Packing: current concepts of "life-saving" surgery

Although endoscopic injection therapy is an effective method for bleeding peptic ulcers, it is associated with significant re-bleeding rate; whether the addition of thermal method improves the outcome is still unclear. Our previous experience showed that Argon Plasma Coagulation (APC) alone is not sufficient in stopping spurting haemorrhage, and potentially dangerous for large non bleeding visible vessels (NBVV). Our hypothesis was that combination of adrenaline injection (AI) and thermal therapy could be more efficient than thermal therapy alone for permanent haemostasis of active bleeding peptic ulcers, and particularly appropriate for NBVV treatment. From October 1998 to February 2000 we examined two hundred patients with upper gastrointestinal bleeding. Fifty-three patients with major peptic ulcer haemorrhages received combined injection therapy with adrenaline 1:10.000 and Argon plasma coagulation; there were 34 male and 19 female with a mean age of 63.2 +/- 1.2 years (range 22-93). The bleeding site was duodenal in 30 patients, gastric in 17 patients, anastomotic in 5 patients and esophageal in 1 patient. Endoscopic findings were the following: active bleeding in 23 patients (6 spurting, 17 oozing), non bleeding visible vessels in 12 patients and fresh adherent clots in 18 patients. Initial haemostasis was achieved in 52/53 patients (98.1%). Re-bleeding was observed in 5/52 cases (9.6%). Surgery was necessary in 3/53 patients (5.6%). Mortality was 7.5% (4 cases). No major complications resulted from this treatment. Primary adrenaline injection provided initial bleeding arrest, facilitating the following application of APC, because of a more precise definition of the active bleeding site. Rates of initial hemostasis were significantly higher with combined therapy (injection + APC) compared to APC treatment alone. We believe that Adrenaline and APC combined therapy is an effective and safe method for treatment of non-variceal gastrointestinal bleeding.