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Gastroduodenal
* What role does surgery play in the modern day management of non-variceal upper gastrointestinal bleeding?
  1. V Jairath *1,
  2. R Logan2,
  3. S Hearnshaw3,
  4. B Kahan4,
  5. S Travis5,
  6. M Murphy1,
  7. K Palmer6
  1. 1NHS Blood and Transplant, Oxford, UK
  2. 2Division of Epidemiology and Public Health, Nottingham, UK
  3. 3Royal Victoria Infirmary, Newcastle, UK
  4. 4MRC Clinical Trials Unit, London, UK
  5. 5John Radcliffe Hospital, Oxford, UK
  6. 6Western General Infirmary, Edinburgh, UK

Abstract

Introduction Combinations of endoscopic, pharmacological and radiological intervention appears to have reduced the need for surgery in non-variceal upper gastrointestinal bleeding (NVUGIB), for what was once a condition primarily managed by surgeons. The place of surgery in today's management of NVUGIB remains poorly characterised.

Methods We examined the clinical characteristics, sequence of intervention and outcomes of NVUGIB in a nationwide study, by analysing patients coming to surgery in the 2007 national audit of Acute Upper Gastrointestinal Bleeding1.

Results The study recruited 6,750 patients. Only 1.9% (127/6750) underwent surgery. The mean age was 69.4 (SD 15) years, 60% (75/127) male, with median of 1 co-morbid illnesses. Indications for surgery were uncontrolled bleeding/high risk stigmata of haemorrhage in 82% (104/127), peritonitis/perforation in 12% (15/127), malignancy in 4% (5/127), and other indications in 9% (12/127). Surgical procedures were oversew or under-run of an ulcer in 65% (83/127), partial gastrectomy in 9% (12/127), excision of an ulcer with vagotomy/pyloroplasty (2%) and other procedure in 20%. Surgery was performed outside of normal working hours in 54% (69/127), lead by a consultant surgeon in 71% (90/127) with a consultant anaesthetist in 64% (81/127). A median of 1 endoscopy was performed prior to surgery and 5% (6/127) had also undergone mesenteric angiography, with apparently successful embolisation in 33% (2/6) of cases. Mortality following surgery was 30% (38/127). Post-operative complications occurred in 65% (82/127). Compared to patients managed non-surgically, patients requiring surgery were older (mean 69.4yrs vs. 64.3 yrs, p<0.0001), more likely to have been shocked (66% vs. 36% p<0.0001), transfused a greater number of red cells (median 9 units vs. 4 units, p<0.0001) and have a higher complete Rockall score (median 6 vs. 4, p<0.0001). AUROC analysis showed that the complete Rockall score usefully predicted the need for surgery (AUC 0.74, 95% CI 0.7-0.78), but the clinical Rockall score did not (AUC 0.613, 95%CI 0.56-0.67).

Conclusion Modern day management of NVUGIB rarely requires surgical intervention. Given the high mortality and complication rates of patients following surgery, its role and timeliness needs re-evaluation in the hope of improving outcomes following AUGIB.

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Footnotes

  • Competing interests None.

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