0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Article |

Transgastric Surgery for Posterior Juxtacardial Ulcers:  A Minimal and Safe Approach FREE

Ricardo A. M. Camprodon, MSC, FRCS; Reyad Al-Ghnaniem, FRCS; Ricard Camprodon, MD, PhD
[+] Author Affiliations

From the Department of Surgery, King's College Hospital, London, England (Drs R. A. M. Camprodon and Al-Ghnaniem), and L'Esperanca Hospital, Barcelona, Spain (Dr R. Camprodon).


Arch Surg. 2003;138(7):757-761. doi:10.1001/archsurg.138.7.757.
Text Size: A A A
Published online

Hypothesis  A transgastric approach may be used succesfully for the treatment of posterior juxtacardial ulcers presenting with massive bleeding.

Methods  Eight patients were admitted during a 6-year period with acute massive upper gastrointestinal bleeding caused by posterior juxtacardial ulcers. All patients had signs of profound hypovolemic shock, and initial endoscopic control was achieved in 3 patients. They all underwent surgery after endoscopy. At operation, the ulcer was approached through an anteromedial gastrostomy and hemostasis was achieved by transfixing stitches. Ulcers were excised whenever possible, or excluded if adherent posteriorly. Four-quadrant biopsy was taken for frozen section to exclude malignancy. Both anterior and posterior gastric walls were then closed with nonabsorbable suture material.

Results  There were 6 men and 2 women with a mean age of 73 years. Hemoglobin levels ranged from 5.2 to 8.0 g/dL. Five patients underwent emergency surgery within 28 hours of admission. The diameter of the ulcers ranged from 2 to 5 cm. Ulcerectomy was performed in 6 cases. In the remaining 2 patients, the crater of the ulcer was adherent to the diaphragm and required exclusion from the gastrointestinal tract. None of the ulcers proved to be malignant, and there were no operative deaths. Patients were followed up for a mean of 3 years with no complications.

Conclusions  Satisfactory results can be achieved with a transgastric approach to these rare ulcers. This allows definitive treatment while avoiding major gastric resection with its potential complications.

Figures in this Article

JUXTACARDIAL ULCERS are defined as those located less than 2 cm from the esophagogastric junction or squamous-columnar mucosal junction, as a sub group of high gastric, subcar dial, or type IV gastric ulcers.1 Few studies report the incidence of these ulcers, which ranges from 0.5% to 3.56%.13

Despite a marked decrease in incidence of peptic ulcer disease and an improvement of both diagnostic methods and management, the overall mortality from acute massive hemorrhage from gastric ulcers has remained fairly constant, ranging from 15.2% to 22%.4,5 This may be partly explained by the increasing age at presentation. Factors that predict further hemorrhage and mortality are old age,6,7 endoscopic stigmas of recent hemorrhage,8 presence of clinical shock on admission,9,10 and rebleeding.7 Important endoscopic signs (ie, active, spurting hemorrhage from a peptic ulcer, visible vessel, fresh clot in ulcer base) are associated with an 80% risk of persistent or recurrent bleeding in patients with shock.9,11 The mortality in this group is about 30%.12

The treatment of patients with juxtacardial ulcers remains controversial with regard to whether surgery is indicated despite endoscopic control of active bleeding and what is the best surgical option, should endoscopic control fail. The timing of surgical intervention is also controversial. In this report, we present our surgical experience and a literature review in this type of gastric ulcer presenting with massive hemorrhage.

PATIENTS

Eight patients were admitted during a 6-year period with acute massive upper gastrointestinal hemorrhage caused by a large (2.0-3.9 cm) or a giant (>4.0 cm) posterior juxtacardial ulcer. Six of them were men and 2 were women (ratio, 3:1), and their ages ranged from 62 to 85 years (mean, 73.12 years).

Two patients had long-standing symptoms of peptic ulcer disease, and 1 patient had been taking nonsteroidal anti-inflammatory drugs with a 1-month history of epigastric pain and vomiting before the episode. Coincidental pathological findings of note were present in only 1 patient (Table 1).

