the stomach is distended with
huge clots, we would place a purse-string suture at the anterior wall of
theantrum,performasmallgastrotomy,andwithalargesuckerremove
and irrigate all clots. An endoscope is then inserted through the
gastrotomy with the purse-string tightened to allow gastric insufflation;
this offers an excellent and controlled view of the stomach and
duodenum.Wecall it‘intra-operative retrograde gastroscopy’. Oneday
thismaneuvermaysaveyourbutt!
Philosophyofsurgicalmanagement
Irememberinthelate1970s,inmymedicalschoolinJerusalem,the
Professors of Surgery quarrelling for hours about which is better:
Hofmeister’s partial gastrectomy or the Polya one? The duels about
which pyloroplasty should be done in a specific case — the Heineke-
Mikulicz? A Finney? And what about a Jaboulay? — were endless.
Today,ayoungsurgeonwhocanrecognizeevenoneofthosenames,let
alone pronounce them correctly, is considered a doyen of history. The
timestheyarea-changin’,eh?
A friend of ours, Asher Hirshberg, aptly stated: “In the era of
Helicobacter pylori, doing a gastrectomy for peptic ulcer is like
doing a lobectomy for pneumonia.” Clearly, where potent anti-ulcer
drugsareavailable,electiveulcersurgeryhasdisappearedanddefinitive
anti-ulcer procedures during emergency surgery for complications of
ulcersaredisappearingrapidly(nay,theyhavetotallyvanished)aswell.
Why do asurgical vagotomy when protonpump inhibitors offera
‘medicalvagotomy’?
The general philosophy is that the role of the surgeon is to
prevent the patient dying of blood loss. This is the main
consideration in severely ill patients. Other considerations are
secondary.
Are there any situations left when adding a definitive anti-ulcer
procedure would be reasonably indicated? While in the previous
editionswementioneditasaviableoptionin‘selectedpatients’wenow
believe that such procedures are indicated only if dictated by
anatomical constraints, as discussed below. However, in the
‘developing world’, when proper anti-ulcer medications are not readily
available,onecouldconsideraddingananti-ulcerprocedureforchronic
ulcers in reasonably stable patients (e.g. a homeless patient in St.
Petersburg—ortheuninsuredhoboinFlorida—withachronicgastric
ulcerandahistoryofrecurrentUGIB).
Thatis — ifyou stillknow howto doit. BTW: when was the last
timeyouperformed,orwatched,avagotomy?
Specificsourcesofbleeding
Duodenalulcer(DU)
If anyone should consider removing half of my good
stomachtocureasmallulcerinmyduodenum,Iwouldrun
fasterthanhe.
CharlesH.Mayo
Aboutgastrectomyforduodenalulcer:inthisoperation…a
segment of an essentially normal stomach is removed to
treatthediseasenextdoorintheduodenum.Itisliketaking
outtheenginetodecreasenoiseinthegearbox.
FrancisD.Moore
Thesourceofbleedingisalwaysthegastroduodenalarteryatthe
base of a posterior ulcer. Hemostasis is accomplished through an
anterior,longitudinalduodenotomy,underrunningthebase(andbleeding
vessel) with two or three (2-0 or 0, a monofilament or Vicryl®) deeply
placed sutures — each placed on a different axis. When bleeding is
active,successfulligationofthevesselwillbeevident;initsabsenceyou
may want to abrade the ulcer’s base, dislodging the clot and inducing
bleeding. Otherwise, just underrun the base, deeply, and in a few
directions.Thetheoreticaldangerofunderrunninganearbycommon
bileducthasbeenmentionedbutweareunawareofevenasingle
reportofsuchacase — however,never saynever; s**tcan happen!
Others have described ligating the gastroduodenal artery from the
outside,above andbehind theduodenum. Wehavenoexperience with
this and would be anxious fishing for the artery at the base of the
gastrohepatic omentum which would be inflamed by the adjacent
ulcerating process. Now carefully close the duodenotomy without
constricting the lumen, and getout. Local hemostasis can beachieved
even in the base of giant ulcers or when the duodenum is extremely
inflamed or scarred. When simple closure of the duodenotomy
appears to compromise the lumen or pyloroplasty is deemed
otherwise unsatisfactory, just close the duodenum and do a
posterior gastroenterostomy(GE). Of course, this is an ‘ulcerogenic
anastomosis’! But such patients will receive proton pump inhibitors for
life;thatisifvagotomyisnotadded.Theeventualcureoftheulceris
lefttoacid-reducingdrugsandanti-Helicobacteragents.
