Surgical therapy

The only time surgery should serve as the first-line therapy is in patients with giant (greater than 3 cm) gastric ulcers.4,5 Elective surgery is the first-line therapy in these patients because of the high rate of complications associated with these lesions and the high rate of medical failure. Otherwise, surgical therapy is reserved for complications resulting from ulcers or for the management of ulcers refractory to medical therapy. Ulcers are considered refractory to medical therapy if the ulcer fails to heal with optimal medical management, or if the patient is noncompliant or does not tolerate medical treatment. By and large, surgery is reserved for dealing with complications that result from gastric ulcers such as bleeding, perforation, and obstruction.

Elective surgery for refractory gastric ulcers is rarely performed. Type I gastric ulcers are treated with distal gastrectomy, including the ulcer, and a gastroduodenal anastomosis, or Billroth I (Fig. 9-3). Type II ulcers can be located anywhere in the distal body of the stomach and are associated with duodenal ulcers. These ulcers are also known to be associated with acid secretion. Therefore, a truncal vagotomy and antrectomy removes the mucosa at risk and eliminates the acid secretory state associated with the

Figure 9-3 Billroth I/ gastroduodenostomy.

ulcer formation. If a Billroth I anastomosis cannot be performed due to extensive duodenal inflammation, a gastrojejunostomy, or Billroth II is performed (Fig. 9-4). Type III ulcers are located in the pyloric region. The procedure of choice is a vagotomy and antrectomy with Billroth I unless extensive scarring and inflammation necessitates a gastrojejunostomy. The greatest disadvantage associated with these procedures is the high incidence of postgastrectomy syndromes8,9 (Table 9-3). Fortunately, these can be managed with mild-to-moderate dietary alterations. Despite greater recurrence rates, some surgeons prefer lesser procedures which do not require gastric resection such as a truncal vagotomy and pyloroplasty or a highly selective vagotomy to treat type I, II, and III ulcers. In addition to a procedure to reduce acid production (vagotomy), the ulcer is generally excised in order to rule out the presence of malignancy. In the rare instance when the ulcer cannot be incorporated into the surgical specimen or excised, multiple biopsies should be taken of both the center and the edge of the ulcer to rule out an underlying malignancy.

Type IV or ulcers at the gastroesophageal junction present a surgical challenge. The procedure of choice is known as a Pauchet procedure4,5 and involves a distal gastrectomy combined with a Billroth I. The gastrectomy involves an extensive resection extending onto the proximal portion of the lesser curvature in order to incorporate the ulcer. Another alternative is

Afferent loop

Figure 9-4 Billroth ¡¡/gastrojejunostomy.

Table 9-3 Postgastrectomy Syndromes

Syndrome

Etiology

Signs and Symptoms

Treatment

Recurrent ulcer

Incomplete vagotomy

Recurrent abdominal

Completion vagotomy

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