Bleeding gastroduodenal ulcers: choice of operations.

Abstract

AbstractManagement of upper gastrointestinal tract hemorrhage continues to present a challenge in surgical judgment. Endoscopy is the mainstay to precise diagnosis and, although some authorities feel that this modality has not reduced overall mortality, it has, however, played an important role in overall patient management. A bleeding patient may be classified into 1 of 3 separate categories and the algorithms outlined in this article are useful in selecting patients for nonoperative and operative treatment. For the good‐risk patient with a massively bleeding duodenal ulcer (DU) who is hemodynamically stable, truncal vagotomy‐antrectomy, Billroth I reconstruction is our procedure of choice if the inflammatory process in the duodenum is conducive to a safe resection. Our operative method is described along with variations in technique which are used when conventional end‐to‐end gastroduodenostomy is not feasible. Closure of the duodenal stump and Roux‐en‐Y reconstruction or placement of a Roux limb on a severely diseased duodenum following resection is employed in highly selected cases. The Billroth II type of reconstruction is rarely used today in our experience. Truncal vagotomy and pyloroplasty (TV‐P) is reserved for the high‐risk patient who is bleeding massively. An increasing number of these patients are currently encountered as transfers from our intensive care units with associated multiple organ disease and organ failures. Proximal gastric vagotomy with ulcer undersewing has limited application, in our judgment, when faced with the massively bleeding patient. Gastric resection with or without vagotomy along with ulcer excision is our choice for the massively bleeding gastric ulcer (GU) located in the distal 50–60% area of the stomach. For the high‐risk patient with GU, ulcer excision followed by TV‐P is indicated. For the rarely encountered giant GU, gastric resection may be the only option even though the patient is high risk.The choice of the proper operative procedure for the individual patient with massive gastric or duodenal hemorrhage should rest on the experience and the judgment of the surgeon.