Bleeding peptic ulcer: An evolving role for surgical intervention

Early surgical intervention was previously advocated in patients > 60 years with bleeding peptic ulcer presenting with haemodynamic instability or ong oing transfusion requirements. It is, however, well recognized that emergen cy surgical intervention with its inherent risks must be reserved for highl y selected patients in whom endoscopy initially fails to control exsanquina ting haemorrhage or in whom life-threatening bleeding recurs. Therapeutic e ndoscopy for bleeding ulcer has led to a remarkable decline in rebleeding r ates, the need for emergency surgery and mortality. Octogenarians are at ri sk, particularly when ulcer size exceeds 2 cm. Poor surgical candidates mak e up two-thirds of patients with major ulcer bleeding and operation is to b e avoided if at all possible. Medical therapy with proton pump inhibitor an d subsequent eradication of Helicobacter pylori following endoscopic treatm ent has been shown to be beneficial to outcomes. Should surgery be deemed n ecessary, it is likely that laparoscopic techniques to control bleeding, wi th or without the addition of an acid-reducing procedure, will find a role in haemodynamically stable patients undergoing operation on an early electi ve basis.