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Active Bleeding Duodenal Ulcer: Management During Ten-Year Period
ADDITIONAL ARTICLE
Active Bleeding Duodenal Ulcer Management During Ten-Year Period LOUIS T. PALUMBO, M.D., F.A.C.S. * WENDELL S. SHARPE, M.D., F.A.C.S.**
Active bleeding from a duodenal ulcer is the most frequent complication of duodenal ulcer. It represents the major indication for surgical intervention in our series of cases. In the past we have reported upon our experience with two surgical procedures during an IS-year period; this included all patients with a history of bleeding or with active bleeding.I, 2, 3, 4 With the application of a more positive approach to this problem, embracing all of the facets of coordinated teamwork, ancillary supportive measures, earlier surgical intervention when indicated, utilization of current modalities in technical local management of the ulcer and bleeding vessel, the use of the newer, more conservative gastric surgical procedures, and ample replacement of whole blood with judicious use of monitoring systems for determination of blood loss, the mortality and morbidity rates have been reduced significantly. Purpose
This report includes the entire scope of the active bleeding duodenal ulcer problem in our hospital during a period from January, 1955 to December, 1965. This represents our total experience with 315 patients admitted or transferred to our surgical service with active bleeding. This is a review of the various procedures we performed in the surgical control of the duodenal ulcer diathesis by altering the gastric secretory physiologic phases responsible for the pathogenesis of this disease. In From the Department of Surgery, Veterans Administration Hospital, Des Moines, Iowa. These results will be included in a cooperative ulcer study being conducted by the Veterans Administration, Research in Surgery. * Chief, Surgical Service, Veterans Administration Hospital; Clinical Professor of Surgery, University of Iowa College of Medicine ** Assistant Chief, Surgical Service, Veterans Administration Hospital
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addition, the various technical local modalities performed to control the bleeding ulcer per se are presented.
Classification of Hemorrhage As reported in our previous articles, we continued to use the same classification for bleeding: Massive. Five or more transfusions of 500 ml. of whole blood required in a period of 24 hours to restore and stabilize the circulatory blood volume, if it could be restored, or a hemoglobin concentration of 7 gm. or less on admission. Moderate. Less than five transfusions required to restore and stabilize the blood volume in a period of 24 hours or a hemoglobin concentration of 7 to 10 gm. on admission. Minimal. All others.
Surgical Procedures and Modalities for Control of Bleeding In recent years several new local techniques were adopted to control the bleeding vessel and to manage the ulcer per se. These technical advances have aided in further reducing the morbidity and mortality rates in this series. By the proper application of these principles in consonance with existing local pathology, current patient status, and surgical experience, the surgical procedures performed can be patterned accordingly. This broad choice, which exists today, has in the proper hands advanced the progress of the surgical management of bleeding ulcer. During this period of over ten years, several surgical procedures were performed for control of active bleeding ulcers. Our operation of choice in 1955-1956 was partial gastrectomy with resection of the ulcer. From 19571963, distal antrectomy-vagectomy with resection of the ulcer in most cases was the procedure performed. However, in January, 1963 to September 1, 1965, a variety of surgical procedures was performed patterned in accordance with the individual problem. However, the operation of choice whenever applicable was distal antrectomy-vagectomy. In this same era, the newer modalities of local surgical technical management of the bleeding vessel and ulcer were employed. The application of these reduced the operating time and blood loss, aided in elimination of, and reduced the incidence of, lethal and serious complications, and helped to simplify the technical aspects of ulcer and vascular controls. Combinations of the newer modalities suited to the local pathologic problem are significant features in advancing the rapid progress in the surgical treatment of patients with active bleeding. This entire program, including indications for operation, management, surgical technique and procedures performed, postoperative management, and repeated in-patient follow-up, was employed by all members of our surgical staff under the direction of the same chief of surgery (L.T.P.). All basic denominators, including evaluation methods, in such a study were equally applied to all groups.
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ACTIVE BLEEDING DUODENAL ULCER
Age Distribution The average age in this series was 54 years. The youngest patient was 24 years old and the oldest 82. The greatest number (23 per cent) were in the 40-49 year age group (Table 1). The numbers of patients below and above the age of 50 years were about equal. Thirty per cent of the patients were over 60 years of age and in 11 per cent of the cases, the patients were over 70 years of age. Duration of Symptoms The average duration of symptoms was 9.5 years. In many cases, the history of ulcer with repeated bleeding episodes was over a much longer period than the average. A number of cases had a short history of ulcer symptoms and several had no typical ulcer symptoms prior to the bleeding episode. Preoperative Gastrointestinal Bleeding Massive hemorrhage continues to be the most common type; 46· per cent of the patients were in this classification, 35 per cent were classified as moderate, and 19 per cent minimal (Table 2). Massive hemorrhage is the most frequent type in practically every decade in this group, the highest incidence being in the 20-29 and 40-49 year age groups. Although 42.8 per cent of the patients had a history of three or more Table 1. AGE
NUMBER
PER CENT
20-29 30-39 40-49 50-59 60-69 70 and over
17 70 73 61 57 37 315
5.4 22.2 23.2 19.4 18.1 11.7 100.0
TOTAL
Table 2. AGE
20-29 30-39 40-49 50-59 60-69 70 and over TOTAL
Age Distribution
Age Incidence and Degree oj Hemorrhage
TOTAL NO. PATIENTS
17 70 73 61 57 37 315 cases
MINIMAL
MODERATE
MASSIVE
(per cent)
(per cent)
(per cent)
11.8 21.4 17.8 21.3 17.6 21.6 19.4
35.3 42.9 27.4 36.1 33.3 32.5 34.6
52.9 35.7 54.8 42.6 49.1 45.9 46.0
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Table 3. AGE
20-29 30-39 40-49 50-59 60-69 70 and over TOTALS
T.
PALUMBO, WENDELL S. SHARPE
Age Incidence and Occurrence oj Hemorrhage
INITIAL EPISODE
SECOND EPISODE
(per cent)
(per cent)
17.7 28.6 24.6 24.6 24.6 10.9 74 (23.5%)
29.4 34.3 42.5 34.4 22.8 32.4 106 (33.7%)
THIRD OR MORE
(per cent) 52.9 37.1 32.9 41.0 52.6 56.7 135 (42.8%)
episodes of bleeding before they were seen by the surgeons or were admitted to our service, in recent years there has been a change due to a closer liaison with our medical colleagues and the fact that all patients with upper gastrointestinal bleeding are now seen by both the physician and surgeon at the time of admission. Definitive surgery is carried out earlier in the current episode of bleeding when indicated. Therefore, in time, a lesser number of patients will be seen or permitted to have repeated episodes of massive hemorrhage before definitive surgery is advised. In this series we are seeing more patients during their initial or second episode of hemorrhage than we did in our partial gastrectomy series of ten years ago. It is interesting to note that, in this series, the patients with three or more hemorrhages were in the 20-29 and over 60-year age groups (Table 3). In recent years a cooperative plan was evolved and all patients with bleeding ulcers were admitted to the surgical service but seen by both the surgeon and internist, so in the ensuing years only a few patients were admitted to the medical service with active bleeding.
