Early surgical involvement in the management of a patient at high risk for recurrent bleeding, despite endoscopic intervention, is often optimal to assure continuity of care. Close collaboration of the surgical team with gastroenterologic endoscopy teams greatly benefits the patient. A detailed description of the location of the bleeding process is of great help for the surgeon as surgical decision making will be influenced by the distance from the gastroesophageal junction or pylorus, location on the anterior or posterior wall, greater or lesser curvature or incisura, and the size of the process.
Surgeons have long been involved in the care of patients with upper gastrointestinal (GI) bleeding. Surgeons’ care for patients with upper GI disease led to the development of endoscopy, including major contributions to the endoscopic treatment of variceal and nonvariceal upper GI bleeding. Surgeons continue to provide a significant amount of endoscopy and endoscopic treatment, especially in rural areas where no gastroenterology support is available. In more urban areas and academic centers, the majority of endoscopic treatment is provided by gastroenterologists, and close collaboration between surgeons and gastroenterologists is important in achieving the best possible outcomes for the bleeding patient.
Timing of surgical intervention
Early surgical involvement in the management of a patient at high risk for recurrent bleeding, despite endoscopic intervention, is often optimal to assure continuity of care and to determine inflection points in the patient’s course that may require a change of approach. The mortality for elective operations for bleeding peptic ulcer is reported to be 2% whereas emergency ulcer operations carry a mortality of up to 30%.
Over recent decades, medical and endoscopic management has significantly improved the outlook for patients with upper GI bleed, reducing the mortality by 40%. Operative interventions for uncontrolled hemorrhage decreased by 86% in one report, while operative interventions for perforated ulcer increased by 30% over 2 decades. For peptic ulcer disease, the urgent or emergency surgical intervention currently takes place in only 2% of patients admitted to hospital. Of these, however, 3% die of uncontrolled bleeding during surgery, and approximately 30% die in the 30 days following the operative procedures. This statistic clearly demonstrates the significant morbidity and mortality associated with the need for surgical intervention in patients with an upper GI bleed. Given the increasing proportion of elderly patients presenting with upper GI bleed, this is likely to increase.
Contributing to this high complication rate is the preselection of patients for surgery who have already failed medical and endoscopic management. Many times, these patients have progressed on a physiologic downward slope described by the time elapsed since admission and the number of blood transfusions. The associated immunologic response results in decreased reserve to withstand the additional stress of a surgical procedure ( Fig. 1 ).
Several studies report better outcomes after surgical therapy if it is performed within 48 hours of admission. In addition, if surgery is performed before the fourth to tenth transfusion, outcomes are improved. The urgency of intervention is supported by improved outcomes when endoscopy is performed within 24 hours of presentation. This improvement is mirrored by recent findings for other acute abdominal conditions in elderly patients, in whom swift surgical intervention (under the assumption of severe comorbidities) leads to improved outcomes compared with a lengthy workup to optimize the medical condition.
Endoscopic management is less invasive and is the preferred option in the treatment of upper GI bleeding in most circumstances, unless the patient cannot be stabilized. A recent consensus statement endorses a second endoscopic intervention if bleeding recurs after initially successful treatment. A second recurrence should prompt consideration of surgical intervention, although angiographic interventions can also be considered if the expertise is available, especially for high-risk surgical patients. Recently, endoscopic ultrasound-directed fine-needle angiotherapy has been reported to be successful for operative candidates with refractory bleeding from GI stromal tumors (GISTs), pseudoaneurysms, and ectopic varices.
Goals of surgical intervention
In an emergency setting the swiftest and least invasive procedure to stop the hemorrhage should be used, and this usually entails a laparotomy with oversewing of a bleeding vessel. Patients in hemorrhagic shock undergoing anesthesia may not be able to tolerate the impact of the pneumoperitoneum required for laparoscopy. Pneumoperitoneum leads to decreased venous return due to increased intra-abdominal pressure and increasing acidosis due to carbon dioxide insufflation. Although this is usually well tolerated in stable patients, it may not be appropriate for a hemodynamically unstable patient.
Additional concerns involve the availability of laparoscopic expertise in an emergency situation. A large portion of minimally invasive gastric surgery in the United States is performed for bariatric procedures in centers of excellence. With the increasing development of emergency surgery teams at larger academic centers, the technical expertise may not overlap. Laparoscopic gastric surgery requires an advanced laparoscopic skill set and preferably a dedicated surgical team, which may not be available in the urgent setting.
In the elective setting, minimally invasive surgery is used for gastric wedge resections, neoplasms, or distal gastrectomy for gastric antral vascular ectasia (GAVE) ; however, it is not in widespread use for emergency upper GI bleed.
