Diagnosis and treatment of patients with recurrent gastroduodenal hemorrhage - Shaprynskyi V.O. 2009

Surgical treatment of recurrent gastroduodenal ulcer bleeding
Outcomes of surgical treatment in patients with recurrent gastroduodenal hemorrhage

We compared the Treatment outcomes of patients with PUD complicated by AGIB who were treated as follows: Group I in 1996, when an active management strategy was used (i.e., almost all patients presenting with AGIB underwent surgery); Group II between 1999 and 2001, when an individualized expectant strategy was employed; and Group III from 2005 to 2006, utilizing an active individualized rational strategy (Table 6.3.1).

Class="center">Table 6.3.1. Treatment outcomes of patients in the three groups

Comparing the treatment outcomes of patients in different groups, representing three distinct therapeutic approaches, we observe significant changes in key indicators: the number of patients operated on at the height of bleeding, overall mortality, postoperative mortality, and mortality among non-operated patients. The percentage of operated patients decreased by nearly half compared to Groups I and II—36,8 % versus 66,7 % and 66,9 %, respectively. We also observed a reduction in overall mortality among patients with AGIB of ulcer Etiology—15,8 % versus 29,2 % and 29,6 %, respectively. Postoperative mortality in Group I, where active management was used, was 25 %, while mortality among non-operated patients was 37,5 %. In Group II, where patients were managed According to the individualized expectant strategy, postoperative mortality was 16,7 %; this significant reduction was due to a more differentiated approach to selecting Surgical treatment and its indications, although mortality among non-operated patients reached 56,5 %.

In Group III, where patients were treated according to the active individualized rational strategy, we noted a slight decrease in postoperative mortality to 14,3 %, which is associated with a more rational choice of surgical method in patients with PEPTIC ULCER DISEASE complicated by AGIB. However, due to this approach, mortality among non-operated patients decreased to 16,7% (Chart 6.3.1).

Chart 6.3.1. Treatment outcomes of patients in the three groups.

Differences were also observed in The Structure of surgical interventions among patients of the three groups (Table 6.3.2). Thus, in Group I patients with gastric ulcer complicated by AGIB, the following techniques were used: for ulcers located in the cardiac and subcardiac regions, vessel ligation in the ulcer base and devascularization of the ulcer zone (ligation of the left gastric artery) were performed; this surgery was carried out in 2 patients. For ulcers located in the gastric body, wedge (sectoral) gastric resection was used, which was performed in 1 patient.

Table 6.3.2. Structure of surgical interventions in patients of different groups.

If the ulcer was localized in the antral and pyloric Regions of the Stomach, or in the presence of other complications of peptic ulcer disease, resectional Methods of surgical treatment were performed. There were no such patients in Group I. For ulcers located in the duodenum, in the absence of other complications of peptic ulcer disease, ulcer excision followed by pyloro- or duodenoplasty was performed. This surgery was performed in 8 patients of Group I. The Procedure was supplemented by one of the types of vagotomy, with selective vagotomy performed in 4 patients and truncal vagotomy in 4 patients. In the presence of other complications of duodenal ulcer disease, resectional methods of surgical treatment were used: Billroth II gastric resection was performed in 5 patients.

Analyzing the structure of surgical interventions in Group II patients with gastric ulcer disease complicated by AGIB, the following techniques were used: for ulcers located in the cardiac and subcardiac regions of The Stomach, excision with devascularization of the ulcer area was performed in 2 patients. This indicates a shift in the surgical management strategy for these patients. For ulcers located in the gastric body, wedge gastric resection was performed (10 patients). Additionally, in the absence of significant degenerative changes around the gastric ulcer located in the body, antral, or pyloric regions, ulcer excision followed by gastroplasty of the defect with a double-row suture was performed (3 patients). For ulcers located in the antral and pyloric regions, as well as in the gastric body, when other complications besides bleeding were present, resectional methods were applied: Billroth I gastric resection was performed in 5 patients, and Billroth II gastric resection in 1 patient. For duodenal ulcers, the following techniques were used: in the absence of other complications of peptic ulcer disease, ulcer excision followed by pyloro- or duodenoplasty was performed (33 patients). The operation was supplemented by one of the types of vagotomy, with selective vagotomy performed in 15 patients and truncal vagotomy in 17. In the presence of other complications of duodenal ulcer disease, ulcer exclusion followed by pyloroplasty and truncal vagotomy was performed (5 patients), and resectional methods of surgical treatment were used: Billroth I gastric resection was performed in 12 patients, and Billroth II gastric resection in 15. In 2 patients, vessel ligation in the ulcer base was performed. It should also be noted that in 4 patients, a Billroth II gastric exclusion resection was performed for ulcers located in the region of the major duodenal papilla (ampulla of Vater) (Table 6.3.2).

