What are the operative steps to repair a gastric ulcer (peptic ulcer disease)?

From the Guidelines

The operative steps to repair a gastric ulcer typically involve a tailored approach based on the location and size of the ulcer, with a laparoscopic approach suggested for stable patients with perforated peptic ulcer, as recommended by the most recent guidelines 1. The procedure begins with general anesthesia administration and appropriate patient positioning.

• For perforated ulcers, the repair involves excising the ulcer edges to create healthy tissue margins, followed by primary closure using interrupted sutures, typically with non-absorbable material like silk.
• The closure is often reinforced with an omental patch (Graham patch) to strengthen the repair and provide additional blood supply.
• For bleeding ulcers, the surgeon identifies the bleeding vessel and achieves hemostasis through direct suturing, vessel ligation, or cauterization.
• In cases of large or complicated ulcers, partial gastrectomy may be necessary, removing the affected portion of the stomach and reconnecting the remaining stomach to the small intestine, as suggested by the guidelines 1. Some key considerations include:
• The use of laparoscopic approach for stable patients with perforated peptic ulcer 1
• The importance of acid suppression therapy and Helicobacter pylori eradication postoperatively to prevent ulcer recurrence and promote healing 1
• The need for a tailored approach based on the location and size of the ulcer, with consideration of the patient's overall condition and potential for malignancy 1 It is essential to note that the most recent and highest quality study 1 recommends laparoscopic or open simple or double-layer suture with or without an omental patch as a safe and effective procedure to address small perforated ulcers, and distal gastrectomy for large perforations near the pylorus or suspicion of malignancy.

From the Research

Operative Steps for Gastric Ulcer Repair

The operative steps for repairing a gastric ulcer (peptic ulcer disease) can vary depending on the severity of the condition and the presence of complications. The following are some of the operative steps that may be involved:

• Simple closure with biopsy: This is a non-resection surgical procedure that involves closing the perforation with sutures and taking a biopsy to rule out malignancy 2.
• Excision of the ulcer with pyloroplasty and vagotomy: This is another non-resection surgical procedure that involves removing the ulcer and performing a pyloroplasty to widen the pyloric canal, as well as a vagotomy to reduce acid production 2.
• Partial gastrectomy: This is a more radical procedure that involves removing a portion of the stomach, and is often recommended for patients with large or malignant ulcers 3, 4.
• Vagotomy and antrectomy: This procedure involves removing the antrum (the lower part of the stomach) and performing a vagotomy to reduce acid production 5.
• Roux-en-Y gastrojejunostomy: This is a reconstructive procedure that involves creating a new connection between the stomach and the small intestine 5.

Considerations for Surgical Intervention

Surgical intervention for gastric ulcer repair is typically reserved for life-threatening complications such as perforation, bleeding, or obstruction 5, 3. The choice of operative procedure depends on the individual patient's condition and the surgeon's expertise. Laparoscopic surgery may be considered for patients with perforated peptic ulcers, but open surgery may be necessary in some cases 3. The goal of surgical intervention is to control bleeding, repair the perforation, and prevent future complications.

Postoperative Management

Postoperative management is critical to prevent complications and promote healing. This may include:

• Monitoring for signs of bleeding or perforation
• Managing pain and discomfort
• Providing nutritional support
• Preventing infection
• Managing any underlying conditions that may have contributed to the development of the gastric ulcer.

The surgical management of gastric ulcers is complex and requires careful consideration of the individual patient's condition and the potential risks and benefits of each operative procedure 6, 5, 2, 3, 4.