Why Is a Partial Gastrectomy Necessary for Peptic Ulcers? Can Less Be Removed?

Peptic ulcers, including both gastric and duodenal ulcers, can often be effectively treated with medication. However, when ulcers fail to heal despite systematic and standardized medical treatment, or when there is suspicion of malignancy—especially in the case of refractory ulcers—or when complications such as pyloric obstruction, perforation, or gastrointestinal bleeding occur, a partial gastrectomy becomes the most effective treatment option. This surgical procedure involves removing approximately two-thirds of the stomach, commonly referred to as a distal partial gastrectomy.

Understanding the Rationale Behind Removing Two-Thirds of the Stomach

Many patients question why such a large portion of the stomach must be removed. Could removing less still be effective? And won't removing so much of the stomach impair digestion? To understand this, it's important to first explore the anatomy and physiological functions of the stomach.

Anatomical Overview of the Stomach

The stomach is located in the upper left quadrant of the abdomen and is divided into two openings (the cardia and pylorus), two curvatures (lesser and greater curvature), and two walls (anterior and posterior). The cardia connects to the esophagus, while the pylorus connects to the duodenum. The stomach is further divided into four regions: the cardia, fundus, body, and pylorus. The pylorus itself is split into the pyloric antrum (or gastric antrum) on the left and the pyloric canal on the right. The junction between the body and antrum along the lesser curvature is known as the angular notch.

Key Physiological Functions of the Stomach

The stomach performs five primary physiological functions:

• Receiving and storing ingested food
• Digesting food through gastric motility and secretions such as hydrochloric acid and pepsin
• Transporting semi-digested food into the small intestine for further digestion and absorption
• Providing a defense mechanism via the mucosal barrier, gastric acid, immunoglobulins (IgA, IgG), and lymphatic tissue
• Secreting essential substances like hydrochloric acid, pepsin, gastrin, motilin, and somatostatin

Hydrochloric acid, secreted by parietal cells in the gastric mucosa, plays a central role in digestion. However, excessive acid production—often exacerbated by the presence of Helicobacter pylori—can damage the gastric lining, leading to ulcer formation in both the stomach and duodenum. This mechanism explains why ulcers predominantly occur in the distal two-thirds of the stomach.

Why Target the Distal Two-Thirds?

Most of the parietal cells responsible for acid secretion are concentrated in the distal portion of the stomach. Additionally, the gastric antrum contains G cells that secrete gastrin, a hormone that stimulates acid production. Since the majority of peptic ulcers occur in this region, removing this section effectively reduces acid production and eliminates the ulcer-prone area.

Benefits of Distal Gastrectomy

Performing a distal partial gastrectomy offers multiple advantages:

1. Reduces acid secretion by removing the majority of parietal cells
2. Eliminates gastrin-secreting G cells in the antrum
3. Removes the primary site of ulcer formation, thereby preventing complications like bleeding, perforation, obstruction, and malignancy

If only a smaller portion of the stomach is removed—such as half or less—there is a high risk of ulcer recurrence due to residual acid-secreting cells. This can lead to ulcers and bleeding at the surgical anastomosis site, which is considered a surgical failure.

Post-Surgery Digestive Function and Recovery

Although partial gastrectomy temporarily affects digestion, patients can adapt well with proper dietary management. It is recommended to eat small, frequent meals (4–5 times daily) and choose easily digestible, nutrient-rich foods. Starting with a liquid diet and gradually transitioning to semi-solid and then regular foods helps the body adjust. In most cases, the remaining stomach tissue expands over time—often reaching near-normal size within a year—and regains much of its digestive function.