When Is Surgery Necessary for Severe Gastric Ulcers?

Gastric ulcers are typically managed with a combination of medications, particularly through a strict 6-8 week course of quadruple therapy. This non-surgical approach is effective for the majority of patients and avoids the risks associated with surgery. However, in certain severe or treatment-resistant cases, surgical intervention may be necessary.

Surgery for gastric ulcers is generally considered only when conservative treatments fail or complications arise that threaten the patient's health. While surgical procedures carry potential complications and do not guarantee prevention of ulcer recurrence, they remain an essential option under specific conditions.

The main indications for gastric ulcer surgery include:
1. Failure of the ulcer to heal after 6-8 weeks of intensive medical therapy.
2. Life-threatening hemorrhage that cannot be controlled by endoscopic or interventional radiology techniques.
3. Acute perforation, chronic penetrating ulcers, pyloric obstruction, or suspicion of malignant transformation.

There are two primary types of surgical procedures for gastric ulcers: partial gastrectomy and vagotomy. Currently, partial gastrectomy is the more commonly performed procedure. Depending on how the digestive tract is reconstructed following surgery, this method can be categorized into three subtypes:

Types of Gastrectomy Procedures:
1. Billroth-I Anastomosis: The remaining stomach is directly connected to the duodenum, preserving more of the natural digestive anatomy and function.
2. Billroth-II Anastomosis: In this method, the remaining stomach is connected to the upper part of the jejunum, while the duodenal stump is closed off. It is often used when there is significant scarring or tension at the original connection site, although it carries a higher risk of postoperative complications.
3. Roux-en-Y Gastrojejunostomy: This technique involves connecting the stomach to the jejunum further down the digestive tract, effectively preventing bile reflux gastritis and reducing the risk of recurrent ulcers at the anastomosis site.

Each surgical option has its own advantages and drawbacks, and the choice must be tailored to the individual patient's condition, overall health, and specific ulcer characteristics. Ultimately, the guiding principles of ulcer surgery are to address the underlying disease, ensure patient safety, and minimize the risk of postoperative complications.