If a patient has a bleeding peptic ulcer, there is about a 75% chance that it will stop bleeding spontaneously, if you treat him non-operatively by replacing the blood he loses, as in the previous section. If he does not bleed again after his admission to hospital, his chances of living are good. If non-operative treatment succeeds, he can, if necessary, have an elective operation for his ulcer later. There is however about a 25% chance that the time will come, when it looks as if transfusion alone is going to fail. At this point you will have to decide whether or not to operate in the hope of saving his life. If he needs surgery, on the indications in the previous section, and he does not get it, he has about a 50% chance of death, especially if he is over 45. If you operate skillfully, his chances of death are only about 10%. In spite of the limitations of your services, about 90% of your patients with severe bleeding should live, most of them as the result of your efforts. One of your main difficulties will be to get enough blood.
The purpose of emergency surgery is to save his life, so you will have to decide when he is more likely to die if you don't operate than if you do. Try, especially, to judge the best time to operate. When you operate, try to find where the blood is coming from, and stop it. Doing an operation which will prevent it recurring is a lesser priority, because you may be able to refer him to someone else for a definitive operation later.
If you decide to operate, you will have to open his stomach and duodenum. If you find a bleeding duodenal or gastric ulcer, the simplest way to stop it bleeding is to underrun it. At the same time, you can[md]if you feel competent enough, and he is fit enough[md]take the opportunity to do a vagotomy and a pyloroplasty or gastroentrostomy, which will reduce the chances of recurrent ulceration afterwards. Cutting his vagus will reduce the acid his stomach secretes, but it will also hinder its emptying. A pyloroplasty will correct this by making a wide opening into his duodenum, through which his stomach can empty more easily. A pyloroplasty also helps a duodenal ulcer, but it should be combined with a vagotomy.
Surgery for gastrointestinal bleeding is difficult. The two common mistakes are: (1) To choose the wrong patients to operate on. (2) To operate at the wrong time[md]if you wait too long, you risk the patient's life, but if you operate too soon, the risk may be equally great, especially if you operate before you have restored his blood volume. Be much more ready to operate if he is over 45, and if he is bleeding moderately or severely.
The bleeding point may be difficult to find, and when you have found it, blood may obscure it, so that controlling it will be difficult. You will need a large opening in his stomach (gastrotomy), a good assistant, a good light, and good suction.
ANATOMY. The oesophagus continues inside the abdominal cavity for about 2 cm before it joins the stomach. One vagus nerve lies under the peritoneum in front of the oesophagus, and one behind it, not quite so close to it. Both of them lie slightly towards the right, and both usually divide into several branches at the point where the oesophagus joins the stomach. Sometimes the anterior vagus, and less often the posterior one, divide into branches before they pierce the diaphragm. So don't be content with only finding a single trunk. These nerves are more easily felt than seen.
SURGERY FOR A BLEEDING PEPTIC ULCER INDICATIONS. If a patient is in group (3) or (4) in the ''Indications for Surgery' in Section 11.3, you should be able to prepare him adequately for surgery. Blood will surely be scarce, and HIV may be a problem, but you should try to restore his haematocrit to 30% before you operate, and have 2 or 3 units of blood ready for the operation. A patient in group (2) requires so much blood that providing it will be a severe strain on your blood bank; even so, you should try.
ANAESTHETIC. Intubate him and give him a general anasthetic. Leave a nasogastric tube in place. The anaesthetist must realize that there may still be clots in his stomach. Find two assistants in addition to the trolley nurse.
WHERE IS HE BLEEDING FROM? Make a high midline incision extending up to his xiphisternum. Open his abdomen, and insert a self-retaining retractor in his abdominal wall. Insert a deep retractor under his liver, so that your assistant can retract it upwards. Gently draw the greater curve of his stomach downwards.
Suggesting peptic ulceration[md]a scarred, deformed first part of his duodenum; a puckered, thickened, hyperaemic area on his stomach, especially on the lesser curve. There may be nothing to feel if a posterior ulcer is eroding into his pancreas.
Suggesting bleeding oesophageal varices[md]a firm or hard, shrunken, irregular liver, and dilated veins on his stomach. If you find this, and there are no signs of an ulcer also, close his abdomen, and treat him as in Section 11.5. Sometimes a patient has varices and an ulcer.
IF THERE IS NO OBVIOUS BLEEDING SITE, feel every part of his stomach between your thumb and forefinger, and go right up to his gastro-oesophageal junction. Open his lesser sac by dividing his greater omentum between the lower edge of his stomach and his colon. Feel the whole posterior surface of his stomach. You may fail to find the source of the bleeding, or to control it, but unless you try, the chances of his surviving are small.