All patients presented with hematemesis, melena, and signs of hypovolemic shock: they were clammy, hypotensive (systolic blood pressure, <100 mm Hg), and tachycardic (pulse, >100 beats/min). Hemoglobin levels ranged from 5.2 to 8.0 g/dL on admission, with mean transfusion requirements of 7 U (range, 4-11 U).

Initial treatment of all patients included cardiovascular optimization with circulatory volume reposition. Once stabilized, all patients underwent emergency endoscopy. A bleeding point was identified in 5 cases and was injected with 1-mL aliquots of 1:10 000 epinephrine by means of an endoscopic flexible needle injector up to a total of 10 mL or until the bleeding stopped.

Unequivocal persistent or recurrent bleeding was defined when hematemesis and/or melena continued and the patient was clinically in shock (ie, systolic blood pressure <100 mm Hg) despite fluid resuscitation, which warranted an emergency operation.

TECHNIQUE

In all patients, the ulcer was visualized through an anteromedial longitudinal gastrostomy, which gave an excellent exposure. This was placed equidistant from both the lesser and greater curvatures across the upper third of the body of the stomach, avoiding the important vascular structures that run along both curvatures.

The surgery was performed in 3 phases. In the hemostatic phase, the bleeding was controlled by placing transfixing nonabsorbable stitches at the bleeding site. In the exploratory phase, a window was achieved in the loose upper part of the lesser omentum that gave quick access as well as direct assessment of the ulcer posteriorly. If a further window was required, this was established through the gastrocolic ligament to gain access to the lesser sac and the ulcer from below and behind. This allowed evaluation of whether the ulcer could be excised. In the therapeutic phase, if the ulcer bed was adherent posteriorly, mobilization by blunt digital dissection was attempted to allow excision of the ulcer (Figure 1). If mobilization failed, the ulcer was excluded (Figure 2A). The ulcer with its chronic, indurated, whitish, inflammatory, and relatively avascular halo was carefully dissected to make suturing easier and safer regardless of whether the ulcer was excised or excluded.

Place holder to copy figure label and caption
Figure 1.

Ulcerectomy specimen showing a large (2.5-cm) ulcer with its inflammatory halo.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

A, Close-up of the posterior gastric wall with a giant (4 × 5-cm) juxtacardial ulcer in situ. A transfixing stitch placed on the bleeding point for hemostasis can be seen. These features have been exposed through an anterior gastrostomy. B, After hemostasis has been achieved and ulcer bed excluded, interrupted nonabsorbable stitches have been placed for posterior gastric wall closure. Note the nylon tape hooking around the cardia. C, Everted edges of anterior gastric wall allow visualization of closed posterior gastrostomy. Nylon hooking tape is again visible. D, Anterior gastrostomy is closed.

Graphic Jump Location

When firmly attached posteriorly (in 2 cases), the ulcer bed was left in situ and the gastric mucosa was diathermized and left behind. In these cases, a 4-quadrant biopsy specimen of the ulcer bed was taken for frozen-section examination to exclude malignancy. Both anterior and posterior gastric walls were closed with interrupted 1-layer nonabsorbable suture material (Figure 2B-D).

Postoperative management consisted of restricting oral intake, treatment with intravenous ranitidine, and nasogastric intubation with continuous low suction usually during the first 3 or 4 days or until normal peristalsis was regained.

Endoscopic examination confirmed the gastric origin of the hemorrhage in all cases, although the bleeding vessel was accurately visualized in only 5 patients. Three patients had massive bleeding at the time of the procedure, making adequate visualization impossible despite vigorous washouts and suction.

Endoscopic control with epinephrine was obtained in only 3 cases. However, despite absence of clinical signs of rebleeding, these patients underwent semielective surgery within 72 hours of admission. The remaining 5 patients required emergency laparotomy between 80 minutes and 28 hours after admission. At laparotomy, hemostasis was obtained in all the emergency cases by transfixing sutures after transgastric exposure through an anteromedial longitudinal gastrostomy. In 2 patients, surgery and resuscitation were performed simultaneously because of persistent shock.

