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Bleeding peptic ulcer
BleedingPeptic Ulcer 10 Years' Experience
Htij Bekada,
MD, Algiers, Algeria
Mohamed Char&hi, MD, Algiers, Algeria Rachid Hakheur, MD, Algiers, Algeria YOUSM Yaneq
MD, Algiers, Algeria
Ba&ir ltbmtowi,MD, Algiers, Algeria
Surgical treatment of bleeding peptic ulcer remains a controversial topic. Many surgical procedures, each with its own group of advocates, have been and continue to be used. We report our experience with regard to mortality and recurrence of bleeding in 430 patients treated in our hospital in Algiers from 1972 to 1981. The two groups of patients, 210 of whom were operated on and 220 of whom were treated medically, were analyzed retrospectively. PatIePts
and Methods
Of the 210 patients treated surgically, 182 were men and 28 were women who ranged in age from 18 to 73 years. Niie of the patients (5.7 percent) were over 60 years of age. The severity of bleeding was sssessecl by the hematocrit value and transfusion requirements. Hematocrit values were below 15 percent in 24 patients (11.5 percent) and between 15 and 20 percent in 40 patients (19 percent). Twenty-four patients (11.4 percent) had gastric ulcer, and 173 (82.4 percent) had ulcers in the duodenum, 11 of which (6.5 percent) were both anterior and posterior. The location of the ulcer was not reported for 57 patients (33 percent). Vagotomy was performed in 183 patients (87 percent) and gaatrectomy in 20 (9.5 percent) (Table I). The uIcer wae closed with &urea in two patienta (1 percent), and the gaatroduodenaI artery was ligated in one. Exploratory Iaparotomy was necessitated by massive bleeding in four patients (1.9 percent). Of the 220 patients who did not undergo operation, 172 were men and 48 were women Hematocrit values were less than 15 percent in 16 patients (7.2 percent) and between
vohm
147, March 1984
15 and 20 percent in 52 patients (23.5 percent). Seven patients (7.7 percent) had gastric ulcer, and in 98 patients (44.5 percent), the ulcer wae duodenal, with four (1.8 percent) showing both anterior and poet&or ulceration. In 107 patients (48.6 percent) the location of the ulcer wae not known. Each patient received a blood transfusion and underwent washing of the stomach through a naaogaatric tube. Upper gastrointestinal roentgenograms ware made and endoacopy wae performed when the hemodynamic status of the patients improved. Medical treatment was given by a gaetroenterologif3t. Resu#s
Surgical treatment: There were 19 operative deaths (9 percent) (Table I), 9 of which occurred in the group of 42 patients (21.4 percent) who underwent emergency operations. Five of the nine had vagotomy, three gastrectomy, and one exploratory Iaparotomy. Among the 163 patients who underwent vagotomy, there were 12 deaths (6.4 percent), and among 20 patients who underwent gastrectomy, there were 4 deaths (20 percent). Sixteen of the 19 patients who died (34.2 percent) had duodenal ulcers. Among the 210 patients, 16 (7.6 percent) had recurrence of bleeding; 13 had undergone vagotomy, 2 gastrectomy, and 1 suture of the ulcer aa treatment for the initial bleeding. Of the 10 patients who had Heinecke-Mickulicx pyloroplesty as initiaI treatment, 2 had another episode of bleeding 6 months later, 3 after 1 year, and 5 after 2 years. All but one patient had conservative treatment and underwent antrectomy. Of the 20 patients who underwent gastrectomy with BiIIroth II reconstruction, 2 had recurrence of bleeding after 2 years; 1 had conservative
375
TABLE I
Burgkal Treatment ot Bleeding Peptic Uker Patients
