- Email: [email protected]
Variations reported in surgical practice for bleeding duodenal ulcers
The American Journal of Surgery 192 (2006) e42– e45
Poster presentation
Variations reported in surgical practice for bleeding duodenal ulcers Brian C. Reuben, M.D.*, Leigh A. Neumayer, M.D., M.S. Division of General Surgery, Department of Surgery, University of Utah School of Medicine, 30 North 1900 East, Salt Lake City, UT 84132, USA Manuscript received May 15, 2006; revised manuscript August 3, 2006 Presented at the 30th Annual Surgical Symposium of the Association of VA Surgeons, Cincinnati, Ohio, May 7–9, 2006
Abstract Background: To determine the current surgical management of bleeding duodenal ulcers in our program, faculty (FAC) and residents (RES) were surveyed. Methods: FAC (n ⫽ 33) and RES (n ⫽ 42) were surveyed regarding their surgery of choice between oversew (OS) or acid-reducing procedures (ARPs) in 4 scenarios. FAC who had recertified in general surgery (RECERT) were compared with young FAC who had not and RES (RES/young FAC). Two-group comparisons were performed. Results: Seventy-three percent of FAC and 62% of RES responded. RES perform more ARPs on hemodynamic (HD), unstable, elderly patients than FAC (P ⫽ .013). On the elderly patient, RES/young FAC perform more ARPs in a HD stable (P ⫽ .07) and unstable condition (P ⫽ .18). HD unstable patients would undergo OS more frequently than stable patients (P ⫽ .016). Conclusions: In this survey, the choice of optimal surgical procedure for an acute bleeding ulcer varies among surgeons based on years of surgical experience and individual patient factors. © 2006 Excerpta Medica Inc. All rights reserved. Keywords: Duodenal ulcer; Peptic ulcer; Vagotomy; Survey; Practice patterns
Time and technology continue to afford a better understanding of the pathogenesis of duodenal ulcer disease as well as improved medications for the treatment of acid hypersecretion. However, the surgical literature lags in evidence-based support for minimal surgical procedures, such as simple oversew (OS) only, for the management of an acutely bleeding duodenal ulcer. New advances bring new questions as to the ideal treatment. Previous surgical dictum states that a vagotomy and pyloroplasty is the ideal choice for this difficult problem [1]. However, this surgery is plagued with significant postoperative complications such as dumping syndrome and diarrhea, can occur in up to 20% of patients [2– 4]. New evidence regarding the role of Helicobacter pylori suggests that this aggressive surgical approach may no longer be needed. In fact, recent studies have shown that ulcerogenic effects of nonsteroidal anti-inflammatory drugs (NSAIDs) can cause a 2-fold increase in the risk of bleeding among patients infected with H pylori in comparison with patients who are H pylori negative, suggesting these conditions are additive [5]. H pylori has been found in 68% to
* Corresponding author. Tel.: ⫹1-801-581-2431; fax: ⫹1-801-585-2425. E-mail address: [email protected]
90% of bleeding duodenal ulcers [6 – 8]. In addition, successful eradication of H pylori has been shown to reduce recurrent ulcer bleeding rates [9,10]. The ulcerogenic role of H pylori is well understood and proton pump inhibitors are used widely, but their impact on surgical management of acutely bleeding duodenal ulcers still remains to be determined. The aim of this study was to assess the variability and current opinion of attending surgeons and residents at our institution regarding OS versus acid-reducing surgery for 4 distinct clinical scenarios of a bleeding duodenal ulcer. Materials and Methods A survey consisting of 4 questions (2 different cases with 2 clinical scenarios) was sent to the faculty (FAC) and residents (RES) of the Division of General Surgery at the University of Utah after Institutional Review Board approval was obtained (Table 1). Surveys were sent to a total of 33 FAC and 42 RES of all levels. Two patient scenarios were presented in both a hemodynamic (HD) stable, and unstable, clinical condition. The respondents then were given 4 options to choose from, ranging from simple OS of the bleeding ulcer, OS of the bleeding ulcer with truncal vagotomy and pyloroplasty, OS of the ulcer and highly selective
0002-9610/06/$ – see front matter © 2006 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2006.08.021
B.C. Reuben and L.A. Neumayer / The American Journal of Surgery 192 (2006) e42– e45
e43
Table 1 Survey questions
Table 2 Respondent demographics
Case 1. A 55 year old female is admitted for an upper G1 bleed. She is on daily NSAIDs for osteoarthritis. No other prior medical history. She requires operative intervention and stabilizes in the operating room. Case 2. Same 55 year old female as above but she is hemodynamically unstable in the operating room and requires vasopressors to maintain her blood pressure. Case 3. An 85 year old male is admitted for an upper GI bleed. He has a long standing history of peptic ulcer disease and is on daily proton pump inhibitor therapy. He has extensive medical co-morbidities to include hypertension, COPD, CHF and CAD. He requires operative intervention and stabilizes in the operating room. Case 4. Same 85 year old male as above but he is hemodynamically unstable in the operating room and requires vasopressors to maintain his blood pressure.