Type of Procedure Performed A variety of surgical procedures was performed for the active bleeding ulcer. In the early phase of this ten-year study, partial gastrectomy with resection of the ulcer was the operation of choice. Then, for six years, the operation performed was distal antrectomy-vagectomy with resection of the ulcer. When various technical modalities to control the bleeding were introduced, these were then performed with distal antrectomy and other conservative surgical procedures. The other conservative procedures were selected and performed for specific problems and types of patients. These were usually performed in the elderly and poorer-risk patients and in those patients with ulcers that precluded a safe duodenal stump closure if distal antrectomy was to be performed. From our experience with a variety of procedures and with our experience in 450 distal antrectomies-vagectomies performed during a 12-year period, our operation of choice still is distal antrectomy with vagectomy in duodenal ulcer including the active bleeders j however, the
~J
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ACTIVE BLEEDING DUODENAL ULCER
Table 4. AGE
DAV
Surgical Procedures Performed (315 Cases) PG
20-29 8 30-39 32 40-49 49 31 50-59 60-69 39 70 and over 17 TOTALS 176(55.9%)
PV
PGV
GEV
HV
6 1 2 0 26 4 2 3 14 1 1 3 22 2 2 1 7 4 2 3 3 1 3 -12 87(27.6%) 16(5.1%) 12(3.8%) 10(3.2%)
0 0 0 1 1 0 2(0.6%)
TOTALS 17 70* 73* 61* 57* 37* 315
* Isolated cases (12) in which pyloroplasty alone, or a pyloroplasty with a unilateral vagotomy, or gastroenterostomy with unilateral vagotomy was performed (because of difficulty in finding other vagus nerve or patient's condition was too precarious for prolonged operative procedure). DAV - Distal antrectomy-vagectomy PG - Partial gastrectomy PV - Pyloroplasty-vagectomy PGV - Partial gastrectomy-vagectomy GEV - Gastroenterostomy-vagectomy HV - Hemigastrectomy-vagectomy
Table 5.
Surgical Procedures Performed 1963-1965 (91 Cases)
TYPE OF PROCEDURE*
NUMBER
PERCENT
65
71.5 12.0 6.6 3.3 2.2 4.4 100.0
DAV PV GEV PGV PG Otherst TOTAL
11
6 3 2 4 91
* For key to abbreviations, see Table 4. t DAV with unilateral vagectomy, PV with unilateral vagectomy, UV, and P.
various local technical procedures are used for the control of bleeding. This will be described in a subsequent section of this survey. In Table 4, the various procedures performed are tabulated by age groups. Fifty-six per cent were distal antrectomies with vagectomy, and the next most common type of procedure performed was partial gastrectomy (Table 4). During the last few years of this study, the performance of other surgical procedures increased (Table 5) as compared to the overall survey shown in Table 4. Local Modalities for Control of Bleeding Ulcer
Since January 1, 1963, the local control of the bleeding ulcer was accomplished by one of three methods, dependent upon the existing local pathology, condition and age of the patient, and)he_definitive operative procedure suited to the individual problem.
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Recently, most of the ulcers have been left in situ either in the duodenum or on the head of the pancreas. With this policy, we have practically eliminated the complication of acute pancreatitis and have had no deaths from this cause. The three modalities are: (1) transfixation of the bleeding points, leaving the ulcer in situ in the duodenum; (2) separation of the ulcer from the duodenal wall, leaving it in situ on the head of the pancreas with transfixation of the bleeding points; and (3) resection of the ulcer with control of the bleeding vessel. This latter is accomplished only in anterior ulcers and in those cases in which the other modalities cannot be applied because of technical problems posed by the anatomic and pathologic findings. These procedures were performed in 91 patientf'!. The ulcer was left in situ either in the duodenum or on the head of the pancreas in 69 per cent of the cases. In the distal antrectomy-vagectomy group, the ulcer was left in situ in the duodenum in 38 per cent of the cases, in situ on the pancreas in 27 per cent, and it was resected in 35 per cent. EMERGENCY SURGERY
In this group are those patients who lost considerable amounts of blood in a short period of time, failed to stop bleeding, and were not stabilizing with massive replacement of whole blood. Eighty-eight patients were in this category, representing 28 per cent of the entire series of 315 patients with active bleeding. Forty per cent of these patients were over 60 years of age. Table 6.
Total Blood Replacement Emergency Group (88 Cases)
PRIOR TO TRANSFER
(44 Cases) AGE
20-29 30-39 40-49 50-59 60-69 70 and over TOTALS =
One unit
NO. OF PATIENTS
1
UNITS OF BLOOD
3 5 5 4 5 4.5 14 3 3 4 units 44 (50%)* 500 cc. whole blood. 11 10
SURGICAL SERVICE
PREOP.
12 8 9 9 10
10 9 units
DURING
3 2 3 3 3 3 3 units
(88 Cases)
POSTOP.
1 2 2 2 2 3 2 unitst
TOTAL PATIENTS
3 17 21 13 20 14 88 patients
* Percentage of total of 88 cases receiving blood prior to transfer or admission to surgical service. t Only 65 % of the patients received blood postoperatively. Fifty percent of the patients received an average of 18 units of blood; 50% received 14 units of blood.
ACTIVE BLEEDING DUODENAL ULCER
245
Fifty per cent of the patients received 4 units of whole blood prior to admission or transfer to the surgical service. The patients required an average of 9 units of blood preoperatively and 3 units during surgery. Sixty-four per cent of the patients received 2 units of blood postoperatively. Fifty per cent were given a total of 14 units and the other 50 per cent required 18 units (Table 6). Complications-Emergency Group Seventeen complications developed in 14 (16.8 per cent) of the patients
Table 7. Postoperative Complications--84 Surviving Patients. Distal Antrectomy-Vagectomy Group (40 Patients) Cardiopulmonary A telectaSlS 1 Pneumonia 1 2 (5.0%) Wound Dehiscence 1 Infection 1 2 (5.0%) Intra-abdominal Hemorrhage, site unknown 1 1 (2.5%) M iscellaneou8 Jaundice, homologous serum 1 Thrombophlebitis 1
2(5.0%) Five patients (12.4%) developed seven complications. Pyloroplasty (5 Surviving Patients) Wound Dehiscence Miscellaneous Shock
1
1 2 (40.0%) One patient (25.0%) developed both complications.
Partial Gastrectomy (29 Surviving Patients) Cardiopulmonary Atelectasis 2 Infarction (pulmonary) 1 Pneumonia 1 4 (13.3%) Wound Abscess 2 Infection 2 - --4 (13.3%) I ntTa-abdominal Abscess, subhepatic 1 Gastric atony 1 2 (6.6%) Eight patients (26.6%) developed 10 complications.
* 16.7% of group developed complications.
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Table 8. AGE
20-29 30-39 40-49 50-59
DEATHS
1 pyloroplasty 3
!PYloro_,
AGE
39
62 55 vagotomy distal antrectomy, 65 vagectomy
60-69
20
70 and over
14 88(28%) 4(4.5%)
TOTALS
PALUMBO, WENDELL S. SHARPE
Emergent;)! Surgery jor Massive Hemorrhage (88 Cases)
NUMBER OF PATIENTS
3 17 21 13
T.
CAUSE
Hepatic-cardiac Coronary occlusion Bronchopneumonia Bronchopneumonia, atelectasis
who survived in this category. The most frequent types were cardiopulmonary and of the wound (Table 7). There were no cases of pancreatitis or duodenal leaks. The ulcer was resected in 25 per cent of the patients; left in situ in the duodenum with transfixation of the bleeding vessel in 32 per cent; and in 42 per cent the ulcer was left on the head of the pancreas and the bleeding vessel was transfixed.
Mortality-Emergency Group Two (50 per cent) of the four deaths occurred in patients over 60 years of age. There were two deaths (4.7 per cent) in the group of 42 patients in the category upon whom a distal antrectomy-vagectomy was performed. The two deaths were due to conditions unrelated to the type of procedure performed; one was due to bronchopneumonia and the other was due to bronchopneumonia and atelectasis. Hepatic and cardiac failure caused the death of a poor-risk patient who was 39 years old. His condition was so precarious that only a pyloroplasty with transfixation of the bleeding vessel could be accomplished. A 62-year-old, very poor-risk patient with hypertensive cardiovascular renal disease and hemiplegia died from coronary occlusion following a pyloroplasty-vagotomy with transfixation. The overall mortality from all causes in this group including all operations was only 4.5 per cent.
