Impact of Early Operation on the Mortality from Bleeding Peptic Ulcer – Ten Years’ Experience

Abstract

In 1984, a risk-dependent combined endoscopic and operative approach for the treatment of bleeding peptic ulcer was developed. This treatment policy has as its major feature an early elective operation in patients with arterial bleeding and a visible vessel, providing that endoscopic control of the bleeding could be achieved. Using this concept in a prospective series resulted in a mortality of 5% compared to a mortality of 14% in a historical control group, where an operation was performed only on demand in case of recurrent bleeding. In 1986, the treatment policy was introduced into clinical routine circumstances at the University Hospital of Düsseldorf. In this paper the results of routine clinical application are presented. The treatment policy was followed in 47% of patients treated respectively primarily transferred to the surgical department. Mortality in arterial bleeding and visible vessel in the conservatively treated group was double the mortality in the early elective operated group (14 vs. 7%). The mortality in patients treated primarily in the department of internal medicine was double the mortality of patients treated at the surgical department (18 vs. 9%). The differences in mortality are mainly due to the procedure in the elderly patients. In patients aged 70 years or more, the mortality rate of patients treated in internal medicine was 31% compared to 16% in the surgery department. Younger patients do not seem to benefit from early elective operation. Our study clearly demonstrates the importance of avoiding late recurrent bleeding. Patients at high risk of this complication should therefore be identified as early as possible and early surgical intervention should be considered by agreed interdisciplinary and evaluated treatment concepts.

Surgical management of peptic ulcer disease today - indication, technique and outcome

“…Mortality was below 10% if initial hemostasis was achieved by endoscopic treatment and patients with a high risk of re-bleeding proceeded to early elective surgery [84,95,96]. Similar mortality rates have been reported by repeated endoscopic treatment, but the need for surgery was reduced [85,87,90].…”

“…This approach reduced mortality to below 10%, while it was previously around 25% in these high-risk patients [84,92,95,96]. However, repeated endoscopic treatment after initial endoscopic bleeding control has been shown to reduce the …”

Systematic Review of the Epidemiology of Complicated Peptic Ulcer Disease: Incidence, Recurrence, Risk Factors and Mortality

“…tables 5 and 6) [12,15,39,46,51,59,60,61,62,63,64,65,66,67]. In most cases, this increase in mortality was associated with age over 60 years.…”

Management of Acute Gastric Ulcer Bleeding

“…It is a reasonable approach in ulcers measuring ≥2 cm or patients with hypotension at rebleeding that independently predicts endoscopic retreatment failure (Lau et al, 1999). Early elective surgery in patients presenting with arterial bleeding or a visible vessel of ≥2 mm is superior to endoscopic retreatment and has a relatively low overall mortality rate of 5% (Imhof et al, 1998(Imhof et al, & 2003. Additional indications for early elective surgery include age >65 years, previous admission for ulcer plication, blood transfusion of more than 6 units in the first 24 hours and rebleeding within 48 hours (Bender et al, 1994;Mueller et al, 1994).…”