GASTRODUODENAL HEMORRHAGE: SURGICAL MANAGEMENT.

Two thousand five hundred forty-five cases of upper gastrointestinal tract hemorrhage were studied especially with a view to determining the indications for urgent surgical treatment. Decisions as to whether and when to operate were as follows:Immediate operation for patients over 50 years with a good history of ulcer and a severe initial bleed. Operation after the first repetition of bleeding in patients (1) over 50 with a good history and a mild initial bleed, (2) over 50 with inconclusive history but severe initial bleed, (3) under 50 with a good history and a severe initial bleed. In all other cases, operation was used only if conservative treatment failed. Absolute indications for operation were (a) association with perforation, (b) association with stenosis, (c) persistence of severe ulcer pain after hemorrhage, (d) continuous bleeding. Since operation is to be avoided if possible in cases of esophagitis, erosive gastritis and small acute or subacute ulcers, emergency gastroscopy has valuable uses. Where operation is deemed necessary and no obvious lesion found at laparotomy, blind gastrectomy appears to be the most satisfactory procedure. The mortality rate associated with upper gastrointestinal tract bleeding in patients less than 60 years of age was low (2.5 per cent). Even in cases in which operation was required, it was 6.2 per cent. Over 60 years the mortality rises steeply with increasing age, and in cases of operation the rise is even steeper. By using the methods of selection the overall mortality rate was appreciably reduced.