Surgical management of peptic ulcer disease

INTRODUCTION — Over the last several decades, the development of potent antisecretory agents (H2 blockers and proton pump inhibitors) and the recognition that treatment for Helicobacter pylori infection can eliminate most ulcer recurrences have reduced the rate of hospitalization and mortality [1,2] and essentially eliminated the need for elective surgery for peptic ulcer disease [3,4].

However, complications related to peptic ulcer disease continue to occur in 10 to 20 percent of patients [5] and include bleeding, perforation, and gastric outlet obstruction. An understanding of surgical management remains important since surgery is the mainstay of emergency treatment of these life-threatening complications and for disease that is refractory to medical management. Also, there remain a significant number of patients who underwent surgery prior to the development of current standard medical therapies who continue to have issues related to their original operation.

Because of the decrease in the hospitalization rate for peptic ulcer disease, surgeons in training now have less exposure to the overall management of peptic ulcer disease, including complications, as well as some of the more technically demanding procedures for treating peptic ulcer disease, such as highly selective vagotomy (parietal cell vagotomy) [6,7]. (See "Vagotomy", section on 'Highly selective vagotomy' and "Postgastrectomy duodenal leak".)

The current indications for surgery, surgical options, and respective treatments for duodenal and gastric ulcers will be reviewed here. The technical aspects of gastrectomy and vagotomy and their complications are reviewed elsewhere. (See "Partial gastrectomy and gastrointestinal reconstruction" and "Total gastrectomy and gastrointestinal reconstruction" and "Vagotomy" and "Postgastrectomy complications".)

INDICATIONS FOR PEPTIC ULCER SURGERY — Peptic ulcer disease was once the most common indication for gastric surgery but now only infrequently requires operation. Currently accepted indications for surgery in the management of peptic ulcer disease include [8]:

●Bleeding – Patients with a bleeding peptic ulcer (including re-bleeding) are usually managed endoscopically (first-line therapy) or with angioembolization (second-line therapy in stable patients). Surgical intervention is indicated when a patient fails repeated endoscopic intervention and/or becomes unstable, especially for a >2 cm ulcer [9]. (See "Overview of the treatment of bleeding peptic ulcers", section on 'Endoscopic therapy'.)

●Perforation – Patients with perforated peptic ulcer causing significant pneumoperitoneum or extraluminal contrast extravasation or signs of peritonitis should undergo urgent surgical exploration [9]. There is little role for endoscopic or nonoperative management, except that nonoperative management may be possible in highly selected patients with sealed perforation confirmed by contrast study [10,11]. (See "Overview of gastrointestinal tract perforation", section on 'Clinical features' and "Overview of complications of peptic ulcer disease", section on 'Perforation'.)

●Obstruction – Gastric outlet obstruction is the least frequent ulcer complication in developed countries. Most cases of gastric outlet obstruction are associated with duodenal or pyloric channel ulceration; gastric ulceration accounts for only 5 percent of cases. (See "Gastric outlet obstruction in adults", section on 'Surgery in selected patients'.)

●Intractable disease – Intractability as an indication for elective gastric surgery is increasingly unusual. The precise time period after which an ulcer should be considered intractable remains poorly defined. Severe symptoms, failure to heal on medical therapy (including antimicrobials), and relapse while on maintenance therapy or after multiple courses of therapy may indicate the need for surgery. More controversial and infrequent indications for surgery also include intolerance or noncompliance with a medical regimen; high risk for ulcer complications, such as organ transplant recipients and those who are steroid dependent or nonsteroidal anti-inflammatory drug (NSAID) dependent; and giant gastric or duodenal ulcer (although most of these can be healed with medical therapy) [12]. (See "Approach to refractory peptic ulcer disease".)

●Suspected malignancy – Infrequently, surgical management is required for peptic ulcers that fail to heal after twice-daily antisecretory therapy with a proton pump inhibitor for 24 weeks in whom other correctable factors (eg, medication noncompliance, NSAID use, and H. pylori infection) have been addressed. Malignancy is rare in duodenal ulcer disease, but surgery may be indicated for chronic nonhealing gastric ulcers as they may harbor a malignancy that is sometimes not detected despite extensive endoscopic biopsy [13-17]. (See "Approach to refractory peptic ulcer disease", section on 'Surgery in selected patients' and "Risk factors for gastric cancer", section on 'Gastric ulcer'.)

