1. MASSIVE BLEEDING the role of the surgeon Balthasar Gerards Foundation Delft, January 1 st, 2006 J.J.B. van Lanschot AMC, Amsterdam The Netherlands

2. De moord op prins Willem I (1533-1584) door Balthasar Gerards op 10 juli 1584 in Delft.

3. BLEEDING PEPTIC ULCER the role of the surgeon Balthasar Gerards Foundation Delft, January 1 st, 2006 J.J.B. van Lanschot AMC, Amsterdam The Netherlands

4. UPPER GI BLEEDING proximal to Treitz’ ligament Gastric ulcer20-25% Duodenal ulcer20-25% Esophageal varices10-20% Mallory-Weiss 5-10% Neoplasms 5% Miscellaneous 25%

5. conventional surgery for peptic ulcer disease partial gastrectomy (Billroth I-II) antrectomy / vagotomy truncal vagotomy / pyloroplasty highly selective vagotomy (H.S.V.) posterior truncal vagotomy plus anterior seromyotomy (Taylor II)

6. conventional strategy for acute ulcer bleeding 1resuscitation 2endoscopic localization of bleeding site 3surgical therapy: - gastro-/duodenotomy: intraluminal ligation - extraluminal ligation: gastroduodenal artery complex - local excision (stomach) - formal gastric resection: excision / exclusion of ulcer

7. intraluminal + extraluminal ligation

8. Local excision of gastric ulcer

9. formal gastric resection with ulcer exclusion X

11. occlusion CBD caused during gastric resection 6.140.395 / 08-10-1933 / ptc with complete visualization of intrahepatic bile ducts, normal cystic duct and leakage at complete transection of CBD in patient after distal gastric resection (after endoscopic therapy and embolisation) for PUH due to fistula between v.c.i. and duodenal ulcer

12. Identification of common bile duct !

13. types of reconstruction

14. Major developments in peptic ulcer disease 1Medical acid suppression - H 2 -receptor antagonists - proton pump inhibitors 2Definite cure by eradication of Helicobacter pylori 3Development of endoscopic therapy - thermal (laser, BICAP) - injection (epinephrin, polidocanol) - clipping

15. SUPPORTIVE MEDICAL THERAPY 1. Is acid inhibition indicated? - Coagulation and platelet aggregation most effective in pH-neutral environment ! Lau, NEJM 2000

16. Omeprazole vs. Placebo in Re-bleeding Risk Lau, NEJM 2000 Omeprazole 80mg + 8mg/h (i.v.) placebo omeprazole 0 20 40 60 80 100

17. SUPPORTIVE MEDICAL THERAPY 1. Is acid inhibition indicated? - Coagulation and platelet aggregation most effective in pH-neutral environment ! 2. Is Helicobacter eradication indicated? - Hp-status is an independent prognostic factor for rebleeding - successful Hp-eradication reduces rebleeding rate substantially Lai, Am J Gastro 2000

18. Hp-pos Hp-neg Risk of Re-bleeding (Hp-pos vs. Hp-neg)

19. SUPPORTIVE MEDICAL THERAPY 1. Is acid inhibition indicated? - Coagulation and platelet aggregation most effective in pH-neutral environment ! 2. Is Helicobacter eradication indicated? - Hp-status is an independent prognostic factor for rebleeding - successful Hp-eradication reduces rebleeding rate substantially 3. NSAIDS should be discontinued, if possible !!

20. “The aim of emergency surgery should be to control the bleeding securely, rather than to prevent ulcer recurrence” Chung and Li British Journal of Surgery 1997

21. PEPTIC ULCER BLEEDING role of surgery ? 1.Timing of surgery ? 2.Type of surgical procedure ?

22. PEPTIC ULCER BLEEDING role of surgery ? 1.Timing of surgery ? 2.Type of surgical procedure ?

23. Preferred therapy for recurrent bleeding ? 1169 patients treated endoscopically no hemostasis in 17 pts (1.5%) surgery rebleeding in 100 pts (8.7%) 92 re-bleeders randomized –endoscopy:epinephrin + heater probe –surgery:surgeon´s preference (50% aggressive) Lau, NEJM 1999

24. Preferred therapy for recurrent bleeding ? randomized trial Lau, NEJM 1999 EndoscopySurgery Hospital stay [d]1011 Units of blood87 Complications 7 * 16 30d Mortality58

25. “Every massive bleeding from large ulcer at posterior wall of duodenal bulb with spurting bleeding or visible vessel should be operated on, esp. in the elderly, even after successful endoscopic hemostasis” Chung and Li British Journal of Surgery 1997 Possible exception ?

26. PEPTIC ULCER BLEEDING role of surgery 1.Timing of surgery ? Endoscopic re-intervention reduces complications with mortality similar to surgery. 2.Type of surgical procedure ?

27. PEPTIC ULCER BLEEDING role of surgery 1.Timing of surgery ? Endoscopic re-intervention reduces complications with mortality similar to surgery. 2.Type of surgical procedure ?

28. Type of surgery for bleeding ulcer randomized trial 1.Minimal surgery (n= 62): - underrunning of bleeding vessel òr - ulcer excision - ranitidine 2.Aggressive surgery (n=67): - vagotomy / pyloroplasty òr - partial gastrectomy (Poxon et al, Br J Surg 1991)

29. Type of surgery for bleeding ulcer randomized trial Overall mortality 29 (23%) minimal16 (26%) aggressive 13 (19%)n.s. Fatal rebleeding minimal 6 (10%) aggressive 0 (0%)p<0.05 (Poxon et al, Br J Surg 1991)

30. Type of surgery for bleeding ulcer retrospective study 1.Minimal surgery (n = 518): - vagotomy - drainage 2.Aggressive surgery (n = 389): - vagotomy - resection (de la Fuenta, J Am Coll Surg, 2006)

31. Type of surgery for bleeding ulcer retrospective study 30-day mortality: minimal18% aggressive 17%n.s. rebleeding > 4 units: minimal 11% aggressive 12%n.s. (de la Fuenta, J Am Coll Surg, 2006)

32. surgery for bleeding ulcer 1988 – AMC - 2001 to be presented by Monique E. van Leerdam during afternoon session

33. surgical therapy of peptic ulcers in the 21 st century -series from a single Vet. Adm. medical center -period 1999 – 2004 -43 patients with perforation or bleeding -47% H. pylori positive; 54% used NSAIDs -66% of patients were ASA class 3 or 4 -hospital mortality = 23% ! -if rebleeding is not the major cause of death, how can we improve outcome ? (Sarosi, Am J Surg 2005)

34. role of transcatheter embolization ?

35. Conclusions (1) aim of emergency surgery: to control bleeding securely, rather than to prevent ulcer recurrence. i.v. proton pump inhibition improves coagulation, and thus outcome. don’t forget Hp-eradication ! stop NSAIDs, if possible.

36. Conclusions (2) 1 st rebleeding is preferably treated again endoscopically. only limited data available on the optimal surgical procedure. negative patient selection (>50% ASA 3-4) induces high surgical mortality. future role of transcatheter arterial embolization ?