What is the surgical management of a type 1 gastric ulcer?

Surgical Management of Type 1 Gastric Ulcer

For type 1 gastric ulcers, antrectomy with truncal vagotomy is the recommended surgical approach, as it addresses both acid production and gastrin mechanisms while allowing for pathological examination to exclude malignancy. 1

Indications for Surgical Intervention

Surgical management is indicated in the following scenarios:

• Failure of endoscopic therapy to control bleeding
• Refractory bleeding after repeated endoscopy/angioembolization
• Large ulcers (≥2 cm) with friable edges
• Suspicion of malignancy
• Failure to heal after 12-15 weeks of medical therapy 2

Surgical Approach Based on Location

Type 1 Gastric Ulcer (Lesser Curvature)

• Primary recommendation: Antrectomy with truncal vagotomy 1
  • Resects 4-5 cm of distal stomach
  • Extends excision in narrow tongue along lesser curvature to include ulcer
  • Includes complete truncal vagotomy
  • Reconstruction typically with Billroth II or Roux-en-Y gastrojejunostomy

This approach is superior because it:

1. Allows for pathological examination to exclude malignancy
2. Addresses both acid production and gastrin mechanisms
3. Provides lower recurrence rates compared to simple repair 1

Reconstruction Options

• Roux-en-Y reconstruction shows significantly better long-term outcomes compared to Billroth I and especially Billroth II reconstructions 3, 4

• Benefits of Roux-en-Y include:

  • More asymptomatic patients
  • Better Visick grading
  • Lower rates of Barrett's esophagus (3% vs 25% with Billroth II)
  • Normal gastric remnant endoscopic findings in 100% of cases 4

• Billroth I reconstruction may be considered as an alternative and has shown:

  • Lower post-operative morbidity compared to Billroth II
  • Less evident enterogastric reflux
  • Apparently longer life expectancy after discharge 5

Management of Large Gastric Ulcers (≥2 cm)

For ulcers larger than 2 cm:

• Gastric resection with reconstruction is strongly recommended 6, 1
• Intraoperative frozen section examination should be performed when malignancy is suspected 6
• The surgical approach must be tailored based on ulcer location 6

Timing of Surgery

• Consultant surgeon should make the decision to operate
• Experienced anesthetist should assess patient's fitness for operation
• If possible, avoid operations between midnight and 7 am 6
• Immediate surgery is indicated for unstable patients with bleeding refractory to endoscopy/angioembolization 6

Post-Surgical Care

• H. pylori testing and eradication if positive 6, 1
• Monitor for nutritional deficiencies (vitamin B12, iron, calcium) 1
• Follow-up endoscopy to ensure complete healing 1

Common Pitfalls to Avoid

1. Failure to exclude malignancy: Always obtain pathological examination of resected specimens
2. Inadequate margins: Ensure complete resection with adequate margins around the ulcer site
3. Incomplete vagotomy: Perform complete truncal vagotomy to prevent recurrence
4. Overlooking H. pylori: Test and eradicate if positive to prevent recurrence
5. Choosing simple repair for large ulcers: Resection is preferred for ulcers ≥2 cm to reduce recurrence risk

The surgical approach to type 1 gastric ulcers has evolved, with strong evidence supporting antrectomy with vagotomy as the procedure of choice, particularly with Roux-en-Y reconstruction for optimal long-term outcomes.