The goal of surgical treatment at the height of recurrent bleeding in gastric and duodenal ulcer disease is to perform the simplest, fastest, and pathogenetically sound surgical intervention that would not only arrest the bleeding but also prevent its recurrence in the postoperative period. However, it should be noted that during urgent and elective surgical interventions, complex forms of peptic ulcer disease are frequently encountered simultaneously, such as ulcers complicated by both penetration and bleeding, perforation and bleeding, double and multiple ulcers, including "kissing" ulcers, giant subcircular and circular ulcers causing gastric outlet and duodenal obstruction, as well as disrupting intestinal motor function.

Given the above, the issue of performing a single-stage, radical, pathogenetically sound operation that would simultaneously correct these disorders and achieve stable recovery becomes particularly relevant.

The extent of surgical intervention in gastric ulcer disease complicated by AGIB depended on the ulcer Location, its size, and the patient's condition. In the presence of a small gastric ulcer (up to 2 cm) with minimal surrounding tissue infiltration, excision of the gastric ulcer within healthy Tissues was performed (6 patients, including 1 patient from Group III); in cases of ulcers larger than 2 cm located in the gastric body, wedge gastric resection was performed (12 patients, including 1 patient from Group III).

We present a clinical case.

Patient B., 46 years old, Case History No. 17659, was admitted to the clinic of hospital surgery on an emergency basis on 06.10.2006. BP - 100/60 mmHg, Ps - 110 bpm. Hb - 68 g/L, erythrocytes - 2.3*109/l, CI - 0.95. Emergency FEGDS was performed. A giant ulcer of the middle third of the gastric body measuring 2 *3 cm was detected, with a visible thrombosed vessel in its center. A large amount of altered Blood and clots was found in the stomach. The patient was examined by a physician: CAD: stable exertional angina FC II. The patient was diagnosed with: Peptic ulcer disease. Giant gastric ulcer complicated by gastric bleeding (F IIa). Grade II hemorrhagic Shock. The risk of AGIB recurrence was assessed using our developed scale and rated as high; the risk of potential mortality was evaluated using the Rockall score—post-endoscopy score was 4, with a predicted mortality rate of 5.3 % (low). Surgical treatment was proposed, which the patient temporarily declined. A series of conservative measures were carried out: hemostatic, antiulcer, infusion, and cardiotropic therapy. The patient's condition stabilized. On 06.10.06 at 12:30, the patient experienced recurrent bleeding: vomiting of fresh blood, loss of consciousness. BP - 70/40 mmHg, Ps - 130 bpm. Emergency surgery was performed for life-saving indications, revealing: an ulcer infiltrate of 4*5 cm in the upper third of the gastric body, with a 4*3 cm ulcer with callous edges, in the center of which was a vessel up to 2 mm actively spurting blood. The stomach, small, and large intestines were filled with blood. Hemostasis was achieved, and a wedge gastric resection was performed. Gastric integrity was restored with double-row sutures in the transverse direction. Abdominal cavity drainage was performed.

The wound was closed in layers.

In the postoperative period, the patient received antibacterial drugs, antisecretory agents, infusion and blood Transfusion Therapy, and analgesics.

Laboratory findings: (7.10.06) Hb - 64 g/L, erythrocytes - 1.9*109/l, CI - 0.95, total protein 47 g/L; total bilirubin 20.0 µmol/L; ALT 1.02 mmol/(h∙L); urea 11.0 mmol/L; K+ - 3.16 mEq/L, Na+ - 144.5 mEq/L, glucose - 5.9 mmol/L, fibrinogen - 2.2 g/L, PI - 107%.

