Laparoscopic Treatment of Bleeding Duodenal Ulcer

Kamran Samakar, MD, Jose Tschen, MD, J Andres Astudillo, MD, Jason Wallen, MD, Carlos Garberoglio, MD. Loma Linda University Medical Center

 

Introduction: A 72 year old male presented to our tertiary care facility with a one day history of hematemesis and coffee-ground stools.  The patient underwent initial resuscitation efforts, blood transfusion, and upper endoscopy. Endoscopy revealed a large posterior ulceration in the duodenal bulb with signs of slow bleeding and difficult visualization secondary to a large amount of blood clot burden. Attempts at endoscopic intervention were ultimately aborted due to limited visibility and procedure related respiratory decompensation. Subsequently the patient was taken to the operating room for surgical intervention.

Objective: Presentation of a rare case along with a description of the procedure and accompanying images. A discussion of the role for laparoscopic surgery in the management of complications from peptic ulcer disease.

Results: The decision to attempt laparoscopic treatment of this patients bleeding duodenal ulcer was based largely on his clinical presentation. His initial hemoglobin upon admission was 7.9 (gm/dl) and improved to 9.6 (gm/dl) after two units of packed red blood cells. While he continued to demonstrate signs of slow bleeding requiring blood products, the patient remained remarkably stable from a hemodynamic standpoint. Initial laparoscopic intervention was undertaken with the understanding that conversion to open repair would require haste if necessary. The patient underwent laparoscopic pylorplasty, oversewing of the gastroduodenal and transverse pancreatic arteries, truncal vagotomy, and placement of a feeding jejunostomy tube. The patient tolerated the procedure well and after a short stay in the ICU was ultimately transferred to the ward and subsequently discharged from the hospital.

Discussion: Treatment of bleeding duodenal ulcers, including the management of hemorrhage and perforation, pyloroplasty, and vagotomy may be feasibly accomplished with the use of minimally invasive techniques. While case series and descriptions of minimally invasive techniques can be found in the literature, laparoscopic approach is usually not performed for acute hemorrhage due to difficulties with visualization and control of bleeding. In select, hemodynamically stable patients, the role of laparoscopic surgery in the treatment of complications from peptic ulcer disease has been advocated as both safe and effective. We report here a description of a laparoscopically treated bleeding peptic ulcer with accompanying intraoperative images and a discussion of the current literature on the use of minimally invasive techniques in this setting.


Session Number: Poster – Poster Presentations
Program Number: P189
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