SURGICAL OPTIONS — Surgical options for peptic ulcer disease range from local therapies that only manage ulcer-related complications (ie, bleeding, perforation, or obstruction) to definitive ulcer operations. Generally, the least morbid procedure that will adequately manage the patient's problem should be used in each instance.

Ulcer bed management — Ulcer bed management may include ligation of bleeding vessels or the placement and fixation of omentum within the ulcer bed to cover the defect and promote healing (ie, Graham patch). In the stomach, it may be most appropriate to excise the ulcer completely because gastric ulcers can be cancerous. (See 'Gastric ulcer' below.)

Gastric drainage — If a truncal vagotomy is performed, a gastric drainage procedure is required. Gastric drainage procedures divide or bypass the pyloric sphincter mechanism to facilitate gastric emptying and avoid gastric stasis (figure 1). Pyloroplasty is generally preferred to gastrojejunostomy because the normal anatomic relationship between the stomach and duodenum is preserved.

●Pyloroplasty is a procedure that widens the opening between the antrum and duodenum to facilitate passage of gastric contents (figure 1).

•The Heineke-Mikulicz pyloroplasty, which divides the sphincter longitudinally and closes it transversely, is the simplest and most commonly performed.

•The Finney and Jaboulay pyloroplasties are gastroduodenostomies: the former divides, while the latter bypasses, the pyloric sphincter.

●Gastrojejunostomy (figure 1 and figure 2), which anastomoses the dependent portion of the stomach to the proximal jejunum, is typically reserved for patients with significant duodenal bulb scarring that precludes safe pyloroplasty.

Definitive ulcer surgery — Gastric acid secretion from parietal cells is regulated by redundant, overlapping pathways that include endocrine (gastrin), neural (acetylcholine release from the vagus nerves), paracrine (locally delivered histamine and somatostatin), and autocrine (transforming growth factor alpha) factors (figure 3). (See "Physiology of gastric acid secretion".)

Definitive ulcer operations may be directed largely or solely at reducing acid secretion (which impairs mechanisms of healing), or they may include strategies for managing the susceptibility of the ulcer bed to recurrent injury.

●Vagotomy is a procedure that transects or removes a portion of the vagus nerves or branches of the vagus nerves to decrease gastric acid secretion. Although definitive ulcer operations are no longer frequently performed, either a truncal vagotomy or a highly selective vagotomy is still considered an integral part of such procedures [18-22]. Vagotomy techniques are discussed in detail separately. (See "Vagotomy".)

●Partial gastrectomy (eg, antrectomy, subtotal gastrectomy) removes the gastrin-producing cells that stimulate acid secretion and a variable number of acid-producing parietal cells, depending upon the extent of the resection. For a gastric ulcer, the portion of the stomach containing the ulcer should also be removed (figure 4).

•Antrectomy/partial gastrectomy – Antrectomy or partial gastrectomy would remove antral G cells but not parietal cells. To remove all of the gastrin-producing antral tissue, it is necessary to resect at least 35 percent of the distal stomach.

•Subtotal gastrectomy – If a partial gastric resection removes greater than 75 percent of the stomach, it is a subtotal gastrectomy. Subtotal gastrectomy removes both antral G cells and reduces much of the parietal cell mass.

In older adults, antral tissue extends to within 2 cm of the gastroesophageal junction. Thus, the line of resection for a high-lying type I gastric ulcer should be taken high onto the lesser curve. In younger patients, the line between antrum and corpus is more distal. It is not difficult to distinguish antrum from corpus, as the rugae in the antrum are linear and longitudinally oriented, while the rugae in the corpus and fundus are obliquely and more transversely oriented.

However, gastric resections add operative time and can be associated with increased perioperative morbidity and long-term adverse physiologic sequelae, and presently there are effective antisecretory medications (eg, proton pump inhibitors) that make them less imperative in current management strategies. (See "Postgastrectomy complications".)

Gastrointestinal reconstruction — Reconstruction is necessary following partial gastrectomy to reestablish gastrointestinal continuity. The Billroth I, Billroth II, and Roux-en-Y reconstruction techniques are the most common (figure 4 and figure 5). Techniques for partial gastrectomy and reconstruction are discussed in detail elsewhere. (See "Partial gastrectomy and gastrointestinal reconstruction".)

●Billroth I reconstruction may be difficult to accomplish due to severe inflammation in the region around the duodenum and pylorus and is generally not advisable.

