Role of surgery in gastrointestinal bleeding

With the help of the evolution of endoscopic and angiographic intervention, nonsurgical techniques became the procedures of choice for the diagnosis and treatment of gastrointestinal (GI) bleeding and role of surgery have been decreased. However, surgical operations are still necessary for controlling bleeding lesions when these maneuvers fail and conventional operations continue to be life-saving in many instances. Laparoscopic surgeries have an advantage of less postoperative pain and wound problem, quicker recovery, and shorter hospital stay and been widely used for GI bleeding. An elective laparoscopic resection of the intestine for appropriate indications may be an ideal application of this technique, while emergent use should be tempered by skillful surgeons because most patients are relatively unstable and time-limited. Newly developed technologies will continue to facilitate collaboration and cooperation between gastroenterologists, radiologists, and surgeons by encouraging working in multispecialty teams. This review will address the surgical approach associated with various treatments for GI bleeding according to many kinds of GI bleeding diseases. Copyright © 2018, Society of Gastrointestinal Intervention. Keyword: Gastrointestinal hemorrhage Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea Received July 23, 2018; Revised August 19, 2018; Accepted August 19, 2018 * Corresponding author. Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea. E-mail address: inseoblee77@gmail.com (I.-S. Lee). ORCID: https://orcid.org/0000-0003-3099-0140 pISSN 2213-1795 eISSN 2213-1809 https://doi.org/10.18528/gii180029 This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction As a result of a series of technologic developments, the role of surgery for gastrointestinal (GI) bleeding has been gradually replaced by non-operative methods. The revolutions of esophagogastroduodenoscopy (EGD) and colonoscopy have enabled the effective hemostasis of bleeding from the stomach or colon at the same time as diagnosing a bleeding focus. In addition, angiography, together with the transcatheter delivery of vasoactive drugs or embolic materials, has significantly reduced the need for surgery of GI bleeding. Nevertheless, with the development of laparoscopic techniques, surgery remains an important modality to treat many bleeding lesions of the GI tract in patients who are highrisk for GI bleeding, such as the elderly, males, users of alcohol, tobacco, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and anticoagulants. Also, morbidity and mortality increase significantly in patients who lost more than 6 units of blood or elderly patients with major comorbid diseases. These patients can be a candidate for early surgical intervention. Upper Gastrointestinal Bleeding The causes of upper GI bleeding are best categorized as either non-variceal sources or bleeding related to portal hypertension that arises from a source proximal to the ligament of Treitz. There are various surgical approaches according to each cause (Table 1). In such cases, EGD is indicated. The non-variceal causes account for approximately 80% of upper GI bleeding, with peptic ulcer disease being the most common. Because variceal bleeding increases morbidity and mortality rates, patients with cirrhosis should generally be assumed to have variceal bleeding and appropriate therapy should be initiated immediately. The best tool for the localization of the bleeding source is EGD, but in 1% to 2% of patients, the source cannot be detected because of excessive blood in the lumen of stomach or duodenum. In this situation, an aggressive lavage of the stomach with normal saline solution can be helpful. If an endoscopy is not available or is unrevealing, an angiography may be appropriate for stable patients. Non-variceal bleeding Peptic ulcer disease Peptic ulcer disease remains the most common cause of upper GI bleeding, accounting for approximately 40% of all cases. Bleeding is the most frequent indication for operation and the principal cause for death in peptic ulcer disease. The recent deJae-Sun Kim and In-Seob Lee / Role of surgery in GI bleeding 137 crease of incidence and related complications of ulcer has been attributed to the advancement of medical therapy, including proton pump inhibitors and regimens for eradication of Helicobacter pylori. Massive bleeding can occur when duodenal or gastric ulcers penetrate into branches of the gastroduodenal artery or left gastric arteries, respectively. Despite significant advances in endoscopic therapy, approximately 10% of patients with bleeding ulcers still require surgical intervention for effective hemostasis. To determine the appropriate timing of surgery, the presence of shock and a low hemoglobin