Surgical treatment of non-variceal upper gastrointestinal bleeding: our experience with 1482 patients

We retrospectively evaluated the medical records of patients admitted to the U.O.C. of General and Emergency Surgery with Surgical and Polyspecialistic Observation of the Emergency Unit of A.O.R.N. A. Cardarelli of Naples for non-variceal upper gastrointestinal bleeding from 2003 to 2006. All data regarding patients submitted to surgery for non-variceal upper gastrointestinal bleeding were collected including the number of patients submitted to surgery after failure of the endoscopic procedure, the diseases most frequently requiring surgery, the endoscopic and surgical procedures most frequently used, and the reasons that prompted the surgical procedure. Of 1482 patients admitted for non-variceal upper gastrointestinal bleeding the lesions that most frequently required surgery were peptic ulcer disease complicated by bleeding in 31 patients (70.5%) and cancer in 13 (29.5%). The most frequent surgical procedure was subtotal gastrectomy (17 patients [38.6%]), followed by direct haemostasis of the ulcer (13 patients [29.5%]), total gastrectomy (11 patients [25%]), and ulcer excision (3 patients [6.9%]). Subtotal or total gastrectomy is the surgical procedure of choice in patients with non-variceal upper gastrointestinal bleeding after failure of endoscopic treatment. The indication for gastrectomy should be determined on the basis of the patient's haemodynamic condition.     

Non-surgical approach to bleeding gastric ulcer

Bleeding gastric ulcers is a common reason for emergency upper endoscopy in Emergency Center of Clinical Center of Serbia. Randomized controlled trials have shown that endoscopic hemostasis is beneficial for patients with a bleeding peptic ulcer. Aim of this study was to analyze the frequency, etiological factors and localization of bleeding gastric ulcer. At the same time we were evaluated a degree of bleeding activity according to Forrest's classification and modality of performed endoscopic hemostasis. All patients who underwent upper gastrointestinal (UGI) endoscopy for bleeding gastric ulcer in Emergency Center (January 2001 - December 2005.) were identified from an endoscopy database and the clinical records were reviewed retrospectivel. A total of 3954 patients underwent UGI endoscopy for presumed acute UGI hemorrhage. More than thirty % of them (31.1)-1230 had an endoscopic diagnosis of bleeding gastric ulcer. We observed 1230 bleeding patients (60% male and 40% female) with a mean age of 64.3. The commonest localization of bleeding gastric ulcers was antrum (54 - 15%). Percentage of patients who received non-steroidal anti-inflammatory drugs (NSAIDs) and/or salicilates before bleeding was 54 6%. The main symptom was melaena, which was observed in 82, 44% of patients with bleeding gastric ulcer. According to Forrest's classification of bleeding activity, the most of patients had F IB and F III degree (23, 41% and 22, 76%). Injection endoscopic hemostasis was performed in 26.34% patients, which had active bleeding (F IA, F IB) Hemostasis was initially obtained in 96% of bleeding patients. Bleeding gastric ulcer is one of the commonest endoscopic diagnosis in Emergency Center of Clinical Center of Serbia. The most frequent etiology factor was no--steroid antinflammatory drugs and/or salicilates. Injection endoscopic hemostasis is a safe procedure with a low cost, and, if successful, substantially reduces the need for emergency surgery.     

Can endoscopic injection of epinephrine prevent surgery in gastroduodenal ulcer bleeding? An analysis of 107 cases

BACKGROUND: Gastroduodenal ulcers are still a common cause of severe upper gastrointestinal bleeding. Endoscopy has gained popularity worldwide over conventional open surgery for the treatment of upper gastrointestinal bleeding. This study aims to assess the efficacy of endoscopic injection of epinephrine in the treatment of gastroduodenal ulcer bleeding. METHODS: This study was conducted between March 2000 and March 2003. We analyzed 107 consecutive patients admitted to our department of trauma and emergency surgery with upper gastrointestinal bleeding. Endoscopy was performed on all 107 patients and bleeding ulcers were treated with injection of diluted epinephrine. RESULTS: Recurrent bleeding was seen in 21 patients (19.6%), all of whom underwent a second endoscopy. Four patients (3.7%) required a third endoscopy session and nine patients (8.5%) needed surgery after endoscopy failed. There were two mortalities (1.9%). The nine patients who required surgery and the two patients who died were all in the Forrest Ia and Ib groups of acute UGI hemorrhage. DISCUSSION: Endoscopic injection therapy with epinephrine reduces operation rates and can be used safely in adequate hemostasis of gastroduodenal ulcers.     