If you still cannot find the source of his bleeding, and he has been having melaena stools, check his small gut first. Blood might be coming from anywhere from his duodeno-jejunal flexure to his caecum. If you are not sure if the contents of his gut are blood or bile insert a needle obliquely and aspirate them. Look for a bleeding leiomyoma of the stomach or small intestine, or a bleeding Meckel's diverticulum. Then check his colon for ileocaecal tuberculosis, carcinoma, amoebic colitis, and intussusception, etc.
If, even after you have done this, you cannot find the source of the bleeding, and he has vomited blood, open his stomach and duodenum. There is no substitute for having a good look.
Alternatively, if you have a cystoscope, consider inserting this into his stomach through a purse string suture. You can see into the second part of his duodenum, and up into his oesophagus. You may have to wash out his stomach to get a clear view.
OPENING THE STOMACH AND DUODENUM [s7]IN GASTROINTESTINAL BLEEDING Insert moist packs to seal off his abdominal cavity. You have a choice of two incisions, depending on the degree of fibrosis of his duodenum.
If the scarring and fibrosis of his duodenum is mild or absent, make a linear incision as in A, Fig. 11-3 with 3/5 of it in his stomach, and 2/5 in his duodenum.
If the scarring and fibrosis of his duodenum is severe, make a Y-shaped incision as in E, Fig. 11-3.
Make your linear or Y-shaped incision through the serous and muscular coats of the anterior wall of his stomach, starting 4 cm proximal to his pylorus, and extending over the front of the first and second parts of his duodenum for 3 cm beyond his pylorus. If he has an ulcer, centre the linear incision on this, and make it about 1 cm above the lower border of his stomach and duodenum, as in (A).
Use tissue forceps and a scalpel to make a nick through the mucosa of the gastric end of the incision, so as to open his stomach. Enlarge the opening a little with scissors. Slowly cut through the remaining mucosa with scissors. Pick up bleeding points as you reach them, or bleeding from the incision will obscure everything. If there are too many haemostats, run a continuous layer of catgut along each side of the incision, and tie the bleeding points.
Inspect the inside of his stomach and duodenum. Mop out clots, and suck out fresh blood, trying to see where it is coming from. Evert the mucosal layer with Babcock forceps. Place a deep retractor in the upper end of the opening in his stomach and ask your assistant to expose as much of its interior as he can. If necessary, extend the incision 2 to 5 cm proximally. Is there blood trickling down from anywhere? Feel the inside of his stomach. You may see or feel: (1) An artery spurting from an ulcer on the posterior wall of the first part of his duodenum (the common site), or round the corner in its second part. (2) An ulcer anywhere in his stomach. (3) Shallow erosions, high on the lesser curve.
If he has had a haematemesis and you cannot find any abnormality: (1) Try to look at his gastro-oesophageal junction from inside his stomach. Make a high longitudinal gastrotomy up to the cardia. You may see oesophageal varices, or forceful vomiting may have produced a Mallory[nd]Weiss tear of his lower oesophagus (see below and 25.16). (2) Put the tip of the sucker, or a swab on a holder, into the second part of his duodenum, to make sure that he is not bleeding from a post-bulbar ulcer.
If you still cannot find any cause for the bleeding, close the incisions in his stomach and his abdomen. Some surgeons would do a truncal vagotomy and a gastroenterostomy, or a pyloroplasty.
If you find an acute ulcer, a solitary erosion, or multiple small bleeding erosions, do a truncal vagotomy and gastroenterostomy, or a pyloroplasty. Postoperatively, warn him not to take drugs containing aspirin.
A CHRONIC BLEEDING ULCER [s7]AT LAPAROTOMY Control bleeding from a chronic duodenal ulcer by underrunning it. Retract the edges of the V-shaped pyloroplasty incision. Using chromic catgut in the stomach and silk in the duodenum on a curved needle, pass 2 or 3 stitches deep to the ulcer, as in B, Fig. 11-3. Tie the sutures so that you stop the bleeding. Ask your assistant to keep the area dry, and be sure to go deep enough to include the walls and base of the ulcer, but not so deep that you catch important structures, such as the common bile duct. Tie the sutures tight, but not so tight that they cut out.
If you don't feel happy about doing a vagotomy, do a pyloroplasty, and refer him for a definitive vagotomy later.
