Parietal cell vagotomy as an emergency procedure for bleeding peptic ulcer

Twenty-three selected patients presenting with massive bleeding from peptic ulcers underwent emergency parietal cell vagotomy (PCV). Nineteen patients had a duodenal ulcer, two a prepyloric ulcer, and one a gastric ulcer. The patients were studied retrospectively with regard to postoperative mortality and morbidity, early rebleeding, and recurrent ulceration. Two patients (9%) died after operation, one of rebleeding. No others suffered rebleeding. One further patient had major respiratory complications and 14 others developed minor complications. The remaining 21 patients were followed for between 2 and 72 months. Two patients (10%) developed recurrent ulcers. The authors conclude that parietal cell vagotomy may be used as an emergency operation for bleeding peptic ulcer in selected cases with an acceptably low mortality, rebleeding rate, and incidence of recurrent ulceration.

Selection of patients for surgery following peptic ulcer haemorrhage

Surgery remains the only widely available and well-proven means of stopping haemorrhage from peptic ulcers and preventing its recurrence but carries an unavoidable morbidity. If surgery is to be used to maximum effect with minimum morbidity, an accurate means of predicting which patients will suffer further haemorrhage is needed. Although over 80 per cent of patients who rebleed have the endoscopic stigmata of haemorrhage, a policy of operation in all patients with stigmata would lead to a very high operation rate and a high proportion of unnecessary operations, as one-half of the patients with stigmata do not rebleed. Clinical data were collected prospectively from 278 cases of peptic ulcer haemorrhage. The data from a randomly selected 75 per cent of the cases were analysed by stepwise logistical regression. Patients who had the endoscopic stigmata of haemorrhage and who had a probability of further haemorrhage, calculated from the regression equation, of more than 0.2 were identified as a high risk group. This definition was validated using the 25 per cent of cases not used in the initial analysis. Eighty-four per cent of patients in the high risk group suffered further haemorrhage and all such patients therefore require early surgery: such a policy would have resulted in an operation rate of 28 per cent. Thirty per cent of the patients who had further haemorrhage were not identified as being at high risk but none of them had a severe rebleed. The regression equation greatly enhanced the value of stigmata in guiding surgical decision making and merits further evaluation.

Conservative management of bleeding duodenal ulcer without a visible vessel: prospective randomized trial

Between January 1983 and December 1985, 305 patients were admitted to our hospital because of bleeding duodenal ulcer. A subgroup of 69 patients aged 50 or above in whom emergency endoscopy showed non-arterial bleeding or signs of recent haemorrhage without a visible vessel entered a prospective therapeutic trial. The patients were randomized to receive either (1) early surgery, implying immediate operation, or (2) expectant management, with surgery reserved only for patients with further haemorrhage. The two groups were homogeneous with respect to age, sex, prior ingestion of ulcerogenic drugs, mode of bleeding, admission haematocrit, number with hypovolaemic shock and number with active bleeding on initial endoscopy. Overall mortality was 8.6 per cent. Mortality in patients submitted to early surgery was five times higher than that in those allocated to expectant therapy (14.7 per cent versus 2.9 per cent; risk ratio 5.07). The results suggest that expectant management is advisable in patients with bleeding duodenal ulcer not bleeding massively and in whom endoscopy does not disclose spurting arterial bleeding or a visible vessel.

Endoscopic therapy of bleeding peptic ulcers: a cost-benefit analysis

Endoscopic hemostatic therapies have become increasingly popular and appear capable of controlling hemorrhage from peptic ulcers and reducing the need for surgery, but many physicians are unsure that the efficacy justifies the cost. In order to study this clinically and economically important issue, we developed a mathematical model to analyze the economics of endoscopic therapy of bleeding peptic ulcers. Endoscopic therapy appears capable of reducing direct hospital costs only when selectively applied to those patients with the highest risk of requiring surgery. Sensitivity analysis identifies efficacy, treatment cost, and the rebleeding rate in untreated patients as the most critical variables affecting the cost of interventional endoscopy. Using neodymium: YAG laser photocoagulation as an example, interventional endoscopy can be cost-effective for treating selected patients with bleeding peptic ulcers. Should other hemostatic devices such as the heater probe and bipolar electrocoagulator prove to be as effective as the laser, even greater cost savings could be achieved.

