What is the Csendes Procedure in Gastric Ulcer?
The Csendes procedure is a specific gastric resection technique designed for high gastric ulcers located very close to the cardia (within 2 cm of the gastroesophageal junction), where standard distal gastrectomy approaches cannot adequately remove the ulcer while maintaining adequate margins 1.
Technical Description
The Csendes procedure involves a high gastric resection that removes the ulcer-bearing portion of the proximal stomach while preserving enough gastric tissue to avoid the complications associated with total or proximal gastrectomy. This technique was specifically developed to address the anatomical challenge of ulcers positioned too high for conventional Billroth procedures (Schoemaker's or Pauchet's procedures) but not requiring the extensive resection of total gastrectomy 1.
Clinical Context and Indications
Location-Based Algorithm for High Gastric Ulcers:
- Ulcers located 5 cm below the cardia: Use Schoemaker's or Pauchet's procedure (standard distal gastrectomy approaches)
- Ulcers located 2 cm or less from the cardia: Use Csendes' procedure or Kelling-Madlener procedure 1
Key Clinical Considerations:
The evidence demonstrates that resective procedures for high gastric ulcers, including the Csendes procedure, show superior outcomes compared to non-resective approaches, with:
- No recurrent ulcers after resective techniques
- Lower postoperative morbidity and mortality compared to total/proximal gastrectomy
- Lower mortality compared to non-resective procedures 1
Important Caveats
Large gastric ulcers (>2 cm) should always raise suspicion for malignancy, as 10-16% of gastric perforations are caused by gastric carcinoma 2. When performing the Csendes procedure or any gastric resection for ulcer disease, frozen section pathologic examination should be obtained whenever possible to rule out malignancy 2.
The procedure is specifically indicated for benign chronic gastric ulcers in the high gastric location. For perforated ulcers in this location, current guidelines recommend gastric resection and reconstruction as the surgical choice for perforations larger than 2 cm 2.
Historical Context
While the Csendes procedure was described in the 1980s as part of the surgical armamentarium for peptic ulcer disease, modern surgical treatment of gastric ulcers is now rarely performed electively due to effective medical management with H. pylori eradication and potent acid-suppressive therapy 3, 4. Surgery is now reserved primarily for complications such as perforation, bleeding refractory to endoscopic management, or suspicion of malignancy 2.