Endoscopic retreatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of bleeding ulcers

Background and Methods After endoscopic treatment to control bleeding of pe ptic ulcers, bleeding recurs in 15 to 20 percent of patients. In a prospect ive, randomized study, we compared endoscopic retreatment with surgery afte r initial endoscopy. Over a 40-month period, 1169 of 3473 adults who were a dmitted 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 retrea tment and 44 were assigned to undergo surgery. The type of operation used w as left to the surgeon. Bleeding was considered to have recurred in the eve nt of any one of the following: vomiting of fresh blood, hypotension and me lena, or a requirement for more than four units of blood in the 72-hour per iod 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 b ecause retreatment failed and 2 because of perforations resulting from ther mocoagulation. Five patients in the endoscopy group died within 30 days, as compared with eight patients in the surgery group (P = 0.37). Seven patien ts in the endoscopy group (including 6 who underwent salvage surgery) had c omplications, as compared with 16 in the surgery group (P = 0.03). The dura tion of hospitalization, the need for hospitalization in the intensive care unit and the resultant duration of that stay, and the number of blood tran sfusions were similar in the two groups. In multivariate analysis, hypotens ion at randomization (P = 0.01) and an ulcer size of at least 2 cm (P = 0.0 3) were independent factors predictive of the failure of endoscopic retreat ment. Conclusions In patients with peptic ulcers and recurrent bleeding after ini tial endoscopic control of bleeding, endoscopic retreatment reduces the nee d for surgery without increasing the risk of death and is associated with f ewer complications than surgery. (N Engl J Med 1999;340:751-6.) (C)1999, Ma ssachusetts Medical Society.