What is the surgical management of a bleeding duodenal ulcer using 3-point ligation?

From the Guidelines

Surgical management of a bleeding duodenal ulcer should involve a 3-point ligation technique, which includes direct suture ligation of the bleeding vessel through a duodenotomy, as it is a effective method for achieving hemostasis in posterior duodenal ulcers where the gastroduodenal artery is commonly involved 1. To perform the 3-point ligation technique, a longitudinal duodenotomy is made opposite to the ulcer site, and the bleeding vessel within the ulcer crater is identified. Three separate sutures are then placed: one directly on the bleeding point and two additional sutures on either side of the vessel. Non-absorbable sutures like 2-0 or 3-0 silk are used, taking care to place them deep enough to incorporate the vessel but avoid the posterior duodenal wall. Some key points to consider when performing this technique include:

• The importance of preoperative resuscitation with IV fluids, blood products, and acid suppression with IV proton pump inhibitors, such as pantoprazole 80mg bolus followed by 8mg/hr infusion.
• The need to continue acid suppression postoperatively and test for Helicobacter pylori, initiating appropriate eradication therapy if positive.
• The potential benefits of intra-operative endoscopy to facilitate the localization of the bleeding site, as suggested by the WSES guidelines 1.
• The consideration of vagotomy/drainage as a surgical procedure, which has been associated with significantly lower mortality than simply local ulcer oversew, according to Schroeder et al. 1. It is also critical to perform triple-loop suturing of bleeding of the GDA due to the collateral blood supply to the transverse pancreatic arteries, and to close the duodenotomy transversely using interrupted seromuscular sutures after achieving hemostasis.

From the Research

Surgical Management of Bleeding Duodenal Ulcer

• The surgical management of bleeding duodenal ulcers involves a structured therapeutic approach due to the higher morbidity and mortality compared to gastric ulcers 2.
• When bleeding persists or rebleeding occurs and endoscopy fails, surgical and radiological procedures are indicated to manage ulcer bleeding 2.
• Surgical procedures are performed to control hemorrhage, but they are still associated with a higher morbidity and a longer hospital stay 2.

3-Point Ligation

• A systematic conservative treatment (CT) involving under-running bleeding gastroduodenal artery (GDA) and ulcer suture through a duodenotomy with or without GDA double ligation along with continuous intravenous PPI has been assessed 3.
• The study found that surgical CT of BDU with continuous PPI is effective, with a low rate of rebleeding 3.
• The use of vagotomy-antrectomy as the standard surgical treatment is questionable, and conservative surgery may be a viable alternative 3, 4.

Alternative Surgical Approaches

• Antrectomy versus conservative surgery is still a topic of debate in the surgical management of duodenal ulcer with hemorrhage from the gastroduodenal artery 4.
• The role of surgery has changed, and its aim is no longer to cure the ulcer diathesis but rather to urgently control bleeding in anticipation of ulcer cure with medical therapy 4.
• The use of proton pump inhibitors has decreased the incidence of rebleeding and reduced the need for surgery for bleeding duodenal ulcer 5, 6.