Spectrum of Endoscopic Findings and Therapy in Patients with Upper Gastrointestinal Symptoms after Laparoscopic Bariatric Surgery

Background: More should be known about the spectrum of endoscopic abnormalities and treatments in patients with upper gastrointestinal (UGI) symptoms after laparoscopic bariatric surgery. Methods: Patients referred for endoscopic evaluation of UGI symptoms after laparoscopic bariatric surgery were studied. Clinical manifestations, endoscopic findings and therapy were recorded and correlated. Results: 76 patients who had undergone laparoscopic vertical banded gastroplasty (LVBG) and 28 who had undergone laparoscopic Roux-en-Y gastric bypass (LRYGBP) underwent 160 instances of upper endoscopy. The symptoms included nausea or vomiting (n=47, 29.4%), epigastric discomfort (n=44, 27.5%), UGI bleeding (n=26, 16.3%), heartburn or acid regurgitation (n=26, 16.3%), dysphagia (n=10, 6.3%) and anemia with dizziness (n=7, 4.4%). The endoscopic diagnosis consisted of normal findings (n=57, 35.6%), marginal ulcer (n=39, 24.4%), erosive esophagitis or esophageal ulcer (n=21, 13.1%), food impaction (n=21, 13.1%), stenosis or stricture (n=14, 8.8%), gastric ulcer (n=7, 4.4%), and duodenal ulcer (n=1, 0.6%). Patients with UGI bleeding, dysphagia and LRYGBP tended to have endoscopic abnormalities (P<0.001, P=0.09 and P=0.021, respectively). Endoscopic therapy was successful in resolving the complications including stenosis, UGI bleeding and food impaction. Conclusions: Endoscopy is an essential method of combining relevant endoscopic findings and therapeutic intervention in symptomatic patients following laparoscopic bariatric surgery.     

内镜下治疗Dieulafoy病出血39例

目的观察内镜下治疗Dieulafoy病出血的疗效及安全性。方法 2004年6月～2009年6月我院对39例Dieulafoy病出血急诊行高张钠-肾上腺素液黏膜内注射联合射频及钛夹治疗。结果 36例经内镜止血成功,首次治疗成功34例(87.2%),2例经2次内镜止血成功(5.1%);3例外科手术治疗(7.7%)。内镜止血术后2～4周再行胃镜检查均未发现溃疡。39例随访0.5～5年,平均2年,均无再发出血。结论高张钠-肾上腺素液黏膜内注射联合射频及钛夹是治疗Dieulafoy病出血的一种较为安全有效的方法 。     

Gastrointestinal tract haemorrhage and ischaemia

Gastrointestinal (GI) bleeding, especially acute upper gastrointestinal bleeding, is a common medical emergency. Peptic ulcer, variceal bleeding and bleeding from stress ulceration in critically ill patients are all associated with significant morbidity and mortality. The Rockall score should be used to identify high-risk patients who need urgent treatment. Adequate resuscitation is essential before attempting endoscopy, which is used to establish the diagnosis and allow effective endoscopic therapies. Terlipressin, a vasopressin analogue, is indicated in patients with suspected variceal bleeding prior to endoscopy, whereas a proton pump inhibitor infusion is recommended in patients with peptic ulcer bleeding only after endoscopic treatment. Selective mesenteric embolization and surgery are reserved for patients with non-variceal bleeding refractory to therapeutic endoscopy. Transjugular intrahepatic portosystemic shunt stenting and shunt surgery are reserved for patients with refractory variceal bleeding in an acute setting or as a bridge therapy for prevention of acute variceal bleeding before liver transplantation. In critically ill patients, adequate resuscitation, cautious use of vasopressors, prophylactic use of gastric acid-suppressing agents and enteral nutrition are the cornerstones of treatment in prevention of stress ulcers. Lower GI investigations should be performed in patients with rectal bleeding after exclusion of upper GI bleeding. GI tract ischaemia plays an important role in the aetiology of stress ulcer disease and ischaemic colitis and is also a potential complication of mesenteric embolization in patients with GI bleeding refractory to therapeutic endoscopy.     