●Billroth II is the preferred gastrointestinal reconstruction after a partial gastrectomy for peptic ulcer disease. If a Billroth II is selected, the gastrojejunostomy should be created to allow gravity to aid drainage. This usually requires the anastomosis to be placed in a dependent area on the posterior wall of the stomach on the greater curvature. Although there are no convincing data showing any significant differences in outcomes of a retrocolic versus antecolic anastomosis (figure 6), angulation of the proximal limb as it joins the lesser curvature should be minimized to prevent afferent limb obstruction, which could potentially blow out the duodenal stump. (See "Postgastrectomy duodenal leak".)

●Roux-en-Y gastrojejunostomy is another option for gastric reconstruction after antrectomy/vagotomy for peptic ulcer disease, but it has several disadvantages over a Billroth II gastrojejunostomy. The most significant issue with a Roux-en-Y gastrojejunostomy is that it exacerbates problems with gastric emptying in patients with gastric outlet obstruction, and motility problems tend to develop over time [23]. While Roux limbs divert biliary and pancreatic secretions away from the stomach, this advantage does not outweigh the disadvantage of poor drainage; plus, it requires an additional anastomosis. Thus, it should not be the preferred method of reconstruction for patients undergoing partial gastrectomy for peptic ulcer disease. (See "Partial gastrectomy and gastrointestinal reconstruction", section on 'Choice of reconstruction'.)  

DUODENAL ULCER

Elective surgery for duodenal ulcer — Elective surgery for duodenal ulcer disease refractory to medical management is based upon techniques that reduce acid secretion. For the elective management of duodenal ulcer disease, we prefer vagotomy to another acid-reducing procedure. Vagotomy reduces the risk of recurrent ulceration while minimizing postoperative complications and long-term sequelae [24,25]. In clinical series dating back to the 1950s and 1960s, when duodenal ulcers were still treated surgically, the ulcer recurrence rate after vagotomy and pyloroplasty was 1.3 to 2.8 percent (with follow-up of two to six years), which was similar to the ulcer recurrence rate after gastrectomy (1.5 to 9.4 percent). However, the complication rate (5.6 versus 15 to 34 percent) and mortality rate (0.5 versus 0.7 to 6.1 percent) associated with a vagotomy and pyloroplasty was much lower than that of a gastrectomy [26].

Techniques of vagotomy have been further refined from truncal vagotomy to highly selective vagotomy, which eliminates only the vagal stimulation to the acid-secreting portion of the stomach without interrupting motor innervation to the antrum and pylorus. With these highly selective vagotomy procedures, pyloric function is preserved, and thus a drainage procedure, with its inherent risk of bile reflux, may not be needed unless there is significant scarring or deformity of the pylorus and duodenum. The techniques of highly selective vagotomy are discussed in another topic. (See "Vagotomy", section on 'Duodenal'.)

In the past, partial gastrectomy, either as an antrectomy and truncal vagotomy, or subtotal gastrectomy was commonly performed for duodenal ulcer disease as well [27]. However, removal of the pylorus with these procedures leads to rapid emptying of liquids and solids from the stomach and, potentially, to reflux of intestinal contents into the stomach. Given the high incidence of postgastrectomy complications, these procedures are generally no longer performed for medically refractory duodenal ulcers. (See "Partial gastrectomy and gastrointestinal reconstruction" and "Postgastrectomy complications".)

Bleeding duodenal ulcer — For bleeding duodenal ulcer, we prefer to directly oversew the bleeder with sutures during open surgery. If the source of hemorrhage has not been identified endoscopically, the proximal duodenum should be opened longitudinally first and inspected for the bleeding vessel. The incision may need to be extended through the pylorus (ie, pyloroduodenotomy) to permit inspection of the duodenal bulb and gastric antrum.

Once identified, the bleeding vessel can be controlled directly by suture ligation or ligation of the gastroduodenal artery at the superior and inferior aspect of the ulcer and control of the transverse pancreatic branch. While a well-placed "U-stitch" may be all that is needed, usually more than one suture is necessary, and hemostasis should be assured before closing the duodenum. Once the bleeder has been controlled, the rest of the procedure depends on patient stability and prior ulcer treatment as follows. Caution should be exercised in placing these sutures too deeply, as there is the potential for injury to the bile duct as it crosses behind the first part of the duodenum.

