Optimal Surgical Treatment for Lesser Curvature Gastric Ulcer After Failed Medical Therapy
For a gastric ulcer in the lesser curvature that has failed medical treatment, antrectomy with truncal vagotomy (option C) is the optimal surgical approach due to its superior long-term outcomes in preventing ulcer recurrence and reducing mortality.
Rationale for Antrectomy with Truncal Vagotomy
Evidence-Based Considerations
- Gastric ulcers in the lesser curvature that fail medical therapy require surgical intervention with careful consideration of the ulcer location and size 1
- For gastric ulcers, resection is strongly recommended over simple repair due to:
- Need to rule out malignancy (10-16% of gastric perforations are caused by gastric carcinoma) 1
- Lower recurrence rates compared to non-resectional procedures
- Better long-term outcomes in terms of mortality and morbidity
Advantages of Antrectomy with Truncal Vagotomy
- Extremely low ulcer recurrence rate of less than 1% compared to 10-15% with other procedures 2
- Addresses both acid production (vagotomy) and gastrin production (antrectomy) mechanisms
- Provides tissue for pathologic examination to exclude malignancy
- Demonstrated long-term effectiveness with 17-year follow-up showing excellent functional results 3
Why Not Billroth I (Option A)?
- Billroth I alone without vagotomy has higher recurrence rates for lesser curvature ulcers
- Does not adequately address the neurohormonal mechanisms of ulcer formation
- May lead to continued acid production without the vagotomy component
Why Not Billroth I with Gastroplasty (Option B)?
- More complex procedure without proven additional benefit over antrectomy with truncal vagotomy
- Lacks strong evidence supporting its superiority for lesser curvature ulcers specifically
- May increase operative time and potential complications without improving outcomes
Surgical Approach Considerations
- The World Journal of Emergency Surgery recommends tailoring the surgical approach based on ulcer location 1
- For gastric location (especially lesser curvature):
- Gastric resection with reconstruction is recommended for ulcers larger than 2 cm
- Antrectomy plus vagotomy is the classic and most commonly described intervention 1
Technical Execution
- Resection of 4-5 cm of the distal stomach (antrectomy)
- Extension of the excision in a narrow tongue along the lesser curvature to include the ulcer
- Complete truncal vagotomy to reduce acid production
- Reconstruction typically with Billroth II or Roux-en-Y gastrojejunostomy
Outcomes and Prognosis
- Studies show satisfactory functional results in 90% of patients with this approach 4
- Mortality rates as low as 1.1% with proper patient selection and technique 3
- Severe postoperative sequelae like postvagotomy diarrhea (0.7%) and postgastrectomy dumping (1.0%) are uncommon 3
Potential Pitfalls
- Ensure complete vagotomy to prevent recurrence
- Obtain adequate margins around the ulcer site
- Always perform pathologic examination of the resected specimen
- Monitor for nutritional deficiencies post-operatively, particularly vitamin B12, iron, and calcium
Antrectomy with truncal vagotomy represents the optimal balance between ulcer cure rate, recurrence prevention, and acceptable side effect profile for lesser curvature gastric ulcers that have failed medical therapy.