level at presentation should be checked. Ulcers larger than 2 cm and located in the posterior duodenum have a significantly higher risk of re-bleeding. Patients with these ulcers need more intensive monitoring and earlier surgical intervention. Indications for surgery have traditionally been based on blood transfusion requiring more than 6 units. Current indications of surgery for peptic ulcer hemorrhages are failure of endoscopic hemostasis, recurrent hemorrhages after initial stabilization, shock, and continued slow bleeding with a transfusion requirement exceeding 3 units/day. Duodenal ulcer: The first step in the operative management for a duodenal ulcer is exposure of the bleeding site. Because most of these lesions are in the duodenal bulb, longitudinal duodenotomy or duodenopyloromyotomy is performed. When ulcers are positioned anteriorly, four-quadrant suture ligation with nonabsorbable thread usually suffices. A posterior ulcer eroding into the pancreaticoduodenal or gastroduodenal artery may require suture ligature of the vessel proximal and distal to the ulcer as well as placement of a U-stitch underneath the ulcer to control the pancreatic branches. The choice between various operations has been based on the hemodynamic condition of the patient and whether there is a long-standing history of refractory ulcer disease. Because the pylorus is often opened in a longitudinal fashion to control the bleeding, closure as a pyloroplasty is combined with a truncal vagotomy is the most frequently used operation for bleeding duodenal ulcers to reduce acid secretion. In a patient who has a known history of refractory duodenal ulcer disease or who has failed to respond to more conservative surgery, an antrectomy with a truncal vagotomy may be more appropriate. However, this procedure is more complex and should be undertaken rarely in a hemodynamically unstable patient. Gastric ulcer: Although the immediate control of bleeding may initially require gastrotomy and suture ligation, these alone are associated with a high risk of re-bleeding in almost 30% of cases. Because of a 10% incidence of malignancy, gastric ulcer resection is generally suggested if feasible. Simple excision alone is associated with re-bleeding in as many as 20% of patients, so gastrectomy is generally preferred. Mallory-Weiss tears Accounting for approximately 5% to 15% of acute upper GI bleeding, Mallory-Weiss tears are related to forceful vomiting, retching, coughing, or straining following binge drinking. Most tears occur along the lesser curvature and less commonly on the greater curve of the stomach. Supportive therapy is often all that is necessary because 90% of bleeding episodes are self-limited, and the mucosa often heals within 72 hours. In rare cases of severe ongoing bleeding, failed endoscopic treatments or failed angiographic hemostases, high gastrotomies and direct oversewing of the mucosal tear are recommended. Stress gastritis Stress-related gastritis is characterized by the appearance of multiple superficial erosions of the entire stomach as severe or life-threatening bleeding. When stress ulceration is associated with major burns, these lesions are referred to as Curling ulcers. In contrast to NSAID-associated lesions, significant hemorrhage from stress ulceration is common phenomenon. In those who develop significant bleeding, acid suppressive therapy is often successful in controlling the hemorrhage. In rare cases of failing endoscopic or angiographic treatment, surgery should be considered. Surgical choices include vagotomy and pyloroplasty with oversewing of the hemorrhage site or a near-total gastrectomy. Esophageal ulcers and erosions The esophagus is an infrequent source of significant hemorrhages. Most esophageal ulcers result from Barrett’s metaplastic epithelium. The superficial mucosal ulcerations generally do not bleed acutely and manifest as anemia or guaiac-positive stools. With infection, hemorrhage can occasionally be massive. Treatment typically includes acid suppressive therapy and endoscopic control. In the rare circumstance bleeding requires surgical intervention, an esophagotomy and over-sewing of the bleeding site is performed. This surgery should be accompanied by an antireflux procedure, such as a Nissen fundoplication, to reinforce the esophagotomy closure and to prevent further reflux injury. Dieulafoy lesion Dieulafoy lesions are vascular malformations of the proximal gastric corpus. An abnormally large submucosal artery (1–3 mm) is typically found within 6 cm of the gastroesophageal junction on the lesser curvature of the stomach. Initial attempts at endoscopic control are often successful. In cases of failed endoscopic or angiographic therapy, a gastrostomy and oversewing of the bleeding site may be necessary. In a case