URGENT SURGERY
Seventy-four patients (23.5 per cent) of the entire series in this classification were those who lost a great quantity of blood during a longer period of time than the emergency group but with less rapidity of loss. They all required massive whole blood replacement. This was accomplished not as rapidly but over a little longer period of time than the other group.
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ACTIVE BLEEDING DUODENAL ULCER
Twenty-eight per cent of these patients were over 60 years of age. Twenty-three per cent of this group received on the average 4 units of whole blood prior to admission or transfer to our service. They required 1 unit less of whole blood preoperatively than the emergency group-an average of 8 units. They received 2 units during surgery and only 35 per cent of the group required blood postoperatively, an average of 2 units (Table 9). The period of treatment prior to surgery was at least five hours longer in this group as compared to the emergency group. The longest period of time was in the patients over 60 years of age. The time factor may be misleading in that many of these patients may have stopped bleeding for a period of time and then rebled but this time more rapidly. These patients required about 2 units less than the emergent group.
Postoperative Complications-Urgent Group Twenty-four (32.9 per cent) complications developed in 18 (24.1 per cent) of the 73 patients who survived. There were no cases of acute pancreatitis and only two cases of duodenal leaks (Table 10). The ulcer was resected in 37.8 per cent of the patients; left in situ in the duodenum with transfixation of the bleeding vessel in 28.4 per cent; and in 33.8 per cent of the patients the ulcer was left on the head of the pancreas with transfixation of the bleeding vessel.
Mortality-Urgent Group There was one death (1.3 per cent) in 74 patients in this group. In Table 9.
Total Blood Replacement in Urgent Group (74 Cases)
PRIOR TO TRANSFER
(74 Cases) Units of Blood
SURGICAL SERVICE
(17 Cases)
AGE
20-29 30-39 40-49 50-59 60-69 70 and over TOTALS
Number of Patients 1 4 2 3 5 2 17 (23%)*
Units of Blood
6 4 6 5 2 3 4 units (average)
Preop.
10
8 7.5 8 8 9 8 units
During
3 2.5 2 2 2 3 2 units
Postop.
2 1
1 1 2 3 2 unitst
TOTAL PATIENTS
4 18 14 17 11 10
74 patients
* Percentage of 74 cases receiving blood prior to transfer or admission to surgical service. t Only 34% of the patients received blood postoperatively. Minimal amount of blood received was 10 units (5000 ee.).
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Table 10.
T.
PALUMBO, WENDELL S. SHARPE
Postoperative Complications in 73 Surviving Patients*
Distal Antrectomy-Vagectomy (47 Surviving Patients) Cardiopulmonary Pneumonia 2 2 (4.2%) Wound
Dehiscence Infection Intra-abdominal Abscess, subphrenic Intestinal obstruction Leak, duodenal stump Peritonitis, acute
1 2 3 (6.4%) 1
2 1 1
5 (10.6%) M iBcellaneous
Electrolyte imbalance
1
1 (2.1%) Nine patients (19.1%) developed 11 complications. Pyloroplasty-Vagotomy (16 Patients) Wound Abscess
1 (6.2%)
Gastroenterostomy-Vagotomy (10 Patients) Intra-abdominal Duodenal fistula 1 Hemorrhage, site unknown 1 2 M iBcellaneous
Shock 1 All complications were in one patient. Partial Gastrectomy (19 Patients) Cardiopulmonary Pneumonia
1 1 (5.2%)
Wound
Abscess Intra-abdominal Abscess, subhepatic Hemorrhage, intraperitoneal
1 1 (5.2%) 1 1 2 (10.4%)
Miscellaneous
Diarrhea, enterocolitis, specific Jaundice, homologous serum Thrombophlebitis Urinary retention
1 1 1
2 5 (26.3%) Six patients (31.6%) developed 9 complications.
* 24.1 % of the patients developed complications.
ACTIVE BLEEDING DUODENAL ULCER
249
the 67 patients upon whom a distal antrectomy-vagectomy was performed, one death (1.5 per cent) occurred. This was in a 69-year-old patient who died within 24 hours from cardiac failure and pulmonary edema. The combined mortality in the emergent-urgent groups was 3 per cent (five deaths in 162 cases).
EARLY ELECTIVE SURGERY
This represents 153 (48.6 per cent) of the entire series of 315 patients with active bleeding. Therefore, of the entire group who were admitted or transferred to our service with active bleeding, over one-half (51.5 per cent) were operated upon as an emergency or urgent case. The remainder of patients fell in the group with minimal bleeding or who stopped bleeding shortly after admission or transfer or who were the slow continuous type bleeders. The combined opinion of the staff, in this group, favored delayed surgery which was carried out at a more favorable time. The time factor was dependent upon the problems confronting each case. The majority of these patients had a long ulcer history, a story of repeated hemorrhages. Many of them were slow bleeders. Therefore, the time of surgery was delayed to about five days following the onset of active bleeding. Fifty-four per cent of this group were under 50 years of age; 25 per cent were over 60 years of age. The procedures performed were: Distal antrectomy-vagectomy Partial gastrectomy Pyloroplasty-vagotomy Partial gastrectomy-vagotomy Gastroenterostomy-vagotomy Distal antrectomy or partial gastrectomy with left vagectomy and others TOTAL
86 39 8 8
(56.2%) (25.5%) ( 5.3%) ( 5.3%) 4 ( 2.6%)
~
(5.3%) 153 cases
In this group the ulcer was resected in 96 (66.7 per cent) of the cases; 2 left in situ in the duodenum in 22 (15.3 per cent) of the patients; and left in situ on the head of the pancreas in 26 (18 per cent) of the cases. These patients received on an average 3 units of blood prior to admission or transfer to our service. During the five-day interim before surgery, the average number of units of blood given were 5; during surgery 2 units and postoperatively 66 (45 per cent) of the patients were given 1 unit of blood (Table 11). Complications in the Elective Group
The complication rate was the lowest in this group, as would be expected; ten (6.7 per cent) of the 148 surviving patients developed 16 complications (Table 12).
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LOUIS T. PALUMBO, WENDELL S. SHARPE
Table 1t.
Total Blood Replacement in the Early Elective Group (153 Cases) PRIOR TO TRANSFER (79 Cases)
AGE
20-29 30-39 40-49 50-59 60-69 70 andover TOTALS
Number of Patients 4 17 29 12 7 10
79 (51.3%)*
Units of Blood
SURGICAL SERVICE (153 Cases) Units of Blood
Preop.
4.5 3 2 3 3 2.5 3 units
5 5 6 5 5.5 4 5 units
During
Postop.
1.5 1 2 2 1.5 2 2 units
1 1 1 1 1 1 1 unitt
TOTAL PATIENTS
5 10
20 11
9 11
66 patients
* Per cent of total of 153 cases received blood prior to transfer or adInission to surgical service. t Only 43% of the patients received blood postoperatively. Fifty-four per cent of the patients received on an average of 3 units of blood and 46% received 8 units.
Table 12.
Postoperative Complications in 148 Surviving Patients-Elective Group' Distal Antrectomy-Vagectomy (81 Cases) 1 Pneumonia 1 Infection, wound 2 (2.5%) Pyloroplasty-Vagotomy (8 Cases) Cardiopulmonary 1 A teIectasis 1 Pneumonia 1 Pulmonary embolism 3 Gastroenterostomy-Vagotomy (4 Cases) Abscess, wound Partial Gastrectomy (39 Cases) Wound Abscess Infection Intra-abdominal Duodenal fistula Gastric atony Stomal obstruction
1
3 2 5 (13%) 1
2 1 4 (10%)
* Ten patients (6.7%) developed 15 complications of the 148 surviving patients in this category.
