Surgical treatment of bleeding from stomach ulcers. Surgeon’s tactics for bleeding from stomach ulcers
The ideal treatment for bleeding from gastric and duodenal ulcers is gastric resection. This operation provides a reliable guarantee of hemostasis and reduces the frequency of repeated bleeding and ulcer recurrence. However, not all patients can undergo this operation due to unstable cardiovascular pathology or severe general condition due to old age and the presence of other concomitant diseases. In such cases, it is recommended to conduct local hemostasis, which, although it is far from an ideal method of treatment, since it can often lead to repeated bleeding, can still save the patient’s life in a difficult situation. The decision to have surgery in these patients must be made before their condition deteriorates significantly. Several factors can help the surgeon in making such a decision: 1. If the bleeding caused shock. 2. If bleeding continues. 3. If the blood loss was 30% of the total circulating blood volume or the patient received blood transfusion in a volume of 1.5 liters every previous day. 4. If bleeding has resumed and blood transfusion was performed against the background of conservative therapy while the patient was in the hospital. 5. If bleeding continues and the patient needs blood transfusion after a good response to conservative treatment. 6. If, during gastroduodenoscopy, an actively bleeding vessel is seen in the ulcer bed. Stomach ulcers bleed in 10-20% of patients. Bleeding is more often an indication for surgery for stomach ulcers than for duodenal ulcers. In addition, stomach ulcers should be operated more urgently than bleeding duodenal ulcers, since stomach ulcers are more common in older patients than duodenal ulcers, and bleeding from them is more likely to recur. Most gastric ulcers are localized on the lesser curvature and are associated with duodenal ulcers in 15% of patients. In 10-15% of cases, stomach ulcers become malignant, so the surgeon must constantly remember about the likelihood of malignancy. When bleeding from a stomach ulcer, two situations can arise: 1. The localization of the bleeding ulcer can be established by examining the stomach from the outside. 2. The localization of the ulcer during external examination of the stomach is impossible to establish. In the first case, it is possible to carry out local hemostasis by longitudinal gastrotomy of the anterior wall of the stomach near the ulcer, which facilitates the imposition of hemostatic sutures. In the second case, longitudinal gastrotomy is performed along the midline of the anterior wall along the entire body of the stomach. Immediately after dissection of the gastric wall, the edges of the incision are grasped with large atraumatic DuvaL clamps. This has two purposes: 1. It stops bleeding from the well-circulated stomach wall without the need for multiple ligatures on the stomach wall, which would result in significant blood loss in addition to bleeding from the ulcer. 2. This allows, by stretching the Duval clamps, to open the stomach wide for revision of its inner surface. In addition to Duval clamps, other retractors can be used, especially for revision of the upper part of the stomach – the esophageal-gastric junction, cardia and fundus. Clots from the stomach lumen can be removed manually. They should not be aspirated, firstly, because it is usually ineffective, and, secondly, because aspiration damages the gastric mucosa, which increases blood loss. The suction cannula can be used directly where bleeding occurs to improve visibility and facilitate correct hemostatic suturing. If the bleeding ulcer is located high in the cardia or subcardial, hemostatic suturing can be difficult. Good lighting plays an important role in this. In such cases, it is very useful to pass the Hurst 50 F bougie through the esophagus to the gastro-gastric junction, but without passing through it, so as not to impair the view when suturing the ulcer base and cause narrowing of the esophagus. This technique is preferably used for local excision of ulcers, as some surgeons suggest in cases where the patient’s condition does not allow performing gastric resection with the removal of the ulcer according to Pauchet, which is the method of choice for this pathology. In patients with bleeding ulcers located high near the greater curvature of the stomach (a very rare location of a peptic ulcer), the surgeon may resort to intussusception of the greater curvature with the right hand to remove the ulcer into a position in which it is more convenient to apply hemostatic sutures. If during the revision of the stomach the bleeding has stopped, the sutures must still be applied. In some patients, instead of performing hemostasis by suturing the bottom of the ulcer, resection of the edge of the stomach, including the ulcer, can be performed, followed by reconstruction of the stomach. Wedge resection is a less voluminous operation than standard resection, but it can only be performed if the ulcer is localized in certain areas of the stomach. Lesser curvature ulcers located above the angular notch can be removed with wedge resection without any concern. When the ulcer is located below the notch, performing a wedge resection is contraindicated, as this will damage the Latarjet nerve.