Editing Upper GI bleed (section)

=== '''Third-line: surgery (needed in 5-10%)''' ===

** Indications:
*** Failed endoscopy x2
*** Haemodynamically unstable despite vigorous resus (>3 units)
**** Previously, >= 6 units in index 24 hrs was indication for surgery
*** Recurrent haemorrhage after haemostasis with endoscopy (reasonable to try twice with endoscopy)
*** Ongoing transfusion requirement >3 units per day
*** Unable to transfuse (rare blood type, refusal of transfusion)
** Technique
*** Upper midline laparotomy (bleeding duodenal ulcers can technically be treated laparoscopically, but difficult)
*** Examine for external signs of ulcer - will often be able to see serosal inflammatory changes at the site of a chronic ulcer
*** If any doubt as to location, use intra-operative gastroscopy
** Duodenal ulcers: intervention will usually be to oversew or ligate bleeding vessel, which is the '''GDA''' at the base of a posterior ulcer

*** May need a Kocher maneuvre to mobilise the duodenum and get manual control
*** Longitudinal duodenotomy/pyloroduodenotomy from pylorus through to anterior wall of D1/D2
*** Remove blood, isolate bleeding
*** Apply pressure and time for anaesthetics to catch up
*** Underrun bleeding vessel with 3-point U-stitch technique of 2/0 Vicryl
**** Careful of CBD - can insert a probe through the ampulla if necessary - although Mosche says he has never heard of it being sutured over
**** Classically need to suture ligate GDA superiorly and inferiorly (12 and 6 o'clock), with another suture at 3 o'clock for transverse pancreatic branch
*** Close the duodenotomy transversely (like a stricturoplasty)
*** Consider vagotomy or other acid-reducing operation, but this is generally unnecessary nowadays

** Gastric ulcers

*** Use the simplest possible operation that will stop the bleeding
*** First gastrotomy and underrun the bleeding ulcer (30% rebleeding risk)
*** Wedge resection may be a good option for greater curvature ulcers, but this gives a 10% rebleeding risk, so distal gastrectomy is favoured
*** Bleeding proximal ulcers near GOJ are quite difficult to manage - proximal or near-total gastrectomy has very high mortality in setting of haemorrhage. Perhaps a distal gastrectomy with a tongue of proximal stomach, or a wedge resection/buttressed oversewing of the ulcer?