Conservative management of bleeding duodenal ulcer without a visible vessel: Prospective randomized trial

Saperas, Esteban; Piqué, Josep M.; Ayuso, Roberto; Bordas, Josep M.; Terés, Josep; Pera, Cristóbal

doi:10.1002/bjs.1800740910

Cited by 29 publications

(18 citation statements)

References 12 publications

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“…Their concept was based on two uncontrolled studies by Dronfield et al [26] and Saperas et al [27], in which the authors showed that a more aggressive surgical policy leads to an unnecessarily high rate of surgical interventions and an increased mortality. Both studies, however, were flawed by the uncontrolled design and the fact that the rationale for surgery did not mirror the concept by Siewert et al [19].…”

Section: Surgical Strategymentioning

confidence: 99%

Surgical therapy for peptic ulcer and nonvariceal bleeding

Schoenberg

2001

Langenbeck's Archives of Surgery

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Wider use of endoscopic hemostasis in upper gastrointestinal bleeding (UGIB) has reduced significantly the need for operation. Nevertheless, surgery still plays a pivotal role. Failure to control bleeding endoscopically should not delay surgery when necessary, and a close cooperation between endoscopists and surgeons is essential. Initial endoscopy stops the bleeding in approximately 94% of patients and helps to identify those patients with a high or low risk of rebleeding. High-risk patients should be examined for rebleeding by clinical and endoscopic assessment within at least the first 2-3 days. Large ulcers are the most likely to rebleed, and in elderly patients with severe comorbidity showing little or no healing tendency, they benefit from repeated fibrin glue treatment. In cases of rebleeding despite initial endoscopic hemostasis and conservative treatment, another attempt to stop the hemorrhage endoscopically is justified in most patients. A subgroup of patients who are old, suffering from hypotension due to rebleeding, with large ulcers and several other illnesses should undergo surgery immediately because endoscopic intervention often fails, and these patients deteriorate quickly. The surgical procedure should be limited to safe hemostasis.

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Section: Surgical Strategymentioning

confidence: 99%

Surgical therapy for peptic ulcer and nonvariceal bleeding

Schoenberg

2001

Langenbeck's Archives of Surgery

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“…in case of recurrent bleeding). Conversely, operation rates of 27–71% were observed when a more aggressive surgical approach was applied with early elective operations in high-risk patients (median 45%) [22, 23]. …”

Section: Discussionmentioning

confidence: 99%

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

Imhof

Schröders²,

Ohmann³

et al. 1998

Dig Surg

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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.

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“…Data from the 1980’s before wide spread availability of modern endoscopic techniques for hemostasis could not prove that early operation for ulcers without active bleeding improved mortality, but it did show that it resulted in an increase in the number of patients undergoing operation 20, 21 . One small trial using modern endoscopic hemostasis techniques that compared early elective operation with endoscopic retreatment per protocol after initial endoscopic control of ulcer bleeding.…”

Section: Bleeding Peptic Ulcermentioning

confidence: 99%