ACTIVE BLEEDING DUODENAL ULCER
251
Mortality-Elective Group
Five (3.3 per cent) deaths occurred in this group of 148 patients. All of these deaths occurred in the group of 86 patients upon whom a distal antrectomy-vagectomy was performed-a mortality of 5.8 per cent. Deaths occurred: in a 33-year-old poor-risk patient with advanced cirrhosis of the liver causing hepatorenal failure; in a 46-year-old patient from hemorrhagic pancreatitis-a technical death, this followed resection of a deep penetrating duodenal ulcer..(current:policy)s to leave these in situ); in a 51-year-old patient who developedJenal-tubular necrosis;~in:67-year-old patient who died from a fulminating staphylococcus pneumonia; and in a 70-year-old patient who died in less than 48 hours from a massive gas bacillus infection of wound and abdominal wall.
SOME OVERALL ASPECTS Postoperative Rebleeding from the Ulcer Site
Two patients (3.7 per cent) developed rebleeding postoperatively in the group of 54 cases in which the ulcer was left in situ in the duodenum with transfixation of the bleeding vessel. The first case occurred in a 62-year-old patient who had a large posterior penetrating duodenal ulcer. A pyloroplasty-vagotomy with transfixation of the bleeding vessel was performed as an emergency procedure. On two occasions postoperatively the bleeding was treated conservatively, but on the sixth postoperative day massive bleeding recurred. The patient was reoperated upon at which time the gastroduodenal artery was ligated and a distal antrectomy was performed. Repeated follow-up studies revealed an excellent result. The second case occurred in a 45-year-old patient who was operated upon as an urgent case because of massive hemorrhage. A distal antrectomyvagectomy with transfixation of the ulcer in situ was performed. Eight days later the patient had tarry stools and dark blood on nasogastric suction. He was treated by repeated transfusions but not reoperated upon. Bleeding stopped after patient had received 6 units of blood. Follow-up studies revealed patient was doing very well. Marginal Ulcer
Only one patient (0.3 per cent) developed a margina(ulcer. This occurred in a 56-year-old patient who was operated upon as an emergency in 1962. A distal antrectomy-vagectomy was performed. Within six months he had a marginal ulcer; 12-hour overnight secretion was 1175 cc. with 52.9 mEq. of free hydrochloric acid present. At the time of reoperation the cardioesophageal area could not be explored because of adhesions; a higher resection was accomplished. In a two-year follow-up the patient was normal; gastric analysis revealed only
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4.9 mEq. free hydrochloric acid. It is our opinion that an incomplete vagus resection was responsible for this marginal ulcer.
Overall Mortality Of the 315 patients with active bleeding, 162 (53.3 per cent) had emergent or urgent surgery. Five deaths (3 per cent) occurred. All (60 per cent) but two were in patients over 60 years of age. The mortality rate in patients over 60 years was three times greater. In 90 cases, a distal antrectomy-vagectomy was performed; three deaths (3.3 per cent) occurred. The other two deaths were in the group upon whom the following procedures were performed: pyloroplasty (1 case) and pyloroplasty-vagotomy (8 cases).
Follow-up These patients were seen as outpatients six months following operation. They were admitted to the hospital for a complete evaluation at the end of the first year, and again two years later, and every three years thereafter. One hundred and eight cases have been followed for more than five years; 94 cases for three or more years; and 91 are due for the first and second year follow-ups.
COMMENT
Massive hemorrhage continues to be the major indication for surgical intervention in patients in all age groups with chronic duodenal ulcer. Bleeding or hemorrhage remains the most frequent complication of this chronic disease. Patients are now seen and admitted earlier in their episode of bleeding than formerly. By the application of the basic principles outlined earlier in this survey, a significant reduction in the morbidity and mortality rates has occurred. Many of these patients have a long history of duodenal ulcer and many have passed through several episodes of severe bleeding in the past, particularly the patients in the older age groups. Because of this, it is important for all of us, particularly our medical colleagues, to refer these patients for surgery earlier in their disease and earlier during a bleeding episode. If the indications for surgery exist, because of complications of the disease, then it is important that an operation 'be performed before the patient becomes older. Our experience in over 800 bleeders during the past 19 years shows that patients 60 years or older are a poorer risk because of intercurrent diseases or conditions. Surgical risk in these patients is four times greater than in patients under 50 years of age. Many of the lethal complications occurring in this age group are beyond the control of the surgeon or the surgical procedure per se that is performed. With a greater number of conservative surgical procedures available and with the judicious application of the various local technical modalities of control of the
ACTIVE BLEEDING DUODENAL ULCHR
253
bleeding ulcer, the morbidity and mortality rates have been reduced even in the older age groups. The overall mortality rate in the 315 cases with active bleeding was 3.1 per cent. It was highest (4.5 per cent) in the emergency group and lowest in the urgent (1.3 per cent) group. No deaths occurred in 95 consecutive and un selected patients under the age of 61 years in the emergent and urgent groups, upon whom a distal antrectomy-vagectomy was performed. These significant reductions in the mortality and morbidity rates are based upon many factors; closer liaison between the internist and the surgeon, earlier admiEsion to the hospital, earlier surgical intervention when indicated, seasoned judgment for selection of time of intervention, adequate blood replacement, judicious utilization of monitoring systems to determine blood replacement needs, better supportive measures and ancillary support, improvement in anesthesia, closer surveillance during the postoperative period in recovery and intensive care units, and finally the surgical procedure performed with careful selection of the local technical modality to control the bleeding ulcer per se.
SUMMARY AND CONCLUSIONS
This is a survey of our experience with 315 patients with active bleeding from a duodenal ulcer from January, 1955 to December, 1965. During this period a number of surgical procedures were performed including, in the latter part of the survey period, a variety of local technical modalities to control the ulcer and bleeding vessel. Hemorrhage from a duodenal ulcer continues to be our major indication for surgical intervention. The mortality and morbidity rates have decreased in our series as a result of closer liaison with our medical colleagues, by effective organized positive treatment and ancillary supportive measures, adequate and rapid whole blood replacement, careful monitoring of blood loss and replacement needs, seasoned surgical judgment in selection of time for intervention, and type of surgical procedure suited to the individual case applying the newer local technical modalities to control the bleeding ulcer per se. Persistent conservative management in the face of all hazards associated in the long-term history of chronic duodenal ulcer and allowing a patient with complications of this disease to become too old before referral for surgical intervention is a policy which most frequently results in prolonged disability and finally in a higher morbidity and mortality rates. This latter can be four times greater than in a patient below the age of 60 years. The current conservative surgical procedures with the various methods of local technical control of the ulcer and bleeding vessel have aided in decreasing the morbidity and mortality rates. These have greatly been
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influenced, also, by the degree and the duration of hemorrhage, the intercurrent diseases, and the age of the patient. Distal antrectomy with vagectomy, utilizing the methods of surgical technical control of the bleeding ulcer, continues to be our operation of choice in bleeding duodenal ulcer, particularly in patients under the age of 60 years. Beyond this age group other procedures are also performed as shown in this study.
REFERENCES 1. Palumbo, L. T., and Sharpe, W. S.: Bleeding duodenal ulcer: Comparison of our results in 715 cases. Surgery 58: 473, 1965. 2. Palumbo, L. T., and Sharpe, W. S.: Dist.al antrectomy with vagectomy for duodenal ulcer. Review of 450 cases. Arch. Surg. 87: 1040,1963. 3. Palumbo, L. T., and Sharpe, W. S.: Distal antrectomy with vagectomy. Over fiveyear follow-up in 158 cases. Arch. Surg. 91: 684,1965. 4. Palumbo, L. T., Sharpe, W. S., et al: Distal antrectomy with vagectomy: Results in 265 cases of chronic duodenal ulcer with hemorrhage. Arch. Surg. 89: 637, 1964.
