Trends in Peptic Ulcer Bleeding and Surgical Treatment

Abstract

An evidence-based approach is followed, with grading of evidence by study design, to evaluate surgical treatment of a bleeding peptic ulcer. In contrast to endoscopic treatment, reports of surgical treatment are rare, with only five randomized trials having been identified. Epidemiologic studies have demonstrated that the incidence of emergency surgery has not changed despite major improvements with endoscopic treatment. There are no proven alternatives to emergency operation for massive bleeding uncontrollable by endoscopic procedures. There is some debate about surgery for rebleeding, but no randomized trial has assessed whether a second endoscopic treatment alone is preferable to surgery with or without repeated endoscopic treatment. Concerning the type of operative procedure, the existing body of evidence, including two randomized studies, indicates that patients are best served by a relatively aggressive surgical approach. Today the value of these studies is limited owing to prevention of ulcer recurrence by eradication and technical improvements of local procedures (e.g., arterial ligation). Early elective surgery was tested in two randomized studies and several uncontrolled series, which demonstrated that it may be beneficial in high risk groups and harmful in others. Indications for early elective surgery should be refined taking into account updated prognostic information and more effective endoscopic treatment. Because of a new understanding of ulcer disease the role of surgery has changed markedly within the last years, no longer aiming to cure the disease but primarily to stop the hemorrhage. Evidence, however, is not derived from properly randomized controlled trials but is based on theoretic arguments and knowledge from studies not primarily dealing with operative treatment.

Surgical Management of Ulcer Disease

“…In a major surgical text [8], Johnston wrote, ''There is one major difference between the operative treatment of hemorrhage from peptic ulcer and the operative treatment of perforation: the use of a definitive ulcer-curing operation is mandatory in patients who have hemorrhage, whereas in patients who have perforation it is optional.'' A recent review of the randomized trials of operative management of bleeding from ulcers [2] opines in its concluding comments, ''With the new approach, surgery, if necessary, should aim at stopping the hemorrhage and not curing the disease.'' Certainly over the interval between publications of these two papers (1989 to 2000) there has been a marked increase in our understanding of pathogenesis of ulcers and of the mechanism of action of H pylori.…”

“…Though there may be more to these discordant recommendations than this alone. In Ohmann and coworkers' report on surgical treatment of peptic ulcer hemorrhage [2], it is noted that only five randomized trials for the management of bleeding peptic ulcers were found upon searching the literature. Some of these trials also compared operative intervention versus endoscopic management as well.…”

“…Eswaran and Roy elsewhere in this issue, the nonoperative management of ulcer disease, both acid-mediated and nonsteroidal anti-inflammatory drug (NSAID)-mediated, has made tremendous strides in the last 40 years. The net effect of this progress on surgeons is to have shifted the types of operations that we perform from a combination of emergent operations on ill people and an array of nearly elective operations on not-as-ill people, to ones of a more emergent nature upon generally even more ill patients [1,2]. Also, the relative decrease in the need for these types of operations has left our ranks with a declining number of surgeons who have more than a passing familiarity with the practice of these operations.…”

Fatores preditivos do tratamento operatório na úlcera péptica hemorrágica

“…Não há dados que demonstrem claramente que uma segunda endoscopia para tratamento destes doentes seria a melhor opção 18 . Embora alguns autores relatem bons resultados com uma segunda tentativa de hemostasia endoscópica, a sua realização poderia representar um fator a mais retardando o tratamento operatório adequado, o que favoreceria um pior prognóstico 8 .…”

Management of Bleeding Gastroduodenal Ulcers

“…The overall incidence has not dramatically changed over the last 25 years and varies between 10 and 50 per 100,000 person-years [1]. …”