GI Bleeding Surgery
GI Bleeding is an emergency. Patients present with massive vomiting of blood or hematemsis. Some of the most common causes of GI bleed are cirrhosis of liver and ulcer disease. Bleeding stops on its own in 90% of the patients. The rest will either require endoscopic treatment or sometimes surgery to effectively stop the bleeding. GI bleeding can be life threatening if not treated on time. It is predominantly characterized by hemorrhage in the GI tract starting from the pharynx down to the rectum.
GI bleed can be broadly classified as upper GI and lower GI bleed. Upper GI bleed originates from the pharynx and ligament of Treitz. Lower GI bleed originates from the colon, rectum or anus.
Where the causes are confirmed as peptic ulcer, gastric erosions due to alcohol and NSAIDs, gastric varices, Mallory-Weiss tear, angiodysplasia and gastric cancer the following surgeries are recommended:
Under-running the ulcer : Peptic ulcers usually stop bleeding spontaneously. But when non-operative methods fail, surgery becomes the only option for a life-threatening situation. The simplest way to stop an ulcer from bleeding is to by underrunning it. The surgery is done under general anesthesia. The laparoscopic procedure involves making a 11mm port just under the xiphisternum. 2 to 3 stitches are passed deep into the ulcer and the sutures are tied tight to stop the bleeding. A major part of the procedure involves just looking for the peptic ulcer which is an extremely tedious and meticulous process.
Pyloroplasty : A pyloroplasty is done to open the lower part of the stomach, a thick, muscular area called the pylorus. Under general anesthesia, a laparoscopic surgery requires three small incisions in the area that connect the stomach and the duodenum. Some of the thickened muscle of the pylorus is divided laterally and cut through to widen it making the connection larger. There are at least three types of pyloroplasty:
- Jaboulay pyloroplasty Without pylorus incision – side to side gastroduodenostomy
- Heineke Mikulicz pyloroplasty longitudinal incision transversely across the pylorus – common procedure
- Finney pyloroplasty With pylorus incision – side to side gastroduodenostomy
Partial gastrectomy : This procedure involves removal of part of the stomach. The procedures are performed under general anesthesia. A midline incision from the xiphoid process to the umbilicus and self-retaining subcostal retractors the upper abdomen is explored for metastasis. The part of the stomach is resected and gastroduodenal anastomosis is achieved after duodenal and omental mobilizations.
Total gastrectomy : This procedure aims at cutting into the abdomen to resect all of the stomach. A midline incision or a bilateral subcostal incision inferior to the umbilicus is made exposing the stomach and distal esophagus. Self-retaining retractors provide a wider exposure. The stomach is retracted and the esophagus is directly connected to the small intestine.
Vagotomy : The vagus nerve which is also called the pneumogastric nerve is resected. There are many types of vagotomy such as:
- Truncal vagotomy First the pylorus is drained and then divides the main trunk of the vagus.
- Selective vagotomy In this procedure too, the pylorus is first drained and then the anterior and posterior nerves of Latarjet are divided.
- Highly selective vagotomy This is also called proximal gastric vagotomy and involves denervation of the fundus and body of the stomach.
Endoscopic variceal ligation (EVL) : For patients who present with bleeding from esophageal varices (swollen veins in the food pipe), endoscopic variceal ligation is the treatment of choice and surgery is usually done as a last resort if all other measures fail. The procedure is done endoscopically where an enlarged vein or varix in the esophagus ligated with a rubber band. In view of the poor liver condition these patients are not good candidates for surgery.
Non-cirrhotics are the ones with portal vein thrombosis or non-cirrhotic portal fibrosis also form a large component of GI bleeding. These patients do very well after surgery because of their preserved liver condition.
Splenorenal shunt and splenectomy with devascularisation : Some patients presenting with intermittent vomiting of blood or passing melena will require surgical treatment as a permanent cure for bleeding. Surgery is either in the form of a spleno-renal shunt in non-cirrhotic patients or splenectomy with devascularisation in cirrhotic patients.
- Splenorenal shunt : In a splenorenal shunt procedure, the vein from the spleen is detached from the portal vein and attached to the renal vein, thereby reducing the varices.
- Splenectomy and devascularization : New procedures for splenectomy and devascularization require that a splenectomy is done first. The distal esophagus is then devascularized through the diaphragm hiatus.
Doctor here is one of the best bariatric surgeons in Chennai. His special area of interest is surgery for Gastro-intestinal bleeding in which he has immense experience. Dr.Radhakrishna has presented his experience in the area of surgery for portal hypertension in many national and international conferences including the Asia-Pacific Hepato-biliary conference in Bangkok and Digestive Diseases Week at New Orleans, USA in 2010.