Acute hemorrhage secondary to gastric ulcer. Results of emergency endoscopic treatment in 775 cases

The aim of this study was to investigate the effects of endoscopic injection therapy on the clinical outcome of patients with gastric ulcer bleeding. Seven hundred and seventy-five patients with gastric ulcer bleeding were observed over a 10-year period (January 1990 to May 2000) in the First Division of General Surgery of the University of Verona. The prognostic and therapeutic implications of endoscopic treatment of acute severe gastrointestinal bleeding were analyzed on the basis of medical history and clinical and endoscopic findings. The ulcers were classified according to Forrest's classification of bleeding activity. Endoscopic therapy was performed in 500 patients with active bleeding. Haemostasis was initially obtained in all patients except one. Rebleeding occurred in 13%. All these patients were treated endoscopically at the first attempt. Multivariate analysis revealed that recent surgery, ulcer site and Forrest classification independently influenced the recurrence rate. The mortality of the entire cohort studied was 8.1%. Only 31 patients (4%) underwent surgical treatment with a higher mortality compared to unoperated patients (19.3% vs 7.7%). Endoscopic treatment is a safe procedure with a low mortality and cost, and, if successful, substantially reduces the need for emergency surgery.     

Endoscopic Nd:YAG laser therapy in upper gastrointestinal bleeding

Between 1983 and 1986 thirty-seven patients with upper gastrointestinal bleeding or stigmata of acute bleeding were treated at the Second Department of Surgery with endoscopic laser therapy. The non-contact method was used. The cause of bleeding was gastric ulcer in 13 cases and duodenal ulcer in 5. Two patients had anastomotic ulcer, 6 had a simple ulcer, 7 had telangiectases (Mb. Osler), 2 had Mallory Weiss tears and 2 bled after gastric biopsy. Twenty-one patients bled during endoscopy and 16 had signs of recent bleeding. During acute bleeding laser treatment was effective in 95% (1, 3). However, 41% of all patients (15/37) rebled within a week after laser therapy and in 30% (11/37) an emergency operation was necessary. The overall mortality rate was 10.8% (4/37). Endoscopic laser coagulation is successful in the initial treatment of acute upper GI-bleeding. However, there is a considerable risk of rebleeding. Acute laser therapy may change an emergency operation into an elective one, provided that the group at risk of rebleeding can be anticipated at first endoscopy.     

消化性溃疡合并上消化道出血影响因素分析

目的探讨消化性溃疡合并上消化道出血的影响因素。方法收集笔者所在医院315例消化性溃疡合并上消化道出血患者为研究组;同期门诊选取656例消化性溃疡无上消化道出血并发症的患者为对照组。再根据研究组中HP阳性者根除HP后随访2年,观察上消化道再出血情况。所有入选患者均统计幽门螺杆菌检测结果、NSAIDs服用、性别、年龄、饮酒史、血小板计数等情况。结果 NSAIDs对消化性溃疡合并上消化道出血的差异有统计学意义（P〈0.05）;年龄对消化性溃疡合并上消化道出血的差异有统计学意义（P〈0.01）;合用不同种类NSAIDs对消化性溃疡合并上消化道出血的差异有统计学意义（P〈0.05）。结论 NSAIDs增加消化性溃疡合并上消化道出血的风险;年龄与消化性溃疡合并上消化道出血相关,大于60岁的老龄消化性溃疡患者更易合并上消化道出血;合用不同种类NSAIDs较单用NSAIDs者消化性溃疡更易合并上消化道出血。     

Evidence‐based Review of Gastrointestinal Bleeding in the Chronic Kidney Disease Patient