Veterans Administration Center Des Moines, Iowa 50308
Active Bleeding Duodenal Ulcer Management During Ten-Year Period LOUIS T. PALUMBO, M.D., F.A.C.S. * WENDELL S. SHARPE, M.D., F.A.C.S.**
Active bleeding from a duodenal ulcer is the most frequent complication of duodenal ulcer. It represents the major indication for surgical intervention in our series of cases. In the past we have reported upon our experience with two surgical procedures during an IS-year period; this included all patients with a history of bleeding or with active bleeding.I, 2, 3, 4 With the application of a more positive approach to this problem, embracing all of the facets of coordinated teamwork, ancillary supportive measures, earlier surgical intervention when indicated, utilization of current modalities in technical local management of the ulcer and bleeding vessel, the use of the newer, more conservative gastric surgical procedures, and ample replacement of whole blood with judicious use of monitoring systems for determination of blood loss, the mortality and morbidity rates have been reduced significantly. Purpose
This report includes the entire scope of the active bleeding duodenal ulcer problem in our hospital during a period from January, 1955 to December, 1965. This represents our total experience with 315 patients admitted or transferred to our surgical service with active bleeding. This is a review of the various procedures we performed in the surgical control of the duodenal ulcer diathesis by altering the gastric secretory physiologic phases responsible for the pathogenesis of this disease. In From the Department of Surgery, Veterans Administration Hospital, Des Moines, Iowa. These results will be included in a cooperative ulcer study being conducted by the Veterans Administration, Research in Surgery. * Chief, Surgical Service, Veterans Administration Hospital; Clinical Professor of Surgery, University of Iowa College of Medicine ** Assistant Chief, Surgical Service, Veterans Administration Hospital
239
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addition, the various technical local modalities performed to control the bleeding ulcer per se are presented.
Classification of Hemorrhage As reported in our previous articles, we continued to use the same classification for bleeding: Massive. Five or more transfusions of 500 ml. of whole blood required in a period of 24 hours to restore and stabilize the circulatory blood volume, if it could be restored, or a hemoglobin concentration of 7 gm. or less on admission. Moderate. Less than five transfusions required to restore and stabilize the blood volume in a period of 24 hours or a hemoglobin concentration of 7 to 10 gm. on admission. Minimal. All others.
Surgical Procedures and Modalities for Control of Bleeding In recent years several new local techniques were adopted to control the bleeding vessel and to manage the ulcer per se. These technical advances have aided in further reducing the morbidity and mortality rates in this series. By the proper application of these principles in consonance with existing local pathology, current patient status, and surgical experience, the surgical procedures performed can be patterned accordingly. This broad choice, which exists today, has in the proper hands advanced the progress of the surgical management of bleeding ulcer. During this period of over ten years, several surgical procedures were performed for control of active bleeding ulcers. Our operation of choice in 1955-1956 was partial gastrectomy with resection of the ulcer. From 19571963, distal antrectomy-vagectomy with resection of the ulcer in most cases was the procedure performed. However, in January, 1963 to September 1, 1965, a variety of surgical procedures was performed patterned in accordance with the individual problem. However, the operation of choice whenever applicable was distal antrectomy-vagectomy. In this same era, the newer modalities of local surgical technical management of the bleeding vessel and ulcer were employed. The application of these reduced the operating time and blood loss, aided in elimination of, and reduced the incidence of, lethal and serious complications, and helped to simplify the technical aspects of ulcer and vascular controls. Combinations of the newer modalities suited to the local pathologic problem are significant features in advancing the rapid progress in the surgical treatment of patients with active bleeding. This entire program, including indications for operation, management, surgical technique and procedures performed, postoperative management, and repeated in-patient follow-up, was employed by all members of our surgical staff under the direction of the same chief of surgery (L.T.P.). All basic denominators, including evaluation methods, in such a study were equally applied to all groups.
241
ACTIVE BLEEDING DUODENAL ULCER
Age Distribution The average age in this series was 54 years. The youngest patient was 24 years old and the oldest 82. The greatest number (23 per cent) were in the 40-49 year age group (Table 1). The numbers of patients below and above the age of 50 years were about equal. Thirty per cent of the patients were over 60 years of age and in 11 per cent of the cases, the patients were over 70 years of age. Duration of Symptoms The average duration of symptoms was 9.5 years. In many cases, the history of ulcer with repeated bleeding episodes was over a much longer period than the average. A number of cases had a short history of ulcer symptoms and several had no typical ulcer symptoms prior to the bleeding episode. Preoperative Gastrointestinal Bleeding Massive hemorrhage continues to be the most common type; 46· per cent of the patients were in this classification, 35 per cent were classified as moderate, and 19 per cent minimal (Table 2). Massive hemorrhage is the most frequent type in practically every decade in this group, the highest incidence being in the 20-29 and 40-49 year age groups. Although 42.8 per cent of the patients had a history of three or more Table 1. AGE
NUMBER
PER CENT
20-29 30-39 40-49 50-59 60-69 70 and over
17 70 73 61 57 37 315
5.4 22.2 23.2 19.4 18.1 11.7 100.0
TOTAL
Table 2. AGE
20-29 30-39 40-49 50-59 60-69 70 and over TOTAL
Age Distribution
Age Incidence and Degree oj Hemorrhage
TOTAL NO. PATIENTS
17 70 73 61 57 37 315 cases
MINIMAL
MODERATE
MASSIVE
(per cent)
(per cent)
(per cent)
11.8 21.4 17.8 21.3 17.6 21.6 19.4
35.3 42.9 27.4 36.1 33.3 32.5 34.6
52.9 35.7 54.8 42.6 49.1 45.9 46.0
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Table 3. AGE
20-29 30-39 40-49 50-59 60-69 70 and over TOTALS
T.
PALUMBO, WENDELL S. SHARPE
Age Incidence and Occurrence oj Hemorrhage
INITIAL EPISODE
SECOND EPISODE
(per cent)
(per cent)
17.7 28.6 24.6 24.6 24.6 10.9 74 (23.5%)
29.4 34.3 42.5 34.4 22.8 32.4 106 (33.7%)
THIRD OR MORE
(per cent) 52.9 37.1 32.9 41.0 52.6 56.7 135 (42.8%)
episodes of bleeding before they were seen by the surgeons or were admitted to our service, in recent years there has been a change due to a closer liaison with our medical colleagues and the fact that all patients with upper gastrointestinal bleeding are now seen by both the physician and surgeon at the time of admission. Definitive surgery is carried out earlier in the current episode of bleeding when indicated. Therefore, in time, a lesser number of patients will be seen or permitted to have repeated episodes of massive hemorrhage before definitive surgery is advised. In this series we are seeing more patients during their initial or second episode of hemorrhage than we did in our partial gastrectomy series of ten years ago. It is interesting to note that, in this series, the patients with three or more hemorrhages were in the 20-29 and over 60-year age groups (Table 3). In recent years a cooperative plan was evolved and all patients with bleeding ulcers were admitted to the surgical service but seen by both the surgeon and internist, so in the ensuing years only a few patients were admitted to the medical service with active bleeding.
