The Necessity of Subtotal Gastrectomy for Peptic Ulcers: Why Remove So Much of the Stomach?

Peptic ulcers, including both gastric and duodenal ulcers, are often treatable with medication. However, when these ulcers fail to respond to standard medical therapy, are suspected of malignant transformation, or lead to complications such as pyloric obstruction, perforation, or gastrointestinal bleeding, subtotal gastrectomy becomes the most effective treatment option. A common question patients ask is: Why remove as much as two-thirds of the stomach? Can't a smaller portion be removed instead?

Understanding the Anatomy and Function of the Stomach

The stomach is located in the upper left quadrant of the abdomen and is divided into four main regions: the cardia, fundus, body, and pylorus. The pyloric region is further divided into the pyloric antrum (or gastric antrum) and the pyloric canal. These anatomical distinctions are important because different areas of the stomach are responsible for various physiological functions.

The stomach performs five essential functions: storing food, mechanical and chemical digestion, transporting digested food to the small intestine, defending against pathogens, and secreting various enzymes and acids. Among these, the secretion of hydrochloric acid and pepsin plays a crucial role in digestion but also contributes to ulcer formation when overactive.

Why Two-Thirds of the Stomach Must Be Removed

Hydrochloric acid is primarily secreted by parietal cells located in the distal two-thirds of the stomach. Additionally, gastrin-secreting G cells in the gastric antrum stimulate acid production through hormonal pathways. Most gastric and duodenal ulcers occur in this distal region, making it a key target for surgical intervention.

Subtotal gastrectomy removes the majority of acid-producing parietal cells and gastrin-secreting G cells, effectively reducing acid secretion. It also eliminates the ulcer-prone area of the stomach, thereby preventing complications like bleeding, perforation, and malignant transformation. This approach ensures long-term relief and significantly reduces the risk of ulcer recurrence.

What Happens If Less of the Stomach Is Removed?

If only a portion of the stomach is removed—such as half or less—there's a high risk of residual parietal cells remaining active. This can lead to recurrent ulcers in the remaining stomach or at the surgical anastomosis site, a condition known as anastomotic ulcer. Such outcomes are considered surgical failures and may require additional interventions.

Recovery and Long-Term Digestive Function After Surgery

While removing a large portion of the stomach may seem drastic, the remaining gastric tissue—approximately one-third—adapts over time. In the initial postoperative period, patients are advised to eat small, frequent meals (4–5 times a day), gradually transitioning from liquid to solid foods. Within a year, the residual stomach often expands to near-normal size and regains much of its digestive capacity.

In conclusion, subtotal gastrectomy is a well-established and effective treatment for severe or complicated peptic ulcers. Despite the significant resection, the long-term impact on digestion is minimal due to the adaptive capacity of the gastrointestinal tract. Patients can expect a return to normal eating patterns and improved quality of life following recovery.