The diameter of the ulcers ranged from 2 to 5 cm. Ulcerectomy (excision of the ulcer) was performed in 6 cases. In 2 patients the ulcer was firmly attached to the diaphragm, making its resection difficult and dangerous. In such cases the exclusion technique was performed, leaving the whole ulcer in situ after applying transfixing stitches and electrocoagulation of the remaining gastric mucosa.

Postoperative complications occurred in 5 patients (Table 2), and there was no perioperative mortality. One patient, a 68-year-old man with end-stage renal failure who was receiving peritoneal dialysis, died 2 months after surgery of small-bowel infarction secondary to mesenteric thrombosis. Another patient presented 5 years after surgery with postprandial dyspepsia, and a barium meal examination showed slow gastric emptying.

Table Graphic Jump LocationTable 2. Surgical Characteristics and Course

The mean hospital stay was 15 days (range, 8-33 days). Patients were followed up with an endoscopic assessment performed 12 months after surgery. The mean follow-up was 36 months (range, 13-72 months), and data were obtained by either outpatient appointments or telephone.

Posterior juxtacardial ulcers are rare within peptic ulcer disease. They demonstrate unique clinical and pathological features that can be attributed to their anatomic location. They are frequently large or giant,13 chronic, deep,14 almost invariably benign, and relatively symptomless.15 They are typically associated with very low levels of acid gastric secretion1,16 and a slow rate of gastric emptying1,17 compared with other types of peptic ulceration.

In our experience, this type of gastric ulcer is mainly encountered in older patients and tends to have a very large crater when it presents with bleeding. Many of these chronic ulcers become complicated by an acute episode of bleeding, which in most instances is profuse or massive. The reason may be the rich blood supply to this part of the posterior gastric wall, which may be increased by the presence of the posterior gastric artery in more than 45% of patients in most series.18 Moreover, the position of the ulcer does influence the risk of rebleeding in up to 77.2% of high gastric ulcers.19

Endoscopic therapy is the method of choice in treating active bleeding ulcers, which is successful in most cases. This is an effective and safe way of reducing the need for an emergency operation.20,21 Therefore, endoscopy is justifiable as the initial treatment of these patients.

Patients bleeding from juxtacardial ulcers constitute a high risk, since they are commonly elderly and present to the hospital with severe hemorrhagic shock. This is compounded by the technical difficulties that they present to both endoscopists and surgeons.

Up to one third of bleeding ulcers are unsuitable for endoscopic therapy, either because of their inaccessibility or because of profuse uncontrollable bleeding.5 The rate of rebleeding within 72 hours of initial treatment in patients with shock who are older than 60 years has been reported to be between 43% and 57%.12,22,23 Evidence of further hemorrhage in such patients carries a 6-fold7 to 12-fold24 increase in mortality. On the other hand, there is a strong temptation to delay the decision to operate in patients who, because of age, chronic comorbidity, or severity of clinical state, are poor surgical risks. However, most of these factors do not diminish when surgery is delayed.

Advocates of early surgery report an operative mortality of 14% within 24 hours after admission to 33% on day 4 and 52% on day 7,25 or a 60% mortality rate when surgery is delayed.26 Others have suggested that an aggressive surgical policy in bleeding peptic ulcer could, if anything, increase the overall mortality.27,28 We, like others, agree with the need for prompt surgical intervention particularly in the elderly with bleeding chronic gastric ulcers (ie, within 24 hours after admission).9,26 Moreover, a good outcome can be achieved with early operative management.

Failure of endoscopic control in these patients makes surgery mandatory; however, the best surgical option still remains controversial. Not all gastric ulcers are managed alike; however, the aim of surgery should be not only to control the active hemorrhage, but also to ensure that a new episode does not occur.

Several authors have made a case for early elective surgery, since it carries a lower operative mortality as well as decreased morbidity and mortality rates from secondary hemorrhage compared with an emergency procedure. However, in our experience, these patients almost always represent true surgical emergencies.