Type of Procedure Performed A variety of surgical procedures was performed for the active bleeding ulcer. In the early phase of this ten-year study, partial gastrectomy with resection of the ulcer was the operation of choice. Then, for six years, the operation performed was distal antrectomy-vagectomy with resection of the ulcer. When various technical modalities to control the bleeding were introduced, these were then performed with distal antrectomy and other conservative surgical procedures. The other conservative procedures were selected and performed for specific problems and types of patients. These were usually performed in the elderly and poorer-risk patients and in those patients with ulcers that precluded a safe duodenal stump closure if distal antrectomy was to be performed. From our experience with a variety of procedures and with our experience in 450 distal antrectomies-vagectomies performed during a 12-year period, our operation of choice still is distal antrectomy with vagectomy in duodenal ulcer including the active bleeders j however, the
~J
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ACTIVE BLEEDING DUODENAL ULCER
Table 4. AGE
DAV
Surgical Procedures Performed (315 Cases) PG
20-29 8 30-39 32 40-49 49 31 50-59 60-69 39 70 and over 17 TOTALS 176(55.9%)
PV
PGV
GEV
HV
6 1 2 0 26 4 2 3 14 1 1 3 22 2 2 1 7 4 2 3 3 1 3 -12 87(27.6%) 16(5.1%) 12(3.8%) 10(3.2%)
0 0 0 1 1 0 2(0.6%)
TOTALS 17 70* 73* 61* 57* 37* 315
* Isolated cases (12) in which pyloroplasty alone, or a pyloroplasty with a unilateral vagotomy, or gastroenterostomy with unilateral vagotomy was performed (because of difficulty in finding other vagus nerve or patient's condition was too precarious for prolonged operative procedure). DAV - Distal antrectomy-vagectomy PG - Partial gastrectomy PV - Pyloroplasty-vagectomy PGV - Partial gastrectomy-vagectomy GEV - Gastroenterostomy-vagectomy HV - Hemigastrectomy-vagectomy
Table 5.
Surgical Procedures Performed 1963-1965 (91 Cases)
TYPE OF PROCEDURE*
NUMBER
PERCENT
65
71.5 12.0 6.6 3.3 2.2 4.4 100.0
DAV PV GEV PGV PG Otherst TOTAL
11
6 3 2 4 91
* For key to abbreviations, see Table 4. t DAV with unilateral vagectomy, PV with unilateral vagectomy, UV, and P.
various local technical procedures are used for the control of bleeding. This will be described in a subsequent section of this survey. In Table 4, the various procedures performed are tabulated by age groups. Fifty-six per cent were distal antrectomies with vagectomy, and the next most common type of procedure performed was partial gastrectomy (Table 4). During the last few years of this study, the performance of other surgical procedures increased (Table 5) as compared to the overall survey shown in Table 4. Local Modalities for Control of Bleeding Ulcer
Since January 1, 1963, the local control of the bleeding ulcer was accomplished by one of three methods, dependent upon the existing local pathology, condition and age of the patient, and)he_definitive operative procedure suited to the individual problem.
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Recently, most of the ulcers have been left in situ either in the duodenum or on the head of the pancreas. With this policy, we have practically eliminated the complication of acute pancreatitis and have had no deaths from this cause. The three modalities are: (1) transfixation of the bleeding points, leaving the ulcer in situ in the duodenum; (2) separation of the ulcer from the duodenal wall, leaving it in situ on the head of the pancreas with transfixation of the bleeding points; and (3) resection of the ulcer with control of the bleeding vessel. This latter is accomplished only in anterior ulcers and in those cases in which the other modalities cannot be applied because of technical problems posed by the anatomic and pathologic findings. These procedures were performed in 91 patientf'!. The ulcer was left in situ either in the duodenum or on the head of the pancreas in 69 per cent of the cases. In the distal antrectomy-vagectomy group, the ulcer was left in situ in the duodenum in 38 per cent of the cases, in situ on the pancreas in 27 per cent, and it was resected in 35 per cent. EMERGENCY SURGERY
In this group are those patients who lost considerable amounts of blood in a short period of time, failed to stop bleeding, and were not stabilizing with massive replacement of whole blood. Eighty-eight patients were in this category, representing 28 per cent of the entire series of 315 patients with active bleeding. Forty per cent of these patients were over 60 years of age. Table 6.
Total Blood Replacement Emergency Group (88 Cases)
PRIOR TO TRANSFER
(44 Cases) AGE
20-29 30-39 40-49 50-59 60-69 70 and over TOTALS =
One unit
NO. OF PATIENTS
1
UNITS OF BLOOD
3 5 5 4 5 4.5 14 3 3 4 units 44 (50%)* 500 cc. whole blood. 11 10
SURGICAL SERVICE
PREOP.
12 8 9 9 10
10 9 units
DURING
3 2 3 3 3 3 3 units
(88 Cases)
POSTOP.
1 2 2 2 2 3 2 unitst
TOTAL PATIENTS
3 17 21 13 20 14 88 patients
* Percentage of total of 88 cases receiving blood prior to transfer or admission to surgical service. t Only 65 % of the patients received blood postoperatively. Fifty percent of the patients received an average of 18 units of blood; 50% received 14 units of blood.
ACTIVE BLEEDING DUODENAL ULCER
245
Fifty per cent of the patients received 4 units of whole blood prior to admission or transfer to the surgical service. The patients required an average of 9 units of blood preoperatively and 3 units during surgery. Sixty-four per cent of the patients received 2 units of blood postoperatively. Fifty per cent were given a total of 14 units and the other 50 per cent required 18 units (Table 6). Complications-Emergency Group Seventeen complications developed in 14 (16.8 per cent) of the patients
Table 7. Postoperative Complications--84 Surviving Patients. Distal Antrectomy-Vagectomy Group (40 Patients) Cardiopulmonary A telectaSlS 1 Pneumonia 1 2 (5.0%) Wound Dehiscence 1 Infection 1 2 (5.0%) Intra-abdominal Hemorrhage, site unknown 1 1 (2.5%) M iscellaneou8 Jaundice, homologous serum 1 Thrombophlebitis 1
2(5.0%) Five patients (12.4%) developed seven complications. Pyloroplasty (5 Surviving Patients) Wound Dehiscence Miscellaneous Shock
1
1 2 (40.0%) One patient (25.0%) developed both complications.
Partial Gastrectomy (29 Surviving Patients) Cardiopulmonary Atelectasis 2 Infarction (pulmonary) 1 Pneumonia 1 4 (13.3%) Wound Abscess 2 Infection 2 - --4 (13.3%) I ntTa-abdominal Abscess, subhepatic 1 Gastric atony 1 2 (6.6%) Eight patients (26.6%) developed 10 complications.
* 16.7% of group developed complications.
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LOUIS
Table 8. AGE
20-29 30-39 40-49 50-59
DEATHS
1 pyloroplasty 3
!PYloro_,
AGE
39
62 55 vagotomy distal antrectomy, 65 vagectomy
60-69
20
70 and over
14 88(28%) 4(4.5%)
TOTALS
PALUMBO, WENDELL S. SHARPE
Emergent;)! Surgery jor Massive Hemorrhage (88 Cases)
NUMBER OF PATIENTS
3 17 21 13
T.
CAUSE
Hepatic-cardiac Coronary occlusion Bronchopneumonia Bronchopneumonia, atelectasis
who survived in this category. The most frequent types were cardiopulmonary and of the wound (Table 7). There were no cases of pancreatitis or duodenal leaks. The ulcer was resected in 25 per cent of the patients; left in situ in the duodenum with transfixation of the bleeding vessel in 32 per cent; and in 42 per cent the ulcer was left on the head of the pancreas and the bleeding vessel was transfixed.
Mortality-Emergency Group Two (50 per cent) of the four deaths occurred in patients over 60 years of age. There were two deaths (4.7 per cent) in the group of 42 patients in the category upon whom a distal antrectomy-vagectomy was performed. The two deaths were due to conditions unrelated to the type of procedure performed; one was due to bronchopneumonia and the other was due to bronchopneumonia and atelectasis. Hepatic and cardiac failure caused the death of a poor-risk patient who was 39 years old. His condition was so precarious that only a pyloroplasty with transfixation of the bleeding vessel could be accomplished. A 62-year-old, very poor-risk patient with hypertensive cardiovascular renal disease and hemiplegia died from coronary occlusion following a pyloroplasty-vagotomy with transfixation. The overall mortality from all causes in this group including all operations was only 4.5 per cent.
