Bleeding from a duodenal ulcer. Operations for bleeding from ulcers
The best treatment for bleeding from a duodenal ulcer is gastric resection, be it a hemigastrectomy combined with a stem vagotomy or a 70% gastrectomy. Local hemostasis can be used in endangered patients to avoid resection. However, local hemostasis does not exclude the possibility of recurrent bleeding, which happens quite often. For local hemostasis in case of bleeding from a duodenal ulcer, a 3 cm incision can be made on the anterior wall of the duodenum, which should start 15 mm below the pylorus. You can also make a duodenopyloroantral incision (5 cm long), 2 cm of which capture the duodenum and approximately 3 cm – the antrum of the stomach. This is the same incision used for the Heineke-Mikulicz pyloroplasty.
With massive ulcerative bleeding from the duodenum, which usually occurs with localization of ulcers on the posterior duodenal wall with penetration into the pancreas, hemostasis is not an easy task. In most cases, massive bleeding from a duodenal ulcer is due to the erosion of the duodenal arterial complex described by Berne and Rosoff in 1969. Less commonly, bleeding from a duodenal ulcer is not related to this complex. If the bleeding is associated with the arterial complex, then it is necessary to ligate the gastrointestinal duodenal artery above, below and lateral to the site of erosion. If this artery is ligated just above the bleeding site, bleeding will continue as blood will flow through the right gastroepiploic and superior and anterior pancreatic duodenal branches of the gastro-duodenal artery.
Suturing the gastro-duodenal artery above and below the eroded area may be insufficient in cases where the transverse pancreatic artery departs medially from the gastro-duodenal artery. To carry out hemostasis with a minimal risk of bleeding recurrence, it is necessary to perform triple stitching according to Beta and Rosoff. If the source of bleeding is not arteries from the gastroduodenal arterial complex, sutures should be applied in the same way. as with stomach ulcers.
In patients with bleeding from duodenal ulcers located in the postbulbar region or in the descending part of the duodenum, local hemostasis is of great importance, allowing to avoid resection, which is very dangerous due to the proximity of the ulcer to the large duodenal papilla and the common bile duct.
After performing local hemostasis , some surgeons complete the operation with a proximal gastric vagotomy or trunk vagotomy with pyloroplasty. If a reliable pyloroplasty cannot be performed due to the presence of a diagnostic duodenal incision, gastrojejunostomy, Finney pyloroplasty, or Jaboulay gastroduodenostomy can be performed.
In patients with bleeding from an anastomotic ulcer , gastric resection is the operation of choice, if the patient’s condition permits. If the patient has previously undergone gastric resection, a second resection must be performed. If the patient has previously undergone vagotomy, a follow-up re-vagotomy should be performed, preferably by supraphrenic access. In severely ill patients, local hemostasis should be considered. However, local hemostasis can be difficult if an anastomotic ulcer occurs in a patient with a previous extensive gastrectomy and posterior colic anastomosis. In some of these patients, local hemostasis can only be accomplished using the thoracoabdominal approach. This incision should be used to perform a supraphrenic vagotomy.
A midline incision was made on the anterior wall of the stomach to revise its inner surface to find the source of bleeding and, if necessary, to carry out local hemostasis.
The anterior wall of the stomach is dissected and its edges are grasped by large Duval forceps. This provides a temporary stop to bleeding from numerous vessels located in the stomach wall. The traction performed with these clamps allows the stomach to open wide for revision. All blood clots from the stomach must be removed manually.
The use of hooks for revision of the upper part of the stomach improves the quality of the examination. Fragment A shows severe erosive gastritis with several massively bleeding acute ulcers. Detail B shows bleeding from a ruptured gastric mucosa near the gastroesophageal junction (Mallory-Weiss syndrome). Fragment C shows a gastric leiomyoma near the cardia, which is the cause of bleeding.
Shown here is a massively bleeding stomach ulcer located on the posterior wall along the lesser curvature. Local hemostasis is performed by suturing the ulcer with non-absorbable sutures. The number of stitches required is determined by the size of the ulcer and its effectiveness in stopping bleeding.
Massive bleeding from a stomach ulcer located in the upper part of it on the posterior wall near the greater curvature. The location of the ulcer is shown with an oval-shaped dotted line. The anterior wall of the stomach was opened and its edges were held in place with Duval atraumatic forceps. The localization of the ulcer prevents adequate local hemostasis. To facilitate the imposition of hemostatic sutures, the gastrocolic ligament is transected and tied at a sufficient length, which allowed invaginating the greater curvature and bringing the ulcer into a position more convenient for local hemostasis.
In some patients, it is impossible to prevent the occurrence of massive bleeding from acute gastric ulcers, despite the use of very effective prophylactic agents currently available. The operation should be resorted to in cases where massive bleeding from an acute stomach ulcer cannot be stopped with the help of drug therapy and endoscopic methods. If bleeding is severe, gastric resection may be indicated for some patients. Acute stomach ulcers usually cannot be detected by palpation, so their localization cannot be established by examining the stomach from the outside. To ensure that the tallest bleeding ulcer is resected, it is useful to mark its location with a staple or suture, which is then excised during resection, as shown in the figure.
The highest bleeding acute ulcer is marked with a suture. The gastrotomy opening was closed with a continuous suture, after which the stomach was immediately resected. The upper resection border is shown with a dashed line. The tallest ulcer is indicated by an oval-shaped dotted line.
Usually, Mallory-Weiss syndrome , which occurs when the gastric mucosa ruptures near the esophageal-gastric junction, is successfully treated with medical and endoscopic methods. In some cases, it is necessary to perform surgery and carry out hemostasis by suturing the torn mucous membrane, as shown in the fragment of the figure.
In some patients with indications for surgical treatment for a bleeding gastric ulcer, hemostasis can be achieved by a wedge-shaped resection of the site containing the ulcer. However, the indications for performing wedge resection are very limited. Wedge resection is feasible if the bleeding ulcer is located on the lesser curvature slightly above the notch. If the ulcer is proximal, it is difficult or impossible to perform a wedge resection. If the ulcer is located below the notch, wedge resection is contraindicated, as it will cut the Latarjet’s nerves. Immediately after the resection, the defect is sutured.