●In stable patients who have received medical treatment for the ulcer, closure with a pyloroplasty (figure 1) and a truncal vagotomy can be performed. For the hemodynamically stable patient who has had a duodenotomy, another option is a selective vagotomy, which transects the nerves of Latarjet supplying the stomach and pylorus while preserving vagal branches to the liver and biliary tract (anterior vagus) and branches to the celiac ganglion (posterior vagus), or a highly selective vagotomy. However, the benefits of selective or highly selective vagotomy are less clear if a pyloroduodenotomy has been performed [28,29]. (See "Vagotomy", section on 'Duodenal'.)

●Managing the ulcer bed alone is appropriate to control bleeding in hemodynamically unstable patients and for managing ulcer complications in those with significant comorbidities that limit life expectancy.

●For patients in whom H. pylori has not yet been treated, control of bleeding alone without an acid-reducing procedure may be appropriate, although this approach has not been systematically evaluated. After surgery, H. pylori-positive patients should receive eradication therapy to prevent re-bleeding. (See "Treatment regimens for Helicobacter pylori in adults".)

Perforated duodenal ulcer

Small, simple perforation — Small perforated duodenal ulcers can generally be treated by closure with a piece of omentum (an idea often misattributed to Graham, who popularized but did not originally propose the patch [30]) or, for perforated ulcers close to the pylorus, by truncal vagotomy with pyloroplasty (incorporating the perforation). Both approaches are simple and expedient, and the results have generally been good [31-35].

Simple patch closure of the perforation is appropriate for patients with shock, delayed presentation, significant medical comorbidities, or significant peritoneal contamination. It may also be performed in patients who have never been treated for peptic ulcer disease and who are candidates for proton pump inhibitors and antibiotic therapy for H. pylori [36,37]. Nonsteroidal anti-inflammatory drug (NSAID)-related perforation can generally be treated with simple closure as the NSAID can almost always be discontinued or switched to a COX-2 inhibitor. Most surgeons perform the repair and secure the omental patch with sutures. Sutureless repair using fibrin glue has been reported (especially in laparoscopic cases) but in some studies had a higher leak rate and a higher reoperation rate than suture repair [38,39]. A closed suction drain is usually placed near the repair site.

In stable patients with a perforated peptic ulcer, laparoscopic repair is recommended over open surgery; open repair is recommended for those who are unstable [9]. A meta-analysis of eight trials linked laparoscopic surgery with a lower wound infection rate and less postoperative pain than open surgery, all other clinical outcomes being comparable [40].

Large (>2 cm) or complex perforation — Large (>2 cm) or complex perforated duodenal ulcers may be challenging to close. Primary closure of a large defect requires securely sewing good tissue, making sure there is as little tension as possible, and bolstering the repair with some vascularized tissue like omentum to provide a barrier to small leaks. A well-crafted open closure is preferred to a marginally adequate closure done laparoscopically. Additionally, the open approach affords the ability to perform an extensive Kocher maneuver to mobilize the duodenum to ensure a sufficiently tension-free closure (figure 7).

Various other procedures, such as jejunal serosal patch, Roux en-Y duodenojejunostomy, pyloric exclusion, and omental plugs, have been described for situations where primary closure is not feasible [41-43]. The proximity of the duodenal ulcer to the ampulla must be noted to avoid injuring the bile duct. When in doubt, intraoperative cholangiography may even be performed to ascertain the anatomy.

Additionally, although the following specialized techniques have not changed since they were introduced in the 1960s, they may not be familiar to surgeons of the modern era, who rarely have chances to practice them.

●Bancroft's technique is best suited for cases in which scarring prevents adequate dissection of the pylorus. It uses a distal muscular cuff of the antrum to close the duodenal stump, which requires complete removal of the antral mucosa to avoid the complications of a retained antrum. Furthermore, the Bancroft procedure requires the right gastric and right gastroepiploic arteries to be preserved in order to maintain the blood supply to the local tissue (figure 8). Thus, the decision to use Bancroft's closure must be made before these vessels are divided [44,45].

●Nissen's technique is particularly useful when a posterior duodenal ulcer has penetrated into the pancreas and is not amenable to resection. It requires the duodenum to be dissected from the proximal portion of the ulcer bed, leaving the ulcer intact with a small rim of tissue for closure. The duodenum is then brought up and closed over the ulcer [46,47].