Figure17.2. Gastroduodenostomy: note thatthe posterior aspectof the anastomosis is
performed with ‘heavy’ (e.g. Vicryl® 2-0) interrupted sutures, taking ‘big bites’ in the
posterior‘lip’ oftheduodenum(whichisadherentto the pancreas) —wellintothescar
tissueatthebaseofthe(nowexcluded)ulcer.
Whichdefinitiveprocedureshouldyouselectintherarepatient?
Obviously, this is considered only in a patient who is stable
hemodynamically and otherwise in a reasonable shape! Our choice
would be adding a truncal vagotomy (TV), extending the
duodenotomyacrossthepylorus,andclosingittoformaHeinekeMikuliczpyloroplasty.Whenandiftheduodenumisextremelyscarred
andfriablewewoulddo a gastroenterostomyrather than pyloroplasty
— just patch the duodenotomy the best you can and hook a proximal
loopofjejunum,sidetoside,totheantrum.
Is there any indication for an antrectomy? The proponents of
antrectomyplusvagotomyforbleedingDUsclaimanincreasedincidence
of rehemorrhage when gastric resection is avoided. In over 100
emergency operations for bleeding DUs, this has not been our
experienceandwebelievethatthereisnosenseinremovingahealthy
stomach, producing a gastric cripple, for benign duodenal disease —
whichin any case can be subsequently cured with medications.When,
however,theduodenumisvirtuallyreplacedbyahugeulcerinvolvingthe
anteriorandposteriorwalloftheduodenalcap-bulb(‘kissingulcers’),one
essentiallyis forced to performanantrectomy(plus/minus a truncal
vagotomy). In this situation, to avoid creating a duodenal stump which
can be difficult to close and can leak, we prefer a Billroth I
gastroduodenostomyasdepictedin Figure17.2).
Gastriculcer(GU)
In the previous editions we bored the hell out of our readers with a
complexclassificationofgastriculcers,recommendingdifferentdefinitive
anti-ulcer procedures, based on the specific type of the GU. This has
become irrelevant as, irrespective of the location and type of the
ulcer, youraim is to achievehemostasis by thesimplest possible
maneuver.Inmostcasesallthatisrequiredissimpleunderrunning
of the lesion through a small gastrotomy. In large chronic gastric
ulcers we first underrun the bleeding point with an absorbable suture;
withaheavyabsorbablesuturewethenobliteratetheulcer’sbase.UGIB
fromamalignantulcerveryrarelyrequiresanemergencyoperation.We
would, however, take tissue from the ulcer’s edges for histology. For
bleedingulcerssituatedatthegreatercurvature,wedgeresectionofthe
bleedingulcermayappearmorepractical.Partialgastrectomybecomes
necessaryonlyincasesofagiantGUonthelessercurvaturewithdirect
involvementoftheleftgastricorsplenicarteries.
JuxtacardiallessercurvatureGUsandtheso-called‘ridingGU’
A riding GU,also called a ‘Cameronulcer’is a variant ofa highGU
associatedwithaslidinghiatalhernia,producedbyinjurytotheherniated
stomach, ‘riding’ against the diaphragm. Typically, such ulcers are
multiple and shallow, and present clinically with chronic UGIB and
associated iron deficiency anemia. However, solitary, deeper ones can
presentas life-threatening UGIB. Rarely, when conservative/endoscopic
therapyfails,anoperationmaybeindicated:itcomprisesreductionofthe
stomachbypinching theulceraway fromtheadherentdiaphragm,local
hemostasis,and crural repair. Thismaybe easier saidthandone since
occasionallythehugeridingulceradherestomediastinalstructuresand
mayrequiremajorresectivesurgery.
Inconclusion,thegenerationofsurgeonsraisedonthedogma that a complicated GU
hastoberesectedisbusyretiringordyingoff(thisincludesus…).Themodernsurgeon
shouldattackthebleedingGUwiththesimplestprocedurepossible,asdictatedbythe
specificanatomyencountered.
