Upper gastrointestinal bleeding surgery
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]
Overview
Surgery is the last resort in the management of upper GI bleeding. Surgical options include TIPS, balloon tamponade, and emergency laparotomy.
Surgery
Surgery is the last resort in the management of upper GI bleeding. Surgical options include:
TIPS
TIPS is a complex nonsurgical shunt which involves insertion of an expandable metal stent that bridges the hepatic vein and an intrahepatic branch of the portal vein. TIPS can halt bleeding in almost all patients, including those with bleeding refractory to other therapies.[1][2][3][4]
Indications
- Uncontrolled variceal hemorrhage from esophageal, gastric, and intestinal varices that do not respond to endoscopic and medical management.
- Refractory ascites
- Hepatic pleural effusion
- Bridge to transplantation and retransplantation
- Budd-Chiari syndrome
- Hepatorenal syndrome (HRS)
- Veno-occlusive disease (VOD)
Procedure
- TIPS involves the percutaneous puncture of the right internal jugular vein and insertion of a vascular sheath into the inferior vena cava and the hepatic vein.[5][3]
- An angioplasty balloon catheter is used to dilate the tract between the hepatic and portal veins, and a stent is then placed across the tract.
- Patients should undergo a baseline Doppler study within 24 hours of the procedure to document functional parameters, including the direction of portal vein flow and flow velocities throughout the shunt and within the hepatic vein.
Complications
- Hepatic encephalopathy[6][7][8]
- Hemolytic anemia
- Intra-abdominal bleeding during stent placement
Balloon tamponade
Balloon tamponade is only used as a temporary measure in patients who fail to respond to pharmacologic and endoscopic intervention. Balloon tamponade stabilizes patients until more definitive treatment can be instituted (TIPS or liver transplantation).[9][10][11]
Procedure
- Balloon tamponade involves the passage of a specialized nasogastric tube, fitted with an inflatable balloon.[12][13]
- When the balloon is inflated, direct pressure staunches bleeding by compressing the varices.
- Controls active bleeding in 80% to 90% of patients although rebleeding after balloon deflation is common.
Indications
- For bleeding varices that are refractory to banding or sclerosant injection.
Complications
- Rebleeding upon balloon deflation
- Esophageal rupture
Emergency laparotomy
Emergency laparotomy is generally not indicated in the management of upper GI bleeding. Laparotomy is only performed as a last resort for managing complications such as perforation. Emergency laparotomy includes open exploration of the abdomen, oversewing of the ulcer, truncal vagotomy and pyloroplasty .[14][15]
| Surgical options for upper GI bleeding | |
|---|---|
| Disease Process | Surgical Options |
| Peptic ulcer disease | Oversew |
| 3-point ligation of gastroduodenal artery | |
| Vagotomy and pyloroplasty | |
| Vagotomy and antrectomy | |
| Highly selective vagotomy | |
| Mallory-Weiss tear | Oversew |
| Dieulafoy lesion | Oversew |
| Wedge resection | |
| Varices | Portacaval shunt |
| Mesocaval shunt | |
| Distal splenorenal shunt | |
| Gastric cancer | Distal gastrectomy |
| Total gastrectomy | |
| D2 lymphadenectomy | |
| Hemobilia | Selective ligation |
| Resection of aneurysm | |
| Nonselective ligation | |
| Liver resection | |
| Aortoduodenal fistula | Angiography and stent (if hemodynamically stable) |
| Open repair | |
| Extra-anatomic bypass | |
References
- ↑ Ferral H, Bilbao JI (2005). "The difficult transjugular intrahepatic portosystemic shunt: alternative techniques and "tips" to successful shunt creation". Semin Intervent Radiol. 22 (4): 300–8. doi:10.1055/s-2005-925556. PMC 3036298. PMID 21326708.