Laboratory findings: (10.10.06) Hb - 78 g/L, erythrocytes - 2.6*109/l, CI - 1.0, total protein 52 g/L; total bilirubin 18.0 µmol/L; ALT 0.6 mmol/(h∙L); urea 8.2 mmol/L; K+ - 3.5 mEq/L, Na+ - 146.8 mEq/L, glucose - 4.8 mmol/L, fibrinogen - 3.5 g/L, PI - 89%.

Laboratory findings: (15.10.06) Hb - 82 g/L, erythrocytes - 2.8*109/l, CI - 1.0, total protein 60 g/L; total bilirubin 24.0 µmol/L; ALT 0.38 mmol/(h∙L); urea 4.6 mmol/L; K+ - 3.7 mEq/L, Na+ - 145.2 mEq/L, glucose - 4.4 mmol/L, fibrinogen - 4.6 g/L, PI - 96%.

The postoperative period was uneventful, and the patient was discharged from the clinic in satisfactory condition on day 12.

In the presence of a large ulcer (larger than 2 cm) in the antral and pyloric regions of the stomach, as well as other complications of peptic ulcer disease, resectional Surgical methods were utilized, specifically performing Billroth I gastric resection (6 patients, including 1 patient from Group III) and Hofmeister-Finsterer gastric resection (2 patients, including 1 patient from Group III).

We present a clinical case.

Patient B., 47 years old, Case History No. 19111, was admitted to the clinic of hospital surgery on an emergency basis on November 3, 2005. BP - 110/70 mmHg, Ps - 98 bpm. Hb - 54 g/L, RBC - 1.5*109/L, CI - 1.0. The patient underwent emergency FEGDS. A giant ulcer measuring 6*4 cm was detected in the region of the gastric angle; it was very deep, with pronounced surrounding mucosal infiltration extending to the pyloric region, and the ulcer base was covered with dirty fibrin and small thrombi. The stomach contained a clear secretion with a dark red tint. The patient was examined by an internist: Metabolic myocardial dystrophy, HF stage 0. The patient was diagnosed with: Peptic ulcer disease. Giant gastric ulcer complicated by gastrointestinal bleeding (Forrest IIb). Severe posthemorrhagic anemia. The risk of acute recurrent gastroduodenal ulcerative bleeding was assessed using the developed scale and rated as high; the risk of mortality was evaluated using the Rockall score: post-endoscopy score was 3, with an estimated mortality rate of 2.9% (low). The patient received a series of conservative measures: hemostatic, antiulcer, infusion, and cardiotropic therapy. The patient's condition stabilized. On November 6, 2005, at 4:05 AM, the patient experienced recurrent bleeding: vomiting of blood clots, loss of consciousness, and profuse melena. BP - 105/70 mmHg, Ps - 106 bpm. Hemostatic therapy was resumed (with octreotide 0.1 IV drip twice daily), along with antiulcer, infusion, and blood transfusion therapy. The patient's condition improved, and the bleeding was controlled conservatively. On November 16, 2005, the patient underwent elective surgery. Intraoperatively, a firm, elastic, poorly mobile ulcerative infiltrate was found on the posterior wall of the gastric antrum, extending from the greater curvature to the gastric angle. The pyloric region of the stomach was involved in the process. Mobilization of the stomach and duodenum was performed. Upon transection of the stomach from the duodenum, an ulcer crater measuring approximately 3 cm in diameter and up to 2.5 cm in depth was found penetrating into the HEAD of the Pancreas. The ulcer was covered with a dirty fibrinous coating. The ulcer was exteriorized.

A Billroth I partial gastrectomy was performed. The abdominal cavity was drained, with drains placed near the ulcer crater and the anastomosis. The wound was closed in layers.

Postoperatively, the patient received antibacterial and antisecretory drugs, infusion-transfusion therapy, and analgesics.

Laboratory findings: (04.11.05) Hb - 54 g/L, RBC - 1.5*109/L, CI - 1.0, total protein 65 g/L; total bilirubin 6.8 µmol/L; ALT 0.1 mmol/(h∙L); urea 12.0 mmol/L; K+ - 4.0 mEq/L, Na+ - 143.7 mEq/L, glucose - 6.2 mmol/L, fibrinogen - 2.2 g/L, PI - 100%.

