Surgery in Bleeding Peptic Ulcers

Abstract

This paper records a study of 400 patients admitted for haematemesis and melaena. Emergency surgery was undertaken on selected patients but the overall mortality increased when more frequent emergency operations were performed in the latter half of the series.The proper management of haematemesis and melaena is a constantly recurring problem. Our material consists of 473 patients admitted for haematemesis and melaena between January, 1953, and July, 1958. Four hundred of these (87%) were for proved or suspected peptic ulceration, and the main object of this paper is to discuss the place of surgery in this group. The overall mortality of the ulcer group was 6.25 %. Ninety-eight (24.5 %) were submitted to emergency surgery. The remaining 73 patients (13 %) bled from causes other than ulcer. The Mansfield hospitals serve a population of some 200,000 in a well-defined area. All patients admitted to hospitals and nursing homes for definite haematemesis and melaena are included and classified according to Avery Jones (1956). ANALYSIS OF RESULTSIn the analysis of results, the ulcer group as a whole is considered first, then all patients in the ulcer series operated on in the acute phase or later. Next comes a summary of other operations done for peptic ulcer over the same period. A more detailed account of the emergency operations (that is within 24 hours of bleeding) in the ulcer group and their results follows. The first 200 and the second 200 of the whole peptic ulcer group are then compared. Finally, there is a short section on the causes of bleeding other than an ulcer, and the emergency operations that were done in this group. (58 %) were diagnosed by radiology or at operation. Duodenal ulcers outnumber gastric ulcers by 159 to 70. The acute lesion group (32 %) refers to those patients in whom radiology failed to show an ulcer three weeks or so after admission. The unclassified group (6 %) refers to incompletely investigated patients with strong presumptive evidence of peptic ulceration. The post-operative group (4 %) followed gastro-enterostomy or partial gastrectomy. The whole series mortality is slightly higher for gastric ulcers (10%) than for duodenal ulcers (8.8 %), although the operative mortality was rather higher for duodenal ulcers. The acute lesion group had a mortality of 4.2%. No necropsy was done on the patient who died in the unclassified group. THE ULCER GROUP AS

Further Haemorrhage after Admission to Hospital for Gastrointestinal Haemorrhage

“…This serious situation faced 20% of all the patients in the series and 25-8% of 511 patients in the peptic ulcer group. These proportions are very similar to those reported by Jones (1956) in 1,414 admissions and Ward-McQuaid et al (1960) in 400 admissions for bleeding peptic ulcer. This group is therefore both numerous and dangerous.…”

Conservative surgery for bleeding peptic ulcer.

“…The overall mortality in the present series is 12%, which compares with 14.3% reported by Ward-McQuaid et al (1960) in a similar group treated by partial gastrectomy. Our mortality when using conservative surgery was 7% compared with 18% for radical surgery.…”

“…Variations in the reported mortality can be accounted for by differences in the cases studied. The average mortality in patients with moderate ro severe haemorrhage from all types of ulcer treated by partial gastrectomy is probably nearer 15 % (Ward-McQuaid, Pease, Smith, and Twort, 1960). Smith and Farris (1958) suggested that this might be reduced by a more conservative operation in duodenal ulcer consisting in direct suture of the bleeding vessel with vagotomy and a gastric drainage procedure.…”

Epidemiology of Upper Gastrointestinal Bleeding

“…Following medical management over 70% of peptic ulcer bleeds and 44% of variceal bleeds resolved with no further bleeding. 52,53 Surgery was mostly reserved for those with unstable ulcer bleeding, whereas other causes such as varices and gastric cancer where not amenable to emergency treatment.…”