Optimal Surgical Procedure for Lesser Curvature Gastric Ulcer After Failed Medical Treatment
For a gastric ulcer in the lesser curvature that has failed medical treatment, antrectomy with truncal vagotomy (option C) is the optimal surgical procedure due to its ability to address both the ulcer and its underlying pathophysiology while allowing for pathological examination to exclude malignancy.
Rationale for Antrectomy with Truncal Vagotomy
- Comprehensive approach: Antrectomy with truncal vagotomy addresses both acid production (via vagotomy) and gastrin production (via antrectomy) mechanisms 1
- Tissue examination: Provides specimen for pathologic examination to exclude malignancy, which is crucial for gastric ulcers 2, 1
- Evidence-based: The World Journal of Emergency Surgery recommends tailoring the surgical approach based on ulcer location, with antrectomy plus vagotomy as the classic intervention for lesser curvature ulcers 1
Surgical Technique
- Resection of 4-5 cm of the distal stomach
- Extension of the excision in a narrow tongue along the lesser curvature to include the ulcer 3
- Complete truncal vagotomy
- Reconstruction typically with Billroth II or Roux-en-Y gastrojejunostomy 1
Comparison with Alternative Options
Billroth I (Option A)
- Higher recurrence rates for lesser curvature ulcers when performed without vagotomy 1
- Does not adequately address the neurohormonal mechanisms of ulcer formation
- The British Society of Gastroenterology guidelines note that while Billroth I reconstruction can be used for duodenal ulcers, it is not specifically recommended as the optimal choice for gastric ulcers in the lesser curvature 2
Billroth I with Gastroplasty (Option B)
- More complex procedure without strong evidence supporting superiority for lesser curvature ulcers 1
- May increase operative time and potential complications without improving outcomes
- Limited evidence in the literature supporting this approach specifically for lesser curvature gastric ulcers
Key Considerations in Decision-Making
- Ulcer location: Lesser curvature location requires specific surgical approaches that include resection along this area 3
- Malignancy risk: Gastric ulcers carry a risk of malignancy, making resection with pathological examination essential 2
- Recurrence prevention: The combination of antrectomy and vagotomy provides the most comprehensive approach to prevent recurrence 1, 4
Postoperative Considerations
- Monitor for nutritional deficiencies, particularly vitamin B12, iron, and calcium
- Follow-up endoscopy may be required to ensure complete healing
- H. pylori testing and eradication if positive 2
Potential Pitfalls and Caveats
- Ensure complete vagotomy to prevent recurrence
- Obtain adequate margins around the ulcer site
- Always perform pathologic examination of the resected specimen
- Consider patient's overall condition when determining the extent of surgery - for elderly or high-risk patients, a more limited procedure may be appropriate 2