Some have suggested limiting the surgical procedure to that necessary to achieve hemostasis (ie, oversewing of the ulcer), avoiding major resectional surgery.5 In our opinion, this approach is conceptually wrong, since it is well known that these chronic gastric ulcers have the tendency to inhabit one particular site and, whenever possible, excision of the ulcer is important in preventing its recurrence as well as its complications.29

Vagotomy, even selective, is not suitable for high gastric ulcers, since these are consistently associated with hypochlorhydria and because it may cause persistent gastric atony even when pyloroplasty is added.30 Others have reported very good or good results when using vagotomy and ulcerectomy with29 or without31 pyloroplasty; however, the latter showed an ulcer recurrence rate of 20% at 8 years for type IV gastric ulcers. Even less justifiable is to leave the ulcer in situ and resect variable amounts of stomach below it, known as the Kelling-Madlener operation.32 Some advocate major resectional surgery such as distal partial gastrectomy with Roux-en-Y esophagogastrojejunostomy,33 any variant of subtotal gastrectomy,1,32 or even total gastrectomy. Another group has reported good results with a pyloric sphincter preservation technique that preserves the blood supply to the gastric stump and pylorus with resection of the posterior gastric wall together with the ulcer, creating a gastric tube with the anterior gastric wall.34 In our opinion, none of these surgical modalities is necessary or justifiable.

Few reports have suggested a transgastric approach, either as an adjunct to more radical procedures or as part of the exploratory phase before definitive and more extensive surgery.29,35 We advocate such an approach for both hemostasis and definitive surgical treatment, which, whenever possible, will consist of ulcerectomy. If difficulties arise because of firm attachment to the posterior abdominal wall, the best choice is ulcer exclusion. Either of these will avoid ulcer rebleeding as well as minimize both operative time and the risks of a more extensive and unnecessary surgery.

In this article, we describe much less aggressive surgical procedures for equally difficult ulcers in similarly complex cases, in which the "ulcer is everything." Our results suggest that the key to successful treatment of patients with this type of ulcer, which will never regress but persevere, is to perform early surgery whether or not endoscopic control of the active hemorrhage has been achieved. Furthermore, we think that this approach is useful in the treatment of posterior juxtacardial ulcers; it seems to be effective, quick, and safe and carries a much lower morbidity and mortality.

Corresponding author and reprints: Ricard Camprodon, MD, PhD, Department of Surgery, Autonomous University of Barcelona, Marques de Monistrol, 30, Sant Just Desvern, 08960 Barcelona, Spain (e-mail: ricardo.camprodon@kingsch.nhs.uk).

Accepted for publication December 22, 2002.

