Reliable procedure for closing the duodenal stump for bleeding posterior duodenal ulcer

Technique of antroduodenectomy without ulcer excision as a safe alternative treatment for bleeding chronic duodenal ulcers

BACKGROUND

The treatment of a bleeding chronic posterior duodenal ulcer, with bleeding recurrence or persistence despite endoscopic therapy, requires surgical treatment and constitutes a challenge for the surgeon; furthermore such chronic ulcers are often wide and sclerotic, so the surgeon needs to avoid the risk of recurrent bleeding if conservative surgery is applied. If radical surgery must be performed, the greater risk involves duodenal leakage, hepatic hilar injury, or pancreatic injury. This study aimed to evaluate the efficacy and complications arising from a surgical procedure, described by Dubois in 1971 (Gastrectomy and gastroduodenal anastomosis for post-bulbar ulcers and peptic ulcers of the second part of the duodenum. J Chir 101:177-186). This operation involves antroduonectomy with gastroduodenal anastomosis. It is similar to a Billroth I gastrectomy but without dissection of the ulcer.

MATERIALS AND METHODS

We retrospectively studied the medical data of patients who underwent this procedure for the treatment of bleeding chronic posterior duodenal ulcers during the past 20 years.

RESULTS

There were 28 such patients admitted to our institution for emergency surgery, who went on to be treated by the Dubois procedure. Ulcerous disease was efficiently treated without rebleeding or duodenal leakage. The mortality rate was 17%; most deaths resulted from medical failure in older patients suffering from massive bleeding. The rate of medical complications reached 21%. Surgical complications developed in 14% of patients.

CONCLUSIONS

The Dubois antroduodenectomy is a safe and effective surgical procedure for the treatment of bleeding chronic duodenal ulcers. The number of fatal outcomes among patients with this condition remains high, particularly in older and vulnerable patients experiencing massive bleeding.

APACHE II score: a useful tool for risk assessment and an aid to decision-making in emergency operation for bleeding gastric ulcer

BACKGROUND

Operating for bleeding gastric ulcer remains controversial. Gastric resection bears a higher surgical risk while limited operation may result in more postoperative hemorrhage. There has been little discussion of effective risk assessment of patients. The aim of this study is to define surgical risk by using the APACHE II scoring system, and to determine optimal management.

STUDY DESIGN

Records from October 1990 to December 1996 were retrospectively reviewed for patients (n=101) with bleeding gastric ulcer who had undergone emergency operation after failed endoscopic therapy. Mortality rates were examined according to different APACHE II scores, and the surgical risk was defined. From January 1997 to December 1997, 35 consecutive patients were enrolled for prospective study. Partial gastric resection (PGR) was performed for patients with huge ulcers (>2 cm) and for low-risk patients with ulcers at the antrum or angularis, while limited operation (oversewing or excision of bleeding ulcer) was reserved for others. The results were compared with the retrospective study.

RESULTS

In the retrospective study, the mortality rates for the group with a score < 15 and > or = 15 were 5% (3 of 63) and 58% (22 of 38), respectively (p < 0.05). In the group with a score < 15, PGR was performed on 27 patients, and one died. For those patients with a score > or = 15, PGR carried a lower mortality than limited operation, although this was not statistically significant (47% vs 65%). Limited operation resulted in an overall rate of 22% postoperative hemorrhage and 12% reoperation rate, in which all patients with a score > or = 15 died. In the prospective study, the mortality rates in those scoring <15 and > or = 15 were 6% and 50%, respectively. This is not significantly different than the retrospective study. However, the rate of postoperative hemorrhage was diminished (5%).

CONCLUSIONS

APACHE II score is a useful tool for assessing risk in patients with bleeding gastric ulcer. The mortality is minimal in those with a score <15, and PGR can be performed with low risk. Although high-risk patients have dreadful outcomes, limited operation cannot improve them if postoperative hemorrhage occurs. Decision making in emergency operation for such patients should be based on the ulcer conditions and the patient's hemodynamic status.

Laparoscopic underrunning of bleeding duodenal ulceration: a minimalist approach to therapy

Surgical management of bleeding duodenal ulcer has traditionally included a procedure to reduce gastric acid production to enable ulcer healing and reduce the likelihood of rebleeding. The availability of intravenous proton pump inhibitors in the peri-operative period may promote rapid ulcer healing and as a component of anti-Helicobacter eradication therapy greatly reduces the incidence of ulcer recurrence. Using this approach, six patients with actively bleeding duodenal ulcer underwent laparoscopic duodenotomy and attempted suturing of the bleeding site. One patient required conversion to open surgery and subsequently re-bled at 60 h, necessitating a partial (Billroth II) gastrectomy. In the remaining five patients suture control of bleeding and luminal closure were completed laparoscopically without complications. Laparoscopic repair of acutely bleeding duodenal ulcers is technically feasible and had a low complication rate in this small series.