SURGICAL MANAGEMENT OF UPPER GASTROINTESTINAL HEMORRHAGE Jeffrey S. Bender, MD, FACS University of Oklahoma College of Medicine

Objectives Follow the changing patterns of the disease Outline the current scope of the problem Diagnostic and non-operative modalities Future management

UGI Hemorrhage Approximately 30% decline in rate over last 15 years 150,000 admissions per year Over $1,000,000,000 annually Associated with NSAID use

UGI Hemorrhage Mortality rate 8-10% >65 now comprise over 30% Peptic ulcer still most common cause Surgery now plays an adjunctive role

UGI Hemorrhage: y.o. man with known or suspected PUD Often significant co-morbidities (drugs, ETOH, etc.) Hematemesis and hypotension NGT placed and volume resuscitated

EGD reveals 1.5 cm DU with visible vessel 6 units PRBC transfused OR: oversewing and vagotomy and pyloroplasty Discharged home POD#4; F/U:?; uninsured:? UGI Hemorrhage: 1985

48 y.o. female s/p Roux-en-Y gastric bypass with subsequent revision One day h/o abdominal pain CT scan: pneumoperitoneum OR: perforated DU: Graham patch UGI Hemorrhage: 2005

POD #2: intermittent BRBPR Volume resuscitated Intermittently hypotensive Nuclear medicine: tagged RBC scan UGI Hemorrhage: 2005

Suspected bleed from transverse colon Bleeding continues Arteriogram performed X 2 UGI Hemorrhage: 2005

Occluded celiac axis Retrograde flow via inferior pancreatico- duodenal artery Fills hepatic, left gastric, splenic arteries Unable to embolize 2 nd branch of IPDA UGI Hemorrhage: 2005

OR: duodenotomy with bleeding point third portion oversewn 20 units PRBC Fascia left open with vac sponge closure Fascia closed POD #4 UGI Hemorrhage: 2005

Prolonged ICU course (30 days) Transferred to rehab center day #45 Insurance: “pre-existing condition” UGI Hemorrhage: 2005

Personal experience 27 gastric resections 17 vagotomies 95th percentile UGI Hemorrhage: 1985

OU experience (15 chiefs, ) 49 resections (3.3/resident) 26 operations for perforation (1.7/resident) 6 vagotomies (0.4/resident) 2 laparoscopic resections UGI Hemorrhage: 2005

10 articles in 5 major journals “Management of Giant Duodenal Ulcer” “Risks of Surgery for UGI Hemorrhage: 1972 vs. 1982” “Improvements in the Diagnosis and Management of Aortoenteric Fistula” UGI Hemorrhage: 1985: Literature

“Changing Patterns of Gastrointestinal Bleeding” “Recurrence After Parietal Cell Vagotomy” “Esophageal Transection Fails…Variceal Bleeding” “Topical Prostaglandin E 2 in…UGI Hemorrhage” UGI Hemorrhage: 1985: Literature

Only 3 references in same 5 journals “Rupture of Splenic Artery Pseudoaneurysms” “Modified Sugiura Procedure” “Effectiveness of Gastric Devascularization and Splenectomy…Gastric Varices” UGI Hemorrhage: 2000’s: Literature

“Celiac Axis Ligation…Unmanageable UGI Hemorrhage” Arterial Embolization for Dieulafoy Bleeding” UGI Hemorrhage: 2005: Literature

Mostly gastroduodenal ulcers Protocol: resuscitation, early endoscopy and operation 66 patients, No deaths Bender, et al. Am Surg 1994 UGI Hemorrhage: 1980’s

Therapeutic endoscopy Discovery of the role of h. pylori Better acid suppression drugs Liver transplant Interventional radiology UGI Hemorrhage: 1990 What Changed?