Laboratory findings: (06.11.05) Hb - 36 g/L, RBC - 1.0*109/L, CI - 1.0, total protein 48 g/L; total bilirubin 6.8; urea 8.2 mmol/L.

Laboratory findings: (18.11.05) Hb - 96 g/L, RBC - 3.2*109/L, CI - 0.9, total protein 76 g/L; total bilirubin 6.8 µmol/L; ALT 0.5 mmol/(h∙L); urea 3.7 mmol/L; K+ - 4.0 mEq/L, Na+ - 143.7 mEq/L, glucose - 5.3 mmol/L, fibrinogen - 4.6 g/L, PI - 86%.

The postoperative period was uneventful; the patient was discharged from the clinic in satisfactory condition on November 25, 2005.

The greatest technical difficulties arise in patients with gastric peptic ulcer disease when the ulcer is localized in the cardiac and subcardiac regions of the stomach. This localization was observed in 2 patients of Group I, where suturing of the bleeding vessel in the ulcer base with devascularization of the ulcer zone was performed, and in 2 patients of Group II; there were no patients with this ulcer localization in Group III. In this case, when gastrointestinal bleeding recurred, ulcer excision and devascularization of the ulcer zone (ligation of the left gastric artery) were performed. In our opinion, this scope of surgery meets all the requirements for surgical interventions performed at the height of active bleeding.

Organ-preserving surgeries should be considered the primary intervention for duodenal peptic ulcers. These include ulcer excision and exteriorization, followed by duodeno- or pyloroduodenoplasty combined with one of the types of vagotomy. Excision, which involves complete removal of the ulcer along with its walls and base, is used when the ulcer is located on the anterior, anterosuperior, or anteroinferior walls, where areas of shallow penetration may be present (48 patients, including 7 patients from Group III).

We present a clinical case observation.

Patient K., 23 years old, Case History No. 15892, was admitted to the clinic of hospital surgery on an emergency basis on September 6, 2006, at 9:25 AM. BP - 110/70 mmHg, Ps - 100 bpm. Hb - 113 g/L, RBC - 3.5*109/L, CI - 0.9. The patient underwent emergency FEGDS. An ulcer measuring up to 1 cm was detected on the anterosuperior wall of the duodenal bulb, with the ulcer base covered in fresh blood. The patient was examined by an internist: neurocirculatory dystonia of the cardiac type. The patient was diagnosed with: Peptic ulcer disease. Ulcer of the anterosuperior wall of the duodenal bulb, complicated by gastrointestinal bleeding (Forrest Ib). The risk of acute recurrent gastroduodenal ulcerative bleeding was assessed using the developed scale and rated as high; the risk of mortality was evaluated using the Rockall score: post-endoscopy score was 6, with an estimated mortality rate of 17.3% (low). The patient received a series of conservative measures: hemostatic, antiulcer, infusion, and cardiotropic therapy. The patient's condition deteriorated. The patient was taken to the operating room on an emergency basis. Intraoperatively, an ulcer measuring up to 1 cm was found on the anterosuperior wall of the duodenal bulb. Hemostasis and excision of the ulcer were performed, followed by pyloroduodenoplasty, selective vagotomy, and abdominal drainage.

The wound was closed in layers.

Postoperatively, the patient received antibacterial drugs, antisecretory agents, infusion therapy, and analgesics.

Laboratory findings: (07.09.06) Hb - 95 g/L, RBC - 3.7*109/L, CI - 0.7, total protein 59 g/L; total bilirubin 8.6 µmol/L; urea 10.4 mmol/L; K+ - 3.7 mEq/L, Na+ - 142 mEq/L, glucose - 5.1 mmol/L, fibrinogen - 3.7 g/L, PI - 100%.

Laboratory findings: (11.09.06) Hb - 87 g/L, RBC - 3.5*109/L, CI - 0.8. The postoperative period was uneventful; the patient was discharged from the clinic in satisfactory condition on September 18, 2006.

In cases of deeply penetrating ulcers, we perform exteriorization of the ulcer outside the duodenal lumen (10 patients, including 5 patients from Group III). From our point of view, this method is radical because an ulcer located outside the lumen of the gastrointestinal tract poses no threat of recurrent bleeding. Such ulcers are predominantly located on the posterior wall of the bulb as well as in the postbulbar region of the duodenum.

