From the Guidelines
For a patient with a history of peptic ulcer disease presenting with hematemesis where endoscopy has failed, the recommended surgical approach is vagotomy and pyloroplasty, as it is associated with significantly lower mortality than simply local ulcer oversew, according to a recent study 1. The choice of surgical procedure should be based on the location and extension of the ulcer and the characteristics of the bleeding vessel.
- In patients with refractory bleeding peptic ulcer, open surgery is recommended when endoscopic treatments have failed and there is evidence of ongoing bleeding, plus or minus hemodynamic instability 1.
- The surgical approach involves ulcer oversew or resection, and bleeding gastric ulcers should be resected or at least biopsied for the possibility of neoplasms 1.
- For duodenal ulcers requiring surgery for persistent bleeding, a vagotomy and pyloroplasty is preferred, as it is associated with lower mortality than local procedures alone 1.
- Prior to surgery, the patient should be stabilized with fluid resuscitation, blood transfusions as needed, and intravenous proton pump inhibitors, and broad-spectrum antibiotics should be administered if perforation is suspected.
- Postoperatively, the patient should continue on proton pump inhibitors, undergo H. pylori testing and treatment if positive, and avoid NSAIDs. The most appropriate answer among the options provided is c. Truncal vagotomy and pyloroplasty, as it is the most suitable surgical procedure for a patient with a history of peptic ulcer disease presenting with hematemesis where endoscopy has failed, based on the evidence from the study 1.
From the Research
Surgical Management of Peptic Ulcer Disease with Hematemesis
The patient presents with a history of peptic ulcer disease and hematemesis, where endoscopy has failed, and surgery is indicated. The recommended surgical approach is crucial in managing this condition.
Recommended Surgical Procedures
- Truncal vagotomy and antrectomy is a recommended procedure for patients with peptic ulcer disease, especially for those with high-risk ulcers or those who have failed endoscopic treatment 2, 3.
- Vagotomy-pyloroplasty is also an option for high-risk patients, while vagotomy-antrectomy is suitable for lower-risk patients 2.
- For bleeding gastric ulcers, resection is recommended if possible 2.
- Laparoscopic ligation of the bleeding vessel is an alternative approach, but its effectiveness depends on the individual surgeon's comfort and experience 3.
Considerations for Surgical Management
- The choice of surgical procedure depends on the specific needs of the individual patient, including the location and size of the ulcer, as well as the patient's overall health status 2, 4.
- Truncal vagotomy has been shown to be effective in reducing morbidity and postoperative complications in patients with complicated peptic ulcer disease 5, 6.
- Distal gastrectomy with reconstruction by jejunal pouch interposition is a surgical option for patients with peptic ulcer disease, but it may require additional procedures, such as truncal vagotomy, to manage complications 6.
Options for Surgical Management
- Truncal vagotomy and antrectomy (option a) is a viable option for patients with peptic ulcer disease and hematemesis.
- Distal gastrectomy (option b) may be considered, but it is not the primary recommended procedure for this specific scenario.
- Truncal vagotomy and pyloroplasty (option c) is an alternative approach, but it may not be the best option for all patients.
- Laparoscopic ligation of the bleeding vessel (option d) is a minimally invasive approach, but its effectiveness depends on the individual surgeon's experience and the patient's specific condition.