Surgical therapy options for bleeding gastroduodenal peptic lesions

INTRODUCTION: Mortality rate of bleeding into the upper GIT has remained relatively unchanged during the past 30 years, i.e. about 30%, even though the development of new technologies brought along substantial changes in diagnostic and therapeutic procedures. METHODOLOGY: This work deals with the surgical solution of bleeding into the upper GIT of peptic etiology. It covers a 5-year period (from January 1, 1999 until October 1, 2003) during which time the Regional Hospital in Pardubice admitted 1,310 patients with bleeding into the upper GIT of peptic etiology. 190 of them were hospitalized at the Surgical Clinic due to the developing hemorrhagic shock; the others were hospitalized at the Clinic of Internal Medicine. If it failed urgent endoscopy to stop the bleeding, the patient was referred to undergo an urgent surgery. If the bleeding was stopped by endoscopy yet it recurred after certain time, a second endoscopic homeostasis was attempted. If it failed, an urgent surgery was indicated. RESULTS: A total number of 24 patients underwent an acute surgery. A frequently used procedure was stomach resection, type BII, which was applied to a total number of 12 patients. However, this type of urgent surgery was accompanied with a relatively high number of complications. Reoperation had to be performed 4 times (33.3%). In one case (8.3%) for recurrent bleeding. In 12 patients one of the other procedures was performed: an injection and a trunkal vagotomy (3x), an injection and the ligation of the gastroduodenal artery (2x), proximal jejunum resection (1x), an injection accompanied with fundoplication according to Nissen-Rosseti (1x). Two of the patients who received this other group of procedures had to be reoperated for recurrent bleeding (16.7%). DISCUSSION: The decision about a suitable surgical procedure applicable to bleeding into the upper GIT after the failure of endoscopic homeostasis poses a substantial problem. It is necessary to choose from more radical procedures--resection--that stop bleeding reliably, yet their execution in an acute condition (often coinciding with the patient's hemorrhagic shock) results in a relatively large number of complications; and from less radical procedures that feature a smaller number of post-surgical complications yet that can be burdened with a larger percentile number of recurrent bleeding. Nearly the same number of serious recurrent bleeding in this study indicates that the appropriate choice of a procedure (according to the patient's current condition, ulcer localization, and associated diseases) makes both approaches (resection vs. a less radical procedure) similar as to the number of necessary reoperations after bleeding. CONCLUSION: The development of endoscopic methods introduced significant changes in the diagnostic-therapeutic algorithm of bleeding into the upper GIT. Nevertheless, the choice of an appropriate surgical procedure continues to present a relevant surgical issue.