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SURGICAL MANAGEMENT OF UPPER GASTROINTESTINAL HEMORRHAGE

SURGICAL MANAGEMENT OF UPPER GASTROINTESTINAL HEMORRHAGE. Jeffrey S. Bender, MD, FACS University 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.

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SURGICAL MANAGEMENT OF UPPER GASTROINTESTINAL HEMORRHAGE

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  1. SURGICAL MANAGEMENT OF UPPER GASTROINTESTINAL HEMORRHAGE Jeffrey S. Bender, MD, FACSUniversity of OklahomaCollege of Medicine

  2. Objectives • Follow the changing patterns of the disease • Outline the current scope of the problem • Diagnostic and non-operative modalities • Future management

  3. 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

  4. UGI Hemorrhage • Mortality rate 8-10% • >65 now comprise over 30% • Peptic ulcer still most common cause • Surgery now plays an adjunctive role

  5. 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

  6. UGI Hemorrhage: 1985 • 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:?

  7. UGI Hemorrhage: 2005 • 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

  8. UGI Hemorrhage: 2005 • POD #2: intermittent BRBPR • Volume resuscitated • Intermittently hypotensive • Nuclear medicine: tagged RBC scan

  9. UGI Hemorrhage: 2005 • Suspected bleed from transverse colon • Bleeding continues • Arteriogram performed X 2

  10. 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

  11. 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

  12. UGI Hemorrhage: 2005 • Prolonged ICU course (30 days) • Transferred to rehab center day #45 • Insurance: “pre-existing condition”

  13. UGI Hemorrhage: 1985 • Personal experience • 27 gastric resections • 17 vagotomies • 95th percentile

  14. UGI Hemorrhage: 2005 • 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

  15. UGI Hemorrhage: 1985: Literature • 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”

  16. 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”

  17. UGI Hemorrhage: 2000’s: Literature • Only 3 references in same 5 journals • “Rupture of Splenic Artery Pseudoaneurysms” • “Modified Sugiura Procedure” • “Effectiveness of Gastric Devascularization and Splenectomy…Gastric Varices”

  18. UGI Hemorrhage: 2005: Literature • “Celiac Axis Ligation…Unmanageable UGI Hemorrhage” • Arterial Embolization for Dieulafoy Bleeding”

  19. UGI Hemorrhage: 1980’s • Mostly gastroduodenal ulcers • Protocol: resuscitation, early endoscopy and operation • 66 patients, 1986-1990 • No deaths Bender, et al. Am Surg 1994

  20. UGI Hemorrhage: 1990What Changed? • Therapeutic endoscopy • Discovery of the role of h. pylori • Better acid suppression drugs • Liver transplant • Interventional radiology

  21. 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

  22. 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

  23. Proton Pump Inhibitors • Appear to be effective at high doses • Especially so with high risk patients • Effects clouded by use of therapeutic endoscopy

  24. 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 deathsCook, et al. Gastroenterology, 1992

  25. Thermal Therapy • Laser (Argon and Nd: YAG) • Monopolar electrocoagulation • Bipolar or mulitpolar electrocoagulation • Heater probe

  26. Injection Therapy • Epinephrine (1:10,000) • Saline • Absolute alcohol • Water • Sclerosing agents

  27. 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%

  28. Endoscopic Therapy - Questions • Lack of standardized definitions, especially in stigmata • Complications: rebleeding, 20%; perforation, 1% • Costs not defined • Role of repeat endoscopy: planned vs. rebleeding

  29. Future Endoscopic Therapies • Cryotherapy • Clips • Argon plasma coagulation • Sewing

  30. Adjunctive Therapies • Prokinetic agents • Octreotide • Dedicated units • ? Earlier surgery

  31. Second Look Endoscopy • Patients at high risk of rebleeding can be identified • Age, site, size, co-existent disease • Baylor Bleeding Score

  32. 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% endoscopyvs. 11% operation (p=0.002)

  33. Endoscopic vs. Operative Treatment • 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

  34. “Modern” Management ofUGI Hemorrhage • Resuscitation • High dose proton pump inhibitors • Early endoscopy with therapeutic intervention • Repeat endoscopy in 2 hours for high risk patients

  35. “Modern” Management ofUGI Hemorrhage • Concomitant decision by surgery and gastroenterology regarding operation • Most deaths still due to repeated episodes of shock

  36. 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

  37. Future Directions • Further risk stratification • Define role of angiography • Earlier operation for those at higher risk

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