For a patient with peptic ulcer disease, what are the surgical indications and preferred operative procedures for perforation, uncontrolled hemorrhage, gastric outlet obstruction, refractory ulcer despite high‑dose proton pump inhibitor therapy and Helicobacter pylori eradication, or suspected malignancy?

Surgical Management of Peptic Ulcer Disease

Surgery for peptic ulcer disease is now reserved exclusively for life-threatening complications: perforation with peritonitis, uncontrolled hemorrhage after failed endoscopic/interventional management, gastric outlet obstruction refractory to endoscopic dilation, and suspected malignancy requiring tissue diagnosis. 1, 2

Indications for Surgical Intervention

Perforation

Operate immediately on any patient with significant pneumoperitoneum, extraluminal contrast extravasation, or clinical signs of peritonitis. 1, 2 Every hour of surgical delay decreases survival probability by 2.4%, making timing critical to mortality reduction. 1

Non-operative management can be attempted only in highly selected patients who meet all of the following "6 R's" criteria: 1

• Radiologically undetected leak (no contrast extravasation on water-soluble contrast study)
• Normal vital signs without signs of peritonitis or sepsis
• Repeated clinical examination capability
• Repeated blood investigations
• Respiratory and renal support available
• Resources for monitoring
• Readiness to operate immediately if deterioration occurs

Exercise extreme caution with non-operative management in patients >70 years old, as they experience paradoxically higher mortality if conservative treatment fails. 1 Patients over 70 are significantly less likely to respond to conservative treatment. 1

Uncontrolled Hemorrhage

Surgery is indicated when endoscopic hemostasis fails or when interventional radiology is unavailable or unsuccessful. 3, 4 Endoscopic treatment achieves definitive hemostasis in >90% of cases, but 1-2% require immediate emergency surgery. 5 Consider early elective surgery after initial endoscopic control in patients with high-risk features for rebleeding, though this remains somewhat controversial. 4

Gastric Outlet Obstruction

Endoscopic balloon dilation controls benign gastric outlet obstruction in 70% of cases, but surgical bypass (gastrojejunostomy) or resection is necessary in 30%. 5

Refractory Ulcer Despite Medical Therapy

This indication has become exceedingly rare in the proton pump inhibitor era and should prompt investigation for H. pylori persistence, NSAID use, or malignancy rather than immediate surgery. 6

Suspected Malignancy

All gastric ulcer perforations require biopsy or resection when feasible, as 10-16% harbor malignancy. 2, 7 Duodenal ulcers typically require only closure without biopsy. 2

Surgical Approach Selection

Laparoscopic vs Open Surgery

For hemodynamically stable patients with perforation, use laparoscopic repair as the preferred approach. 1, 2 Laparoscopic surgery offers reduced postoperative pain, fewer wound infections, and comparable mortality to open surgery. 2

Mandatory indications for open surgery include: 1, 2

• Hemodynamic instability (pneumoperitoneum worsens shock)
• Absence of laparoscopic expertise or equipment
• Severe sepsis
• Technical difficulties requiring conversion

Operative Procedures by Indication

Perforated Duodenal Ulcer

For perforations <2 cm: Perform simple closure with or without omental patch (Graham patch). 2, 8 Simple closure alone has a leak rate of 12-17%, which is acceptable given the simplicity of the procedure. 2

For perforations ≥2 cm or those near the ampulla of Vater: Consider complex procedures including jejunal serosal patch, Roux-en-Y duodenojejunostomy, or pyloric exclusion. 8 Thoroughly investigate proximity to the common bile duct and ampulla; intraoperative cholangiography may be necessary. 8

Critical technical point: Oversewing of bleeding duodenal ulcer via duodenotomy with ligation of the gastroduodenal artery is the definitive surgical hemorrhage control method when endoscopy fails. 3

Perforated Gastric Ulcer

For small perforations (<2 cm) with healthy tissue: Perform laparoscopic simple closure with direct suture repair (single or double layer). 7 No routine need for omental patch in straightforward cases. 7

For large perforations (≥2 cm) with friable edges or suspected malignancy: Perform gastric resection with frozen section examination. 2, 7 The gastric fundus location is generally easier to repair than duodenal perforations and more amenable to resection when indicated. 7

Bleeding Peptic Ulcer

Emergency surgical hemostasis options include: 3, 5

• Direct suture ligation of the bleeding vessel
• Extraluminal ligation of the gastroduodenal artery
• Gastric resection for bleeding gastric ulcers (preferred when feasible)

For massive hemorrhage from stress ulceration requiring surgery: Perform near-total or total gastrectomy. 9

Gastric Outlet Obstruction

Perform gastrojejunostomy or gastric resection (vagotomy-antrectomy preferred). 5, 9 Vagotomy with drainage is an acceptable alternative. 9

Acid-Reduction Procedures: No Longer Indicated

Do not perform definitive acid-reducing procedures (vagotomy, antrectomy) in the emergency setting. 2 Modern proton pump inhibitors have eliminated the need for these procedures, which add operative time and morbidity without improving outcomes. 2, 4 Only 19.8% of contemporary operations include acid-reduction procedures, and their omission does not increase recurrence rates when combined with PPI therapy and H. pylori eradication. 6

The historical practice of adding vagotomy-pyloroplasty or vagotomy-antrectomy to perforation repair is obsolete. 9

Essential Perioperative Management

All patients require: 2, 7

• Thorough peritoneal lavage and drainage regardless of approach
• Empiric antibiotics covering gram-negative and anaerobic organisms, continued for several days postoperatively
• Postoperative H. pylori testing and eradication therapy if positive (most important intervention for preventing recurrence)
• Continued proton pump inhibitor therapy
• Strict avoidance of NSAIDs (etiologic in 36% of cases and associated with increased mortality)

Critical Prognostic Factors

Key predictors of mortality include: 1

• Age >70 years
• Shock on admission
• Preoperative metabolic acidosis
• Surgical delay >24-36 hours
• Perforation-to-surgery interval >36 hours

Overall mortality for emergency peptic ulcer surgery ranges from 7.4-19.8%, with significantly higher mortality in hemorrhage cases (38.9%) compared to perforation (14.5%). 6

Common Pitfalls to Avoid

Do not delay surgery for extensive preoperative optimization in perforation cases—every hour counts. 1 The 2.4% per-hour mortality increase is unforgiving. 1

Do not attempt simple closure on large perforations (≥2 cm) with friable tissue—leak rates are unacceptably high. 7

Do not miss occult malignancy in gastric perforations—maintain high suspicion and obtain frozen section if the ulcer appears atypical. 2, 7

Do not attempt complex resections in hemodynamically unstable patients—damage control principles with simple closure and planned reoperation if necessary. 7, 8

Avoid endoscopic treatment (clipping, fibrin glue, stenting) for perforated peptic ulcer—clips are ineffective in fibrotic tissue and these modalities are not validated as standard approaches. 1