When is gastric resection indicated for an adult patient with a history of peptic ulcer disease, possibly due to Helicobacter pylori infection or Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) use, who has failed medical management?

Gastric Resection in Gastric Ulcers

Gastric resection is indicated for gastric ulcers when medical management fails after 2-3 months, when malignancy cannot be excluded, for large ulcers (≥2 cm), or when life-threatening complications occur including refractory bleeding, perforation, or gastric outlet obstruction. 1, 2, 3, 4

Primary Indications for Gastric Resection

Failure of Medical Management

• Gastric ulcers that fail to heal after 2-3 months of maximal medical therapy (PPI therapy with H. pylori eradication if present) require surgical resection. 1, 3
• Medical therapy successfully heals only 43% of gastric ulcers, with 57% eventually requiring surgical intervention. 3
• The preferred operation is subtotal gastrectomy or antrectomy that includes the ulcer site. 1, 3

Inability to Exclude Malignancy

• All gastric ulcers requiring surgery must have biopsies taken to exclude malignancy, as 10-16% of gastric perforations are caused by gastric carcinoma. 1, 2
• Large gastric ulcers with suspicion of malignancy require resection with intraoperative frozen section examination. 2
• Patients treated medically for presumed benign ulcers have been found to harbor carcinoma even after years of treatment, making tissue diagnosis critical. 3

Life-Threatening Complications

Bleeding:

• Seek surgical consultation when endoscopic therapy fails to control bleeding. 1
• For bleeding gastric ulcers, excision or partial gastrectomy is recommended depending on size and location. 1
• Percutaneous embolization can be considered as an alternative to surgery where available. 1

Perforation:

• Immediate surgical exploration is mandatory in unstable patients with peritonitis. 2
• For large perforations (≥2 cm), resection rather than simple repair is preferred for gastric ulcers. 2
• Hemodynamically stable patients with small perforations (<1 cm) can undergo laparoscopic repair with omental patch, but biopsies are still mandatory. 2

Gastric Outlet Obstruction:

• Obstruction from chronic ulceration requires surgical bypass or resection. 5, 4

Surgical Approach Based on Clinical Scenario

For Elective Surgery (Failed Medical Management)

• Perform antrectomy or subtotal gastrectomy to include the ulcer site. 1, 3
• Vagotomy may be added in selected cases, though it is less necessary in the era of powerful antisecretory agents. 1, 3
• The addition of vagotomy to resection resulted in only 2 marginal ulcers in 42 patients in one series. 3

For Emergency Surgery (Bleeding/Perforation)

• In elderly patients or those in poor physical condition, perform the minimum operation to stop bleeding—either local excision or underrunning of the ulcer. 1
• For hemodynamically unstable patients with perforation, employ damage control surgery principles and avoid complex definitive procedures. 2
• Timing of surgery should avoid midnight to 7am when possible, as mortality correlates with preoperative physiologic status. 1

For Large Ulcers (≥2 cm)

• Large gastric ulcers require resection rather than simple repair due to high malignancy risk and poor healing potential. 2, 3
• Tailored approach based on ulcer location is necessary. 2
• Gastric ulcers larger than 2 cm may require 8 weeks of medical treatment to heal, making surgical resection more definitive. 6

Critical Post-Operative Management

Risk Factor Modification

• Permanently discontinue all NSAIDs, as they are the strongest independent risk factor for ulcer recurrence and perforation. 7, 6, 8
• Complete smoking cessation is mandatory. 9, 7
• Test for H. pylori and provide eradication therapy if present, as this reduces recurrence from 50-60% to 0-2%. 1, 6

Follow-Up Endoscopy

• Patients who have bled from gastric ulcers should undergo repeat endoscopy approximately 6 weeks after discharge to confirm ulcer healing and exclude malignancy. 1
• Continue PPI therapy until that point. 1

Common Pitfalls to Avoid

• Never omit biopsies during surgical repair of gastric ulcers, as 10-16% harbor malignancy. 2, 9
• Do not attempt complex resections in hemodynamically unstable patients with severe sepsis—focus on damage control. 2
• Avoid prolonging medical management beyond 2-3 months for non-healing gastric ulcers, as this delays definitive diagnosis and risks missing malignancy. 1, 3
• Do not assume all gastric ulcers are benign—endoscopic biopsy has improved but can still miss malignant ulcers. 3
• In patients requiring continued NSAID therapy post-operatively, recognize that even NSAID plus PPI or COX-2 inhibitor alone carries clinically important recurrence risk. 1