Patients aged 80 years or greater had the highest risk of rebleeding and death. For patients below 80 years of age, significant factors related to a fatal outcome included co-morbid illness, complications and the need for mechanical ventilation. For patients aged 80 years or older, the significant factors were ulcer size greater than 2 cm and admission with serum bilirubin level above 20 mmol/l. Endoscopic treatment for the very elderly was effective if carried out early.
We recently surgically treated 24 patients incapacitated by recurrent cholangitis after biliary-enteric anastomosis performed for benign disease. Contrary to commonly held dogma, as many as one third of the patients had no evidence of anastomotic stricture indicated by radiologic and operative findings. We identified several other primary and coexistent pathogenetic factors including intrahepatic stricture in 42% of the patients, intrahepatic calculi in 25%, improperly constructed enteric conduits in 13%, and conditions that predispose to bacterial overgrowth in the biliary tree in 17%. Seventy-one percent of the patients had multiple etiologic factors, and of those patients without demonstrable anastomotic stricture, intrahepatic stricture was particularly common. Seventy-one percent remained symptom-free in their first year after operation. The most difficult situation to manage, and the factor responsible for most recurrences after our reoperation, involved intrahepatic stricture. A combined surgical and interventional radiologic approach to complex cases may be useful in selected patients.
Early surgical intervention was previously advocated in patients > 60 years with bleeding peptic ulcer presenting with haemodynamic instability or ongoing transfusion requirements. It is, however, well recognized that emergency surgical intervention with its inherent risks must be reserved for highly selected patients in whom endoscopy initially fails to control exsanquinating haemorrhage or in whom life-threatening bleeding recurs. Therapeutic endoscopy for bleeding ulcer has led to a remarkable decline in rebleeding rates, the need for emergency surgery and mortality. Octogenarians are at risk, particularly when ulcer size exceeds 2 cm. Poor surgical candidates make up two-thirds of patients with major ulcer bleeding and operation is to be avoided if at all possible. Medical therapy with proton pump inhibitor and subsequent eradication of Helicobacter pylori following endoscopic treatment has been shown to be beneficial to outcomes. Should surgery be deemed necessary, it is likely that laparoscopic techniques to control bleeding, with or without the addition of an acid-reducing procedure, will find a role in haemodynamically stable patients undergoing operation on an early elective basis.
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