Fig. 11-3 PYLOROPLASTY (Heinicke[nd]Miculicz). A, the incision when there is only moderate fibrosis. The incision into the stomach is slightly longer than that into the duodenum. B, the incision held open with stay sutures, held in haemostats, while a bleeding ulcer is being undersewn. C, the stay sutures have been pulled, so as to elongate the incision transversely. It is being closed with close sutures of 2/0 chromic catgut through all coats. D, the completed pyloroplasty. E, if there is severe pyloric stenosis, which makes suturing in the transverse direction impossible, make a Y-shaped incision. F, the flap of the incision (''p') is going to be sutured into the duodenum (''q') so as to make a ''V'. G, suturing has begun. H, the finished pyloroplasty.
PYLOROPLASTY [s7](Heinicke[nd]Miculicz) INDICATIONS. (1) A bleeding duodenal ulcer. (2) For other complications of a duodenal ulcer, see 11.2.
METHOD. First make sure bleeding is controlled as described above. The kind of pyloroplasty you should make will depend on the kind of incision you made, which in turn depended on the severity of the fibrosis you found.
If you made a linear incision, because there was only mild fibrosis, hold it open with stay sutures. Pull on these so as to elongate it transversely, and close it with close 2/0 chromic catgut sutures through the mucosa and serosa.
If you made a Y-shaped incision, because there was much fibrosis, either: (1) Close it as you found it, and do a gastroenterostomy. Or, (2) sew it up as a ''V', as in G, and H, Fig. 11-3.
Finally, with both incisions, bring up a tag of omentum and fix this across the suture line with a few sutures which pick up only the seromuscular layer (C, 11-2).
VAGOTOMY [s7]FOR PEPTIC ULCERATION Postpone this if his condition does not permit it[md]you have already done the life saving part of the operation. You must get adequate access. This may be difficult if he is fat, or has a deep chest, or if the left lobe of his liver is large.
Extend the abdominal incision right up into the notch between his costal margin and his xiphisternum. Ask your assistant to lift up his left costal margin with a deep gauze- covered retractor. With your right hand draw his stomach and colon downwards,, and keep them packed down with 2 or 3 large moist abdominal packs. Feel for the short abdominal part of his oesophagus, and for the nasogastric tube running through it. Or slide your hand upwards over the fundus and body of his stomach, until you reach his diaphragm, and then feel for his oesophagus.
You have now to free the left lobe of his liver from his diaphragm. Grasp its free edge between the index and middle finger of your pronated left hand, and pull it downwards and medially. This will reveal his left triangular ligament attaching this part of his liver to his diaphragm. Under good vision and with a long pair of scissors cut about 4 to 6 cm of this bloodless attachment from left to right, making sure that you do not go too far medially (B, in Fig. 11-4), because his inferior vena cava is there. Then reflect the left lobe of his liver medially and to the right, and hold it there with a deep (Deaver's) retractor over a large pack (C).
Pick up the peritoneum over his oesophagus with a long (25 cm) haemostat, and use scissors, or a long-handled scalpel with a small blade, to make a very superficial 2 cm transverse or longitudinal incision in it, just above its junction with his stomach.
CAUTION ! (1) Cut his peritoneum only. This is a thin layer. Don't cut the muscle of his oesophagus. (2) Don't cut any of the branches of his left gastric vein, on the right margin of his stomach.
Using gauze on a sponge holder (D), gently push away the peritoneum from the site of the incision, so exposing the front of his oesophagus (E). Dissecting with your right index, and repeatedly spreading your index and middle finger to open up tissue planes, free his oesophagus from the areolar tissue holding it to the right crus of his diaphragm and his aorta. If you dissect like this there is little chance of your tearing blood vessels, or damaging his oesophagus. But, don't ''finger dissect' too close to his oesophagus posteriorly, or you will push his posterior vagus nerve away from it, so that finding it will be difficult. Stay close to the crus, especially as you dissect towards the right side of his oesophagus. On the right your finger may be arrested by peritoneal folds and small vessels. Persist with blunt dissection, and resist the urge to cut anything, until you have gone all round his oesophagus with your finger.
Gently draw his oesophagus downwards until you can feel 4[nd]5 cm of it. Pass a long curved clamp, such as a Lahey, behind his mobilized oesophagus, and use it to draw a soft catheter, or nasogastric tube, through and around it, so that you can pull on it (F). This will help to expose the site better, and will hold the vagus taut, so you can feel it.
