The management of gastric ulcers. A current review

In the past 10 years, 163 patients with documented gastric ulcers were treated at Vanderbilt University and Metropolitan Nashville General Hospitals. One hundred thirty-five were initially managed medically. Medical therapy was successful in 58 patients (43%) in this group. Twenty-eight (17%) patients required surgical treatment initially. An additional 77 patients (57%) became candidates for surgical management when their medical management failed. Of this group, 40 now have been surgically treated and 37 still have symptoms while on medical treatment. Three patients being treated for benign ulcers, two for as long as six years each, were found to have carcinoma of the stomach diagnosed by subsequent endoscopy and biopsy in one and by laparotomy with gastrectomy to include the ulcer in two. We consider subtotal gastrectomy or surgical resection of the antrum, including the ulcer site, to be the preferred surgical treatment for gastric ulcers, and this was done in 50 cases. Vagotomy was done in addition to the antrectomy in 31 of these, and in addition to the subtotal resection in 11. Two patients who had vagotomy and resection subsequently developed a marginal ulcer. One of these who had a subtotal resection and vagotomy healed with medical treatment. The one who had a vagotomy and antrectomy required a second vagotomy for a missed vagus nerve. Gastrointestinal endoscopy in the past 10 years has improved to the point that very few malignant ulcers are missed by endoscopic biopsy. Large ulcers, those that perforate or continue to bleed, and those that fail to heal on medical treatment for a maximum of 2 to 3 months should be submitted to an antrectomy that includes the ulcer. Vagotomy should be added in selected cases.