Procedure Truncal vag 6 pyloro Truncal vag & GEA Truncal vag 8 Finney Truncal veg 8 antrectomy Truncal vag & Jaboulay’s wloro Belective vag d pyloro Highly selective vag Highly selective vag & Finney’k pyloro Truncal vag (complementary) Billroth I procedure Billroth II procedure Exploratory laparotomy Ligation Buture Total
Deaths 5 4 2
16 2
:
10 1 2 0 0
: 1
0 0
0 0 0
2
0
0
9 11 4 1 2
1 3 2 1 0
0 2 0 0 1
19
16
GEA = gastroenteroanastomosis; pyloro = pyloroplasty; vag = vwPtorw*
treatment, and the other died from massive hemorrhage before operation could be undertaken. Follow-up data were obtained by direct interview or by responses to questionnaires. Of the 191 survivors of the initial treatment, 55 were lost to follow-up within 6 months. Of the 33 patients who returned the questionnaires, only 1 was dissatisfied with the results of vagotomy and pyloroplasty. Among 33 who underwent follow-up duodenoscopy, 3 were found to have stenosis, 3 recurrent ulcer, and 18 had gastritis. Medical treatment: Fifteen of the 220 patients treated medically died (6.8 percent), 9 of whom were older than 60 years of age (60 percent). Twelve of the patients who died had hematocrit values under 20 percent. Two of 205 patients (0.9 percent) had recurrent bleeding, the first 1 year postoperatively, and the second 4 years postoperatively. Both patients were treated medically. Follow-up was possible in 42 patients (20 percent), 25 of whom underwent duodenoscopy more than 2 years after the primary operation. Ten were found to have recurrent ulcer and 7 gastritis. Comments The age range was the same in the group of patients operated on and the group treated medically, although the percentage of patients over 60 years of age (5.7 percent) was lower than in other published series (44 and 46 percent) [l-3]. Our finding that bleeding was severe in 30 percent of our patients was at variance with the fmdings of others [2+]. Bleeding was associated with posterior duodenal ulcer in 15.7 percent of our patients, whereas this location was responsible for bleeding in 16.9 percent of the pa-
376
Comparative Operative Mortality* Vagotomy 8
Recurrences
77 46 33
210
TABLE II
Reference
Year
Gastrectomy Patients Deaths
Foster et al [ 7] Carruthers et al
1965 1967
101 56
PrZnt
1961
20
32 (31.6) 10 (16.1) 4(20)
PylorOplaSty
Patients Deaths 100 57
12 (12) 4 (7)
77
5 (6.4)
report l
Numbers in parentheses are percentages.
tients in the series of Hubert et al [7] and in 78 percent of those in the series of Sava et al [3] (Table II). Death was the outcome for 6.8 percent of the patients treated medically, whereas operative deaths accounted for 9 percent of those in the surgical group. Of 42 patients who underwent emergency operations, 9 died (21.4 percent), 7.9 percent between the fourth and eighth days and 4.7 percent after the eighth day. As Hollender et al [S] pointed out, mortality was higher among patients operated on in whom bleeding was acute. Again, as pointed out by Hollender et al [9], more deaths occurred among those who had duodenal ulcers of the posterior wall. The mortality after vagotomy in our patients was 6.5 percent, whereas it was reported by Edelmann [S] to be 10 percent and by Foster et al [I] to be 25 percent, with 66 percent of their patients over 60 years of age, and by Sava et al [3] to be 26 percent. Mortality after gastrectomy in our patients was 20 percent, whereas Carruthers et al [5] reported it to be 18 percent and Foster et al [I] 30 percent. On the whole, mortality was greater after gastrectomy than after vagotomy (Table II). In the 220 patients treated medically, 15 (6.8 percent) died. Nine of the 15 who died were over 60 years of age (60 percent) and 12 (80 percent) had hematocrit