Optimal Surgical Management for Lesser Curvature Gastric Ulcers Refractory to Medical Treatment
Antrectomy with truncal vagotomy is the optimal surgical procedure for a gastric ulcer in the lesser curvature that has failed medical treatment. 1 This approach provides the best outcomes in terms of reducing mortality and morbidity while improving quality of life by addressing both the ulcer and its underlying pathophysiology.
Rationale for Antrectomy with Truncal Vagotomy
Evidence-Based Benefits:
- Addresses both acid production and gastrin mechanisms involved in ulcer formation
- Allows for pathological examination to exclude malignancy (crucial for lesser curvature ulcers)
- Provides lower recurrence rates compared to simple repair or Billroth I alone
- Recommended specifically for lesser curvature ulcers by the American College of Surgeons and British Society of Gastroenterology 1
Surgical Considerations:
- For lesser curvature ulcers, resection is strongly recommended over simple repair due to:
- Need to rule out malignancy
- Lower long-term recurrence rates
- Better functional outcomes
Why Not Other Options?
Billroth I Alone (Option A):
- Higher recurrence rates for lesser curvature ulcers specifically
- Does not adequately address the neurohormonal mechanisms of ulcer formation
- Lacks the acid-reducing benefits of vagotomy 1
Billroth I with Gastroplasty (Option B):
- More complex procedure without evidence supporting superiority for lesser curvature ulcers
- May increase operative time and potential complications without improving outcomes 1
- Does not address the vagal component of acid secretion
Technical Aspects of the Procedure
The antrectomy should:
- Include adequate margins (at least 5 cm beyond the distal extent of the ulcer) 2
- Be combined with complete truncal vagotomy to reduce acid production
- Include intraoperative frozen section examination when malignancy is suspected 1
- Be performed by an experienced surgeon considering the patient's condition 1
Post-Operative Management
- H. pylori testing and eradication if positive to prevent recurrence
- Monitoring for nutritional deficiencies (vitamin B12, iron, calcium)
- Follow-up endoscopy to ensure complete healing 1
Potential Pitfalls to Avoid
- Failure to exclude malignancy (always obtain pathological examination)
- Inadequate margins or incomplete vagotomy leading to recurrence
- Overlooking H. pylori infection
- Performing complex procedures without evidence supporting their superiority 1
Long-Term Outcomes
Studies have shown that antrectomy with vagotomy:
- Reduces gastric acid secretory capacity by approximately 80% 3
- Has recurrence rates of less than 1% when properly performed 4
- Provides satisfactory functional results in approximately 90% of patients 5
While some studies suggest increased risk of postgastrectomy syndromes with the addition of vagotomy to antrectomy 3, the benefits of reduced recurrence rates outweigh these risks, particularly for lesser curvature ulcers that have failed medical management.