Surgery for duodenal and gastric ulcers

Most appropriate elective surgical procedure for duodenal ulcers and each type of gastric ulcer

The choice of operation for gastric ulcers depends on several factors: ulcer location, acid secretory status, and presence of a coexistent duodenal ulcer. In general, gastric ulcers should be included with the resection while duodenal ulcers heal after acid suppression.

  • Type I: antrectomy with inclusion of the ulcer and Billroth I or II reconstruction. Although type I gastric ulcers are associated with low to normal acid secretion, most surgeons include a truncal vagotomy, unless achlorhydria is demonstrated. It is associated with excellent symptomatic relief and low recurrence rates.
  • Type II and III: truncal vagotomy, antrectomy with inclusion of the gastric ulcer and Billroth I reconstruction. Type II (gastric body) and III (prepyloric) gastric ulcers are associated with high rates of acid secretion and therefore the goal of the surgery is removal of the gastric mucosa at risk for ulceration and reduction of acid secretion. Highly selective vagotomy has been associated with poor results and high recurrence rates.
  • Type IV: distal gastrectomy with resection proximally to include the ulcer high on the lesser curvature and Billroth I anastomosis. Because type IV ulcers are located high on the lesser curvature, they are surgically challenging.
  • Type V: surgery is reserved for treatment of complications. Type V gastric ulcers generally heal rapidly with cessation of aspirin or a nonsteroidal antiinflammatory drug (NSAID) and institution of an H -receptor antagonist or PPI. An intractable type V gastric ulcer should raise suspicion for underlying malignancy.
  • Duodenal ulcer: historically, the highly selective vagotomy has been the mainstay of treatment. However, the intractable duodenal ulcer is a rare entity in the PPI era and may represent a more resistant variant with a higher rate of recurrence. Therefore truncal vagotomy with pyloroplasty is predominantly used today.
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