Goals of surgical intervention
In an emergency setting the swiftest and least invasive procedure to stop the hemorrhage should be used, and this usually entails a laparotomy with oversewing of a bleeding vessel. Patients in hemorrhagic shock undergoing anesthesia may not be able to tolerate the impact of the pneumoperitoneum required for laparoscopy. Pneumoperitoneum leads to decreased venous return due to increased intra-abdominal pressure and increasing acidosis due to carbon dioxide insufflation. Although this is usually well tolerated in stable patients, it may not be appropriate for a hemodynamically unstable patient.
Additional concerns involve the availability of laparoscopic expertise in an emergency situation. A large portion of minimally invasive gastric surgery in the United States is performed for bariatric procedures in centers of excellence. With the increasing development of emergency surgery teams at larger academic centers, the technical expertise may not overlap. Laparoscopic gastric surgery requires an advanced laparoscopic skill set and preferably a dedicated surgical team, which may not be available in the urgent setting.
In the elective setting, minimally invasive surgery is used for gastric wedge resections, neoplasms, or distal gastrectomy for gastric antral vascular ectasia (GAVE) ; however, it is not in widespread use for emergency upper GI bleed.
Options for surgical intervention
As described in other articles by Acosta R; Wong RKH elsewhere in this issue, the differential diagnosis of nonvariceal upper GI bleeding is not short. Most frequently, bleeding is caused by benign duodenal or gastric ulcers, severe stress gastritis, or esophagitis. Other sources include Dieulafoy lesions; Mallory-Weiss tears; neoplastic gastric lesions such as gastric cancer, leiomyomas, lipomas, or lymphomas; Zollinger-Ellison syndrome; or GISTs and esophageal tumors. Angioectasias, such as GAVE, idiopathic angiodysplasia, the telangiectasias of hereditary hemorrhagic telangiectasia, and other vascular lesions such as pseudoaneurysms, postsurgical (anastomotic) bleeding, hemosuccus pancreaticus, and hemobilia can be causes of upper GI bleeding in need of operative intervention.
Here the authors focus on the operative approaches for intraluminal gastric and duodenal bleeding sources, especially peptic ulcer disease, as they are the more likely situations requiring surgical intervention. The operative options for GI bleeding depend significantly on the clinical situation of the patient, the pathophysiology of the bleeding, and the location of the bleeding site.
Peptic ulcer disease
The classic approaches to ulcer surgery were described prior to the introduction to H2 blockers, Helicobacter pylori treatment, and proton-pump inhibitors. Surgery for intractable peptic ulcer disease is now very rare, and many of the previously performed surgical procedures (eg, highly selective vagotomy) are infrequently performed, due to a lack of indication and expertise. For surgeons, ulcer location and concerns for persistent acid hypersecretion have long influenced the choice of operative procedures for peptic ulcer disease. The modified Johnson classification expresses these considerations ( Table 1 ).
| Type | Location | Acid Hypersecretion |
|---|---|---|
| I | Lesser curvature, incisura | No |
| II | Body of stomach, incisura, plus duodenal ulcer (active or healed) | Yes |
| III | Prepyloric | Yes |
| IV | High on lesser curve, near gastroesophageal junction | No |
| V | Anywhere (medication induced) | No |
Gastric ulcers
Type I gastric ulcers at the incisura or the lesser curvature are most frequently benign gastric ulcers, and are rarely associated with excessive acid production; they do not require vagotomy.
Type II and III gastric ulcers, as per the Johnson classification, are thought to be associated with acid hypersecretion and may benefit from acid-reducing interventions. Antrectomy (distal gastrectomy) ( Fig. 2 A) with inclusion of the ulcer and truncal vagotomy may reduce acid production and ulcer recurrence. Proximal gastric vagotomy with ulcer excision is an alternative that can be considered in a patient who requires a less morbid procedure; however, the recurrence rate for this type of ulcer is higher with this approach.
Related posts:
Differential Diagnosis of Upper Gastrointestinal Bleeding Proximal to the Ligament of Trietz
Pathology of Diseases that Cause Upper Gastrointestinal Tract Bleeding
Epidemiology and Demographics of Upper Gastrointestinal Bleeding: Prevalence, Incidence, and Mortality
Pharmacologic Therapy for Nonvariceal Upper Gastrointestinal Bleeding
Radiologic Techniques and Effectiveness of Angiography to Diagnose and Treat Acute Upper Gastrointestinal Bleeding
New Diagnostic Imaging Technologies in Nonvariceal Upper Gastrointestinal Bleeding
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