We present a clinical case observation.

Patient S., 34 years old, Case History No. 10672, was admitted to the clinic of hospital surgery on an emergency basis on June 11, 2006. BP - 100/60 mmHg, Ps - 100 bpm. Hb - 66 g/L, RBC - 2.18*109/L, CI - 0.9. The patient underwent emergency FEGDS. An ulcerative defect of about 2 cm was found on the posterior wall of the duodenal bulb, with a visible thrombosed vessel in the center. The patient was diagnosed with: Peptic ulcer disease. Ulcer of the posterior wall of the duodenal bulb complicated by gastrointestinal bleeding (Forrest IIa). The risk of acute recurrent gastroduodenal ulcerative bleeding was assessed using the developed scale and rated as high; the risk of mortality was evaluated using the Rockall score: post-endoscopy score was 2, with an estimated mortality rate of 0.2% (low). The patient received a series of conservative measures: hemostatic, antiulcer, infusion, and cardiotropic therapy. The patient's condition deteriorated on June 13, 2006, at 2:30 AM. Hemostatic and infusion therapy were resumed, along with blood transfusion. The patient was taken to the operating room on an emergency basis. Intraoperatively, an ulcerative infiltrate was found along the posterosuperior wall with an ulcer niche up to 1 cm in diameter, penetrating into the head of the pancreas; the ulcer was exteriorized after the vessel in the ulcer base was suture-ligated. Pyloroplasty, selective vagotomy, and abdominal drainage were performed. The wound was closed in layers.

Postoperatively, the patient received antibacterial and antisecretory drugs, infusion therapy, analgesics, and blood transfusions.

Laboratory findings: (12.06.06) Hb - 34 g/L, RBC - 1.3*109/L, CI - 0.78, total protein 55 g/L; total bilirubin 14 µmol/L; urea 11.9 mmol/L; K+ - 3.57 mEq/L, Na+ - 139 mEq/L, glucose - 4.9 mmol/L, fibrinogen - 1.9 g/L, PI - 100%.

Laboratory findings: (19.06.06) Hb - 92 g/L, RBC - 2.8*109/L, CI - 0.78, total protein 52 g/L; total bilirubin 8.6 µmol/L; urea 4.2 mmol/L; K+ - 3.4 mEq/L, Na+ - 144 mEq/L, glucose - 4.9 mmol/L, fibrinogen - 6.4 g/L, PI - 104%. The postoperative period was uneventful; the patient was discharged from the clinic in satisfactory condition on June 22, 2006.

In the presence of a giant ulcer (i.e., more than 2 cm in diameter), other complications besides bleeding, multiple ulcers, or ulcers of dual localization, we prefer resectional methods of surgical treatment with ulcer removal or exteriorization. There were 40 such patients; Billroth I partial gastrectomy was performed in 15 patients, and Hofmeister-Finsterer or Vitebsky modifications were used in 25 patients. In Group III, Billroth I gastrectomy was performed in 3 patients, and the Hofmeister-Finsterer modification was used in 1 patient.

We present a clinical case observation.