Per-endoscopic bipolar diathermy coagulation of visible vessels using a 3.2 mm probe--a randomised clinical trial

Forty-four patients who had bled from peptic ulcers and whose ulcers showed stigmata of haemorrhage (bleeding, visible vessel or adherent clot) entered a trial of treatment with a 3.2 mm bipolar diathermy probe. Two patients had spurting haemorrhage when endoscoped and both were treated with the probe, control being obtained in one. The remaining patients were randomised to treatment or control groups. One patient who was treated was withdrawn because the ulcer proved to be malignant. Six of 20 treated patients rebled compared with 8 of 21 controls (relative risk 0.79; 90% CI 0.26-1.97). The operation rate, transfusion requirement and hospital stay were similar in the two groups. One perforation occurred in the treatment group. Per-endoscopic bipolar diathermy treatment confers little benefit in bleeding peptic ulcer disease.

Massive gastrointestinal hemorrhage in children with posterior fossa tumors

Over a 12-month period (September 1984 to September 1985), 64 children with newly diagnosed brain tumors were admitted to the Neurosurgical Service at The Children's Hospital of Philadelphia. Of these children, 29 had posterior fossa tumors. Of this population of children with posterior fossa tumors, three patients aged 4 months, 22 months, and 4 years old developed massive exsanguinating upper gastrointestinal hemorrhage within seven days of their primary neurosurgical procedure. In each instance, large posterior duodenal ulcers were encountered and were treated with oversewing of the duodenal ulcer and vagotomy-pyloroplasty. Follow-up currently ranges from 18 to 26 months. All three children have survived and none have had any gastrointestinal bleeding since then. Massive exsanguinating hemorrhage was not seen in children with brain tumors in locations other than the posterior fossa. In this population of patients, we advocate the use of prophylactic cimetidine and titration of gastric acidity with antacids.

Multipolar electrocoagulation in the treatment of active upper gastrointestinal tract hemorrhage. A prospective controlled trial

The benefit of nonsurgical therapy in the treatment of active nonvariceal upper gastrointestinal tract hemorrhage is uncertain. I performed a prospective controlled trial of endoscopic multipolar electrocoagulation for active upper gastrointestinal hemorrhage. Patients were considered for entry if they had a bloody nasogastric aspirate, melena, or hematochezia, and any of the following: unstable vital signs, a requirement of greater than or equal to 2 units of blood per 12 hours, or a drop in hematocrit of greater than or equal to 6 percent in 12 hours. Forty-four patients were randomly assigned to receive multipolar electrocoagulation or sham multipolar electrocoagulation if endoscopy revealed active bleeding from an ulcer (24 patients), a Mallory-Weiss tear (17), or a vascular malformation (3). The group receiving multipolar electrocoagulation did significantly better in terms of hemostasis (90 percent vs. 13 percent, P less than 0.0001), mean (+/- SE) transfusion requirements (2.4 +/- 0.9 vs. 5.4 +/- 0.9 U; P = 0.002), mean number of hospital days (4.4 +/- 0.8 vs. 7.2 +/- 1.1, P = 0.02), and percentage needing emergency surgery or another intervention (14 vs. 57 percent, P = 0.01). Although mortality was lower in the group receiving multipolar electrocoagulation (0 vs. 13 percent), this difference was not statistically significant. The mean cost of hospitalization for treated patients was less than half that for the controls ($ 3,420 +/- 750 vs. $ 7,550 +/- 1,480, P = 0.001). I conclude that multipolar electrocoagulation markedly improves the hospital course in patients with major, nonvariceal upper gastrointestinal hemorrhage.

Laser photocoagulation for the treatment of acute peptic-ulcer bleeding. A randomized controlled clinical trial

We tested the hypothesis that therapeutic endoscopy using the Nd:YAG (neodymium:yttrium-aluminum-garnet) laser would benefit patients with acute peptic-ulcer bleeding. Over 43 months, 174 patients with active bleeding (n = 32) or stigmata of recent bleeding (n = 142) due to peptic ulcers were randomly assigned during endoscopy to either standard treatment with laser photocoagulation or therapy without photocoagulation. There were no significant differences in a number of outcomes between the group treated with laser photocoagulation and the control group. Continued bleeding or rebleeding was observed in 22 percent of the laser-treated group and in 20 percent of the control group. Urgent surgery was necessary in 16 percent of the laser-treated patients and in 17 percent of the controls. Laser-treated patients spent a mean of 41 hours in the intensive care unit, and controls spent a mean of 32 hours. The mean hospital stay was 12 days in the laser-treated group and 11 days in the control group. One death occurred in each group. When patients with active bleeding were analyzed separately, there was no significant difference in outcome, even though laser photocoagulation stopped active bleeding in 88 percent of cases. Among patients with visible vessels, rebleeding occurred in 5 of 14 (36 percent) who received laser treatment and 2 of 15 (13 percent) who did not. Laser treatment precipitated bleeding in four patients and duodenal perforation in one. We conclude that Nd:YAG-laser photocoagulation does not benefit patients with acute upper gastrointestinal bleeding from peptic ulcers.