Patients with end‐stage renal disease are more likely to suffer from gastrointestinal (GI) problems, including bleeding from upper and lower sources. Peptic ulcer disease is the most common cause of upper GI bleeding, and although there is some debate in the literature regarding whether the frequency of ulcer disease is higher in patients with kidney disease, it is well established that outcomes are worse in patients with compromised renal function. Angioectasias can be found throughout the GI tract and are another common cause of bleeding; management can be divided into localized endoscopic therapy and systemic hormonal treatment, or surgery for refractory cases. The most frequent causes of lower GI bleeding in this population, in addition to angioectasias, are diverticulosis, hemorrhoids, and ischemic colitis.     

Estenosis de la anastomosis gastroyeyunal en el bypass gástrico laparoscópico. Experiencia en una serie de 280 casos en 8 años

ObjetiveGastrojejunal stricture (GYS), not only is a common complication after laparoscopic gastric bypass, but its frequency is about 15% according to bibliography. Our aim is to present our experience after 280 laparoscopic gastric bypass.Patients and methodFrom January 2004 to December 2012, 280 patients underwent a laparoscopic Roux en Y gastric bypass with creation of the gastrojejunal anastomosis is performed with circular stapler type CEAA No 21 in 265 patients and with a linear stapler in 15 patients. In all patients with persistent feeding intolerance were performed barium transit and/or gastroscopy. When gastrojejunal stricture showed proceeded to endoscopic pneumatic dilation.ResultsTwenty cases (7.1%) developed a gastrojejunal stricture, in 4 of these cases the initial diagnosis was made by barium transit and all case were confirmed by endoscopy. Five patients had a history of digestive bleeding that required endoscopic sclerosis of the bleeding lesion. All cases were resolved by endoscopic dilatation. One patient suffered a perforation and a re-intervention. At follow-up has not been detected re-stricture.ConclusionStructure at the gastrojejunal anastomosis after gastric bypass is the commonest complication early after surgery. Endoscopic balloon dilatation is a safe and effective therapy.     

Principles of medical care of patients with gastrointestinal ulcer hemorrhage]

A new protocol of treatment policy is proposed based on the results of treatment of 518 patients with gastrointestinal ulcer bleedings. All the patients are divided into 3 groups: with continued bleeding, with unstable spontaneous hemostasis, and with stable spontaneous hemostasis. Corresponding policy of treatment was used: surgery, endoscopic hemostasis, conservative treatment. In endoscopic hemostasis we preferred to clamp vessel or ulcer leading to hemostasis in all 36 cases. Hemostasis was not achieved in 6% patients, recurrence of bleeding was in 4.2% patients, 24.6% patients underwent emergency operations. The majority of operated patients underwent stomach resection (51.6%). The proposed principles of treatment permitted to decrease overall lethality from 5.2 to 2.6%, postoperative lethality--from 15.7 to 7.5%.     

Current management of upper gastrointestinal bleeding.

Over a four-year period, 585 patients were hospitalized for massive upper gastrointestinal bleeding. Endoscopy diagnosed the cause of bleeding in 80% of 200 patients so studied. Selective angiography localized the bleeding site in 12 of 20 patients, and infusion of vasopressor stopped hemorrhage in six. Barium studies was 90% accurate in diagnosing ulcer disease but failed to detect gastritis. One hundred thirty (22%) patients were operated upon for medically uncontrolled bleeding. The proportion of patients requiring surgery fell from 33% in year one to 13% in year four. Benign ulcer disease caused bleeding in 51% of surgical patients, while gastritis was found in 20%, esophageal varices in 15% and stress ulcer in 8%. Overall operative mortality was 29%. Among 38 duodenal ulcer patients, mortality was 18%. Vagotomy and pyloroplasty were more effective than resection in this group. Resection for distal gastric ulcers in 22 patients resulted in a mortality of 14% and no rebleeding. While V&P controlled bleeding in 12 alcoholics with gastritis, five (42%) died postoperatively. Mortality among 20 patients with esophageal varices was 35%, although all five survived who had porto-caval shunts. Eight of 10 patients operated upon for stress ulcer bleeding died. Postoperative rebleeding occurred in 14 patients, eight of whom were again operated upon. In all but one a new lesion was found to be responsible for hemorrhage. Increasing use of gastroscopy and selective angiography can be expected to improve diagnostic capabilities in patients with upper gastrointestinal bleeding. Infusing vasopressor into selected arteries should reduce the need for surgical control of gastritis, variceal and stress ulcer bleeding, conditions poorly managed by current operative techniques.     