Variable
Rate
Number of residents (PGY1-5) Response rate Average age of residents PGY of resident respondents: PGY 5/4 PGY 3/2/1 Number of attendings Response rate Average age of attendings ABS recertification Completed a surgical fellowship Years since first ABS certification Average number of surgical procedures for bleeding duodenal ulcers per year
26/42 62% 30.96 ⫾ 2.95 y
Response Options: A. Oversew of the bleeding ulcer B. Oversew of the bleeding ulcer, truncal vagotomy and pyloroplasty C. Oversew of the ulcer, highly selective vagotomy D. Oversew of the ulcer, vagotomy and antrectomy with Billroth I/II or Roux-en-Y reconstruction. E. Other, .
vagotomy, and antrectomy with either Billroth I/II or Rouxen-Y reconstruction. Respondents were given the option to enter a fifth response if they felt that none of the above were appropriate. Respondent demographics also were gathered, including age, sex, year of American Board of Surgery (ABS) certification, year of ABS recertification, completion of a fellowship, residency program, and number of ulcer surgeries performed per year. Comparisons were made between RES and FAC responses. To determine the effect of training more recently, we also compared surgeons who had recertified with the ABS (RECERT) with those who were younger and not yet eligible for recertification (RES/young FAC). Comparisons between the study groups for dichotomous outcomes were performed using the chi-square test if the minimum expected cell frequency assumption was met (80% of the cells have expected frequencies of at least 5 and no cell has an expected frequency of ⬍1). Otherwise, the Fisher exact test was used. Two-group comparisons for ordered categoric variables was performed using the Wilcoxon-Mann-Whitney test. A P value of less than .05 was considered significant. All descriptive statistical analyses were performed with STATA 9.0 (Stata Corp, College Station, TX).
8 18 24/33 73% 46.91 ⫾ 9.32 y 54% (13/24) 42% (10/24) 12.91 ⫾ 9.18 y 2.4 (range, 0–10)
Values are given with the SD from the mean. PGY ⫽ postgraduate year.
(P ⫽ .013) (Fig. 1). Several RES chose to perform an antrectomy with either Billroth or Roux-en-Y reconstruction whereas all FAC chose either a simple OS of the ulcer or OS with vagotomy and pyloroplasty. RES also differed from FAC on patient 1, with RES tending to perform more OS surgeries with a young patient on NSAIDs (P ⫽ .0751) (Fig. 1). Patient HD stability In the 2 cases of HD stability, all surgeons (RES and FAC) performed ARPs a majority of the time, 58% and 74% for patients 1 and 2, respectively. However, with intraoperative HD instability, regardless of the clinical situation, RES and FAC performed OS of the bleeding ulcer the majority of the time, 82% and 72% for patients 3 and 4, respectively. Overall, HD unstable patients would undergo OS more frequently than HD stable patients (P ⫽ .016). ARPs were performed less frequently in the younger patient taking NSAIDs versus an elderly man with multiple comorbidities, although the difference was not statistically significant (P ⫽ .263). RECERT versus RES/young FAC RECERT tended to perform a more aggressive surgery on the 55-year-old patient by performing more ARPs than
Results Demographics There were 24 FAC (73%) and 26 RES (62%) who completed the survey. The RES and FAC demographic information is listed in Table 2. RES versus FAC RES differed significantly from FAC in the management of the 85-year-old man in a HD unstable condition with RES performing more acid-reducing procedures (ARPs)
Fig. 1. Responses for RES and FAC for management of an acute bleeding duodenal ulcer. *Significant difference between FAC and RES in management of patient 4, P ⫽ .013.
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B.C. Reuben and L.A. Neumayer / The American Journal of Surgery 192 (2006) e42– e45
Fig. 2. Responses between RES/young FAC and RECERT for patient 1. P ⫽ .103 for differences between RES/young FAC and RECERT using the Wilcoxon-Mann-Whitney test.