As a last resort in septic patients who cannot tolerate a prolonged resectional or repair procedure, a damage control procedure such as pyloric exclusion, T tube biliary drainage, or duodenostomy tube drainage may be performed to divert the gastric stream and bile away from the duodenum to allow the ulcer to heal. (See "Postgastrectomy duodenal leak", section on 'Adjunctive measures'.)

Pyloric exclusion involves closing the pylorus with creating a gastrojejunal anastomosis for gastric drainage [48]. It can be performed in several different ways:

●One common method is to create a gastrotomy along the greater curvature through which the pylorus can be grasped and sutured closed with a nonabsorbable suture. The gastrotomy can then either be closed primarily or used to complete the gastrojejunostomy.

●Another method fires a noncutting stapler across the pylorus, although care must be taken to avoid misfire across the proximal duodenum.

Pyloric exclusion with a gastrojejunal anastomosis permits continued oral feeding. In most cases, the pyloric closure will open spontaneously within several weeks, by which time the ulcer would have healed.

Although pyloric exclusion has been used in patients with traumatic or post-endoscopic retrograde cholangiopancreatography (ERCP) injuries for years, the results have been mixed in ulcer patients [49-51]. For peptic ulcer disease, we use pyloric exclusion selectively when a patch repair has failed, when the risk of a large duodenal leak is high, when the degree of inflammation is severe, or when either the overall health of the patient or the quality of local tissue is poor, rather than in all patients.

Definitive ulcer surgery with an acid-reducing procedure may be desirable in patients with perforation, especially when the perforation is close to the pylorus, and in patients for whom the risk of recurrent complications cannot be reliably reduced (such as the rare patients who will require continued use of an NSAID or those who are likely to resume NSAID use against medical advice). Most historic series of definitive ulcer surgery reported low recurrence rates [35,37,52-54]; similar recurrence rates (but with less morbidity) have been described in patients who underwent highly selective vagotomy [54]. (See 'Definitive ulcer surgery' above.)

Gastric outlet obstruction — Inflammation from peptic ulcer disease, especially a pyloric channel or duodenal ulceration, causes edema and duodenal spasm and is the most common cause of benign gastric outlet obstruction. Acute inflammation may respond to medical management or progress to chronic inflammation [55]. Endoscopic balloon dilation may transiently relieve gastric outlet obstruction, but repeated balloon dilatation is associated with risks such as perforation, which can complicate future surgical management [56]. Thus, for a subgroup of patients, surgical management of gastric outlet obstruction may be indicated for the long-term relief of symptoms. (See "Overview of complications of peptic ulcer disease", section on 'Gastric outlet obstruction'.)

Surgical treatment of gastric outlet obstruction is almost never an emergency. Thus, preoperative preparation can usually be carried out as follows:

●Because most patients present with some degree of malnutrition and frequently have electrolyte imbalances (ie, hypokalemic, hypochloremic metabolic alkalosis secondary to vomiting or nasogastric suctioning), it is important to correct any derangements and optimize the patient's medical status prior to proceeding with surgery. Failure to identify and correct these issues increases perioperative morbidity.

●It may also be reasonable to try to improve the patient's overall nutritional status with nutritional support as these patients are frequently malnourished and can have significant postoperative delayed gastric emptying due to their atonic stomach.

●Many experienced gastric surgeons advocate preoperative nasogastric sump decompression to decrease gastric dilation and, hopefully, gastric atony.

The goals of surgical treatment are to relieve gastric outlet obstruction and provide definitive control of peptic ulcer disease. Surgical options for gastric outlet obstruction due to peptic ulcer disease include:

●Antrectomy/distal gastrectomy relieves the obstruction and definitively rules out malignancy. Antrectomy/distal gastrectomy has traditionally been combined with vagotomy to decrease the risk of ulcer recurrence. With the pylorus removed, alkaline intestinal contents bathing the stomach stimulate acid secretion, which can be suppressed by either lifelong antisecretory therapy or vagotomy. Although vagotomy adds minimal additional morbidity to the procedure, it can cause gastric atony. There are no data to guide whether antrectomy plus vagotomy versus antrectomy plus lifelong antisecretory therapy is more efficacious or cost effective. (See "Vagotomy", section on 'Gastric outlet obstruction'.)

However, surgery can be challenging because of inflammation and scarring in the pyloric region that may extend into the porta hepatis. Inflammation in this region can result in distorted anatomy and lead to potential difficulties in securely closing the duodenal stump following antrectomy. Because the fibrotic process may alter the usual anatomic relationships, critical vascular structures and the common bile duct may be nearer to the duodenal stump than anticipated and difficult to identify. For these reasons, antrectomy may be a less suitable choice.