Feel for his anterior vagus nerve. You may see it as a fine white strand running down in front of the central part of his oesophagus, but it is usually easier to feel (G). Run your right index finger across his oesophagus[md]feel for a taut thread or fine cord, quite different from anything else. Follow it up to where it emerges from under the crus of his diaphragm. Place a long O'Shaughnessy or Lahey haemostat on the nerve and draw it down slightly, to make sure that it does not have any branches. Apply another long clamp just distal to the first, and cut the vagus between them. Draw the second clamp and the vagus downwards, and cut off a 1 cm segment of the nerve (H and I). Search the anterior aspect of his oesophagus for other branches of his vagus[md]incomplete vagotomy is the commonest reason why the operation fails.
Look for his posterior vagus nerve[md]it is harder to find, but is larger. If your dissection has been adequate, you should find it. Pass a finger of your right hand round the back of his oesophagus, and feel for the thick cord of his posterior vagus, just behind the right edge of his oesophagus. Try lifting it forwards over the tip of your finger (J); then clean away any obscuring strands of tissue with a pledget of gauze on the end of a sponge forceps. You should be able to expose a short section of it without rupturing any of the small veins. Remove a piece of his posterior vagus as you did his anterior one (K), and look for accessory branches. Control minor bleeding by packing his subphrenic area with warm moist packs for a few minutes. Control more active bleeding by ligation.
CAUTION ! Feel for these nerves, pull them up on a finger, see them, and then cut them.
Remove the sling round his oesophagus. Close his abdomen, preferably in a single layer by Everett's or Goligher's methods (9.8). Don't insert a drain, unless you are worried about the safety of the anastomosis of his pyloroplasty. He has bled severely, and his wound is likely to heal poorly. If it breaks down, he will be in danger.
''Suck and drip him', and replace his gastric aspirate, as usual (9.9, A 15.5). If his postoperative haematocrit is less than 35%, transfuse him.
Fig. 11-4 VAGOTOMY. A, make a high midline or left paramedian incision. B, free the attachment of the left lobe of the patient's liver from his diaphragm. C, incise the peritoneum[md][f10]only[f11][md]over the anterior of his oesophagus. D, gently push the peritoneum away from the incision. E, open up the tissue planes with your index and middle finger. F, draw a catheter round his oesophagus. G, pull his oesophagus down and feel for his anterior vagus. H, and I, cut out a length of vagus. J, feel for his posterior vagus. K, cut his posterior vagus. L, the anatomy of the vagus nerves.
DIFFICULTIES [s7]WITH GASTROINTESTINAL BLEEDING Expect respiratory complications (9.11), and wound breakdown (9.13).
If the BLEEDING POINT IN HIS DUODENUM IS OBSCURED BY BLOOD, apply warm packs and pressure, and wait 10 minutes.
If BLEEDING RESTARTS after the operation, manage him non-operatively, or refer him; don't try to explore him again.
If you find what looks like a MALIGNANT GASTRIC ULCER, adapt what you do to the size of the lesion:
If the lesion is small, do a local excision with a 2 cm margin, and repair the defect in two layers.
If the lesion is advanced, take a biopsy, and if it has metastasized to lymph nodes or his liver, refer him for more radical surgery later if you can.
If he BLED AFTER A SEVERE INJURY, or a burn, a head injury, or a major surgical operation, or he is an alcoholic or takes drugs, such as aspirin, indomethacin, or phenylbutazone, suspect STRESS ULCERS (superficial erosions in the stomach or typically in the second or third parts of the duodenum). These are usually multiple, shallow, and irregular. He will have had little pain, and severe bleeding is likely to have been the first sign. Minor harmless gastric bleeding is common after an alcoholic bout. Ulceration of this kind may ooze severely, so that he has melaena stools for several days. Give him antacids half-hourly, and try a noradrenalin in saline lavage (11.3) and, if possible, intravenous cimetidine. Don't operate if you can avoid doing so. If you have to operate, do a vagotomy and gastroenterostomy. His chances of dying are high, whatever you do.
If you are giving him cimetidine intravenously, give him 100[nd]200 mg/hour for 2 hours repeated after an interval of 4[nd]6 hours. Or, 400 mg in 100 ml of 0.9% sodium chloride infused over half to one hour, repeated after 4[nd]6 hours. Or, by continuous infusion at an average rate of 50[nd]100 mg/hour over 24 hours, maximum 2.4 g daily.
If he started to BLEED AFTER A SEVERE EPISODE OF VOMITING from some other cause, such as a drinking bout, suspect that he has a tear in his oesophagus at, or just above, his gastro-oesophageal junction (the Mallory[nd]Weiss syndrome). See Section 25.16.
If you ENTER HIS OESOPHAGUS DURING A VAGOTOMY (which should never happen!), repair the tear as in Section 25.16 and Fig 25-12.