RES/young FAC (P ⫽ .103) (Fig. 2). The opposite trend exists between RES/young FAC and RECERT when surveyed regarding an elderly man with a history of ulcers and multiple comorbidities. RECERT tend to perform less aggressive surgical procedures (simple OS or OS with vagotomy and pyloroplasty) compared with RES/young FAC who attempted either highly selective vagotomy or antrectomy in the stable 85-year-old (P ⫽ .071) (Fig. 3). RES/ young FAC also tended to more frequently attempt an antrectomy with Billroth or Roux-en-Y reconstruction in the unstable elderly patient (P ⫽ .179). Nonsurgical treatment Surgeon age and number of years since certification did not show a significant difference in the incidence of OS versus ARP. When questioned about the proper postoperative evaluation and management and care for a patient with a duodenal ulcer, RES and FAC recognized the need for H pylori testing, the use of proton pump inhibitors, and cessation of NSAIDs if able. No other responses were filled in for a fifth surgical option. Comments To elucidate the discrepancies and variability in the surgical management of an acute bleeding duodenal ulcer, our faculty and residents were surveyed regarding their ideal procedure of choice given 2 distinct patient populations. The results indicate that at our institution, the difficult clinical scenario of a bleeding duodenal ulcer is managed in a variety of ways, and suggests an opportunity for improvement in resident education. It is not surprising that surgeons performed the most expeditious surgery of OS the majority of the time when either patient was HD unstable. However, with HD stability, the variability in surgeon preference becomes evident. When looking at all surgeons, ARPs were more common in a HD stable patient. However, RES/young FAC are more apt to perform simple OS on a younger patient population, perhaps implying their understanding of the successful medical management or highlighting their lack of experience and comfort performing ARPs. Meanwhile, this same group is more reluctant to perform the same surgery on a stable elderly patient with multiple comorbidities. The lack of prospective surgical trials evaluating minimal surgery with proton pump therapy and H pylori eradication against tra-
ditional procedures leaves the surgeon to rely on their best clinical judgment, often emanating form their personal experience. There is strong evidence in the older surgical literature that rebleeding events can be catastrophic and most recommendations for surgical management of elderly patients with comorbid disease and/or HD instability who have active arterial ulcer hemorrhage include emergent surgical intervention and classic ARPs [1,11,12]. A more recent review of the older literature has brought into question the validity of some of the older studies, demonstrating that early surgical intervention for bleeding ulcers may not be as beneficial as once was thought [13]. Significant controversy still exists regarding the optimal treatment of bleeding duodenal ulcers primarily because of a lack of up-to-date evidence. The purpose of comparing young attending surgeons and residents (RES/young FAC) with FAC with more than 10 years of experience (RECERT) was to determine if a younger generation of surgeons possess differing perspectives on the management of a bleeding duodenal ulcer. We can only speculate, but perhaps, as part of a new surgical era, today’s young surgeons may embrace theory and perhaps have a stronger foundation in pharmacology than older surgeons who have passed through traditional teaching programs. Perhaps surgeons in practice long enough to have recertified have more experience with ARPs and thus feel more comfortable performing this surgery. Recent surveys of general surgeons have indicated that surgeons rarely perform a vagotomy for a bleeding peptic ulcer [14]. Our study evaluates the different practice patterns stratified by time in surgical practice as evidenced by ABS recertification status. Indeed, variations in practice patterns by surgeon experience level do exist in an otherwise healthy patient population (patients 1 and 2) at our institution. RECERT surgeons tend to be more aggressive than RES/young FAC with stable, low-complexity patients. In cases of increasing patient comorbidities and HD instability, RES/young FAC perform more aggressive ARPs. The rationale for such decisions may be sound, but surgeons still lack evidence from up-todate clinical trials when evaluating options for acutely bleeding duodenal ulcers. The procedural variability becomes even more important when we examine resident education. Several studies have documented that resident surgical experiences with vagotomy decreased greater than 3-fold during the 1990s [15,16].
Fig. 3. Responses between RES/young FAC and RECERT for patient 3. P ⫽ .071 for differences between RES/young FAC and RECERT using the Wilcoxon-Mann-Whitney test.
B.C. Reuben and L.A. Neumayer / The American Journal of Surgery 192 (2006) e42– e45
This provides fewer teaching opportunities on a technical surgery such as truncal or highly selective vagotomy. Could this trend impact future decision making on behalf of RES when faced with the decision of simple OS versus an ARP? Clearly, if RES have insufficient experience performing vagotomies, they are unlikely to perform this procedure once in practice. In addition, the indications for such a procedure may be misunderstood and the surgery ultimately misused. In our internal survey, there was a discernable difference in the responses between upper-level residents (postgraduate years 4/5) and junior residents (postgraduate years 1/2/3) with upper-level residents making more appropriate clinical management decisions. However, without practical experience performing these surgeries, are residents going to be able to perform them once out in practice? Simple OS of the bleeding ulcer has reported recurrence rates for bleeding of anywhere from 3% to 20%. Interestingly, mortality remains unchanged between local and radical surgery [17–19]. Thus, is it necessary to perform an ARP in any clinical scenario? A recent survey of general surgeons in Great Britain and Ireland in 2001 showed that 39% of surgeons would never perform a vagotomy for a bleeding duodenal ulcer whereas 2.5% of respondents said they would always perform a vagotomy [14]. Other recent evidence continues to suggest that perhaps surgeons are trending away from ARP in the face of an emergency duodenal bleed [20]. The current literature on surgical management of an acute bleeding duodenal ulcer lacks prospective, randomized trials on the outcomes of conservative versus aggressive surgery (OS vs. ARP). The understanding of the role of H pylori and the influence of its eradication on overall mortality and the rebleeding rate provide the theoretic argument for conservative treatment for a bleeding duodenal ulcer despite this lack of level I evidence [21,22]. In summary, our study suggests that a variety of surgical procedures may be applied to a given clinical patient scenario based on surgeon experience and patient factors. The clinical scenarios presented are not encountered commonly and thus resident case exposure is low. With a lack of randomized trials in this area, surgical decision making is highly variable and appears to be based on the knowledge and experience of the operating surgeon. References [1] Cowles RA, Mulholland MW. Surgical management of peptic ulcer disease in the helicobacter era—management of bleeding peptic ulcer. Surg Laparosc Endosc Percutan Tech 2001;11:2– 8.
