What are the indications for distal gastrectomy (removal of the lower portion of the stomach) in patients with Peptic Ulcer Disease (PUD)?

Indications for Distal Gastrectomy in Peptic Ulcer Disease

Distal gastrectomy is indicated for peptic ulcer disease in cases of large gastric perforations near the pylorus, gastric corpus perforations, suspicious malignancy, and refractory bleeding that cannot be managed by endoscopic or angiographic interventions. 1

Primary Indications

• Large perforations (≥2 cm) - Particularly when located near the pylorus or in the gastric corpus, where simple repair may be inadequate 1
• Suspected malignancy - When ulcers have suspicious features requiring histopathological examination 1
• Refractory bleeding - When endoscopic and angiographic interventions fail to control hemorrhage 1
• Gastric outlet obstruction - From chronic fibrotic disease causing stenosis 1

Patient Selection Considerations

• Hemodynamic stability - Patient's condition must allow for a more extensive procedure than simple repair 1
• Patient classification - Class A or B patients (based on physiological status) are better candidates than Class C patients who may require damage control approaches 1
• Perforation characteristics - Size, location, and chronicity of the perforation influence the decision 1

Surgical Approach Decision Algorithm

1. For perforated peptic ulcer:

   • Small perforation (<2 cm): Simple or double layer suture with or without omental patch 1
   • Large perforation (≥2 cm): Distal gastrectomy, especially near pylorus or in gastric corpus 1

2. For bleeding peptic ulcer:

   • First-line: Endoscopic treatment attempts 1
   • Second-line: Angiographic embolization if available 1
   • Third-line (when above fail): Surgical intervention 1
     • For duodenal ulcers: Consider duodenotomy with oversewing of bleeding vessel 1
     • For gastric ulcers: Distal gastrectomy preferred over simple oversewing 1

Technical Considerations

• Extent of resection - Standard distal gastrectomy involves removal of approximately two-thirds of the stomach 1
• Lymph node dissection - D1 lymphadenectomy is typically sufficient for benign disease 1
• Reconstruction options - Billroth I, Billroth II, or Roux-en-Y gastrojejunostomy 2

Post-Operative Management

• Helicobacter pylori testing - All patients should be tested and treated if positive 1
• Proton pump inhibitor therapy - Should be continued post-operatively 1
• Avoidance of NSAIDs - Patients should discontinue use to prevent recurrence 3

Complications and Pitfalls

• Mortality risk - Distal gastrectomy carries higher mortality than simple repair, especially in elderly or unstable patients 1
• Dumping syndrome - Common post-gastrectomy complication affecting quality of life 4
• Nutritional deficiencies - May develop post-gastrectomy, requiring monitoring and supplementation 4
• Delayed diagnosis - Increases mortality; every hour of delay from admission to surgery is associated with 2.4% decreased probability of survival 1

Modern Trends

• Declining elective surgery - With effective medical management of H. pylori and acid suppression, elective surgery for PUD has diminished significantly 5
• Emergency surgery remains common - For complications like perforation and bleeding 5
• Laparoscopic approach - Should be considered when expertise is available 6

Remember that while distal gastrectomy was historically common for peptic ulcer disease, its use has become more selective in the era of effective medical therapy, and is now primarily reserved for complicated cases where simpler interventions are inadequate or inappropriate 1, 6.