Csendes  ABraghetto  ISmok  G Type IV gastric ulcer: a new hypothesis. Surgery. 1987;101361- 366
PubMed
Grassi  G La Terapia chirurgica dall'ulcera gastrica e duodenale. Chir Gastroenterol. 1976;10471- 476
Davis  ZEVVerheyden  CNVan Heerden  JAJudd  ES The surgically treated chronic gastric ulcer: an extended followup. Ann Surg. 1977;185205- 209
PubMed Link to Article
Welch  CERodkey  GVvon Ryll Gryska  P A thousand operations for ulcer disease. Ann Surg. 1986;204454- 467
PubMed Link to Article
Holman  RAEDavis  MGough  KRGartell  PBritton  DCSmith  RB Value of centralised approach in the management of haematemesis and melaena: experience in a district hospital. Gut. 1990;31504- 508
PubMed Link to Article
Swynnerton  BFTanner  NC Chronic gastric ulcer: a comparison between a gastroscopically controlled series treated medically and a series treated by surgery. BMJ. 1953;4841- 847
Link to Article
Schiller  KFRTruelove  SCWilliams  DG Haematemesis and melaena, with special reference to factors influencing the outcome. BMJ. 1970;27- 14
PubMed Link to Article
Foster  DNMiloszewski  KJALosowsky  MS Stigmata of recent haemorrhage in diagnosis and prognosis of upper gastrointestinal bleeding. BMJ. 1978;11173- 1177
PubMed Link to Article
Bornman  PCTheodorou  NAShuttleworth  RDEssel  HPMarks  IN Importance of hypovolaemic shock and endoscopic signs in predicting recurrent haemorrhage from peptic ulceration: a prospective evaluation. BMJ. 1985;291245- 247
PubMed Link to Article
Clason  AEMacleod  DADElton  RA Clinical factors in the prediction of further haemorrhage or mortality in acute upper gastrointestinal haemorrhage. Br J Surg. 1986;73985- 987
PubMed Link to Article
Dallal  HJPalmer  KR ABC of the upper gastrointestinal tract: upper gastrointestinal haemorrhage. BMJ. 2001;3231115- 1117
PubMed Link to Article
Jones  PFJohnston  SJMcEwan  ABKyle  JNeedham  CD Further haemorrhage after admission to hospital for gastrointestinal haemorrhage. BMJ. 1973;3660- 664
PubMed Link to Article
Palmer  ED Chronic gastric ulcer on the posterior wall. JAMA. 1974;230459
PubMed Link to Article
Sun  DCHStempien  SJ Site and size of the ulcer as determinants of outcome. Gastroenterology. 1971;61576- 584
PubMed
Johnson  HD The classification and principles of treatment of gastric ulcers. Lancet. 1957;2518- 520
Link to Article
Johnson  HD Gastric ulcer: classification, blood group characteristics, secretion patterns and pathogenesis. Ann Surg. 1965;162996- 1004
PubMed Link to Article
George  JD New clinical method for measuring the rate of gastric emptying: the double sampling test meal. Gut. 1968;9237- 242
PubMed Link to Article
DiDio  LJAChristoforidis  AJChandnani  PC Posterior gastric artery and its significance as seen in angiograms. Am J Surg. 1980;139333- 337
PubMed Link to Article
Swain  CPSalmon  PRNorthfield  TC Does ulcer position influence presentation or prognosis of upper gastrointestinal bleeding [abstract]? Gut. 1986;27A632
Chnug  SCSLeung  JWCSteele  RJCCrofts  TJSLi  AKC Endoscopic injection of adrenaline for actively bleeding ulcers: a randomised trial. BMJ. 1988;2961631- 1633
PubMed Link to Article
Steele  RJCPark  KGMCrofts  TJ Adrenaline injection for endoscopic haemostasis in non-variceal upper gastrointestinal haemorrhage. Br J Surg. 1991;78477- 479
PubMed Link to Article
Oshita  YOkazaki  YTakemoto  TKawai  K What are the signs of recent hemorrhage, and what do they mean? criteria for massive bleeding. Endoscopy. 1986;18 Suppl211- 14
PubMed Link to Article
Storey  DWBown  SGSwain  PSalmon  PRKirkham  JSNorthfield  TC Endoscopic prediction of recurrent bleeding in peptic ulcers. N Engl J Med. 1981;305915- 916
PubMed Link to Article
Avery Jones  F Hematemesis and melena: with special reference to causation and to the factors influencing the mortality from bleeding peptic ulcers. Gastroenterology. 1956;30166- 190
Cocks  JRDesmond  AMSwynnerton  BFTanner  NC Partial gastrectomy for haemorrhage. Gut. 1972;13331- 340
PubMed Link to Article
Morris  DLHawker  PCBrearley  SSimms  MDykes  PWKeighley  MRB Optimal timing of operation for bleeding peptic ulcer: prospective randomised trial. BMJ. 1984;2881277- 1280
PubMed Link to Article
Dronfield  MWAtkinson  MLangman  MJS Effect of different operation policies on mortality from bleeding peptic ulcer. Lancet. 1979;11126- 1128
PubMed Link to Article
Hellers  GIhre  T Impact of change to early diagnosis and surgery in major upper gastrointestinal bleeding. Lancet. 1975;21250- 1251
PubMed Link to Article
Daniels  HAStrachan  AWB Gastric ulcer treated by vagotomy, pyloroplasty and ulcerectomy. Br J Surg. 1973;60389- 391
PubMed Link to Article
Kennedy  TKelly  JMGeorge  JD Vagotomy for gastric ulcer. BMJ. 1972;2371- 373
PubMed Link to Article
Emas  SGrupcev  GEriksson  B Ten-year follow-up of a prospective, randomised trial of selective proximal vagotomy with ulcer excision and partial gastrectomy with gastroduodenostomy for treating corporeal gastric ulcer. Am J Surg. 1994;167596- 600
PubMed Link to Article
Lewis  AQvist  G Operative treatment of high gastric ulcer with special reference to Pauchet's method. Br J Surg. 1972;591- 4
PubMed Link to Article
Csendes  ALazo  MBraghetto  I A surgical technic for high (cardial or juxtacardial) benign chronic gastric ulcer. Am J Surg. 1978;135857- 858
PubMed Link to Article
Gorbashko  AIBatchaev  OKHAkimov  VP A method of treating high ulcers of the posterior gastric wall [in Russian]. Vestn Khir Im I I Grek. 1989;427- 11
PubMed
Chung  RS Transgastric approach to posterior juxta-esophageal gastric ulcer. Am Surg. 1981;47247- 250
PubMed