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[2] Mulholland MW, Debas HT. Chronic duodenal and gastric ulcer. Surg Clin North Am 1987;67:489 –507. [3] Johnston D, Blackett RL. Recurrent peptic ulcers. World J Surg 1987;11:274 – 82. [4] Thompson JC, Wiener I. Evaluation and surgical treatment of duodenal ulcer: short- and long-term effects. Clin Gastroenterol 1984;13: 569 – 600. [5] Aalykke C, Lauritsen JM, Hallas J, et al. Helicobacter pylori and risk of ulcer bleeding among users of nonsteroidal anti-inflammatory drugs: a case-control study. Gastroenterology 1999;116:1305–9. [6] Callicutt CS, Behrman S. Incidence of Helicobacter pylori in operatively managed acute nonvariceal upper gastrointestinal bleeding. J Gastrointest Surg 2001;5:614 –9. [7] Castro Fernandez M, Sanchez Munoz D, Garcia Diaz E, et al. Diagnosis of Helicobacter pylori infection using urease rapid test in patients with bleeding duodenal ulcer: influence of endoscopic signs and simultaneous corporal and antral biopsies. Rev Esp Enferm Dig 2004;96:599 – 602. [8] Chan HL, Wu JC, Chan FK, et al. Is non-Helicobacter pylori, nonNSAID peptic ulcer a common cause of upper GI bleeding? Gastrointest Endosc 2001;53:438 – 42. [9] Rokkas T, Karameris A, Mavrogeorgis A, et al. Eradication of Helicobacter pylori reduces the possibility of rebleeding in peptic ulcer disease. Gastrointest Endosc 1995;41:1– 4. [10] Jaspersen D, Koerner T, Schorr W, et al. Helicobacter pylori eradication reduces the rate of rebleeding in ulcer hemorrhage. Gastrointest Endosc 1995;41:5–7. [11] Cochran T. Bleeding peptic ulcer: surgical therapy. Gastroenterol Clin North Am 1993;22:751–78. [12] Feliciano D. Do perforated duodenal ulcers need an acid-decreasing surgical procedure now that omeprazole is available? Surg Clin North Am 1992;72:369 – 80. [13] Millat B, Fingerhut A, Borie F. Surgical treatment of complicated duodenal ulcers: controlled trials. World J Surg 2000;24:299 –306. [14] Gilliam AD, Speake W, Lobo DN, et al. Current practice of emergency vagotomy and Helicobacter pylori eradication for complicated peptic ulcer in the United Kingdom. Br J Surg 2003;90:88 –90. [15] Espat NK, Ong ED, Helton WS, et al. 1990-2001 US general surgery chief resident gastric surgery operative experience: analysis of a paradigm shift. J Gastrointest Surg 2004;8:471– 8. [16] Parsa CJ, Organ CH, Barkan H. Changing patterns of resident operative experience from 1990 to 1997. Arch Surg 2000;135:570 –3. [17] Ohmann C, Imhof M, Roher HD. Trends in peptic ulcer bleeding and surgical treatment. World J Surg 2000;24:284 –93. [18] Poxon VA, Keighley MB, Dykes PW, et al. Comparison of minimal and conventional surgery in patients with bleeding peptic ulcer: a multicentre trial. Br J Surg 1991;78:1344 –5. [19] Kubba AK, Choudari C, Rajgopal C, et al. The outcome of urgent surgery for major peptic ulcer haemorrhage following failed endoscopic therapy. Eur J Gastroenterol Hepatol 1996;8:1175– 8. [20] Paimela H, Oksala NK, Kivilaakso E. Surgery for peptic ulcer today. A study on the incidence, methods and mortality in surgery for peptic ulcer in Finland between 1987 and 1999. Dig Surg 2004;21:185–91. [21] Johnson AG, Chir M. Proximal gastric vagotomy: does it have a place in the future management of peptic ulcer? World J Surg 2000;24: 259 – 63. [22] Schwesinger WH, Page CP, Sirinek KR, et al. Operations for peptic ulcer disease: paradigm lost. J Gastrointest Surg 2001;5:438 – 43.
