Trattamento chirurgico

La chirurgia è ormai riservata solo a pazienti che si presentano con emorragia massiva in atto, refrattaria alla terapia endoscopica ed in caso di recidiva emorragica. La percentuale di pazienti con emorragia digestiva superiore non varicosa che necessita di intervento chirurgico sembra essere diminuita negli ultimi anni, passando dal 7,1% al 4,5%91_{. Non ci sono indicazioni sulla procedura chirurgica ottimale. Esiste solo uno}

studio randomizzato sul trattamento delle ulcere duodenali, in cui si osserva che il tasso di sanguinamento è minore nei pazienti sottoposti a gastrectomia (Billroth tipo 1 o 2) rispetto ai pazienti sottoposti a terapia conservativa. La mortalità però è risultata simile nei due gruppi, a causa delle maggiori complicanze postoperatorie verificatesi nel primo gruppo. Il trattamento chirurgico è inoltre indicato nel 18-25% delle emorragie gastrointestinali inferiori che richiedono emotrasfusioni. Anche in questi casi il trattamento chirurgico trova principalmente indicazione nei pazienti emodinamicamente instabili ed in caso di recidive emorragiche, in particolare quando è possibile identificare accuratamente la causa e la localizzazione del sanguinamento al fine di effettuare interventi meno demolitivi. La resezione colica “alla cieca” o la resezione colica guidata dalla sola scintigrafia sono gravate da alti tassi di recidiva (circa il 33%) e mortalità (33-57%). L'individuazione del preciso sito di sanguinamento sotto guida angiografica permette di contro di ridurre notevolmente la morbidità perioperatora. In uno studio di Parkes e collaboratori, il tasso di recidiva ad un anno era del 14% dopo colectomia segmentale guidata da reperti angiografici, contro il 42% della colectomia segmentale eseguita “alla cieca” .

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