URGENT SURGERY
Seventy-four patients (23.5 per cent) of the entire series in this classification were those who lost a great quantity of blood during a longer period of time than the emergency group but with less rapidity of loss. They all required massive whole blood replacement. This was accomplished not as rapidly but over a little longer period of time than the other group.
247
ACTIVE BLEEDING DUODENAL ULCER
Twenty-eight per cent of these patients were over 60 years of age. Twenty-three per cent of this group received on the average 4 units of whole blood prior to admission or transfer to our service. They required 1 unit less of whole blood preoperatively than the emergency group-an average of 8 units. They received 2 units during surgery and only 35 per cent of the group required blood postoperatively, an average of 2 units (Table 9). The period of treatment prior to surgery was at least five hours longer in this group as compared to the emergency group. The longest period of time was in the patients over 60 years of age. The time factor may be misleading in that many of these patients may have stopped bleeding for a period of time and then rebled but this time more rapidly. These patients required about 2 units less than the emergent group.
Postoperative Complications-Urgent Group Twenty-four (32.9 per cent) complications developed in 18 (24.1 per cent) of the 73 patients who survived. There were no cases of acute pancreatitis and only two cases of duodenal leaks (Table 10). The ulcer was resected in 37.8 per cent of the patients; left in situ in the duodenum with transfixation of the bleeding vessel in 28.4 per cent; and in 33.8 per cent of the patients the ulcer was left on the head of the pancreas with transfixation of the bleeding vessel.
Mortality-Urgent Group There was one death (1.3 per cent) in 74 patients in this group. In Table 9.
Total Blood Replacement in Urgent Group (74 Cases)
PRIOR TO TRANSFER
(74 Cases) Units of Blood
SURGICAL SERVICE
(17 Cases)
AGE
20-29 30-39 40-49 50-59 60-69 70 and over TOTALS
Number of Patients 1 4 2 3 5 2 17 (23%)*
Units of Blood
6 4 6 5 2 3 4 units (average)
Preop.
10
8 7.5 8 8 9 8 units
During
3 2.5 2 2 2 3 2 units
Postop.
2 1
1 1 2 3 2 unitst
TOTAL PATIENTS
4 18 14 17 11 10
74 patients
* Percentage of 74 cases receiving blood prior to transfer or admission to surgical service. t Only 34% of the patients received blood postoperatively. Minimal amount of blood received was 10 units (5000 ee.).
248
LOUIS
Table 10.
T.
PALUMBO, WENDELL S. SHARPE
Postoperative Complications in 73 Surviving Patients*
Distal Antrectomy-Vagectomy (47 Surviving Patients) Cardiopulmonary Pneumonia 2 2 (4.2%) Wound
Dehiscence Infection Intra-abdominal Abscess, subphrenic Intestinal obstruction Leak, duodenal stump Peritonitis, acute
1 2 3 (6.4%) 1
2 1 1
5 (10.6%) M iBcellaneous
Electrolyte imbalance
1
1 (2.1%) Nine patients (19.1%) developed 11 complications. Pyloroplasty-Vagotomy (16 Patients) Wound Abscess
1 (6.2%)
Gastroenterostomy-Vagotomy (10 Patients) Intra-abdominal Duodenal fistula 1 Hemorrhage, site unknown 1 2 M iBcellaneous
Shock 1 All complications were in one patient. Partial Gastrectomy (19 Patients) Cardiopulmonary Pneumonia
1 1 (5.2%)
Wound
Abscess Intra-abdominal Abscess, subhepatic Hemorrhage, intraperitoneal
1 1 (5.2%) 1 1 2 (10.4%)
Miscellaneous
Diarrhea, enterocolitis, specific Jaundice, homologous serum Thrombophlebitis Urinary retention
1 1 1
2 5 (26.3%) Six patients (31.6%) developed 9 complications.
* 24.1 % of the patients developed complications.
ACTIVE BLEEDING DUODENAL ULCER
249
the 67 patients upon whom a distal antrectomy-vagectomy was performed, one death (1.5 per cent) occurred. This was in a 69-year-old patient who died within 24 hours from cardiac failure and pulmonary edema. The combined mortality in the emergent-urgent groups was 3 per cent (five deaths in 162 cases).
EARLY ELECTIVE SURGERY
This represents 153 (48.6 per cent) of the entire series of 315 patients with active bleeding. Therefore, of the entire group who were admitted or transferred to our service with active bleeding, over one-half (51.5 per cent) were operated upon as an emergency or urgent case. The remainder of patients fell in the group with minimal bleeding or who stopped bleeding shortly after admission or transfer or who were the slow continuous type bleeders. The combined opinion of the staff, in this group, favored delayed surgery which was carried out at a more favorable time. The time factor was dependent upon the problems confronting each case. The majority of these patients had a long ulcer history, a story of repeated hemorrhages. Many of them were slow bleeders. Therefore, the time of surgery was delayed to about five days following the onset of active bleeding. Fifty-four per cent of this group were under 50 years of age; 25 per cent were over 60 years of age. The procedures performed were: Distal antrectomy-vagectomy Partial gastrectomy Pyloroplasty-vagotomy Partial gastrectomy-vagotomy Gastroenterostomy-vagotomy Distal antrectomy or partial gastrectomy with left vagectomy and others TOTAL
86 39 8 8
(56.2%) (25.5%) ( 5.3%) ( 5.3%) 4 ( 2.6%)
~
(5.3%) 153 cases
In this group the ulcer was resected in 96 (66.7 per cent) of the cases; 2 left in situ in the duodenum in 22 (15.3 per cent) of the patients; and left in situ on the head of the pancreas in 26 (18 per cent) of the cases. These patients received on an average 3 units of blood prior to admission or transfer to our service. During the five-day interim before surgery, the average number of units of blood given were 5; during surgery 2 units and postoperatively 66 (45 per cent) of the patients were given 1 unit of blood (Table 11). Complications in the Elective Group
The complication rate was the lowest in this group, as would be expected; ten (6.7 per cent) of the 148 surviving patients developed 16 complications (Table 12).
250
LOUIS T. PALUMBO, WENDELL S. SHARPE
Table 1t.
Total Blood Replacement in the Early Elective Group (153 Cases) PRIOR TO TRANSFER (79 Cases)
AGE
20-29 30-39 40-49 50-59 60-69 70 andover TOTALS
Number of Patients 4 17 29 12 7 10
79 (51.3%)*
Units of Blood
SURGICAL SERVICE (153 Cases) Units of Blood
Preop.
4.5 3 2 3 3 2.5 3 units
5 5 6 5 5.5 4 5 units
During
Postop.
1.5 1 2 2 1.5 2 2 units
1 1 1 1 1 1 1 unitt
TOTAL PATIENTS
5 10
20 11
9 11
66 patients
* Per cent of total of 153 cases received blood prior to transfer or adInission to surgical service. t Only 43% of the patients received blood postoperatively. Fifty-four per cent of the patients received on an average of 3 units of blood and 46% received 8 units.
Table 12.
Postoperative Complications in 148 Surviving Patients-Elective Group' Distal Antrectomy-Vagectomy (81 Cases) 1 Pneumonia 1 Infection, wound 2 (2.5%) Pyloroplasty-Vagotomy (8 Cases) Cardiopulmonary 1 A teIectasis 1 Pneumonia 1 Pulmonary embolism 3 Gastroenterostomy-Vagotomy (4 Cases) Abscess, wound Partial Gastrectomy (39 Cases) Wound Abscess Infection Intra-abdominal Duodenal fistula Gastric atony Stomal obstruction
1
3 2 5 (13%) 1
2 1 4 (10%)
* Ten patients (6.7%) developed 15 complications of the 148 surviving patients in this category.
