Managing Recurrent Peptic Ulcer Bleeding: The Scalpel or the Scope?

Arai, Ronen; Barkin, Jamie S.; Johnson, David
November 1999
American Journal of Gastroenterology;Nov1999, Vol. 94 Issue 11, p3365
Academic Journal
This prospective randomized study compared endoscopic retreatment with surgery for patients whose peptic ulcers rebled after initial endoscopic hemostasis had been achieved. Over a 3 1/2-yr period at a single institution in Hong Kong, 3473 adult patients were admitted with the diagnosis of bleeding peptic ulcer. A total of 1169 patients required endoscopic therapy for actively bleeding ulcers or ulcers with nonbleeding visible vessels. Therapy consisted of epinephrine injection of the ulcer followed by coaptive thermocoagulation to the vessel with a heater probe. Initial hemostasis was achieved in 1152 of the 1169 patients (98.5%), and 17 patients required immediate surgery for failure of endoscopic hemostasis. Another 100 patients (8.7%) had recurrent bleeding, of which seven patients with cancer and one with a cardiac arrest were excluded from further study. The remaining 92 patients were randomized either to repeat endoscopic treatment (48 patients) or to surgery (44 patients). Endoscopic retreatment used a mean of 11.2 ± 5.1 ml of 1:10,000 epinephrine solution and a median of 12 pulses with the heater probe at 30 Joules. In the group randomized to surgery, the choice of operation was left to the individual surgeon. There were no significant differences in demographics between the two groups. An intention-to-treat analysis was used. In the endoscopic retreatment group, long-term hemostasis was achieved in 35 of 48 patients (73%), and 13 patients underwent salvage surgery for bleeding (11 patients) or perforation (two patients). Multiple logistic-regression analysis revealed that hypotension at randomization and ulcer size >2 cm were independent factors predicting failure of endoscopic therapy. In the group randomized to surgery, the most commonly performed procedures were partial gastrectomy, vagotomy with pyloroplasty, and ulcer plication or excision. In the primary outcome measures of length of hospitalization, ICU days, and transfusion requirements, there were no differences between the groups. There were significantly fewer complications, defined as cardiovascular, respiratory, infectious, bleeding, and organ failure, in the endoscopy group compared to the surgical group (seven vs 16 patients, 14% vs 36%, respectively, p = 0.03). Of note, six of the seven patients with complications in the endoscopy group had their complications after salvage surgery. There was no significant difference in 30-day mortality between the two groups: five patients (10%) in the endoscopy group and eight patients (18%) in the surgical group died. Four of the five deaths in the endoscopy group occurred after salvage surgery. The authors conclude that in patients with recurrent bleeding after initial endoscopic control of peptic ulcer bleeding, endoscopic retreatment reduces the need for surgery and is associated with fewer complications, without increasing the risk of death.


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