- ↑ Rössle M, Haag K, Ochs A, Sellinger M, Nöldge G, Perarnau JM, Berger E, Blum U, Gabelmann A, Hauenstein K (1994). "The transjugular intrahepatic portosystemic stent-shunt procedure for variceal bleeding". N. Engl. J. Med. 330 (3): 165–71. doi:10.1056/NEJM199401203300303. PMID 8264738.
- ↑ 3.0 3.1 Jalan R, Redhead DN, Hayes PC (1995). "Transjugular intrahepatic portasystemic stent-shunt in the treatment of variceal haemorrhage". Br J Surg. 82 (9): 1158–64. PMID 7551988.
- ↑ Jalan R, Redhead DN, Hayes PC (1995). "Transjugular intrahepatic portosystemic stent shunt". Natl Med J India. 8 (1): 15–21. PMID 7696939.
- ↑ Stanley AJ, Redhead DN, Hayes PC (1997). "Review article: update on the role of transjugular intrahepatic portosystemic stent-shunt (TIPSS) in the management of complications of portal hypertension". Aliment. Pharmacol. Ther. 11 (2): 261–72. PMID 9146762.
- ↑ Freedman AM, Sanyal AJ, Tisnado J, Cole PE, Shiffman ML, Luketic VA, Purdum PP, Darcy MD, Posner MP (1993). "Complications of transjugular intrahepatic portosystemic shunt: a comprehensive review". Radiographics. 13 (6): 1185–210. doi:10.1148/radiographics.13.6.8290720. PMID 8290720.
- ↑ Sanyal AJ, Freedman AM, Luketic VA, Purdum PP, Shiffman ML, Cole PE, Tisnado J, Simmons S (1997). "Transjugular intrahepatic portosystemic shunts compared with endoscopic sclerotherapy for the prevention of recurrent variceal hemorrhage. A randomized, controlled trial". Ann. Intern. Med. 126 (11): 849–57. PMID 9163285.
- ↑ Grace ND, Conn HO, Resnick RH, Groszmann RJ, Atterbury CE, Wright SC, Gusberg RJ, Vollman R, Garcia-Tsao G, Fisher RL (1988). "Distal splenorenal vs. portal-systemic shunts after hemorrhage from varices: a randomized controlled trial". Hepatology. 8 (6): 1475–81. PMID 3056820.
- ↑ Cook D, Laine L (1992). "Indications, technique, and complications of balloon tamponade for variceal gastrointestinal bleeding". J Intensive Care Med. 7 (4): 212–8. doi:10.1177/088506669200700408. PMID 10147943.
- ↑ Tiuca N, Sztogrin W (2011). "The news of treatment of variceal upper gastrointestinal bleeding". J Med Life. 4 (4): 395–8. PMC 3227155. PMID 22514572.
- ↑ Sauerbruch T, Fischer G (1991). "Conservative treatment of upper gastrointestinal bleeding in portal hypertension". Hepatogastroenterology. 38 (5): 350–4. PMID 1684947.
- ↑ Ashbridge KR, Booth RJ, Watson JD, Lathigra RB (1989). "Nucleotide sequence of the 19 kDa antigen gene from Mycobacterium tuberculosis". Nucleic Acids Res. 17 (3): 1249. PMC 331747. PMID 2493628.
- ↑ Cremers I, Ribeiro S (2014). "Management of variceal and nonvariceal upper gastrointestinal bleeding in patients with cirrhosis". Therap Adv Gastroenterol. 7 (5): 206–16. doi:10.1177/1756283X14538688. PMC 4107701. PMID 25177367.
- ↑ Gustavsson S, Kelly KA, Melton LJ, Zinsmeister AR (1988). "Trends in peptic ulcer surgery. A population-based study in Rochester, Minnesota, 1956-1985". Gastroenterology. 94 (3): 688–94. PMID 3338637.
- ↑ Croce E, Azzola M, Golia M, Russo R, Angelini S, Contin G, Ubezio D, Pompa C (1994). "Laparoscopic posterior truncal vagotomy and anterior proximal gastric vagotomy". Endosc Surg Allied Technol. 2 (2): 113–6. PMID 8081927.