Emergency diagnosis of upper gastrointestinal bleeding by fiberoptic endoscopy.

Emergency esophagogastroduodenoscopy has been performed in 192 consecutive patients admitted with massive gastrointestinal bleeding. Accurate endoscopic diagnosis was made in 184 or 96%; 58 patients underwent emergency operations to control bleeding with an overall operative mortality of 26%. Excluding 16 patients who underwent emergency portacaval shunting, the operative mortality was 7%. In 6 patients, the bleeding was controlled by endoscopic electrocoagulation. There were no complications. Emergency endoscopy should be done routinely as the primary diagnostic approach in the diagnosis of upper gastrointestinal bleeding.     

Back to basics – clinical diagnosis in bariatric surgery. Routine drains and upper GI series are unnecessary

Background The routine use of closed suction drains and upper GI (UGI) series has been used to aid in the diagnosis and management of gastrojejunal leak after gastric bypass as well as diagnose intra-abdominal bleeding. Materials and Methods 352 consecutive laparoscopic gastric bypass procedures were performed without the use of routine drains or post-operative UGI series. Results There were no adverse events related the lack of routine drains or UGI studies. Five patients (1.4%) did have a drain placed at the time of surgery, at the surgeon’s discretion, due to a particularly difficult gastrojejunal anastomosis although none developed an anastomotic leak. UGI series were ordered post-operatively in seven patients all for unexplained tachycardia, none of who had abnormal radiographic findings. Two patients with tachycardia and normal UGIs had a negative diagnostic laparoscopy to rule out a leak. No UGI series demonstrated a leak although one tachycardic patient with a normal UGI did have a leak diagnosed at laparoscopy. Five patients had clinical signs of a severe gastrojejunal obstruction. Three resolved completely within 48 hours, and two patients required endoscopic intervention without the need for UGI. Six patients (1.7%) required a blood transfusion; all developed tachycardia and five were from bleeding in the GI tract. Conclusions Routine use of drains and UGI series were not necessary for the safe management of gastric bypass patient in our series. In this small series, clinical indicators for leak, obstruction or bleeding were obvious without the additional data from a drain or UGI.     

Gastrointestinal complications after cardiac surgery.

Gastrointestinal complications after cardiac surgery are uncommon, but are associated with a high morbidity and mortality. Over 11 years 8559 procedures requiring cardiopulmonary bypass were performed in this unit and 35 patients were identified who developed gastrointestinal complications after surgery, an incidence of 0.41%. There were nine deaths in this group, a mortality of 25.7% compared with an overall mortality after cardiac surgery in Ireland ranging from 3.24% to 4.81%. These complications required surgery in 21 patients. The most common indication for surgical intervention was upper gastrointestinal bleeding in 10 patients, three patients had acute pancreatitis, two patients had perforated peptic ulcer; two patients had intestinal ischaemia, with five cases of colon pathology. The difficulties of making an early diagnosis are outlined and a low threshold to exploratory laparotomy is recommended.     

