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Previous Volume 340:751-756 March 11, 1999 Number 10 Next

	Full Text PDF Editorial by Jensen, D. M. Letters Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited PubMed Citation

ABSTRACT

Background and Methods After endoscopic treatment to control bleeding of peptic ulcers, bleeding recurs in 15 to 20 percent of patients. In a prospective, randomized study, we compared endoscopic retreatment with surgery after initial endoscopy. Over a 40-month period, 1169 of 3473 adults who were admitted to our hospital with bleeding peptic ulcers underwent endoscopy to reestablish hemostasis. Of 100 patients with recurrent bleeding, 7 patients with cancer and 1 patient with cardiac arrest were excluded from the study; 48 patients were randomly assigned to undergo immediate endoscopic retreatment and 44 were assigned to undergo surgery. The type of operation used was left to the surgeon. Bleeding was considered to have recurred in the event of any one of the following: vomiting of fresh blood, hypotension and melena, or a requirement for more than four units of blood in the 72-hour period after endoscopic treatment.

Results Of the 48 patients who were assigned to endoscopic retreatment, 35 had long-term control of bleeding. Thirteen underwent salvage surgery, 11 because retreatment failed and 2 because of perforations resulting from thermocoagulation. Five patients in the endoscopy group died within 30 days, as compared with eight patients in the surgery group (P=0.37). Seven patients in the endoscopy group (including 6 who underwent salvage surgery) had complications, as compared with 16 in the surgery group (P=0.03). The duration of hospitalization, the need for hospitalization in the intensive care unit and the resultant duration of that stay, and the number of blood transfusions were similar in the two groups. In multivariate analysis, hypotension at randomization (P=0.01) and an ulcer size of at least 2 cm (P=0.03) were independent factors predictive of the failure of endoscopic retreatment.

Conclusions In patients with peptic ulcers and recurrent bleeding after initial endoscopic control of bleeding, endoscopic retreatment reduces the need for surgery without increasing the risk of death and is associated with fewer complications than surgery.

Source Information

From the Departments of Surgery (J.Y.W.L., Y.L., A.C.W.C., E.K.W.N., D.W.H.L., R.C.Y.S., S.C.S.C.) and Medicine and Therapeutics (J.J.Y.S., F.K.L.C.), Prince of Wales Hospital and Chinese University of Hong Kong, Shatin, Hong Kong, China.

Address reprint requests to Dr. Chung at the Department of Surgery, Prince of Wales Hospital, Shatin, Hong Kong, China, or at sydneychung{at}cuhk.edu.hk.

Full Text of this Article

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Endoscopic Retreatment or Surgery for Severe Ulcer Rebleeding
Schein M., Lau J. Y.W., Sung J. J.Y., Chung S.C. S.
Extract | Full Text  
N Engl J Med 1999; 341:455-456, Aug 5, 1999. Correspondence

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