Gastric Perforation (Gastrotomy)/Necrosis

Acute non-variceal upper gastrointestinal bleeding

• Choice of surgical procedure for bleeding peptic ulcers
• The choice of surgical procedure for bleeding peptic ulcers, when required, has not been adequately examined in the era following routine eradication of Helicobacter pylori and high-dose PPI therapy. Many surgeons maintain that under-running of ulcers alone combined with acid suppression using high-dose PPI therapy is safer than definitive surgery by either gastric resection or vagotomy.

• Two randomised studies looking at the different surgical procedures used to control bleeding peptic ulcers have been reported,but both predate the PPI and routine H. pylori eradication era and therefore their results must be interpreted with considerable caution.
• One of these was a multicentre study comparing minimal surgery (under-running the vessel or ulcer excision alone plus intravenous histamine receptor antagonist) versus definitive ulcer surgery (vagotomy and pyloroplasty or partial gastrectomy) in patients with gastric and duodenal ulcers.

• The other trial was carried out by the French Association of Surgical Research and included only bleeding duodenal ulcers. The patients in this trial were randomly assigned to either under-running plus vagotomy and drainage (58 patients) or partial gastrectomy (60 patients). Recurrent bleeding occurred in 10 of 58 patients (17%) after under-running and vagotomy.

• In the group assigned to partial gastrectomy, only two patients (3%) re-bled and both recovered without the need for further surgery. The rate of duodenal stump leak in the gastrectomy group was 8 in 60 (13%). When the results were analysed on an intention-to-treat basis, and those with duodenal leaks after re-operations for re-bleeding in the under-running and vagotomy group were included, duodenal leak rate was similar in both groups (7/58 vs. 8/60). 

• The mortality in both groups was similar (22% after vagotomy and 23% after gastrectomy). In the era of PPI therapy, the role of vagotomy has disappeared. A proper ligation of the gastroduodenal artery complex including the right gastroepiploic and the transverse pancreatic branches is the key to avoid recurrent bleeding.