A 72-year-old patient with an intractable type I ulcer along the incisura with a significant amount of scarring along the entire length of the lesser curvature. Select the appropriate surgical procedure for the patient. (SELECT 1 PROCEDURE)
Gastric ulcers have been classified as type I (incisura or most inferior portion of lesser curvature), type II (gastric and duodenal), type III (pyloric and prepyloric), and type IV (juxtacortical). Indications for surgery are intractability, perforation, obstruction, and bleeding. A patient with an intractable type I ulcer can be treated with an antrectomy alone or with a proximal gastric vagotomy. If done properly, antrectomy offers slightly lower recurrence rates and a higher incidence of postoperative sequelae as compared with proximal gastric vagotomy. However, significant scarring along the lesser curvature makes a proximal gastric vagotomy technically unfeasible.Gastric outlet obstruction and severe inflammation around the pylorus and duodenum make resection a difficult and dangerous option. Similarly, pyloroplasty is often not adequate in the setting of gastric outlet obstruction to provide adequate drainage. Vagotomy and gastrojejunostomy, although associated with the highest recurrence rate, offers the best choice in the described setting.In an elderly patient with a bleeding duodenal ulcer, recurrence rates are less of a consideration and thus the simplest and most expedient operation offers the best surgical outcome. Vagotomy and pyloroplasty with oversewing of the ulcer is the best choice in this setting. Finally, in a young patient with intractable type III ulcers, antrectomy with vagotomy offers the best long-term outcome. Recurrence rates following this procedure are about 2-3%, as compared with 7.4% for vagotomy and drainage and 10-31% in patients receiving a proximal gastric vagotomy only.
Vagotomy and antrectomy
Antrectomy alone
Vagotomy and pyloroplasty
Vagotomy and gastrojejunostomy
Liver