Abstract
The best surgical procedure to treat bleeding bulbar peptic ulcer is unknown. The rates of postoperative bleeding recurrence, duodenal leakage, and mortality were compared in patients undergoing oversewing plus vagotomy (O+V) or gastric resection (GR) with ulcer excision. Of 202 patients undergoing emergency surgery for massive, persistent, or recurrent bleeding from bulbar peptic ulcer, 120 patients were enrolled in a prospective randomized trial. Fiftynine were assigned to O+V and 61 to GR. One patient in each group was excluded after randomization. The two groups were well matched with respect to clinical and prognostic factors. The rate of postoperative bleeding recurrence was 17% after O+V and 3% after GR (p<0.05). The duodenal leak rate was higher after GR than after O+V (13% vs. 3%) (p<0.10) but was not different when the morbidity of reoperations for bleeding recurrence after O+V was considered on an “intention to treat” basis (12% vs. 13%). Overall postoperative mortality was similar: 22% (O+V) versus 23% (GR). Sixteen deaths were unrelated to the surgical procedure itself. Of 82 nonrandomized patients, 10 were not analyzed. In the 72 other nonrandomized patients, bleeding recurrence, duodenal leakage, and postoperative mortality rates were consistent with the results of the controlled trial, as they were 29% (O+V 32%; GR 0.7%), 16% (O+V 0.7%; GR 26%) and 27% (O+V 18%; GR 33.3%), respectively. We conclude that GR with ulcer excision is the procedure of choice for the emergency surgical treatment of bleeding duodenal ulcer because postoperative bleeding recurrence is lower, and the overall rates of mortality and duodenal leakage are the same as with O+V.
Résumé
La meilleure technique chirurgicale pour traiter l'ulcère du bulbe hémorragique n'est pas connue avec certitude. On a comparé les fréquences de récidive hémorragique, de lâchage du moignon duodénal et de mortalité chez des malades ayant une vagotomie avec suture de l'ulcère (VS) avec celles des patients ayant eu une gastrectomie avec excision de l'ulcère (GE). Parmi 202 malades ayant eu une chirurgie d'urgence pour ulcère du bulbe dont l'hémorragie était massive, persistante ou recidivante, 120 ont été tirés au sort dans le cadre d'une étude prospective randomisée. Cinquante-neuf malades ont eu une VS et 61, une GE. Les deux groupes étaient similaires en ce qui concerne les facteurs pronostiques et leurs caractéristiques cliniques. La fréquence de récidive hémorragique a été de 17% après VS et de 3% après GE (p<0.05). La fréquence de lâchage du moignon était plus élèvée après VS (13% vs 3%) (p <0.01) mais ne différait plus lorsque ces mêmes fréquences ont été calculées en incluant les malades qui ont eu une gastrectomie secondaire après échec de VS (12% vs 13%). La mortalité postopératoire globale était similaire dans les deux groupes: 22% (VS) vs 23% (GE). Seize des décès n'étaient pas en rapport avec l'acte chirurugical lui-même. Parmi 82 autres malades non randomisés, 10 dossiers n'ont pas été analysés. Des 72 malades restants, la fréquence de récidive hémorragique, de lâchage du moignon duodénal et de mortalité postopératoire étaient compatibles avec les résultats de l'étude randomisée: 29% (VS: 32%; GE 0.7%), 16% (VS: 0.7% vs GE: 26%) et 27% (VS: 18%; GE: 33.3%), respectivement. Nous concluons que, par rapport à la VS, la GE est le procédé de choix pour traiter l'ulcère duodénal hémorragique car la fréquence de récidive hémorragique est plus basse mais la fréquence globale de mortalité et de lâchage du moignon sont similaires.