Patient M., 26 years old, Case History No. 7719, was admitted to the clinic of hospital surgery on an emergency basis on April 22, 2006. BP - 60/40 mmHg, Ps - 94 bpm. Hb - 61 g/L, RBC - 2.0*109/L, CI - 0.9. According to the medical history, she had been in the neurology department of one of the city hospitals for lumbar osteochondrosis with severe pain syndrome. On April 21, 2006, at 4:35 AM, the patient's condition deteriorated sharply; at 5:30 AM, she was transferred to the surgical department of the same facility. Conservative hemostatic, infusion, and antiulcer therapy was administered. The patient's condition improved, and the bleeding was controlled conservatively. On April 21, 2006, at 10:00 PM, the patient experienced recurrent bleeding; she was examined by a professor and transferred to the department of abdominal surgery of the hospital surgery clinic, where she underwent emergency FEGDS. The stomach contained up to 800 mL of blood clots. The duodenal bulb was severely deformed, with two-thirds of it occupied by a fresh thrombus, and fresh blood was actively flowing from the lumen. The patient was diagnosed with: Peptic ulcer disease. Giant duodenal ulcer complicated by profuse recurrent intestinal bleeding (Forrest Ia). Grade III hemorrhagic shock. The risk of acute recurrent gastroduodenal ulcerative bleeding was assessed using the developed scale and rated as high; the risk of mortality was evaluated using the Rockall score: post-endoscopy score was 5, with an estimated mortality rate of 10.8% (low). After brief preoperative preparation (hemostatic agents, infusion therapy, blood transfusions), the patient was taken to the operating room on an emergency basis. Intraoperatively, a giant semicircular ulcer of the duodenal bulb was found, penetrating into the head of the pancreas and causing stenosis of the duodenal bulb. In the center of the ulcer crater, there was a vessel with ongoing pulsatile bleeding. The vessel was suture-ligated. The ulcer was exteriorized. A Billroth I partial gastrectomy was performed. The abdominal cavity was drained. The wound was closed in layers.

Postoperatively, the patient received antibacterial and antisecretory drugs, infusion and blood transfusion therapy, and analgesics.

Laboratory findings: (22.04.2006) Hb - 61 g/L, RBC - 2.0*109/L, CI - 0.9, total protein 44 g/L; total bilirubin 12 µmol/L; urea 5.4 mmol/L; K+ - 3.6 mEq/L, Na+ - 139 mEq/L, glucose - 6.2 mmol/L, fibrinogen - 2.5 g/L, PI - 100%.

Laboratory findings: (25.04.2006) Hb - 71 g/L, RBC - 2.8*109/L, CI - 0.7, WBC - 9.0*109/L, total protein 48 g/L; total bilirubin 6.8 µmol/L; urea 4.6 mmol/L, glucose - 7.2 mmol/L, fibrinogen - 3.6 g/L, PI - 84%.

Laboratory findings: (1.05.2006) Hb - 101 g/L, RBC - 3.0*109/L, CI - 1.0, WBC - 6.6*109/L.

The postoperative period was uneventful, and the patient was discharged from the clinic in satisfactory condition on 03.05.2006.

In 3 patients across all groups, suturing of the duodenal ulcer was performed during active bleeding; however, this limited scope of intervention was chosen because the patients were in extremely critical condition.

In cases of ARGIB in patients with peptic ulcer disease who had previously undergone surgery for PUD complications, we consider it appropriate to use resectional methods of surgical treatment (1 patient from Group II).

Table 6.3.3. Modifications of surgical interventions in patients with peptic ulcer disease complicated by ARGIB

Comparing the treatment outcomes of the three groups, the postoperative mortality rate after resectional methods in Group III was the same (Table 6.3.3). Therefore, we believe that a mandatory condition for surgical treatment during active ARGIB in gastric and duodenal PUD is performing a pathogenetically justified surgical intervention that not only arrests the bleeding but also prevents its recurrence in the postoperative period. Furthermore, in Group III, 18 surgical interventions were performed on an emergency basis (under 12 hours) and 3 Procedures were delayed (from 12 to 48 hours).

The following postoperative complications occurred (Table 6.3.4).

Table 6.3.4. Postoperative complications in patients with peptic ulcer disease complicated by ARGIB

In Group I patients, where an active surgical strategy was utilized, postoperative complications occurred in 12.5% (2) of cases. Consequently, 2 relaparotomies were performed, and all of these patients died. In Group II, where an individualized watchful waiting strategy was employed, complications occurred in 30.5% (29) of patients. This necessitated 13 relaparotomies, resulting in 6 deaths. Group III patients experienced no postoperative complications. This is because risk prediction combined with an active, individualized, and rational strategy prevented the performance of so-called "desperation surgeries," which are predominantly followed by severe postoperative complications and, ultimately, patient death.

Thus, summarizing the above, the most appropriate strategy for treating patients with peptic ulcer disease complicated by acute recurrent gastrointestinal bleeding is an active, individualized, and rational strategy, which allowed for a reduction in postoperative mortality in these patients from 25 % to 14,3 %, mortality among non-operated patients from 37,5 % to 16,7 %, and overall mortality from 29,6 % to 15,8 %.