Surgical approach in severe bleeding peptic ulcer

Hospitalisation and surgery for uncomplicated peptic ulcers have decreased over the past 20 to 30 years, but the total number of operations for bleeding peptic ulcer has increased. Haemorrhage remains the most common complication of peptic ulcer and also the one with the highest mortality rate. Emergency operations to control the bleeding have a mortality rate in the range of 10% to 20%. With the advent of endoscopic haemostasis, the hospital mortality rate is reduced, by reducing rebleeding and emergency operation rate. Emergency operative intervention is clearly indicated for patients with active haemorrhage refractory or inaccessible to endoscopic haemostasis. Combination of successful endoscopic haemostasis and elective early operative intervention favorably influences mortality only if applied to selected patient at high risk of rebleeding and death before sequelae of shock. For those at low risk for recurrent haemorrhage, early operation would be associated with an unacceptable operative risk. Truncal vagotomy and pyloroplasty, with ulcer oversew is the best surgical approach for elective and emergency operation in poor risk patients with duodenal ulcer haemorrhage. Proximal gastric vagotomy and ulcer oversew may be chosen in selected good risk patient. Gastric ulcers are associated with an increased risk of recurrent haemorrhage and malignancy. A more radical procedure (partial gastrectomy) should be favoured since it reduces bleeding recurrence rate without increasing mortality.