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MASSIVE BLEEDING the role of the surgeon

MASSIVE BLEEDING the role of the surgeon. Balthasar Gerards Foundation Delft, January 1 st , 2006 J.J.B. van Lanschot AMC, Amsterdam The Netherlands. De moord op prins Willem I (1533-1584) door Balthasar Gerards op 10 juli 1584 in Delft. BLEEDING PEPTIC ULCER the role of the surgeon.

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MASSIVE BLEEDING the role of the surgeon

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  1. MASSIVE BLEEDING the role of the surgeon Balthasar Gerards Foundation Delft, January 1st, 2006 J.J.B. van Lanschot AMC, Amsterdam The Netherlands

  2. De moord op prins Willem I (1533-1584) door Balthasar Gerards op 10 juli 1584 in Delft.

  3. BLEEDING PEPTIC ULCERthe role of the surgeon Balthasar Gerards Foundation Delft, January 1st, 2006 J.J.B. van Lanschot AMC, Amsterdam The Netherlands

  4. UPPER GI BLEEDINGproximal to Treitz’ ligament • Gastric ulcer 20-25% • Duodenal ulcer 20-25% • Esophageal varices 10-20% • Mallory-Weiss 5-10% • Neoplasms 5% • Miscellaneous 25%

  5. conventional surgery for peptic ulcer disease • partial gastrectomy (Billroth I-II) • antrectomy / vagotomy • truncal vagotomy / pyloroplasty • highly selective vagotomy (H.S.V.) • posterior truncal vagotomy plus anterior seromyotomy (Taylor II)

  6. conventional strategy for acute ulcer bleeding • resuscitation • endoscopic localization of bleeding site • surgical therapy: - gastro-/duodenotomy: intraluminal ligation - extraluminal ligation: gastroduodenal artery complex - local excision (stomach) - formal gastric resection: excision / exclusion of ulcer

  7. intraluminal + extraluminal ligation

  8. Local excision of gastric ulcer

  9. formal gastric resection with ulcer exclusion X

  10. formal gastric resection with ulcer exclusion

  11. occlusion CBD caused during gastric resection 6.140.395 / 08-10-1933 / ptc with complete visualization of intrahepatic bile ducts, normal cystic duct and leakage at complete transection of CBD in patient after distal gastric resection (after endoscopic therapy and embolisation) for PUH due to fistula between v.c.i. and duodenal ulcer

  12. Identification of common bile duct !

  13. types of reconstruction

  14. Major developments in peptic ulcer disease • Medical acid suppression - H2-receptor antagonists - proton pump inhibitors • Definite cure by eradication of Helicobacter pylori • Development of endoscopic therapy - thermal (laser, BICAP) - injection (epinephrin, polidocanol) - clipping

  15. SUPPORTIVE MEDICAL THERAPY 1.Is acid inhibition indicated? - Coagulation and platelet aggregation most effective in pH-neutral environment ! Lau, NEJM 2000

  16. omeprazole 0 20 40 60 80 100 placebo Omeprazole vs. Placebo in Re-bleeding Risk Omeprazole 80mg + 8mg/h (i.v.) Lau, NEJM 2000

  17. SUPPORTIVE MEDICAL THERAPY 1. Is acid inhibition indicated? - Coagulation and platelet aggregation most effective in pH-neutral environment ! 2. Is Helicobacter eradication indicated? - Hp-status is an independent prognostic factor for rebleeding - successful Hp-eradication reduces rebleeding rate substantially Lai, Am J Gastro 2000

  18. Risk of Re-bleeding (Hp-pos vs. Hp-neg) Hp-neg Hp-pos Lai, Am J Gastro 2000

  19. SUPPORTIVE MEDICAL THERAPY 1.Is acid inhibition indicated? - Coagulation and platelet aggregation most effective in pH-neutral environment ! 2. Is Helicobacter eradication indicated? - Hp-status is an independent prognostic factor for rebleeding - successful Hp-eradication reduces rebleeding rate substantially 3. NSAIDS should be discontinued, if possible !!

  20. “The aim of emergency surgery should be to control the bleeding securely, rather than to prevent ulcer recurrence” Chung and Li British Journal of Surgery 1997

  21. PEPTIC ULCER BLEEDINGrole of surgery ? • Timing of surgery ? • Type of surgical procedure ?

  22. PEPTIC ULCER BLEEDINGrole of surgery ? • Timing of surgery ? • Type of surgical procedure ?

  23. Preferred therapy for recurrent bleeding ? • 1169 patients treated endoscopically • no hemostasis in 17 pts (1.5%) surgery • rebleeding in 100 pts (8.7%) • 92 re-bleeders randomized • endoscopy: epinephrin + heater probe • surgery:surgeon´s preference (50% aggressive) Lau, NEJM 1999

  24. Preferred therapy for recurrent bleeding ?randomized trial Lau, NEJM 1999

  25. Possible exception ? “Every massive bleeding from large ulcer at posterior wall of duodenal bulb with spurting bleeding or visible vessel should be operated on, esp. in the elderly, even after successful endoscopic hemostasis” Chung and Li British Journal of Surgery 1997

  26. PEPTIC ULCER BLEEDINGrole of surgery • Timing of surgery ? Endoscopic re-intervention reduces complications with mortality similar to surgery. 2. Type of surgical procedure ?

  27. PEPTIC ULCER BLEEDINGrole of surgery • Timing of surgery ? Endoscopic re-intervention reduces complications with mortality similar to surgery. 2. Type of surgical procedure ?

  28. Type of surgery for bleeding ulcerrandomized trial 1. Minimal surgery (n= 62): - underrunning of bleeding vessel òr - ulcer excision - ranitidine 2. Aggressive surgery (n=67): - vagotomy / pyloroplasty òr - partial gastrectomy (Poxon et al, Br J Surg 1991)

  29. Type of surgery for bleeding ulcerrandomized trial Overall mortality 29 (23%) minimal 16 (26%) aggressive 13 (19%) n.s. Fatal rebleeding minimal 6 (10%) aggressive 0 (0%) p<0.05 (Poxon et al, Br J Surg 1991)

  30. Type of surgery for bleeding ulcerretrospective study 1. Minimal surgery (n = 518): - vagotomy - drainage 2. Aggressive surgery (n = 389): - vagotomy - resection (de la Fuenta, J Am Coll Surg, 2006)

  31. Type of surgery for bleeding ulcerretrospective study 30-day mortality: minimal 18% aggressive 17% n.s. rebleeding > 4 units: minimal 11% aggressive 12% n.s. (de la Fuenta, J Am Coll Surg, 2006)

  32. surgery for bleeding ulcer1988 – AMC - 2001 to be presented by Monique E. van Leerdam during afternoon session

  33. surgical therapy of peptic ulcersin the 21st century • series from a single Vet. Adm. medical center • period 1999 – 2004 • 43 patients with perforation or bleeding • 47% H. pylori positive; 54% used NSAIDs • 66% of patients were ASA class 3 or 4 • hospital mortality = 23% ! • if rebleeding is not the major cause of death, how can we improve outcome ? (Sarosi, Am J Surg 2005)

  34. role of transcatheter embolization ?

  35. Conclusions (1) • aim of emergency surgery: to control bleeding securely, rather than to prevent ulcer recurrence. • i.v. proton pump inhibition improves coagulation, and thus outcome. • don’t forget Hp-eradication ! • stop NSAIDs, if possible.

  36. Conclusions (2) • 1st rebleeding is preferably treated again endoscopically. • only limited data available on the optimal surgical procedure. • negative patient selection (>50% ASA 3-4) induces high surgical mortality. • future role of transcatheter arterial embolization ?

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