values under 20 percent. Bleeding gastric and duodenal ulcers are associated with a grave prognosis in the elderly [IO]. This phenomenon is probably related to arterial bleeding from an arteriosclerotic vessel. The mortality rate reported by Zitouni et al [4] was 17 percent and by Fraisse et al [11] 12 percent. Bleeding recurred in 7.6 percent of the patients treated surgically (Table I), 6.1 percent of whom had undergone vagotomy and 10 percent gastrectomy. Other observers have reported a similar increase of recurrent bleeding after surgical treatment [12,13]. Two of 205 patients treated medically (0.9 percent) suffered recurrence of bleeding. It must be recognized that the diagnosis of bleeding peptic ulcer made in the past was presumptive, as duodenoscopy was not feasible. It is our opinion that emergency endoscopy plays a definite role in the
The Amerlcen Journal ol Surgery
management of patients with acute bleeding. When emergency treatment is required, we prefer conservative procedures, since it is primarily the technical difficulty of operating on patients with acutely bleeding ulcers rather than the severity of their disease that leads to a fatal outcome. Analysisof our two groups ofpatients with bleeding ulcer established no clear differences, but we conclude that mortality was higher in those with posterior duodenal peptic ulcer and after gastrectomy rather than after vagotomy. Mortality after emergency operations was high. The incidence of recurrence of bleeding was similar after gastrectomy and after vagotomy. Summary From 1972 to 1981,430 patients were treated for bleeding peptic ulcer. Two hundred ten of the patients were treated surgically and 220 medically. In the surgically treated patients, mortality was high among those with posterior duodental peptic ulcer and after gastrectomy rather than after vagotomy. Mortality after emergency operations was also high. The incidence of rebleeding was similar after gastrectomy and after vagotomy. In the medically treated patients,mortalitywas high among those who were elderly. References 1. FostewJH,HkkdcDF,DurphyJE.Chengingconceptsinthe swgicalw6atmmtotm5s8ive~heronhage. Ann !Stq 1965;161:968-74.
VohRm 147, hwcll
IS84
2. PrandiD.PiotJC,FknentY,RueffB,Ftadom~ V,tortatJJL. h3uRatsduwtementenugacedsslJkareadrarlqueg gastrodwdenewhmorragkiuesapmpoade91 cas.Ann Chii 1973;27: 1143-8. 3. SavaG.hwscauxJ,QrenierJF.Placedelaqotomietrcnw adakeawcbcek-bh#wnnt deruiclwe duodenal hemonaglque. J Chtr 198Q12S83-7. 4. ZitouniM,houdK.hnkMpatM_~ ~.Rsppat~-_-~~ Alger. May 1975. 5. -RK,Gilk3sGR*clarkco.~JC_cawwrvative swgeiy for blefing Pepuc ukxr. Br t&d J 196f:l:80-2. 6.Edeh~mnG.Letra~mwtdesks massives(hypertensianportek,ex~)ckhn,dela discussion. Chirurgie 1968;92:890-901. 7. HubertJPJr,KiemanPD,BealwsOH,BwhWH.MitwRE. Tnncalvaealomyandrwxtionhhe+sadmart ofduodmal ulcer. Mayo Clin Proc 198@55:19-24. 8. HollenderLF,MarrieA.MeywC.hglnGF,BMguJF.Les hWlU@ESgaVead9leflUX4posblan,dU1~duabnun. Probhwspmtiqwset-ac&#&t’btmMment.A propos de 107 ca. J Chir 1961;118:38Mt3. 9. HohnderLF,PatelJC,PerrotinJ,V~J.Lachhrgkdes lllcemshem#ragiquesposbrkusdu~-.~ aux VI“ jownees de chirurgb digesth. J Chir 1981;118: 433-40. 10. Antler AS. Pkdumni CS,-Quy~E,-i3S. ~-bleeding~~eldarfy,mabldny,maQhf, and cause. Am J Surg 1981;142:271-3. 11. Fraksse H, Etalx JN, Livoireat~ N. CwrUUnnaI’etubdeks hemaregtesdigesthresdkNtghOlhOIUWO.Apqursd’~ statwqwdel23ca8sirimtpta:dD476-~ odenaux. J Mad Lyan 196&1:339-63. 12. WehbergJA.Treatmfmtofmmkhtybbsdkgduodsnal~ by ligation pybroplasty and wqotomy. Am J 3w.g 1981; 102:158-67. 13. Cox A, Williams JA. Vagotomy on trial. London: Hsinemam, 1973:136-53.