Helicobacter Pylori First reported 1983 in mucosal biopsies of patients with active gastritis Initially debated about role in ulcer disease Abundant producer of urase Elicits robust inflammatory response

H. Pylori Double therapy (antibiotic plus adjunctive agent) - no longer used Triple therapy (two antibiotics plus adjunctive agent) – current mainstay Quadruple therapy (two antibiotics plus two adjunctive agents) – resistant organisms “Cure” in 90% of compliant patients

Pharmacologic Therapy Oral antacids have no effect on bleeding H 2 - receptor antagonists have had 27 RCT’s on over 2500 patients Marginal improvement in surgery and death Still widely used Collins, et al. NEJM, 1985

Proton Pump Inhibitors Appear to be effective at high doses Especially so with high risk patients Effects clouded by use of therapeutic endoscopy

220 patients with UGI hemorrhage from PUD All underwent endoscopy - stigmata present Omeprazole 40 mg twice daily vs. placebo Patients in shock excluded Proton Pump Inhibitors

Omeprazole (n=110)Control (n=110)p Rebleed1240<0.001 Surgery826<0.001 Deaths26.20 Not effective in those with arterial bleeding Khuroo, et al. NEJM, 1997 Proton Pump Inhibitors

240 patients with bleeding from PUD All received endoscopy with epinephrine injection and heater probe 80 mg bolus injection of omeprazole plus 8 mg/hr infusion Control groups received placebo Proton Pump Inhibitors

Omeprazole (n=120)Control (n=120)p Rebleed Surgery Death Omperazole also had shorter LOS and fewer units transfused Lau, et al. NEJM, 2000

Endoscopic Therapy Widely accepted as most effective method Not only controls ulcer bleeding but prevents rebleeding Decreases need for surgery Only meta analysis shows decrease in deaths Cook, et al. Gastroenterology, 1992

Thermal Therapy Laser (Argon and Nd: YAG) Monopolar electrocoagulation Bipolar or mulitpolar electrocoagulation Heater probe

Laser Therapy First shown to be effective Expensive and cumbersome Largely supplanted

Monopolar Electrocoagulation Effective with both bleeding and non- bleeding vessels Tissue adherence problems Unpredictable energy deposition ? Highest rate of perforation

Direct probe pressure to help in tamponade Large (3.2 mm) probe Low watt (15 to 25) setting Need prolonged period (7-10 seconds) Bipolar or Multipolar Electrocoagulation

Heater Probe Produces thermal energy to coagulate tissue Direct pressure to help with tamponade 25 to 30 joule setting Repeated applications

Injection Therapy Epinephrine (1:10,000) Saline Absolute alcohol Water Sclerosing agents

Which Endoscopic Therapy? Injection, laser, multi- / bipolar and heater probe equivalent Latter three most common (simplest) Combination therapy not been shown more effective Rebleed rates 15-20%

Lack of standardized definitions, especially in stigmata Complications: rebleeding, 20%; perforation, 1% Costs not defined Role of repeat endoscopy: planned vs. rebleeding Endoscopic Therapy - Questions

Future Endoscopic Therapies Cryotherapy Clips Argon plasma coagulation Sewing

Adjunctive Therapies Prokinetic agents Octreotide Dedicated units ? Earlier surgery

Second Look Endoscopy Patients at high risk of rebleeding can be identified Age, site, size, co-existent disease Baylor Bleeding Score

1 point for each decade of life after 30 Up to 5 points for associated disease Up to 5 points for site and stigma of bleeding High risk of rebleeding with pre-endoscopy score of 5 or greater or post-endoscopy score of 10 or greater

Endoscopic vs. Operative Treatment 55 patients (of 61) with arterial bleeding or visible vessel > 2 mm Repeated endoscopy in 24 hrs (32) or early operation (23) Gastric resection in 79% Rebleed: 48% endoscopy vs. 11% operation (p=0.002)

22% required operation in endoscopy group Mortality: 6% endoscopy vs. 7% operation No subgroup or intent-to-treat analysis Early 1990’s Imhof, et al. Langenbecks Arch Surg, 2003 Endoscopic vs. Operative Treatment

“Modern” Management of UGI Hemorrhage Resuscitation High dose proton pump inhibitors Early endoscopy with therapeutic intervention Repeat endoscopy in 2 hours for high risk patients

Concomitant decision by surgery and gastroenterology regarding operation Most deaths still due to repeated episodes of shock “Modern” Management of UGI Hemorrhage

Operation for UGI Hemorrhage Likely to become even less frequent Therefore operative mortality will likely increase No need to do a curative ulcer operation Control hemorrhage only

Future Directions Further risk stratification Define role of angiography Earlier operation for those at higher risk