Endoscopic Retreatment Compared with Surgery in Patients with Recurrent Bleeding after Initial Endoscopic Control of Bleeding Ulcers

Lau, James Y.; Sung, Joseph J.Y.; Lam, Y. H.; Chan, Angus C.W.; Ng, Enders Kwok Wai; Lee, Danny W.H.; Chan, Francis K.L.; Suen, R.; Chung, S. C. S.

doi:10.1056/nejm199903113401002

Cited by 450 publications

(191 citation statements)

References 25 publications

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“…In the modern era of management of bleeding peptic ulcers, surgery is reserved as a salvage to rescue those who failed endoscopic and pharmacological management. These patients who sustained rebleeding are likely to be poor surgical candidates [17, 18]. These ulcers would also be large in size, located in difficult areas and bleeding from a major vessel with a size >2 mm [17, 19, 20].…”

Section: Discussionmentioning

confidence: 99%

Surgical Salvage of Bleeding Peptic Ulcers after Failed Therapeutic Endoscopy

Chiu¹,

Ng²,

Wong³

et al. 2009

Dig Surg

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Background: The approach to salvage surgery after failed endoscopic therapy for a bleeding peptic ulcer is controversial. We aimed to compare the outcomes of salvage surgery after failed endoscopic therapy for bleeding peptic ulcers over a 10-year period. Methods: Patients receiving salvage surgery for bleeding peptic ulcers were divided into 2 cohorts, the 1st from 1993 to 1998 and the 2nd from 1999 to 2004. The type of salvage surgery was defined as minimal if ulcer plication or an ulcerectomy was performed, and definitive if the patient received a vagotomy or gastrectomy. Results: One hundred and twenty-three patients received salvage surgery in the 1st cohort, while 42 patients received surgical hemostasis for the bleeding peptic ulcer in the 2nd cohort. Patients in the 2nd cohort consisted of a larger proportion of in-hospital bleeders (cohort 1: 12.2%, cohort 2: 42.9%; p < 0.005) and had a significantly higher proportion of comorbidities. A larger number of patients received minimal surgery in cohort 2 (cohort 1: 42.3%, cohort 2: 73.8%; p < 0.005). Conclusions: With advances in therapeutic endoscopy, patients who developed failed endoscopic hemostasis are likely to be poor surgical candidates with multiple comorbidities. The approach to salvage surgery has inclined towards minimal surgery to hasten surgical hemostasis among these fragile patients.

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Section: Discussionmentioning

confidence: 99%

Surgical Salvage of Bleeding Peptic Ulcers after Failed Therapeutic Endoscopy

Chiu¹,

Ng²,

Wong³

et al. 2009

Dig Surg

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“…In the case of ulcer hemorrhage, emergency surgery is still required, but today bleeding from gastric ulceration can also be successfully controlled by an endoscopic hemostatic procedure which replaces surgery in the case of a bleeding gastric as well as duodenal ulceration [16]. With regard to emergency surgical therapy for a bleeding duodenal ulcer, there is a shift to more conservative treatment, i.e.…”

Section: Discussionmentioning

confidence: 99%

Surgery for Peptic Ulcer Today

2004

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Background: During the past 20 years medical therapy of peptic ulcer disease (PUD) has dramatically improved. Simultaneously there has been a significant improvement in living and dietary habits. Quite presumably, all these significant events are reflected in the incidence and results of surgery for peptic ulcerations. Aim: To study the incidence, methods and mortality of surgery for PUD. Methods: The nationwide data between 1987 and 1999 were obtained from the National Research and Development Centre for Welfare and Health. In the analysis the codes of the ICD 9–10 were used. Results: The annual incidence of elective surgery for PUD decreased from 15.7 to 1.7 operations (per 10⁵ inhabitants, mean of 2 consecutive years) between 1987 and 1999 (p < 0.05). Simultaneously, the annual incidence of emergency surgery increased from 5.2 to 7.0 operations (per 10⁵ inhabitants, p < 0.05). In 1987, local procedures (duodeno-/gastrorrhaphy or duodeno-/gastrostomy and suture) were applied in 25% of operations for PUD, whereas in 1999 they were 90% of the methods in PUD surgery. The overall annual mortality from PUD surgery remained 8% between 1987 and 1999. Conclusions: Elective ulcer surgery has virtually disappeared and parietal cell vagotomy has become history, whereas the incidence of emergency surgery increased significantly between 1987 and 2000, with the exception of the most recent years. Local procedures are overwhelmingly applied in emergency surgery and more extensive surgery is unnecessary. Nevertheless, the overall surgical mortality remained 8% between 1987 and 1999.

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“…There were significantly less complications in the group with repeat endoscopic therapy compared to the group with surgery [3]. In the present case, repeat endoscopy was the treatment of first choice.…”

Section: Case Reportmentioning

confidence: 67%

“…This last conclusion should be revised based on the third, recently published, randomized trial by Lau et al [3], who showed that in patients with recurrent bleeding, endoscopic retreatment reduces the need for surgery without increasing the risk of death and is associated with fewer complications than surgery.…”

Section: Case Reportmentioning

confidence: 99%