377
Htij Bekada,
MD, Algiers, Algeria
Mohamed Char&hi, MD, Algiers, Algeria Rachid Hakheur, MD, Algiers, Algeria YOUSM Yaneq
MD, Algiers, Algeria
Ba&ir ltbmtowi,MD, Algiers, Algeria
Surgical treatment of bleeding peptic ulcer remains a controversial topic. Many surgical procedures, each with its own group of advocates, have been and continue to be used. We report our experience with regard to mortality and recurrence of bleeding in 430 patients treated in our hospital in Algiers from 1972 to 1981. The two groups of patients, 210 of whom were operated on and 220 of whom were treated medically, were analyzed retrospectively. PatIePts
and Methods
Of the 210 patients treated surgically, 182 were men and 28 were women who ranged in age from 18 to 73 years. Niie of the patients (5.7 percent) were over 60 years of age. The severity of bleeding was sssessecl by the hematocrit value and transfusion requirements. Hematocrit values were below 15 percent in 24 patients (11.5 percent) and between 15 and 20 percent in 40 patients (19 percent). Twenty-four patients (11.4 percent) had gastric ulcer, and 173 (82.4 percent) had ulcers in the duodenum, 11 of which (6.5 percent) were both anterior and posterior. The location of the ulcer was not reported for 57 patients (33 percent). Vagotomy was performed in 183 patients (87 percent) and gaatrectomy in 20 (9.5 percent) (Table I). The uIcer wae closed with &urea in two patienta (1 percent), and the gaatroduodenaI artery was ligated in one. Exploratory Iaparotomy was necessitated by massive bleeding in four patients (1.9 percent). Of the 220 patients who did not undergo operation, 172 were men and 48 were women Hematocrit values were less than 15 percent in 16 patients (7.2 percent) and between
vohm
147, March 1984
15 and 20 percent in 52 patients (23.5 percent). Seven patients (7.7 percent) had gastric ulcer, and in 98 patients (44.5 percent), the ulcer wae duodenal, with four (1.8 percent) showing both anterior and poet&or ulceration. In 107 patients (48.6 percent) the location of the ulcer wae not known. Each patient received a blood transfusion and underwent washing of the stomach through a naaogaatric tube. Upper gastrointestinal roentgenograms ware made and endoacopy wae performed when the hemodynamic status of the patients improved. Medical treatment was given by a gaetroenterologif3t. Resu#s
Surgical treatment: There were 19 operative deaths (9 percent) (Table I), 9 of which occurred in the group of 42 patients (21.4 percent) who underwent emergency operations. Five of the nine had vagotomy, three gastrectomy, and one exploratory Iaparotomy. Among the 163 patients who underwent vagotomy, there were 12 deaths (6.4 percent), and among 20 patients who underwent gastrectomy, there were 4 deaths (20 percent). Sixteen of the 19 patients who died (34.2 percent) had duodenal ulcers. Among the 210 patients, 16 (7.6 percent) had recurrence of bleeding; 13 had undergone vagotomy, 2 gastrectomy, and 1 suture of the ulcer aa treatment for the initial bleeding. Of the 10 patients who had Heinecke-Mickulicx pyloroplesty as initiaI treatment, 2 had another episode of bleeding 6 months later, 3 after 1 year, and 5 after 2 years. All but one patient had conservative treatment and underwent antrectomy. Of the 20 patients who underwent gastrectomy with BiIIroth II reconstruction, 2 had recurrence of bleeding after 2 years; 1 had conservative
375
TABLE I
Burgkal Treatment ot Bleeding Peptic Uker Patients
