What is the Oversewing Technique?
Oversewing is a surgical technique where the surgeon directly sutures a bleeding vessel or ulcer defect, typically performed through a duodenotomy to visualize and control hemorrhage from the ulcer base. This method is primarily used for bleeding peptic ulcers, particularly posterior duodenal ulcers where the gastroduodenal artery is the bleeding source 1.
Technical Approach
The oversewing technique involves:
- Direct visualization of the bleeding vessel through a duodenotomy (surgical opening of the duodenum)
- Triple-loop suturing of the bleeding gastroduodenal artery, which is critical due to collateral blood supply from the transverse pancreatic arteries 1
- Intraoperative endoscopic guidance to localize the bleeding site when the surgeon cannot identify it preoperatively 1
Clinical Context and Indications
Oversewing is indicated for refractory bleeding peptic ulcers that have failed endoscopic treatment and/or angioembolization 1. According to the 2020 WSES guidelines, surgical intervention should be considered:
- After failure of repeated endoscopy
- In patients with hypotension/hemodynamic instability
- When ulcers are larger than 2 cm at first endoscopy 1
Surgical Approach Options
The choice between oversewing alone versus more definitive procedures depends on the clinical scenario:
- Simple oversewing: Provides immediate hemorrhage control but may have higher mortality rates
- Oversewing plus vagotomy/drainage: Associated with significantly lower postoperative mortality compared to simple oversewing alone for intractable bleeding ulcers 1
- Gastric resection with ulcer excision: May be preferred for certain cases, particularly gastric ulcers where malignancy must be excluded 1
Important Caveat
Most duodenal ulcers requiring surgery for persistent bleeding are large, posterior lesions with gastroduodenal artery involvement 1. These represent the most technically challenging cases with higher 90-day mortality and reoperation rates compared to gastric ulcers 1.
Laparoscopic vs. Open Approach
While laparoscopic oversewing under endoscopic guidance has been reported 2, the 2020 WSES guidelines recommend open surgery for refractory bleeding peptic ulcers due to the complexity and need for rapid hemorrhage control in unstable patients 1.
Key Technical Points
- The bleeding vessel must be directly visualized on the ulcer floor
- Triple-loop suturing is mandatory for gastroduodenal artery bleeding
- Intraoperative endoscopy facilitates localization when the bleeding source is unclear preoperatively
- For perforated ulcers (different indication), oversewing refers to simple suture closure of the perforation, which is distinct from the bleeding control technique 1