Resumen
No se sabe cual es el mejor procedimiento quirúrgico en el manejo de una úlcera duodenal bulbar sangrante. Las tasas de resangrado postoperatorio, de fuga de la sutura duodenal y de mortalidad fueron comparadas en pacientes sometidos a sutura + vagotomía (S+V) o a resección gástrica (RG) con resección de la úlcera. De 202 pacientes sometidos a cirugía de urgencia por hemorragia masiva, persistente o recurrente a partir de una úlcera péptica bulbar, 120 fueron incorporados en un ensayo clínico prospectivo y randomizado. Cincuenta y nueve fueron asignados a S+V y 61 a RG. Un paciente de cada grupo fue excluido luego de la randomización. Los dos grupos eran similares en cuanto a factores clínicos y de pronóstico. La tasa de sangrado recurrente postoperatorio fue 17% después de S+V y de 3% después de GR (p<0.05). La tasa de fuga de la sutura duodenal fue mayor con la RG que con la S+V (13% vs. 3%) (p<0.10), pero no hubo diferencia cuando la morbilidad de las reoperaciones por recurrencia del sangrado después de S+V fue considerada sobre la base de una “intención de tratamiento” (12% vs. 13%). La mortalidad postoperatoria global fue similar: 22% (S+V) vs. 23% (RG). Dieciseis muertes no estuvieron relacionadas con el procedimiento quirúrgico mismo. De 82 pacientes no randomizados, 10 no fueron analizados; en los otros 72 no randomizados, las tasas de sangrado recurrente, escape duodenal y mortalidad postoperatoria aparecieron consistentes con los resultados observados en el ensayo clínico controlado: 29% (S+V: 32%; RG: 0.7%), 16% (S+V: 0.7%; RG: 26%) y 27% (S+V: 18%; RG: 33.3%), respectivamente. Nuestra conclusión es que la RG con resección de la úlcera es el procedimiento de elección en el tratamiento quirúrgico de urgencia de la úlcera duodenal sangrante, en virtud de una menor tasa de recurrencia postoperatoria del sangrado al tiempo que las tasas de mortalidad y de fugas de la sutura duodenal son iguales a las de la S+V.
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The following surgeons participated in this study: Xavier Pouliquen, M.D., Bernard Vacher, M.D. (Argenteuil); Jean-François Charles, M.D., Patrick Lozach, M.D. (Brest); François Gayral, M.D., Bertrand Millat, M.D. (Clamart); Yves Flamant, M.D., Guy Zeitoun, M.D., Jean-Marie Hay, M.D. (Colombes); Gérard Kohlmann, M.D. (Corbeil); Pierre-Louis Fagniez, M.D., Nelly Rotman, M.D. (Créteil); Pierre Cubertafond, M.D., Alain Gainant, M.D. (Limoges); Odile LangloisZantain, M.D. (Maubeuge); Gérard Desvignes, M.D. (Montargis); Patrick Boissel, M.D., Laurent Bressler, M.D. (Vandœuvre-lèsNancy); Jean-Louis Sicard, M.D. (Nice); Jean-Louis Bernard, M.D. (Orléans); Michel Rodary, M.D. (Orsay); François Desmaizières, M.D. (Paray-le-Monial); Patrice Valleur, M.D., François Dazza, M.D. (Paris); Jean Pourcher, M.D., Philippe Oberlin, M.D., Abe Fingerhut, M.D. (Poissy); Henri Hennet, M.D. (Romorantin); Jacques Testart, M.D., Francis Michot, M.D., Paul Ténière, M.D. (Rouen), Rida Benhamida, M.D. (Sousse); Daniel Jaeck, M.D. (Strasbourg); Chadli Dziri, M.D Tahar Khalfallah, M.D. (Tunis).
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Millat, B., Hay, JM., Valleur, P. et al. Emergency surgical treatment for bleeding duodenal ulcer: Oversewing plus vagotomy versus gastric resection, a controlled randomized trial. World J. Surg. 17, 568–573 (1993). https://doi.org/10.1007/BF01659109
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DOI: https://doi.org/10.1007/BF01659109