Influence of selective mesenteric arteriography on the outcome of emergency surgery for massive, lower gastrointestinal hemorrhage

Abstract

From 1970 to 1984, 64 patients with massive hemorrhage of lower gastrointestinal origin were treated at the intensive care unit, Surgical Department, Malmö General Hospital. The records of these patients have been studied retrospectively. Emergency exploration for hemostasis was performed on 31 patients, while in 33 patients hemorrhage stopped with conservative therapy. Acute selective mesenteric arteriography revealed the bleeding site in 16 of 28 patients (57 percent). The commonest bleeding sources detected by selective mesenteric arteriography were diverticular disease and angiodysplastic lesions of the colon. Fourteen patients with positive arteriography finding were operated on as emergencies, resulting in two postoperative deaths. Ten patients were operated on as emergencies without preoperative arteriography. Despite intraoperative efforts, no bleeding source was found in three of those patients. In the remaining seven patients, the diagnoses were similar to the 14 patients with positive arteriography. Five of 10 patients in this group died postoperatively. Emergency laparotomy eventually was necessary in seven of 12 patients with negative arteriography. This group had a variety of diagnoses and no postoperative mortality. Positive preoperative mesenteric arteriography findings allowed the surgeon to perform a limited resection of the bleeding bowel segment with a reduced postoperative mortality.

Orthograde Lavage in the Treatment Policy of Acute Intestinal Bleeding

“…Multiple enterotomies in an attempt to reveal the bleeding site intraoperatively by looking for the outflow of blood or methylene blue are likewise risky. A high rate of intraperitoneal sepsis [5] following enterotomy dehiscence of the unprepared gut weighs heavily against such procedures. Therefore, mortality rates of emergency surgery for unidentified bleeding show values up to 50% [1][2][3][4][5][6].…”

“…'Blind' segmental resection leads to an untenable high rate of rebleedings, i.e. between 30 and 60% [4,5,14]. Multiple enterotomies in an attempt to reveal the bleeding site intraoperatively by looking for the outflow of blood or methylene blue are likewise risky.…”

“…As modern diagnostic procedures such as intraoperative fiberoptic enteroscopy [7,8], intraoperative angiography [5,9,10], methylene blue injection [8,11], or preopera tive diagnostic procedures were not available, one can easily imagine the difficulties. Multiple enterotomies, multiple enterostomies, or at least a large number of blind subtotal colectomies were the consequences.…”

“…Therefore, a large number of emer gency operations had to be performed in unidentified bleeding. Of course, it was the surgeon who was blamed for the inevitable high mortality of up to 50% [1][2][3][4][5][6],…”

Multidetector computed tomography in acute lower gastrointestinal bleeding

“…[1][2][3] The major issue, after the acute management of the bleeding, is the detection of the bleeding site. 99mTc-labeled red blood cell scintigraphy, [4][5][6][7][8] colonoscopy, [9][10][11][12][13][14][15] and angiography [16][17][18][19][20][21][22][23][24][25][26] are the tests usually performed to reach this objective. 27 Scintigraphy is sensitive but is of poor positive predictive value in determining the precise site of bleeding, and is also rarely available in an emergency.…”