●Vagotomy and drainage is an alternative to antrectomy/distal gastrectomy. In a randomized trial of patients with duodenal ulcer-induced gastric outlet obstruction, both the postoperative morbidity and acid reduction were comparable between vagotomy/drainage and vagotomy/antrectomy [18].

When vagotomy and drainage are chosen, debate persists as to the optimal drainage procedure. Patients whose ulcer disease is severe enough to create obstruction rarely have a duodenum that is pliable enough to permit a pyloroplasty. In those rare instances where fibrosis is minimal or confined only to a small area, a Finney pyloroplasty may be an option [57]. However, foreshortening of the first part of the duodenum may make a Jaboulay pyloroplasty (latero-lateral gastroduodenostomy) a better alternative (figure 1). The Jaboulay has gained popularity because of its technical simplicity and because the anastomosis is performed in healthy tissue, away from the ulcer bed [58]. However, the randomized trial mentioned above suggested that gastrojejunostomy may be better than a Jaboulay [18]. If the duodenal stump is difficult to close, a posterior gastrojejunostomy without antrectomy should provide adequate drainage and should preferably include biopsy of the ulcer. Although gastrojejunostomy may theoretically reduce some of the advantages of highly selective vagotomy, vagotomy should nonetheless be considered. However, some are concerned that it may exacerbate gastroparesis in a chronically obstructed stomach. (See 'Gastric drainage' above.)

GASTRIC ULCER — Fundamental differences between gastric and duodenal ulcers affect surgical decision making, even though both are peptic lesions. Because gastric ulcers may be cancerous, the ulcer bed must be either extensively biopsied or, preferably, excised. Thus, most patients with a gastric ulcer, either uncomplicated or complicated, will require a partial gastrectomy and reconstruction, the extent of which depends on the ulcer location. (See "Partial gastrectomy and gastrointestinal reconstruction".)

However, patients with gastric ulcer tend to be an older and more debilitated population, increasing the risk for perioperative morbidity and mortality. In older or frail patients, alternatives include ulcer excision for bleeding or omental patch closure for perforation, possibly combined with vagotomy and gastric drainage.

Elective surgery for gastric ulcer — Gastric ulcers can be classified based upon their anatomic location and acidity (table 1) [59,60]:

Type I gastric ulcer — Type I gastric ulcers are the most common type of gastric ulcer (58 percent). These occur in the body of the stomach along the lesser curvature at the incisura angularis. Patients with type I gastric ulcers have normal acidity or hypoacidity.

For most patients with type I gastric ulcer and indications for surgery, we suggest distal gastrectomy with Billroth I or Billroth II reconstruction. Recurrent ulcer rates are low (0 to 5 percent), and excellent symptomatic relief is usually achieved [61]. Mortality ranges from 0 to 6 percent [61,62].

Although type I gastric ulcer has classically been considered the consequence of inadequate gastric mucosal defense, as opposed to increased acid secretion, many advocate the addition of some form of vagotomy to the gastric resection. However, in a retrospective review of 349 cases of gastric ulcer at the Cleveland Clinic from 1950 to 1979, no significant differences were found in recurrence rates for gastric resection with or without vagotomy [62]. After a median follow-up of more than 11 years, excellent or good results, fair or poor results, or ulcer recurrence were reported in 91.5, 4.9, and 3.6 percent of patients who underwent gastrectomy alone and in 91.0, 4.7, and 4.3 percent of those who underwent gastrectomy plus vagotomy. This study also found comparable results for truncal vagotomy and pyloroplasty plus ulcer excision or biopsy (94, 1.6, and 4.2 percent). Thus, vagotomy is not absolutely necessary but is not unreasonable for type I gastric ulcer.

Although most prefer distal gastrectomy, highly selective vagotomy has been used for type I gastric ulcer. The value of highly selective vagotomy in gastric ulcer may derive from its ability to decrease acid secretion while maintaining adequate gastric emptying and minimizing postoperative duodenogastric reflux. The procedure is performed as for duodenal ulcer, with the addition of a gastrotomy to resect or biopsy the ulcer bed. This approach has been questioned on theoretical grounds because highly selective vagotomy may promote a degree of gastric stasis and gastrin hypersecretion, two factors hypothesized to contribute to gastric ulcer pathogenesis. Despite these concerns, clinical results have been promising. In one series of 48 patients, the ulcer recurrence rate was comparable to gastrectomy at 6.5 percent with few adverse effects [63]. Ulcer diameter and location may make this highly selective vagotomy difficult for some patients in whom ulcer-induced inflammation, edema, or scarring may obscure accurate dissection of lesser curvature vagus nerves.

