Surgical management of gastrointestinal bleeding

GI_Bleeding_Ozimo_Gama

Severe gastrointestinal bleeding has historically been a clinical problem primarily under the purview of the general surgeon. Diagnostic advances made as the result of newer technologies, such as fiberoptic and video endoscopy, selective visceral arteriography, and nuclear scintigraphy, have permitted more accurate and targeted operations. More importantly, they have led to safe, effective nonoperative therapeutic interventions that have obviated the need for surgery in many patients. Today, most gastrointestinal bleeding episodes are initially managed by endoscopic or angiographic control measures. Such interventions are often definitive in obtaining hemostasis. Even temporary cessation or attenuation of massive bleeding in an unstable patient permits a safer, more controlled operative procedure by allowing an adequate period of preoperative resuscitation. Despite the less frequent need for surgical intervention, traditional operative approaches, such as suture ligation, lesion or organ excision, vagotomy, portasystemic anastomosis, and devascularization procedures, continue to be life-saving in many instances. The proliferation of laparoscopic surgery has fostered the application of minimally invasive techniques to highly selected patients with gastrointestinal bleeding. Intraoperative endoscopy has greatly facilitated the accuracy of laparoscopic surgery by endoscopic localization of bleeding lesions requiring excision. It is anticipated that the evolving technologies pertinent to the diagnosis and management of gastrointestinal bleeding will continue to promote collaboration and cooperation between gastroenterologists, radiologists, and surgeons.

Surgical Management

The role of surgery in acute peptic ulcer bleeding has markedly changed over the past two decades. The widespread use of endoscopic treatment has reduced the number of patients requiring surgery. Therefore, the need for routine early surgical consultation in all patients presenting with acute UGIB is now obviated (Gralnek et al., 2008). Emergency surgery should not be delayed, even if the patient is in haemodynamic shock, as this may lead to mortality (Schoenberg, 2001). Failure to stop bleeding with endoscopic haemostasis and/or interventional radiology is the most important and definite indication. The surgical procedures under these circumstances should be limited to achieve haemostasis. The widespread use of PPIs obviated further surgical procedures to reduce acid secretion. Rebleeding tends to necessitate emergency surgery in approximately 60% of cases with an increase in morbidity and mortality (Schoenberg et al.; 2001). The reported mortality rates after emergency surgery range from 2 – 36%. Whether to consider endoscopic retreatment or surgery for bleeding after initial endoscopic control is controversial (Cheung et al., 2009). A second attempt at endoscopic haemostasis is often effective (Cheung et al., 2009), with fewer complications avoiding some surgery without increasing mortality (Lau et al., 1999). Therefore, most patients with evidence of rebleeding can be offered a second attempt at endoscopic haemostasis. This is often effective, may result in fewer complications than surgery, and is the current recommended management approach. Available data suggest that early elective surgery for selected high-risk patients with bleeding peptic ulcer might decrease the overall mortality rate. It is a reasonable approach in ulcers measuring ≥2 cm or patients with hypotension at rebleeding that independently predicts endoscopic retreatment failure (Lau et al., 1999). Early elective surgery in patients presenting with arterial bleeding or a visible vessel of ≥2 mm is superior to endoscopic retreatment and has a relatively low overall mortality rate of 5% (Imhof et al., 1998 & 2003). Additional indications for early elective surgery include age >65 years, previous admission for ulcer plication, blood transfusion of more than 6 units in the first 24 hours and rebleeding within 48 hours (Bender et al., 1994; Mueller et al., 1994). This approach is associated with a low 30–day mortality rate as low as 7%.

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