Procedure Truncal vag 6 pyloro Truncal vag & GEA Truncal vag 8 Finney Truncal veg 8 antrectomy Truncal vag & Jaboulay’s wloro Belective vag d pyloro Highly selective vag Highly selective vag & Finney’k pyloro Truncal vag (complementary) Billroth I procedure Billroth II procedure Exploratory laparotomy Ligation Buture Total
Deaths 5 4 2
16 2
:
10 1 2 0 0
: 1
0 0
0 0 0
2
0
0
9 11 4 1 2
1 3 2 1 0
0 2 0 0 1
19
16
GEA = gastroenteroanastomosis; pyloro = pyloroplasty; vag = vwPtorw*
treatment, and the other died from massive hemorrhage before operation could be undertaken. Follow-up data were obtained by direct interview or by responses to questionnaires. Of the 191 survivors of the initial treatment, 55 were lost to follow-up within 6 months. Of the 33 patients who returned the questionnaires, only 1 was dissatisfied with the results of vagotomy and pyloroplasty. Among 33 who underwent follow-up duodenoscopy, 3 were found to have stenosis, 3 recurrent ulcer, and 18 had gastritis. Medical treatment: Fifteen of the 220 patients treated medically died (6.8 percent), 9 of whom were older than 60 years of age (60 percent). Twelve of the patients who died had hematocrit values under 20 percent. Two of 205 patients (0.9 percent) had recurrent bleeding, the first 1 year postoperatively, and the second 4 years postoperatively. Both patients were treated medically. Follow-up was possible in 42 patients (20 percent), 25 of whom underwent duodenoscopy more than 2 years after the primary operation. Ten were found to have recurrent ulcer and 7 gastritis. Comments The age range was the same in the group of patients operated on and the group treated medically, although the percentage of patients over 60 years of age (5.7 percent) was lower than in other published series (44 and 46 percent) [l-3]. Our finding that bleeding was severe in 30 percent of our patients was at variance with the fmdings of others [2+]. Bleeding was associated with posterior duodenal ulcer in 15.7 percent of our patients, whereas this location was responsible for bleeding in 16.9 percent of the pa-
376
Comparative Operative Mortality* Vagotomy 8
Recurrences
77 46 33
210
TABLE II
Reference
Year
Gastrectomy Patients Deaths
Foster et al [ 7] Carruthers et al
1965 1967
101 56
PrZnt
1961
20
32 (31.6) 10 (16.1) 4(20)
PylorOplaSty
Patients Deaths 100 57
12 (12) 4 (7)
77
5 (6.4)
report l
Numbers in parentheses are percentages.
tients in the series of Hubert et al [7] and in 78 percent of those in the series of Sava et al [3] (Table II). Death was the outcome for 6.8 percent of the patients treated medically, whereas operative deaths accounted for 9 percent of those in the surgical group. Of 42 patients who underwent emergency operations, 9 died (21.4 percent), 7.9 percent between the fourth and eighth days and 4.7 percent after the eighth day. As Hollender et al [S] pointed out, mortality was higher among patients operated on in whom bleeding was acute. Again, as pointed out by Hollender et al [9], more deaths occurred among those who had duodenal ulcers of the posterior wall. The mortality after vagotomy in our patients was 6.5 percent, whereas it was reported by Edelmann [S] to be 10 percent and by Foster et al [I] to be 25 percent, with 66 percent of their patients over 60 years of age, and by Sava et al [3] to be 26 percent. Mortality after gastrectomy in our patients was 20 percent, whereas Carruthers et al [5] reported it to be 18 percent and Foster et al [I] 30 percent. On the whole, mortality was greater after gastrectomy than after vagotomy (Table II). In the 220 patients treated medically, 15 (6.8 percent) died. Nine of the 15 who died were over 60 years of age (60 percent) and 12 (80 percent) had hematocrit values under 20 percent. Bleeding gastric