Type II gastric ulcer — Type II gastric ulcers occur in combination with or secondary to scarring of another ulcer in the duodenum or pyloric ring. They are the second most common type of gastric ulcers (22 percent). Patients with type II gastric ulcers have hyperacidity.

For type II gastric ulcer, we suggest antrectomy and vagotomy. (See "Partial gastrectomy and gastrointestinal reconstruction".)

Type III gastric ulcer — Type III gastric ulcers occur close to the pylorus and are generally distal to the incisura angularis. They are the third most common type of gastric ulcers (20 percent). Patients with type III gastric ulcers also have hyperacidity.

For type III gastric ulcer, we suggest antrectomy and vagotomy rather than another treatment (eg, selective vagotomy or medical therapy) due to poor results and high recurrence rates. The reported rate of ulcer recurrence after partial gastrectomy was 0 to 4.4 percent with an approximately 10 year follow-up [64], whereas selective vagotomy was associated with an ulcer recurrence rate of 19 percent over five to 10 years [65], and medical treatment with a histamine-2 blocker was associated with a three-year ulcer recurrence rate of 65 percent [66]. Additionally, these ulcers may harbor an occult cancer. (See "Partial gastrectomy and gastrointestinal reconstruction".)

Type IV gastric ulcer — Type IV gastric ulcers are located high along the lesser curvature, close to within 1 to 2 cm of the gastroesophageal junction. Patients with type IV gastric ulcers have hypoacidity and present with dysphagia and gastroesophageal reflux.

Surgery for type IV gastric ulcer is difficult because of its high location. If the integrity of the distal esophagus can be assured, subtotal gastric resection (including the ulcer bed) is considered optimal therapy. Typically, an attempt is made to preserve a margin of unaffected stomach to facilitate the anastomosis. Alternatives include the Pauchet procedure, which is a distal gastrectomy extended along the lesser curvature to include the ulcer, or the Kelling-Madlener procedure, in which distal gastrectomy is performed but the ulcer is left in place to avoid compromise of the gastroesophageal junction. (See 'Definitive ulcer surgery' above.)

Although there is no consensus in the literature, many surgeons feel more comfortable performing an esophageal anastomosis knowing that the ulcer is removed. When most of the stomach is removed, a Roux-en-Y reconstruction is often performed.

Recurrent gastric ulcer — Finally, in patients who have undergone multiple failed procedures for refractory ulcer disease, subtotal or total gastrectomy may be used as the last line of definitive surgical treatment. Such a procedure would remove the portion of the stomach containing the ulcer, the antral gastrin-producing cells that stimulate acid secretion, and the acid-producing parietal cells in the body and fundus of the stomach. (See "Total gastrectomy and gastrointestinal reconstruction".)

Bleeding gastric ulcer — For patients with a bleeding gastric ulcer, we suggest a partial gastrectomy (figure 4) because of the risk for gastric malignancy with Billroth I or II reconstruction (figure 5). For patients with medical comorbidities, ulcer excision combined with truncal vagotomy and pyloroplasty is an option [60,67]. However, ulcer excision alone is associated with rebleeding in as many as 20 percent of patients. By comparison, the risk of rebleeding was 5 percent after a partial gastrectomy [68].

Perforated gastric ulcer — Because patients with perforated gastric ulcer tend to be older adults and have comorbidities, surgery is associated with high overall mortality (ranging from 10 to 40 percent) regardless of treatment [60,67,69-71].

The choice of procedure is usually made during the operation. For patients who can tolerate a formal resection, we suggest a partial gastrectomy to include the ulcer because of the risk of gastric malignancy [71]. Wedge resection of the ulcer or patch closure may be performed in older or sicker patients. Patch closure alone is associated with postoperative gastric obstruction in approximately 15 percent of cases. When patch closure is performed, biopsy of the ulcer is necessary to rule out malignancy [71].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Peptic ulcer disease".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Beyond the Basics topics (see "Patient education: Peptic ulcer disease (Beyond the Basics)" and "Patient education: Helicobacter pylori infection and treatment (Beyond the Basics)").

