In a medically fit patient with a high gastric ulcer located approximately 5 cm below the cardia, how is the Pauchet procedure performed and what are the key operative steps and postoperative considerations?

Pauchet Procedure for High Gastric Ulcer

For a medically fit patient with a high gastric ulcer located approximately 5 cm below the cardia, the Pauchet procedure involves a distal gastric resection that includes the ulcer-bearing segment with reconstruction via gastroduodenostomy (Billroth I) or gastrojejunostomy (Billroth II), preserving the proximal stomach and cardia.

Historical Context and Current Relevance

The Pauchet procedure is a specific type of partial gastrectomy designed for high gastric ulcers positioned in the mid-to-upper body of the stomach. While elective surgical treatment for peptic ulcer disease has become nearly obsolete due to effective medical management 1, understanding these techniques remains critical for managing complications or refractory cases.

Key Operative Steps

Preoperative Considerations

• Rule out malignancy: High gastric ulcers (especially those >2 cm) should raise suspicion for gastric cancer, as 10-16% of gastric perforations are caused by carcinoma 2
• Obtain frozen section capability if resection is planned 2
• For ulcers located 5 cm below the cardia, the Pauchet or Schoemaker procedure represents the optimal resective approach 3

Surgical Technique

The Pauchet procedure involves:

1. Mobilization: Free the greater curvature and mobilize the stomach adequately to allow tension-free resection
2. Resection margins: Resect the distal 40-50% of the stomach, ensuring the ulcer is included in the specimen with adequate margins
3. Proximal preservation: Unlike more extensive resections, the Pauchet procedure preserves the proximal stomach and gastroesophageal junction
4. Reconstruction: Perform either:
   • Billroth I (gastroduodenostomy) - preferred when feasible
   • Billroth II (gastrojejunostomy) - if duodenal closure is difficult

Critical Technical Points

• The resection line should be positioned to include the ulcer with healthy tissue margins
• Ensure adequate blood supply to the gastric remnant
• Create a tension-free anastomosis
• Consider vagotomy if not already performed, though this is less commonly added in modern practice

Postoperative Considerations

Immediate Postoperative Management

• Nasogastric decompression: Maintain until gastric function returns (typically 3-5 days)
• Acid suppression: Initiate high-dose proton pump inhibitor therapy; vonoprazan is now considered first-line when available 4
• Nutritional support: Begin early enteral feeding when appropriate
• Monitor for complications: Anastomotic leak, bleeding, delayed gastric emptying

Long-Term Outcomes

Based on long-term follow-up data (mean 9 years), the Pauchet procedure demonstrates 3:

• Low postoperative morbidity and mortality when performed for ulcers 5 cm below the cardia
• No recurrent ulcers after resective procedures
• Superior outcomes compared to non-resective approaches or more extensive resections (total/proximal gastrectomy)

Common Pitfalls to Avoid

• Inadequate resection margins: Ensure the ulcer is completely excised with healthy tissue
• Tension on anastomosis: Inadequate mobilization leads to anastomotic complications
• Overlooking malignancy: Always send specimen for permanent pathology; frozen section intraoperatively if suspicion exists
• Choosing wrong procedure: For ulcers <2 cm from cardia, consider Csendes' procedure or Kelling-Madlener procedure instead 3

Alternative Approaches

For comparison, when the ulcer is located differently:

• 2 cm or less from cardia: Csendes' procedure or Kelling-Madlener procedure preferred 3
• Perforated ulcers >2 cm: Gastric resection with reconstruction is the surgical choice 2
• Emergency/unstable patients: Consider damage control approaches rather than definitive resection 2

Modern Context

While the Pauchet procedure represents sound surgical technique for high gastric ulcers at 5 cm below the cardia, contemporary practice emphasizes medical management first. Surgery is now reserved for complications (perforation, bleeding, obstruction) or when malignancy cannot be excluded 1, 5.