Recent advances in endovascular techniques for management of acute nonvariceal upper gastrointestinal bleeding

Over the past two decades,transcatheter arterial embolization has become the first-line therapy for the management of upper gastrointestinal bleeding that is refractory to endoscopic hemostasis.Advances in catheter-based techniques and newer embolic agents, as well as recognition of the effectiveness of minimally invasive treatment options,have expanded the role of interventional radiology in the management of hemorrhage for a variety of indications,such as peptic ulcerbleeding,malignant disease,hemorrhagic Dieulafoy lesions and iatrogenic or trauma bleeding.Transcatheter interventions include the following:selective embolization of the feeding artery,sandwich coil occlusion of the gastroduodenal artery,blind or empiric embolization of the supposed bleeding vessel based on endoscopic findings and coil pseudoaneurysm or aneurysm embolization by three-dimensional sac packing with preservation of the parent artery.Transcatheter embolization is a fast,safe and effective,minimally invasive alternative to surgery when endoscopic treatment fails to control bleeding from the upper gastrointestinal tract.This article reviews the various transcatheter endovascular techniques and devices that are used in a variety of clinical scenarios for the management of hemorrhagic gastrointestinal emergencies.     

Current therapy for nonvariceal upper gastrointestinal bleeding

Upper gastrointestinal bleeding continues to plague physicians despite the discovery of Helicobacter pylori and advances in medical therapy for peptic ulcer disease. Medical therapy with new nonsteroidal anti-inflammatory medications and somatostatin/octreotide and intravenous proton pump inhibitors provides hope for reducing the incidence of and treating bleeding peptic ulcer disease. Endoscopic therapy remains the mainstay for diagnosis and treatment of upper gastrointestinal bleeding. Many methods of endoscopic hemostasis have proven useful in upper gastrointestinal hemorrhage. Currently, combination therapy with epinephrine injection and bicap or heater probe therapy is most commonly employed in the United States. Angiography and embolization play a role primarily when endoscopic therapy is unsuccessful.     

Is endoscopic injection hemostasis of bleeding gastrointestinal ulcers obsolete in 1995?

Bleeding non-neoplastic lesions of the upper gastrointestinal tract, not due to portal hypertension, are a frequent cause of emergency admission. In the present paper we report our retrospective experience in hemostatic injection treatment of these lesions. From May 1990 to May 1994, 164 patients were admitted to our institution for a bleeding gastrointestinal lesion. In 124 cases an ulcer classified according Forrest's criteria was detected. Four patients underwent immediate surgery. The second group of 86 patients (FIIa/FIIb/FIII) were treated conservatively. The third group of 34 patients (FIa/FIb/FIIa) underwent perilesional injection of adrenaline 1:10,000 and polidocanol 1% saline solution during endoscopic examination; 29% (25 pts) of the second group re-bled during the first 72 h vs 8.8% (3 pts) of the third group. The postoperative morbidity in the rebleeding patients was higher in the second group: 38.4% vs 0%. The importance of immediate, inexpensive, and simple hemostatic treatment extended to Forrest IIa lesions is emphasized.     

Management of acute upper gastrointestinal bleeding in a district hospital

BACKGROUND: This study was conducted to assess the management of acute upper gastrointestinal bleeding in a district hospital and to compare these results with national guidelines and the published literature. MATERIALS AND METHODS: This prospective and retrospective study included 112 patients, mean age 66 years, who presented with acute upper gastrointestinal bleeding between July 2004 and February 2005. All patients were assigned a Rockall risk assessment score. RESULTS: The surgical on-call teams managed all the patients according to an agreed protocol. Forty-nine patients had a Rockall score > or =4. Endoscopy was performed in all patients, with 60% accomplished within the first 24 hours. The most common cause found was peptic ulcer (30%). Therapeutic endoscopy was undertaken in 10 patients (9%) with a success rate of 70%. Open surgery was performed in 3 patients. One patient died after having surgery and the Rockall score was >5. Of the patients admitted with acute upper gastrointestinal bleeding, 90.2% were discharged without complication. Eleven patients died (9.8%) and all of them from the high risk group with Rockall scores > or =5. Their mean hospital stay was 17.8 days (range, 2-43 days). CONCLUSION: High-standard results in acute upper gastrointestinal bleeding can be achieved in a district hospital. The management, including the use of the operating theater facilities with operative and anesthetic support, was safe and efficient. A 24-hour-a-day endoscopy service is important to achieve early diagnosis and to plan management. A protocol and early endoscopy improve clinical outcome and reduce mortality, which occurred mostly among elderly patients with high risk scores. It is advisable to introduce the Rockall scoring system in practice.