Stress ulceration requiring definitive surgery after severe trauma

Despite antiulcer prophylaxis 19 severely injured patients at our instituti on developed stress ulceration (SU) between 1989 and 1999 requiring surgery for perforation (n=4) or bleeding (n=15). A herald bleed (HB) 10.7 +/-1.2 days after admission, 7.2 +/-1.2 days before definitive operative therapy, and requiring 7.1 +/-0.9 units of blood occurred in 93 per cent of patients operated on for bleeding. Bleeding preceded perforation in one patient. Ce ntral nervous system damage was part of the injury pattern in 68 per cent o f the patients including spinal cord (42%), severe head injury (16%), or bo th (10%). Forty-two per cent had acalculous cholecystitis found at surgery. Eight patients had vagotomy and antrectomy (VA), and 11 patients had vagot omy and pyloroplasty NO. VA required more time than VP (255 +/- 41 vs 158 /- 13 minutes; P=0.02). One patient (12.5%) rebled after VA versus two (18% ) after VP; one patient in each group required reoperation. There was no di fference in mortality, length of stay, or intensive care unit stay. A heral d bleed preceded recurrent hemorrhage of SU by one week. Spinal cord or hea d injury increase the risk of SU. More than 40 per cent of patients with SU had acalculous cholecystitis found at operation. VA provides no benefit on rebleeding or reoperation over VP, so anatomical considerations and not re bleed rates should determine the surgical procedure.