Nonreflux complications of hiatal hernia

Patients with massive incarcerated hiatal hernia and no appreciable esophagitis present with a distinctly different clinical picture from those with hiatal hernia and reflux peptic esophagitis. In a recent review, 17 patients were encountered with this problem. The patients were often elderly and presented with the following grave complications: upper gastrointestinal obstruction; upper gastrointestinal bleeding, both acute and chronic, from gastric ulcerations; and perforated gastric ulcerations. In these patients, the surgical approach is better accomplished through the abdominal route. These patients should be distinguished from those with a shortened esophagus resulting from chronic reflux peptic esophagitis who often require thoracotomy for surgical correction.

Chronic duodenal and gastric ulcer

During the past two decades, major advances have been made in our understanding of basic gastric physiology. Appreciation of cellular biology has contributed to rapid progress in gastric pharmacology. Clinicians may choose from a large and rapidly growing list of antiulcer drugs. The proper choice of medical or surgical therapy depends on knowledge of the pathophysiology of peptic ulceration and of the inherent limitations of each approach. Selective drug use, tailoring of medical regimens to individual clinical situations, and the combination of medical and surgical treatments will play prominent roles in the future management of peptic ulceration.

Neodymium-YAG laser photocoagulation versus multipolar electrocoagulation for the treatment of severely bleeding ulcers: a randomized comparison

A randomized trial comparing the efficacy of BICAP electrocoagulation and YAG laser photocoagulation was carried out in 100 patients presenting at endoscopy with peptic ulcer and a spurting or oozing vessel or a nonbleeding vessel. Fifty patients were enrolled in each treatment group. All lesions were pretreated with injection of epinephrine 1:10,000. Subsequently, 1-sec pulses of 80 watt YAG laser power were applied to the vessel or 1- to 2-sec pulses of electrocoagulation of 25 watt BICAP at a setting of 10. The 10 F BICAP probe was always used. Definitive hemostasis after one treatment amounted to 72% in both the laser and in the BICAP group. After two sessions the cumulative success rate was 88% in the laser group and 86% in the BICAP group. Emergency surgery and mortality were also comparable. One perforation occurred in each treatment group and both patients were operated upon without complications. It is concluded that both YAG laser and BICAP are highly and equally effective in the treatment of severe bleeding from peptic ulcers. This study stresses the importance of repeated treatment sessions in order to obtain optimal results.

[Principles of risk research in surgery: definition, calculation and clinical use in the problem of upper gastrointestinal hemorrhage]

In surgery, risk research is of great importance at the present time but is controversely discussed with contradictory definitions, calculations and applications. In this paper standardized and quantitative definitions of risk and risk factors using probabilities are given. A calculation of risk, risk factors and risk rates is performed using data from studies on bleeding duodenal ulcers. Possible applications of risk and risk factor research (risk analysis) in suitable treatment policies are demonstrated using data from patients with bleeding duodenal ulcers. The utility of this type of approach, using decision tree analysis, clearly manifests itself in the reduction of lethality. Objective and quantitative surgical risk research and its application as risk analysis using probabilities can improve patient care in standard surgical situations.

Non-steroidal anti-inflammatory drugs and life threatening complications of peptic ulceration

Two hundred and thirty five consecutive patients with a life threatening complication of peptic ulceration, who either died or required emergency surgery, have been studied over a 36 month period. Seventy eight of these high risk patients died; 25 at home, 19 in hospital without surgery and 34 postoperatively. Ninety eight patients had bleeding ulcers, 132 perforated ulcers and five had both bleeding and perforated ulcers. One hundred and forty one of these 235 patients (60%) were taking a non-steroidal anti-inflammatory drugs (NSAID) and the individual agents have been listed. The overall incidence of NSAID use in a hospital control group was 9.9%. The first sign of an ulcer was a life threatening complication in 58.2% of patients taking a NSAID. Nearly 80% of all ulcer related deaths occurred in patients using an anti-inflammatory agent. Patients using these drugs were older, with more pre-existing medical conditions and had larger ulcers than those not taking NSAIDs. The mortality associated with a peptic ulcer complication in patients taking a NSAID was more than twice that in patients with no such drug history. There appears to be a relationship between the development of a life threatening complication of peptic ulceration and NSAID ingestion. Much of the associated mortality and morbidity may be potentially avoidable.