SUMMARY AND RECOMMENDATIONS

●Indications for surgery – Surgical management is reserved for peptic ulcer disease that is refractory to medical and/or endoscopic management, for suspicion of a malignancy within an ulcer, or for the management of complications of peptic ulcer disease (ie, bleeding, perforation, obstruction). (See 'Indications for peptic ulcer surgery' above.)

●Duodenal ulcer:

•Elective – For patients with duodenal ulcer and indications for elective surgery, we suggest vagotomy rather than another acid-reducing procedure (eg, partial gastrectomy) (Grade 2C). Vagotomy reduces the risk of recurrent ulceration while minimizing postoperative complications and long-term sequelae. (See 'Elective surgery for duodenal ulcer' above.)

•Bleeding – For patients with a bleeding duodenal ulcer who have received adequate medical treatment, we suggest performing a truncal vagotomy and pyloroplasty after controlling bleeding, rather than another procedure (Grade 2C).

Managing the ulcer bed alone to control bleeding is appropriate in hemodynamically unstable patients, patients with significant comorbidities that limit life expectancy, and patients with untreated Helicobacter pylori infection. (See 'Bleeding duodenal ulcer' above.)

•Perforation – For patients with a small perforated duodenal ulcer, we suggest closing the perforation with a piece of omentum (Graham patch) (Grade 2C). For perforated ulcers close to the pylorus, truncal vagotomy with a pyloroplasty that incorporates the perforation is a reasonable alternative.

Large (>2 cm) or complex perforated duodenal ulcers may require specialized techniques to close and/or exclude. (See 'Perforated duodenal ulcer' above.)

•Obstruction – Most cases of gastric outlet obstruction are associated with duodenal or pyloric channel ulceration. For patients with gastric outlet obstruction complicating peptic ulcer disease and no major medical comorbidities, we suggest distal gastrectomy rather than another procedure (Grade 2C). A truncal vagotomy is traditionally added to prevent recurrence, but lifelong antisecretory medical therapy is a reasonable alternative.

For patients with significant risk factors for perioperative morbidity and mortality, or when a distal gastrectomy is anatomically difficult, a drainage procedure, such as gastrojejunostomy, is an acceptable alternative. A vagotomy may be added, but some are concerned that it may exacerbate gastroparesis in a chronically obstructed stomach. (See 'Gastric outlet obstruction' above.)

●Gastric ulcer – Because gastric ulcers may harbor malignancy, the ulcer bed must be either extensively biopsied or excised. (See 'Gastric ulcer' above.)

•Elective – For uncomplicated gastric ulcers in good surgical candidates, we suggest partial gastrectomy with or without vagotomy rather than another procedure (Grade 2C). The exact procedure(s) depend on the location of the ulcer and whether it is caused by hyperacidity (table 1) (see 'Elective surgery for gastric ulcer' above):

-Type 1 gastric ulcer – Distal gastrectomy

-Type 2 gastric ulcer – Antrectomy plus vagotomy

-Type 3 gastric ulcer – Antrectomy plus vagotomy

-Type 4 gastric ulcer – Subtotal gastrectomy

•Bleeding – For bleeding gastric ulcers in good surgical candidates, we suggest partial gastrectomy including the ulcer bed rather than another procedure (Grade 2C). (See 'Bleeding gastric ulcer' above.)

•Perforation – For perforated gastric ulcers in good surgical candidates, we suggest partial gastrectomy including the ulcer bed rather than another procedure (Grade 2C). (See 'Perforated gastric ulcer' above.)

For patients with significant medical comorbidities who cannot tolerate a partial gastrectomy, reasonable alternatives include ulcer excision for bleeding or omental patch closure for perforation, possibly combined with vagotomy and gastric drainage.

●Gastrointestinal reconstruction – Reconstruction is necessary following partial gastrectomy to reestablish gastrointestinal continuity. The Billroth I, Billroth II, and Roux-en-Y reconstruction techniques are the most common (figure 5).

For patients undergoing partial gastrectomy for peptic ulcer disease, we suggest a Billroth II rather than a Billroth I or Roux-en-Y reconstruction (Grade 2C). (See 'Gastrointestinal reconstruction' above and "Partial gastrectomy and gastrointestinal reconstruction".)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Ashley H Vernon, MD, who contributed to earlier versions of this topic review.