ACTIVE BLEEDING DUODENAL ULCER
251
Mortality-Elective Group
Five (3.3 per cent) deaths occurred in this group of 148 patients. All of these deaths occurred in the group of 86 patients upon whom a distal antrectomy-vagectomy was performed-a mortality of 5.8 per cent. Deaths occurred: in a 33-year-old poor-risk patient with advanced cirrhosis of the liver causing hepatorenal failure; in a 46-year-old patient from hemorrhagic pancreatitis-a technical death, this followed resection of a deep penetrating duodenal ulcer..(current:policy)s to leave these in situ); in a 51-year-old patient who developedJenal-tubular necrosis;~in:67-year-old patient who died from a fulminating staphylococcus pneumonia; and in a 70-year-old patient who died in less than 48 hours from a massive gas bacillus infection of wound and abdominal wall.
SOME OVERALL ASPECTS Postoperative Rebleeding from the Ulcer Site
Two patients (3.7 per cent) developed rebleeding postoperatively in the group of 54 cases in which the ulcer was left in situ in the duodenum with transfixation of the bleeding vessel. The first case occurred in a 62-year-old patient who had a large posterior penetrating duodenal ulcer. A pyloroplasty-vagotomy with transfixation of the bleeding vessel was performed as an emergency procedure. On two occasions postoperatively the bleeding was treated conservatively, but on the sixth postoperative day massive bleeding recurred. The patient was reoperated upon at which time the gastroduodenal artery was ligated and a distal antrectomy was performed. Repeated follow-up studies revealed an excellent result. The second case occurred in a 45-year-old patient who was operated upon as an urgent case because of massive hemorrhage. A distal antrectomyvagectomy with transfixation of the ulcer in situ was performed. Eight days later the patient had tarry stools and dark blood on nasogastric suction. He was treated by repeated transfusions but not reoperated upon. Bleeding stopped after patient had received 6 units of blood. Follow-up studies revealed patient was doing very well. Marginal Ulcer
Only one patient (0.3 per cent) developed a margina(ulcer. This occurred in a 56-year-old patient who was operated upon as an emergency in 1962. A distal antrectomy-vagectomy was performed. Within six months he had a marginal ulcer; 12-hour overnight secretion was 1175 cc. with 52.9 mEq. of free hydrochloric acid present. At the time of reoperation the cardioesophageal area could not be explored because of adhesions; a higher resection was accomplished. In a two-year follow-up the patient was normal; gastric analysis revealed only
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PALUMBO, WENDELL S. SHARPE
4.9 mEq. free hydrochloric acid. It is our opinion that an incomplete vagus resection was responsible for this marginal ulcer.
Overall Mortality Of the 315 patients with active bleeding, 162 (53.3 per cent) had emergent or urgent surgery. Five deaths (3 per cent) occurred. All (60 per cent) but two were in patients over 60 years of age. The mortality rate in patients over 60 years was three times greater. In 90 cases, a distal antrectomy-vagectomy was performed; three deaths (3.3 per cent) occurred. The other two deaths were in the group upon whom the following procedures were performed: pyloroplasty (1 case) and pyloroplasty-vagotomy (8 cases).
Follow-up These patients were seen as outpatients six months following operation. They were admitted to the hospital for a complete evaluation at the end of the first year, and again two years later, and every three years thereafter. One hundred and eight cases have been followed for more than five years; 94 cases for three or more years; and 91 are due for the first and second year follow-ups.
COMMENT
Massive hemorrhage continues to be the major indication for surgical intervention in patients in all age groups with chronic duodenal ulcer. Bleeding or hemorrhage remains the most frequent complication of this chronic disease. Patients are now seen and admitted earlier in their episode of bleeding than formerly. By the application of the basic principles outlined earlier in this survey, a significant reduction in the morbidity and mortality rates has occurred. Many of these patients have a long history of duodenal ulcer and many have passed through several episodes of severe bleeding in the past, particularly the patients in the older age groups. Because of this, it is important for all of us, particularly our medical colleagues, to refer these patients for surgery earlier in their disease and earlier during a bleeding episode. If the indications for surgery exist, because of complications of the disease, then it is important that an operation 'be performed before the patient becomes older. Our experience in over 800 bleeders during the past 19 years shows that patients 60 years or older are a poorer risk because of intercurrent diseases or conditions. Surgical risk in these patients is four times greater than in patients under 50 years of age. Many of the lethal complications occurring in this age group are beyond the control of the surgeon or the surgical procedure per se that is performed. With a greater number of conservative surgical procedures available and with the judicious application of the various local technical modalities of control of the
ACTIVE BLEEDING DUODENAL ULCHR
253
bleeding ulcer, the morbidity and mortality rates have been reduced even in the older age groups. The overall mortality rate in the 315 cases with active bleeding was 3.1 per cent. It was highest (4.5 per cent) in the emergency group and lowest in the urgent (1.3 per cent) group. No deaths occurred in 95 consecutive and un selected patients under the age of 61 years in the emergent and urgent groups, upon whom a distal antrectomy-vagectomy was performed. These significant reductions in the mortality and morbidity rates are based upon many factors; closer liaison between the internist and the surgeon, earlier admiEsion to the hospital, earlier surgical intervention when indicated, seasoned judgment for selection of time of intervention, adequate blood replacement, judicious utilization of monitoring systems to determine blood replacement needs, better supportive measures and ancillary support, improvement in anesthesia, closer surveillance during the postoperative period in recovery and intensive care units, and finally the surgical procedure performed with careful selection of the local technical modality to control the bleeding ulcer per se.
SUMMARY AND CONCLUSIONS
This is a survey of our experience with 315 patients with active bleeding from a duodenal ulcer from January, 1955 to December, 1965. During this period a number of surgical procedures were performed including, in the latter part of the survey period, a variety of local technical modalities to control the ulcer and bleeding vessel. Hemorrhage from a duodenal ulcer continues to be our major indication for surgical intervention. The mortality and morbidity rates have decreased in our series as a result of closer liaison with our medical colleagues, by effective organized positive treatment and ancillary supportive measures, adequate and rapid whole blood replacement, careful monitoring of blood loss and replacement needs, seasoned surgical judgment in selection of time for intervention, and type of surgical procedure suited to the individual case applying the newer local technical modalities to control the bleeding ulcer per se. Persistent conservative management in the face of all hazards associated in the long-term history of chronic duodenal ulcer and allowing a patient with complications of this disease to become too old before referral for surgical intervention is a policy which most frequently results in prolonged disability and finally in a higher morbidity and mortality rates. This latter can be four times greater than in a patient below the age of 60 years. The current conservative surgical procedures with the various methods of local technical control of the ulcer and bleeding vessel have aided in decreasing the morbidity and mortality rates. These have greatly been
254
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PALUMBO, WENDELL S. SHARPE
influenced, also, by the degree and the duration of hemorrhage, the intercurrent diseases, and the age of the patient. Distal antrectomy with vagectomy, utilizing the methods of surgical technical control of the bleeding ulcer, continues to be our operation of choice in bleeding duodenal ulcer, particularly in patients under the age of 60 years. Beyond this age group other procedures are also performed as shown in this study.
REFERENCES 1. Palumbo, L. T., and Sharpe, W. S.: Bleeding duodenal ulcer: Comparison of our results in 715 cases. Surgery 58: 473, 1965. 2. Palumbo, L. T., and Sharpe, W. S.: Dist.al antrectomy with vagectomy for duodenal ulcer. Review of 450 cases. Arch. Surg. 87: 1040,1963. 3. Palumbo, L. T., and Sharpe, W. S.: Distal antrectomy with vagectomy. Over fiveyear follow-up in 158 cases. Arch. Surg. 91: 684,1965. 4. Palumbo, L. T., Sharpe, W. S., et al: Distal antrectomy with vagectomy: Results in 265 cases of chronic duodenal ulcer with hemorrhage. Arch. Surg. 89: 637, 1964.
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