Cut to the Point: Revisiting the Role of Gastrectomy in Peptic Ulcer Disease

Introduction

The surgical management of peptic ulcer disease (PUD) has undergone profound changes over the past decades.^1,2 Historically, peptic ulcers were a prevalent cause of morbidity, often necessitating laparotomy and gastroduodenal resection or repair as standard treatment. However, this paradigm shifted as the use of proton pump inhibitors (PPI), H2 blockers, and the medical management of Helicobacter pylori infection has significantly reduced the incidence and severity of complicated PUD. ³ As a result, the role of surgery has decreased, and now cases requiring surgical intervention are far less common.

Despite this reduced need for surgical intervention in the management of PUD, the absence of standardized, evidence-based guidelines for when gastroduodenal resection is warranted presents a significant gap in the literature. A 2016 Cochrane Database Systematic Review of the management of refractory PUD describes, a “lack of recent, high-quality evidence comparing medical and surgical treatments (including vagotomy) for refractory or recurrent peptic ulcers.” ⁴ Current recommendations often draw from older studies conducted before the widespread use of newer medical management techniques, limiting their applicability to contemporary clinical practice. This review seeks to address this deficiency by summarizing the current literature and clarifying the indications for gastrectomy in the management of PUD, offering a framework for consistent and informed surgical decision-making.

Methods

Based on recent published data and societal recommendations, we conducted a broad literature search to identify current guidelines and suggestions for the operative management of perforated PUD (Figure 1). We searched PubMed, Google Scholar, and the Cochrane Library for studies of human participants, published in English between 2010 and 2024. Keywords utilized included “gastrectomy,” “surgical management in PUD,” “omental flap,” and “vagotomy.” Exclusion criteria included studies not primarily written in English, studies without a primary focus on patients with PUD or surgical management, individual case studies, and small sample sizes (n < 25). Data regarding medical and surgical management recommendations for PUD were extracted for each study that met the inclusion criteria.

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Figure 1.

Flow chart of the systematic literature search conducted to identify studies that reported the surgical management of PUD related to total or partial gastrectomy. CONSORT diagram for study selection.

Results

From the total of 6250 publications retrieved from the databases, we ultimately included 29 publications following a review of the abstracts and manuscripts (Figure 1). Eight studies described the updated guidelines of PUD management including the decreasing prevalence of operative management as the initial treatment therapy. Nine publications discussed the current recommendations for complicated ulcers, while 6 studies described operative management for large ulcers and 6 studies reported on the use of surgery in critically-ill patients.

Discussion

The management of PUD has evolved significantly shifting from a primarily surgical approach to one dominated by medical interventions.^2,5 Advances in pharmacotherapy, nutritional support, and endoscopic techniques have greatly reduced the need for surgical treatment. Complications such as bleeding and perforation are now managed using well-established methods like endoscopic intervention or trans-arterial catheter embolization (TAE) for hemostasis, which are considered standard for treating bleeding ulcers. ² The surgical approach to ulcer management has also adapted to include omental flaps and simple suture repair. ⁶ Additionally, the growing understanding of H. pylori as a major contributor to PUD has further transformed treatment strategies.^2,3,5-8 Collectively, these advancements have significantly reduced the role of surgery in PUD management. However, even with these advances, there are specific situations when resection via distal, partial, or total gastrectomy is still recommended as the management of choice, specifically in complicated PUD. A review in 2020 in the World Journal of Emergency Surgery described complications occurring in 10-20% of patients with PUD, with the most common complication being hemorrhage. ⁹ The most recent recommendations focus on four categories for when a gastrectomy should be completed over other surgical methods—these include large ulcers >2-3 cm, multiple ulcers, incidental malignancy discovery, salvage operations, and complicated disease including perforations and hemorrhage.^2,6,8,10-12

The Journal of Gastroenterology published their updated guidelines for the management of perforated ulcers. Current recommendations for nonsurgical management of PUD begin with H. Pylori eradication and PPIs. The management algorithm continues to include complicated ulcerative disease including perforation and bleeding. ³ With the use of the latest recommendations surgical management as the index therapy continues to decrease. Moreover, advancements in endoscopic hemostatic techniques and image-guided embolization have further minimized the need for emergency surgery. Endoscopy is the first-line treatment for achieving hemostasis in both gastric and duodenal ulcers and has been shown to reduce mortality rates and the need for surgical intervention. ⁸ A meta-review from 2023 discussing endoscopic techniques usage in nonvariceal upper GI bleeding concludes that the addition of endoscopic Doppler probe decreased the risk of rebleeding, bleeding-related mortality, and need for surgery compared to standard endoscopic methods. ⁷ All together as advancements continue to be made in medical management, there will continue to be a shift in the surgical recommendations for PUD.