Poster presentation
Variations reported in surgical practice for bleeding duodenal ulcers Brian C. Reuben, M.D.*, Leigh A. Neumayer, M.D., M.S. Division of General Surgery, Department of Surgery, University of Utah School of Medicine, 30 North 1900 East, Salt Lake City, UT 84132, USA Manuscript received May 15, 2006; revised manuscript August 3, 2006 Presented at the 30th Annual Surgical Symposium of the Association of VA Surgeons, Cincinnati, Ohio, May 7–9, 2006
Abstract Background: To determine the current surgical management of bleeding duodenal ulcers in our program, faculty (FAC) and residents (RES) were surveyed. Methods: FAC (n ⫽ 33) and RES (n ⫽ 42) were surveyed regarding their surgery of choice between oversew (OS) or acid-reducing procedures (ARPs) in 4 scenarios. FAC who had recertified in general surgery (RECERT) were compared with young FAC who had not and RES (RES/young FAC). Two-group comparisons were performed. Results: Seventy-three percent of FAC and 62% of RES responded. RES perform more ARPs on hemodynamic (HD), unstable, elderly patients than FAC (P ⫽ .013). On the elderly patient, RES/young FAC perform more ARPs in a HD stable (P ⫽ .07) and unstable condition (P ⫽ .18). HD unstable patients would undergo OS more frequently than stable patients (P ⫽ .016). Conclusions: In this survey, the choice of optimal surgical procedure for an acute bleeding ulcer varies among surgeons based on years of surgical experience and individual patient factors. © 2006 Excerpta Medica Inc. All rights reserved. Keywords: Duodenal ulcer; Peptic ulcer; Vagotomy; Survey; Practice patterns
Time and technology continue to afford a better understanding of the pathogenesis of duodenal ulcer disease as well as improved medications for the treatment of acid hypersecretion. However, the surgical literature lags in evidence-based support for minimal surgical procedures, such as simple oversew (OS) only, for the management of an acutely bleeding duodenal ulcer. New advances bring new questions as to the ideal treatment. Previous surgical dictum states that a vagotomy and pyloroplasty is the ideal choice for this difficult problem [1]. However, this surgery is plagued with significant postoperative complications such as dumping syndrome and diarrhea, can occur in up to 20% of patients [2– 4]. New evidence regarding the role of Helicobacter pylori suggests that this aggressive surgical approach may no longer be needed. In fact, recent studies have shown that ulcerogenic effects of nonsteroidal anti-inflammatory drugs (NSAIDs) can cause a 2-fold increase in the risk of bleeding among patients infected with H pylori in comparison with patients who are H pylori negative, suggesting these conditions are additive [5]. H pylori has been found in 68% to
* Corresponding author. Tel.: ⫹1-801-581-2431; fax: ⫹1-801-585-2425. E-mail address: [email protected]
90% of bleeding duodenal ulcers [6 – 8]. In addition, successful eradication of H pylori has been shown to reduce recurrent ulcer bleeding rates [9,10]. The ulcerogenic role of H pylori is well understood and proton pump inhibitors are used widely, but their impact on surgical management of acutely bleeding duodenal ulcers still remains to be determined. The aim of this study was to assess the variability and current opinion of attending surgeons and residents at our institution regarding OS versus acid-reducing surgery for 4 distinct clinical scenarios of a bleeding duodenal ulcer. Materials and Methods A survey consisting of 4 questions (2 different cases with 2 clinical scenarios) was sent to the faculty (FAC) and residents (RES) of the Division of General Surgery at the University of Utah after Institutional Review Board approval was obtained (Table 1). Surveys were sent to a total of 33 FAC and 42 RES of all levels. Two patient scenarios were presented in both a hemodynamic (HD) stable, and unstable, clinical condition. The respondents then were given 4 options to choose from, ranging from simple OS of the bleeding ulcer, OS of the bleeding ulcer with truncal vagotomy and pyloroplasty, OS of the ulcer and highly selective
0002-9610/06/$ – see front matter © 2006 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2006.08.021
B.C. Reuben and L.A. Neumayer / The American Journal of Surgery 192 (2006) e42– e45
e43
Table 1 Survey questions
Table 2 Respondent demographics
Case 1. A 55 year old female is admitted for an upper G1 bleed. She is on daily NSAIDs for osteoarthritis. No other prior medical history. She requires operative intervention and stabilizes in the operating room. Case 2. Same 55 year old female as above but she is hemodynamically unstable in the operating room and requires vasopressors to maintain her blood pressure. Case 3. An 85 year old male is admitted for an upper GI bleed. He has a long standing history of peptic ulcer disease and is on daily proton pump inhibitor therapy. He has extensive medical co-morbidities to include hypertension, COPD, CHF and CAD. He requires operative intervention and stabilizes in the operating room. Case 4. Same 85 year old male as above but he is hemodynamically unstable in the operating room and requires vasopressors to maintain his blood pressure.