Anastomotic(stomal)ulcer
This ulcer develops on the jejunal side of the gastrojejunal
anastomosis following a previous vagotomy (or when vagotomy was
omitted or is ‘incomplete’) and gastroenterostomy or Billroth II
gastrectomy. Because stomal ulcers almost never involve a large
blood vessel, hemorrhage is usually self-limiting or amenable to
endoscopictherapy. Rememberalsothat allstomalulcers willhealon
modern acid-suppressing medications. Persisting or recurrent
hemorrhage, however, will forceyou, rarely, tooperate. In thehigh-risk
patientdotheminimum:throughasmallgastrotomy,perpendiculartothe
anastomosis,examinethestomaandulcer;underrunthelatterwithafew
deeply placed absorbable sutures; close the gastrotomy and put the
patientonH2antagonistsorPPIsforlife.
The role of a definitive procedure is limited, following the above
stated philosophy. If the previous operation was a vagotomy plus GE,
look for a missed vagal nerve or add an antrectomy. In the case of a
previousBillrothIIgastrectomy,addTVorconsiderahighergastrectomy
(donotforgettoruleoutZollinger-Ellisonsyndromelateron).Remember
— hemorrhage froma stomal ulcercan be arrested with asimple
surgicalmaneuver(underrunning);trytostayoutoftroublebynot
escalating the emergency procedure into complicated
reconstructivegastricsurgery,whichmaykillyourbleedingpatient.
UGIBaftergastricbypassproceduresformorbidobesity
Thisnotuncommonentityshouldbeaddressedasanystomalulcer.If
endoscopic hemostasis fails, just overrun the bleeding ulcer through a
gastrotomyinthe‘gastricpouch’immediatelyabovetheanastomosis.
However, bleeding ulcers may develop in the distal, excluded
stomachortheduodenum—locationswhicharenotaccessibleto
conventional endoscopy. Angiography (diagnostic/therapeutic) is a
reasonable option; percutaneous, lap-assisted endoscopy has been
described as well. If forced to operate you may want to resect the
excluded,ulceratedstomach.
Dieulafoy’slesion
This small, solitary and difficult to diagnose gastric vascular
malformationtypicallycausesarecurrent‘obscure’massiveUGIB.
Ifnotcontrolledbyendoscopicmaneuvers(orangio),theyhavebecome
these days not an uncommon indication for UGIB surgery. Surgeons
continuetodebatewhattodoafterthelesionhasbeenexposedthrough
an anterior gastrotomy: local excision?; underrunning?; do it through a
laparoscope?Well,juststopditheringanddealwiththebleedingthebest
youcan!
Acutesuperficialmucosallesions
Duetoeffectiveanti-ulcer prophylaxisincritically illpatients,youmay
neverbecalledupon tooperateonsuchlesions.Intheremotepastwe
hadtointerveneinafewsuchcaseswhosediffusebleedingfrom‘stress
gastritis’persisted despite managementwith PPIs and vasopressin. Of
course,endoscopictreatmentsareuselessinthissituationasthe
involvedgastricmucosalooksandbehaveslikeablood-soakedand
drippingsponge.Surgicaloptionsmentionedbythestandardtextbooks
includeTVand drainage or total gastrectomy. The former is associated
with a very high rate of rebleeding and the latter with a prohibitive
mortality rate. In this situation we have carried out gastric
devascularization by ligating the two gastroepiploic, and left and
rightgastricarteriesnearthestomach’swall.Inourexperience,this
relatively simple and well-tolerated procedure results in an
immediatedryingofthegastricsponge.
Torecap…
AdmitpatientswithUGIBtoyoursurgicalservice.Donotleavethemto
the internists who will call you when the patient is almost dead. After
resuscitation diagnose the source of hemorrhage and stage it. Give
endoscopictreatmentachancebutdonotdelayanindicatedoperation.
At surgery the goal is to stop the bleeding — remembering that
mostulcerscanbecuredlateronbymedication.Lifecomesfirst.
Perhapsthisrhymewillhelpyoutoremember…
Whenthebloodisfreshandpinkandthepatientisold
Itistimetobeactiveandbold.
Whenthepatientisyoungandthebloodisdarkandold
Youcanrelaxandputyourknifeonhold.
1
AcutePhysiologyandChronicHealthEvaluationII.
2
Moveyourass.
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