and duodenal ulcers are associated with a grave prognosis in the elderly [IO]. This phenomenon is probably related to arterial bleeding from an arteriosclerotic vessel. The mortality rate reported by Zitouni et al [4] was 17 percent and by Fraisse et al [11] 12 percent. Bleeding recurred in 7.6 percent of the patients treated surgically (Table I), 6.1 percent of whom had undergone vagotomy and 10 percent gastrectomy. Other observers have reported a similar increase of recurrent bleeding after surgical treatment [12,13]. Two of 205 patients treated medically (0.9 percent) suffered recurrence of bleeding. It must be recognized that the diagnosis of bleeding peptic ulcer made in the past was presumptive, as duodenoscopy was not feasible. It is our opinion that emergency endoscopy plays a definite role in the
The Amerlcen Journal ol Surgery
management of patients with acute bleeding. When emergency treatment is required, we prefer conservative procedures, since it is primarily the technical difficulty of operating on patients with acutely bleeding ulcers rather than the severity of their disease that leads to a fatal outcome. Analysisof our two groups ofpatients with bleeding ulcer established no clear differences, but we conclude that mortality was higher in those with posterior duodenal peptic ulcer and after gastrectomy rather than after vagotomy. Mortality after emergency operations was high. The incidence of recurrence of bleeding was similar after gastrectomy and after vagotomy. Summary From 1972 to 1981,430 patients were treated for bleeding peptic ulcer. Two hundred ten of the patients were treated surgically and 220 medically. In the surgically treated patients, mortality was high among those with posterior duodental peptic ulcer and after gastrectomy rather than after vagotomy. Mortality after emergency operations was also high. The incidence of rebleeding was similar after gastrectomy and after vagotomy. In the medically treated patients,mortalitywas high among those who were elderly. References 1. FostewJH,HkkdcDF,DurphyJE.Chengingconceptsinthe swgicalw6atmmtotm5s8ive~heronhage. Ann !Stq 1965;161:968-74.
VohRm 147, hwcll
IS84
2. PrandiD.PiotJC,FknentY,RueffB,Ftadom~ V,tortatJJL. h3uRatsduwtementenugacedsslJkareadrarlqueg gastrodwdenewhmorragkiuesapmpoade91 cas.Ann Chii 1973;27: 1143-8. 3. SavaG.hwscauxJ,QrenierJF.Placedelaqotomietrcnw adakeawcbcek-bh#wnnt deruiclwe duodenal hemonaglque. J Chtr 198Q12S83-7. 4. ZitouniM,houdK.hnkMpatM_~ ~.Rsppat~-_-~~ Alger. May 1975. 5. -RK,Gilk3sGR*clarkco.~JC_cawwrvative swgeiy for blefing Pepuc ukxr. Br t&d J 196f:l:80-2. 6.Edeh~mnG.Letra~mwtdesks massives(hypertensianportek,ex~)ckhn,dela discussion. Chirurgie 1968;92:890-901. 7. HubertJPJr,KiemanPD,BealwsOH,BwhWH.MitwRE. Tnncalvaealomyandrwxtionhhe+sadmart ofduodmal ulcer. Mayo Clin Proc 198@55:19-24. 8. HollenderLF,MarrieA.MeywC.hglnGF,BMguJF.Les hWlU@ESgaVead9leflUX4posblan,dU1~duabnun. Probhwspmtiqwset-ac&#&t’btmMment.A propos de 107 ca. J Chir 1961;118:38Mt3. 9. HohnderLF,PatelJC,PerrotinJ,V~J.Lachhrgkdes lllcemshem#ragiquesposbrkusdu~-.~ aux VI“ jownees de chirurgb digesth. J Chir 1981;118: 433-40. 10. Antler AS. Pkdumni CS,-Quy~E,-i3S. ~-bleeding~~eldarfy,mabldny,maQhf, and cause. Am J Surg 1981;142:271-3. 11. Fraksse H, Etalx JN, Livoireat~ N. CwrUUnnaI’etubdeks hemaregtesdigesthresdkNtghOlhOIUWO.Apqursd’~ statwqwdel23ca8sirimtpta:dD476-~ odenaux. J Mad Lyan 196&1:339-63. 12. WehbergJA.Treatmfmtofmmkhtybbsdkgduodsnal~ by ligation pybroplasty and wqotomy. Am J 3w.g 1981; 102:158-67. 13. Cox A, Williams JA. Vagotomy on trial. London: Hsinemam, 1973:136-53.
377