Variable
Rate
Number of residents (PGY1-5) Response rate Average age of residents PGY of resident respondents: PGY 5/4 PGY 3/2/1 Number of attendings Response rate Average age of attendings ABS recertification Completed a surgical fellowship Years since first ABS certification Average number of surgical procedures for bleeding duodenal ulcers per year
26/42 62% 30.96 ⫾ 2.95 y
Response Options: A. Oversew of the bleeding ulcer B. Oversew of the bleeding ulcer, truncal vagotomy and pyloroplasty C. Oversew of the ulcer, highly selective vagotomy D. Oversew of the ulcer, vagotomy and antrectomy with Billroth I/II or Roux-en-Y reconstruction. E. Other, .
vagotomy, and antrectomy with either Billroth I/II or Rouxen-Y reconstruction. Respondents were given the option to enter a fifth response if they felt that none of the above were appropriate. Respondent demographics also were gathered, including age, sex, year of American Board of Surgery (ABS) certification, year of ABS recertification, completion of a fellowship, residency program, and number of ulcer surgeries performed per year. Comparisons were made between RES and FAC responses. To determine the effect of training more recently, we also compared surgeons who had recertified with the ABS (RECERT) with those who were younger and not yet eligible for recertification (RES/young FAC). Comparisons between the study groups for dichotomous outcomes were performed using the chi-square test if the minimum expected cell frequency assumption was met (80% of the cells have expected frequencies of at least 5 and no cell has an expected frequency of ⬍1). Otherwise, the Fisher exact test was used. Two-group comparisons for ordered categoric variables was performed using the Wilcoxon-Mann-Whitney test. A P value of less than .05 was considered significant. All descriptive statistical analyses were performed with STATA 9.0 (Stata Corp, College Station, TX).
8 18 24/33 73% 46.91 ⫾ 9.32 y 54% (13/24) 42% (10/24) 12.91 ⫾ 9.18 y 2.4 (range, 0–10)
Values are given with the SD from the mean. PGY ⫽ postgraduate year.
(P ⫽ .013) (Fig. 1). Several RES chose to perform an antrectomy with either Billroth or Roux-en-Y reconstruction whereas all FAC chose either a simple OS of the ulcer or OS with vagotomy and pyloroplasty. RES also differed from FAC on patient 1, with RES tending to perform more OS surgeries with a young patient on NSAIDs (P ⫽ .0751) (Fig. 1). Patient HD stability In the 2 cases of HD stability, all surgeons (RES and FAC) performed ARPs a majority of the time, 58% and 74% for patients 1 and 2, respectively. However, with intraoperative HD instability, regardless of the clinical situation, RES and FAC performed OS of the bleeding ulcer the majority of the time, 82% and 72% for patients 3 and 4, respectively. Overall, HD unstable patients would undergo OS more frequently than HD stable patients (P ⫽ .016). ARPs were performed less frequently in the younger patient taking NSAIDs versus an elderly man with multiple comorbidities, although the difference was not statistically significant (P ⫽ .263). RECERT versus RES/young FAC RECERT tended to perform a more aggressive surgery on the 55-year-old patient by performing more ARPs than
Results Demographics There were 24 FAC (73%) and 26 RES (62%) who completed the survey. The RES and FAC demographic information is listed in Table 2. RES versus FAC RES differed significantly from FAC in the management of the 85-year-old man in a HD unstable condition with RES performing more acid-reducing procedures (ARPs)
Fig. 1. Responses for RES and FAC for management of an acute bleeding duodenal ulcer. *Significant difference between FAC and RES in management of patient 4, P ⫽ .013.
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B.C. Reuben and L.A. Neumayer / The American Journal of Surgery 192 (2006) e42– e45
Fig. 2. Responses between RES/young FAC and RECERT for patient 1. P ⫽ .103 for differences between RES/young FAC and RECERT using the Wilcoxon-Mann-Whitney test.