Figures

Place holder to copy figure label and caption
Figure 1.

Ulcerectomy specimen showing a large (2.5-cm) ulcer with its inflammatory halo.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

A, Close-up of the posterior gastric wall with a giant (4 × 5-cm) juxtacardial ulcer in situ. A transfixing stitch placed on the bleeding point for hemostasis can be seen. These features have been exposed through an anterior gastrostomy. B, After hemostasis has been achieved and ulcer bed excluded, interrupted nonabsorbable stitches have been placed for posterior gastric wall closure. Note the nylon tape hooking around the cardia. C, Everted edges of anterior gastric wall allow visualization of closed posterior gastrostomy. Nylon hooking tape is again visible. D, Anterior gastrostomy is closed.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 2. Surgical Characteristics and Course

References

Csendes  ABraghetto  ISmok  G Type IV gastric ulcer: a new hypothesis. Surgery. 1987;101361- 366
PubMed
Grassi  G La Terapia chirurgica dall'ulcera gastrica e duodenale. Chir Gastroenterol. 1976;10471- 476
Davis  ZEVVerheyden  CNVan Heerden  JAJudd  ES The surgically treated chronic gastric ulcer: an extended followup. Ann Surg. 1977;185205- 209
PubMed Link to Article
Welch  CERodkey  GVvon Ryll Gryska  P A thousand operations for ulcer disease. Ann Surg. 1986;204454- 467
PubMed Link to Article
Holman  RAEDavis  MGough  KRGartell  PBritton  DCSmith  RB Value of centralised approach in the management of haematemesis and melaena: experience in a district hospital. Gut. 1990;31504- 508
PubMed Link to Article
Swynnerton  BFTanner  NC Chronic gastric ulcer: a comparison between a gastroscopically controlled series treated medically and a series treated by surgery. BMJ. 1953;4841- 847
Link to Article
Schiller  KFRTruelove  SCWilliams  DG Haematemesis and melaena, with special reference to factors influencing the outcome. BMJ. 1970;27- 14
PubMed Link to Article
Foster  DNMiloszewski  KJALosowsky  MS Stigmata of recent haemorrhage in diagnosis and prognosis of upper gastrointestinal bleeding. BMJ. 1978;11173- 1177
PubMed Link to Article
Bornman  PCTheodorou  NAShuttleworth  RDEssel  HPMarks  IN Importance of hypovolaemic shock and endoscopic signs in predicting recurrent haemorrhage from peptic ulceration: a prospective evaluation. BMJ. 1985;291245- 247
PubMed Link to Article
Clason  AEMacleod  DADElton  RA Clinical factors in the prediction of further haemorrhage or mortality in acute upper gastrointestinal haemorrhage. Br J Surg. 1986;73985- 987
PubMed Link to Article
Dallal  HJPalmer  KR ABC of the upper gastrointestinal tract: upper gastrointestinal haemorrhage. BMJ. 2001;3231115- 1117
PubMed Link to Article
Jones  PFJohnston  SJMcEwan  ABKyle  JNeedham  CD Further haemorrhage after admission to hospital for gastrointestinal haemorrhage. BMJ. 1973;3660- 664
PubMed Link to Article
Palmer  ED Chronic gastric ulcer on the posterior wall. JAMA. 1974;230459
PubMed Link to Article
Sun  DCHStempien  SJ Site and size of the ulcer as determinants of outcome. Gastroenterology. 1971;61576- 584
PubMed
Johnson  HD The classification and principles of treatment of gastric ulcers. Lancet. 1957;2518- 520
Link to Article
Johnson  HD Gastric ulcer: classification, blood group characteristics, secretion patterns and pathogenesis. Ann Surg. 1965;162996- 1004