With the increased use of other surgical techniques, the use of gastrectomy has decreased due to many studies showing better outcomes. Primary repair is generally recommended in patients with perforated peptic ulcers smaller than 2 cm. While historically adding an omental patch was considered the standard, recent studies suggest that simple suture repair is equally effective, with no significant difference in leakage rates between the two methods. Omentopexy, however, increases operative time and requires advanced laparoscopic skills, making its routine use unnecessary unless the ulcer is large or has friable edges, where an omental patch may reduce the risk of suture cut through.^3,13

Large ulcers, particularly those over 2-3 cm in size, often necessitate resection surgery, including gastrectomy, due to the complexity and risk associated with these lesions. In cases of hemorrhage, resection is typically required to fully remove the bleeding ulcer. This approach is particularly important for preventing recurrence or missing a potentially malignant lesion. Many studies have assessed that the size threshold for performing an omental flap has increased from 2 to 3 cm, emphasizing the need for more aggressive surgical management of larger ulcers.^1,14-16 Ulcers over 3-4 cm, especially those located on the gastric wall or greater curvature, or those involving multiple or giant ulcers (exceeding 5 cm), are more likely to require partial or even near-total gastric resections. In these cases, resection not only addresses the immediate risk of bleeding and perforation but also ensures the removal of lesions that could involve neighboring organs or present an ongoing risk for complications.^6,9,14,15,17 Multiple gastric ulcers, secondary to NSAID use, stress ulcers, or neoplastic conditions, can present a significant challenge in management and may require resection, including gastrectomy when other treatments fail.^3,6

Gastrectomy may be required as a salvage procedure in cases of peptic ulcer disease that do not respond to standard treatments, such as laparoscopic perforation repair, endoscopic interventions, or arterial embolization.^4,8 A 2016 review from two institutions recommended that antroduodenectomy should be considered for critically-ill, well-selected patients, especially those with large perforations or recurrent massive bleeding after unsuccessful endoscopic or radiologic treatment of a duodenal ulcer. ¹² When other management strategies have been attempted and failed, gastrectomy becomes a viable option for definitive surgical intervention. ¹⁸

Acute complications of PUD, such as perforated and bleeding ulcers, can necessitate gastrectomy due to the associated increased risk of mortality. Bleeding PUD has a reported mortality rate ranging from 5% to 14%.^8,13 A 2022 review of over 15,000 cases demonstrated that patients with perforated ulcers who did not undergo surgery faced significantly higher mortality risks.^1,2 This underscores the importance of surgical intervention in cases of acute complications, where surgery often proves more effective than nonoperative therapies. A 2024 systematic review on the management of perforated ulcers further emphasized that emergent surgery is critical for treating hemorrhagic perforated ulcers. ¹⁰ Research into the use of artificial intellifence (AI) models for predicting which patients are at higher risk of perforation is ongoing, with promising results. Zhao et al ¹¹ showed that AI applications could improve the prediction of patient outcomes and risks. In cases of acute bleeding or perforated ulcers, gastrectomy may still be required to manage the ulcer and prevent further hemodynamic instability.

Conclusion

The management of PUD has undergone a significant transformation, shifting from predominantly surgical interventions to advanced medical therapies, supported by innovations in pharmacotherapy, nutritional support, and endoscopic techniques. These advancements have reduced the need for surgery, particularly in managing complications like hemorrhage and perforation, where endoscopic intervention and TAE now play central roles. However, surgery, particularly gastrectomy, remains essential in specific cases such as large or multiple ulcers, ulcers associated with malignancy, and complicated cases that do not respond to other treatments. Emerging technologies, including AI, continue to refine risk prediction and patient management, offering hope for further reducing surgical interventions. Despite these advancements, timely surgical intervention remains critical in acute, high-risk cases, particularly for managing life-threatening complications such as perforated or bleeding ulcers.