RES/young FAC (P ⫽ .103) (Fig. 2). The opposite trend exists between RES/young FAC and RECERT when surveyed regarding an elderly man with a history of ulcers and multiple comorbidities. RECERT tend to perform less aggressive surgical procedures (simple OS or OS with vagotomy and pyloroplasty) compared with RES/young FAC who attempted either highly selective vagotomy or antrectomy in the stable 85-year-old (P ⫽ .071) (Fig. 3). RES/ young FAC also tended to more frequently attempt an antrectomy with Billroth or Roux-en-Y reconstruction in the unstable elderly patient (P ⫽ .179). Nonsurgical treatment Surgeon age and number of years since certification did not show a significant difference in the incidence of OS versus ARP. When questioned about the proper postoperative evaluation and management and care for a patient with a duodenal ulcer, RES and FAC recognized the need for H pylori testing, the use of proton pump inhibitors, and cessation of NSAIDs if able. No other responses were filled in for a fifth surgical option. Comments To elucidate the discrepancies and variability in the surgical management of an acute bleeding duodenal ulcer, our faculty and residents were surveyed regarding their ideal procedure of choice given 2 distinct patient populations. The results indicate that at our institution, the difficult clinical scenario of a bleeding duodenal ulcer is managed in a variety of ways, and suggests an opportunity for improvement in resident education. It is not surprising that surgeons performed the most expeditious surgery of OS the majority of the time when either patient was HD unstable. However, with HD stability, the variability in surgeon preference becomes evident. When looking at all surgeons, ARPs were more common in a HD stable patient. However, RES/young FAC are more apt to perform simple OS on a younger patient population, perhaps implying their understanding of the successful medical management or highlighting their lack of experience and comfort performing ARPs. Meanwhile, this same group is more reluctant to perform the same surgery on a stable elderly patient with multiple comorbidities. The lack of prospective surgical trials evaluating minimal surgery with proton pump therapy and H pylori eradication against tra-
ditional procedures leaves the surgeon to rely on their best clinical judgment, often emanating form their personal experience. There is strong evidence in the older surgical literature that rebleeding events can be catastrophic and most recommendations for surgical management of elderly patients with comorbid disease and/or HD instability who have active arterial ulcer hemorrhage include emergent surgical intervention and classic ARPs [1,11,12]. A more recent review of the older literature has brought into question the validity of some of the older studies, demonstrating that early surgical intervention for bleeding ulcers may not be as beneficial as once was thought [13]. Significant controversy still exists regarding the optimal treatment of bleeding duodenal ulcers primarily because of a lack of up-to-date evidence. The purpose of comparing young attending surgeons and residents (RES/young FAC) with FAC with more than 10 years of experience (RECERT) was to determine if a younger generation of surgeons possess differing perspectives on the management of a bleeding duodenal ulcer. We can only speculate, but perhaps, as part of a new surgical era, today’s young surgeons may embrace theory and perhaps have a stronger foundation in pharmacology than older surgeons who have passed through traditional teaching programs. Perhaps surgeons in practice long enough to have recertified have more experience with ARPs and thus feel more comfortable performing this surgery. Recent surveys of general surgeons have indicated that surgeons rarely perform a vagotomy for a bleeding peptic ulcer [14]. Our study evaluates the different practice patterns stratified by time in surgical practice as evidenced by ABS recertification status. Indeed, variations in practice patterns by surgeon experience level do exist in an otherwise healthy patient population (patients 1 and 2) at our institution. RECERT surgeons tend to be more aggressive than RES/young FAC with stable, low-complexity patients. In cases of increasing patient comorbidities and HD instability, RES/young FAC perform more aggressive ARPs. The rationale for such decisions may be sound, but surgeons still lack evidence from up-todate clinical trials when evaluating options for acutely bleeding duodenal ulcers. The procedural variability becomes even more important when we examine resident education. Several studies have documented that resident surgical experiences with vagotomy decreased greater than 3-fold during the 1990s [15,16].
Fig. 3. Responses between RES/young FAC and RECERT for patient 3. P ⫽ .071 for differences between RES/young FAC and RECERT using the Wilcoxon-Mann-Whitney test.
B.C. Reuben and L.A. Neumayer / The American Journal of Surgery 192 (2006) e42– e45
This provides fewer teaching opportunities on a technical surgery such as truncal or highly selective vagotomy. Could this trend impact future decision making on behalf of RES when faced with the decision of simple OS versus an ARP? Clearly, if RES have insufficient experience performing vagotomies, they are unlikely to perform this procedure once in practice. In addition, the indications for such a procedure may be misunderstood and the surgery ultimately misused. In our internal survey, there was a discernable difference in the responses between upper-level residents (postgraduate years 4/5) and junior residents (postgraduate years 1/2/3) with upper-level residents making more appropriate clinical management decisions. However, without practical experience performing these surgeries, are residents going to be able to perform them once out in practice? Simple OS of the bleeding ulcer has reported recurrence rates for bleeding of anywhere from 3% to 20%. Interestingly, mortality remains unchanged between local and radical surgery [17–19]. Thus, is it necessary to perform an ARP in any clinical scenario? A recent survey of general surgeons in Great Britain and Ireland in 2001 showed that 39% of surgeons would never perform a vagotomy for a bleeding duodenal ulcer whereas 2.5% of respondents said they would always perform a vagotomy [14]. Other recent evidence continues to suggest that perhaps surgeons are trending away from ARP in the face of an emergency duodenal bleed [20]. The current literature on surgical management of an acute bleeding duodenal ulcer lacks prospective, randomized trials on the outcomes of conservative versus aggressive surgery (OS vs. ARP). The understanding of the role of H pylori and the influence of its eradication on overall mortality and the rebleeding rate provide the theoretic argument for conservative treatment for a bleeding duodenal ulcer despite this lack of level I evidence [21,22]. In summary, our study suggests that a variety of surgical procedures may be applied to a given clinical patient scenario based on surgeon experience and patient factors. The clinical scenarios presented are not encountered commonly and thus resident case exposure is low. With a lack of randomized trials in this area, surgical decision making is highly variable and appears to be based on the knowledge and experience of the operating surgeon. References [1] Cowles RA, Mulholland MW. Surgical management of peptic ulcer disease in the helicobacter era—management of bleeding peptic ulcer. Surg Laparosc Endosc Percutan Tech 2001;11:2– 8.