PubMed Link to Article
George  JD New clinical method for measuring the rate of gastric emptying: the double sampling test meal. Gut. 1968;9237- 242
PubMed Link to Article
DiDio  LJAChristoforidis  AJChandnani  PC Posterior gastric artery and its significance as seen in angiograms. Am J Surg. 1980;139333- 337
PubMed Link to Article
Swain  CPSalmon  PRNorthfield  TC Does ulcer position influence presentation or prognosis of upper gastrointestinal bleeding [abstract]? Gut. 1986;27A632
Chnug  SCSLeung  JWCSteele  RJCCrofts  TJSLi  AKC Endoscopic injection of adrenaline for actively bleeding ulcers: a randomised trial. BMJ. 1988;2961631- 1633
PubMed Link to Article
Steele  RJCPark  KGMCrofts  TJ Adrenaline injection for endoscopic haemostasis in non-variceal upper gastrointestinal haemorrhage. Br J Surg. 1991;78477- 479
PubMed Link to Article
Oshita  YOkazaki  YTakemoto  TKawai  K What are the signs of recent hemorrhage, and what do they mean? criteria for massive bleeding. Endoscopy. 1986;18 Suppl211- 14
PubMed Link to Article
Storey  DWBown  SGSwain  PSalmon  PRKirkham  JSNorthfield  TC Endoscopic prediction of recurrent bleeding in peptic ulcers. N Engl J Med. 1981;305915- 916
PubMed Link to Article
Avery Jones  F Hematemesis and melena: with special reference to causation and to the factors influencing the mortality from bleeding peptic ulcers. Gastroenterology. 1956;30166- 190
Cocks  JRDesmond  AMSwynnerton  BFTanner  NC Partial gastrectomy for haemorrhage. Gut. 1972;13331- 340
PubMed Link to Article
Morris  DLHawker  PCBrearley  SSimms  MDykes  PWKeighley  MRB Optimal timing of operation for bleeding peptic ulcer: prospective randomised trial. BMJ. 1984;2881277- 1280
PubMed Link to Article
Dronfield  MWAtkinson  MLangman  MJS Effect of different operation policies on mortality from bleeding peptic ulcer. Lancet. 1979;11126- 1128
PubMed Link to Article
Hellers  GIhre  T Impact of change to early diagnosis and surgery in major upper gastrointestinal bleeding. Lancet. 1975;21250- 1251
PubMed Link to Article
Daniels  HAStrachan  AWB Gastric ulcer treated by vagotomy, pyloroplasty and ulcerectomy. Br J Surg. 1973;60389- 391
PubMed Link to Article
Kennedy  TKelly  JMGeorge  JD Vagotomy for gastric ulcer. BMJ. 1972;2371- 373
PubMed Link to Article
Emas  SGrupcev  GEriksson  B Ten-year follow-up of a prospective, randomised trial of selective proximal vagotomy with ulcer excision and partial gastrectomy with gastroduodenostomy for treating corporeal gastric ulcer. Am J Surg. 1994;167596- 600
PubMed Link to Article
Lewis  AQvist  G Operative treatment of high gastric ulcer with special reference to Pauchet's method. Br J Surg. 1972;591- 4
PubMed Link to Article
Csendes  ALazo  MBraghetto  I A surgical technic for high (cardial or juxtacardial) benign chronic gastric ulcer. Am J Surg. 1978;135857- 858
PubMed Link to Article
Gorbashko  AIBatchaev  OKHAkimov  VP A method of treating high ulcers of the posterior gastric wall [in Russian]. Vestn Khir Im I I Grek. 1989;427- 11
PubMed
Chung  RS Transgastric approach to posterior juxta-esophageal gastric ulcer. Am Surg. 1981;47247- 250
PubMed

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 2

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles
JAMAevidence.com