EDITORIAL
The Management of Upper Gastrointestinal Bleeding Gregory D. Skalkeas, MD, Athens, Greece
Bleeding from the gastrointestinal tract above the ligament of Treitz remains even today a major concern of the clinician. Esophagogastroscopy and selective angiography of celiac artery branches have considerably reduced the percentage of bleeding of undetermined origin. Nevertheless, a number of patients with upper gastrointestinal bleeding are led to the operating table without a definite diagnosis. Emergency surgery, apart from a very limited number of cases, is not mandatory. Correct policy is to manage these cases conservatively, which allows for a better diagnosis and an amelioration of the patient’s general condition so that he will tolerate surgery better. Besides, bleeding will cease spontaneously under conservative treatment in a significant percentage of cases and emergency surgery is thus deferred. The application of the Sengstaken-Blakemore tube and the intravenous administration of pitressin remain the methods of choice for bleeding varices. For most of the other causes of bleeding, the intraarterial infusion of vasopressin after selective catheterization associated with gastric lavage with icecold normal saline has given the most promising results. After failure of conservative treatment, we believe
Reprint requests should be addressed to &eqxy 0. Skalkeas, MD. Athens University School of Medicine. Second Department of Propedeutlc Surgery, King Paul’s Hospital, Athens 609. Greece.
654
that the best procedure for the management of bleeding varices is emergency shunt operation, preferably a mesocaval shunt, as long as the patient fulfills the relative criteria. When shunting is not indicated, a more conservative approach is a portaazygos disconnection completed by gastric transection. The recurrence of hemorrhage after vagotomy and drainage for a bleeding duodenal ulcer limits, in our experience, use of this procedure. We are returning to the use of typical subtotal gastrectomy or antrectomy, either procedure completed by truncal vagototny and removal of the ulcer. For bleeding gastric ulcers we favor subtotal gastrectomy with removal of the ulcer. In very ill, poor risk patients vagotomy and pyloroplasty with oversewing of the ulcer may be all that can be tolerated. For bleeding acute ulcers, truncal vagotomy and drainage with oversewing of ulcer is the method of choice, although recurrence of bleeding and reoperation, sometimes necessitating almost total gastrectomy, are not unusual. It seems that partial gastrectomy with vagotomy controls bleeding more effectively than resection alone. The best overall results can be expected when physicians and surgeons work in close cooperation, so that neither an overzealous attitude for emergency surgery nor an unjustified procrastination is favored.
The American Journal of Surgery
The Management of Upper Gastrointestinal Bleeding Gregory D. Skalkeas, MD, Athens, Greece
Bleeding from the gastrointestinal tract above the ligament of Treitz remains even today a major concern of the clinician. Esophagogastroscopy and selective angiography of celiac artery branches have considerably reduced the percentage of bleeding of undetermined origin. Nevertheless, a number of patients with upper gastrointestinal bleeding are led to the operating table without a definite diagnosis. Emergency surgery, apart from a very limited number of cases, is not mandatory. Correct policy is to manage these cases conservatively, which allows for a better diagnosis and an amelioration of the patient’s general condition so that he will tolerate surgery better. Besides, bleeding will cease spontaneously under conservative treatment in a significant percentage of cases and emergency surgery is thus deferred. The application of the Sengstaken-Blakemore tube and the intravenous administration of pitressin remain the methods of choice for bleeding varices. For most of the other causes of bleeding, the intraarterial infusion of vasopressin after selective catheterization associated with gastric lavage with icecold normal saline has given the most promising results. After failure of conservative treatment, we believe
Reprint requests should be addressed to &eqxy 0. Skalkeas, MD. Athens University School of Medicine. Second Department of Propedeutlc Surgery, King Paul’s Hospital, Athens 609. Greece.
654
that the best procedure for the management of bleeding varices is emergency shunt operation, preferably a mesocaval shunt, as long as the patient fulfills the relative criteria. When shunting is not indicated, a more conservative approach is a portaazygos disconnection completed by gastric transection. The recurrence of hemorrhage after vagotomy and drainage for a bleeding duodenal ulcer limits, in our experience, use of this procedure. We are returning to the use of typical subtotal gastrectomy or antrectomy, either procedure completed by truncal vagototny and removal of the ulcer. For bleeding gastric ulcers we favor subtotal gastrectomy with removal of the ulcer. In very ill, poor risk patients vagotomy and pyloroplasty with oversewing of the ulcer may be all that can be tolerated. For bleeding acute ulcers, truncal vagotomy and drainage with oversewing of ulcer is the method of choice, although recurrence of bleeding and reoperation, sometimes necessitating almost total gastrectomy, are not unusual. It seems that partial gastrectomy with vagotomy controls bleeding more effectively than resection alone. The best overall results can be expected when physicians and surgeons work in close cooperation, so that neither an overzealous attitude for emergency surgery nor an unjustified procrastination is favored.
The American Journal of Surgery