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[2] Mulholland MW, Debas HT. Chronic duodenal and gastric ulcer. Surg Clin North Am 1987;67:489 –507. [3] Johnston D, Blackett RL. Recurrent peptic ulcers. World J Surg 1987;11:274 – 82. [4] Thompson JC, Wiener I. Evaluation and surgical treatment of duodenal ulcer: short- and long-term effects. Clin Gastroenterol 1984;13: 569 – 600. [5] Aalykke C, Lauritsen JM, Hallas J, et al. Helicobacter pylori and risk of ulcer bleeding among users of nonsteroidal anti-inflammatory drugs: a case-control study. Gastroenterology 1999;116:1305–9. [6] Callicutt CS, Behrman S. Incidence of Helicobacter pylori in operatively managed acute nonvariceal upper gastrointestinal bleeding. J Gastrointest Surg 2001;5:614 –9. [7] Castro Fernandez M, Sanchez Munoz D, Garcia Diaz E, et al. Diagnosis of Helicobacter pylori infection using urease rapid test in patients with bleeding duodenal ulcer: influence of endoscopic signs and simultaneous corporal and antral biopsies. Rev Esp Enferm Dig 2004;96:599 – 602. [8] Chan HL, Wu JC, Chan FK, et al. Is non-Helicobacter pylori, nonNSAID peptic ulcer a common cause of upper GI bleeding? Gastrointest Endosc 2001;53:438 – 42. [9] Rokkas T, Karameris A, Mavrogeorgis A, et al. Eradication of Helicobacter pylori reduces the possibility of rebleeding in peptic ulcer disease. Gastrointest Endosc 1995;41:1– 4. [10] Jaspersen D, Koerner T, Schorr W, et al. Helicobacter pylori eradication reduces the rate of rebleeding in ulcer hemorrhage. Gastrointest Endosc 1995;41:5–7. [11] Cochran T. Bleeding peptic ulcer: surgical therapy. Gastroenterol Clin North Am 1993;22:751–78. [12] Feliciano D. Do perforated duodenal ulcers need an acid-decreasing surgical procedure now that omeprazole is available? Surg Clin North Am 1992;72:369 – 80. [13] Millat B, Fingerhut A, Borie F. Surgical treatment of complicated duodenal ulcers: controlled trials. World J Surg 2000;24:299 –306. [14] Gilliam AD, Speake W, Lobo DN, et al. Current practice of emergency vagotomy and Helicobacter pylori eradication for complicated peptic ulcer in the United Kingdom. Br J Surg 2003;90:88 –90. [15] Espat NK, Ong ED, Helton WS, et al. 1990-2001 US general surgery chief resident gastric surgery operative experience: analysis of a paradigm shift. J Gastrointest Surg 2004;8:471– 8. [16] Parsa CJ, Organ CH, Barkan H. Changing patterns of resident operative experience from 1990 to 1997. Arch Surg 2000;135:570 –3. [17] Ohmann C, Imhof M, Roher HD. Trends in peptic ulcer bleeding and surgical treatment. World J Surg 2000;24:284 –93. [18] Poxon VA, Keighley MB, Dykes PW, et al. Comparison of minimal and conventional surgery in patients with bleeding peptic ulcer: a multicentre trial. Br J Surg 1991;78:1344 –5. [19] Kubba AK, Choudari C, Rajgopal C, et al. The outcome of urgent surgery for major peptic ulcer haemorrhage following failed endoscopic therapy. Eur J Gastroenterol Hepatol 1996;8:1175– 8. [20] Paimela H, Oksala NK, Kivilaakso E. Surgery for peptic ulcer today. A study on the incidence, methods and mortality in surgery for peptic ulcer in Finland between 1987 and 1999. Dig Surg 2004;21:185–91. [21] Johnson AG, Chir M. Proximal gastric vagotomy: does it have a place in the future management of peptic ulcer? World J Surg 2000;24: 259 – 63. [22] Schwesinger WH, Page CP, Sirinek KR, et al. Operations for peptic ulcer disease: paradigm lost. J Gastrointest Surg 2001;5:438 – 43.