Stomach Ulcer Surgery: Everything You Need to Know

Stomach ulcer surgery (also known as gastric ulcer surgery or peptic ulcer surgery) is one of several procedures used for treating a stomach ulcer. Surgery is generally indicated when peptic ulcer disease causes pain or bleeding that doesn't improve with non-surgical treatment.

In addition to a gastrectomy which removes part of the stomach, there are surgeries that specifically target parts of the stomach that produce stomach acid. Others patch perforations (holes) in the stomach or improve the movement of food through the stomach so that acid buildup is reduced.

This article describes five different surgeries used to treat stomach ulcers, including when they are needed, what they do, and the possible risks and complications.

Types of Stomach Ulcer Surgery

Peptic ulcer surgery is an operation used to treat an open sore (ulcer) on the lining of the stomach or the upper portion of the small intestine, called the duodenum. The surgery may be used to remove bleeding tissues that fail to heal or slow the production of acid that causes stomach ulcers.

The surgery may approached in different ways, some of which are more invasive than others:

• Laparotomy: This is a traditional open surgery in which a large incision is made in the abdomen.
• Minimally invasive laparoscopic surgery: This involves making two or three small "keyhole" incisions through which a lighted scope (laparoscope) and specialized equipment can be inserted to perform surgery.
• Endoscopic surgery: This minimally invasive procedure involves a flexible tube with a lighted scope (endoscope) that is fed down the throat and into the stomach. Specialized surgical tools can then be threaded to the scope to cut, burn, or remove tissues.

There are five specific surgeries commonly used to treat stomach ulcers, some of which are used in combination:

Graham Patch

A Graham patch, also known as an omental patch or Graham omentoplasty, is used to repair a perforation caused when an ulcer breaks (or is about to break) through the wall of the stomach. It involves taking a patch of omentum (fatty tissue that normally covers the stomach and intestines) and suturing it over the hole in the stomach.

The Graham patch can be done laparoscopically but may require open surgery in a medical emergency. The surgery takes roughly two hours to complete. Recovery time depends on the severity of the perforation.

Subtotal Gastrectomy

Subtotal gastrectomy, also known as a partial gastrectomy, is the removal of part of the stomach. It is sometimes used when the bleeding of an ulcer cannot be stopped with any other conservative means.

With a partial gastrectomy, an area of the stomach affected by ulcers is resected (removed), and the cut ends are stitched together to close the wound. Depending on how much tissue is resected, the surgery can take anywhere from two to six hours to complete.

If the ulcer is located near the duodenum, the stomach may need to be reconnected to the small intestine. Similarly, if the ulcer is located near the esophagus (feeding tube), reconnection of those structures may be needed.

Subtotal gastrectomy can be performed as an open laparotomy or done laparoscopically depending on the size and location of the resection. People who undergo a gastrectomy can usually return to normal physical activity in four to six weeks, although complete recovery may take longer.

Vagotomy

A vagotomy is a surgical procedure in which one or more branches of the vagus nerve are cut, resected, or ablated (burned).

The vagus nerve, which runs from the brain to the large intestine (colon), stimulates the release of stomach acid when exposed to the sight, smell, or taste of food. In some people, the vagus nerve may be overly stimulated and produce too much stomach acid. Strategically severing the nerve may significantly reduce acid production.

Vagotomy can be performed on its own endoscopically but is more commonly done with other surgeries such as antrectomy or pyloroplasty. Recovery times vary based on which combination of procedures are used.

Antrectomy

Antrectomy is a surgery that removes the lower third of the stomach, called the antrum, which produces a hormone called gastrin. Gastrin stimulates the production of stomach acid from specialized cells lining the stomach and duodenum, called parietal cells.

Antrectomy may also lower the proportion of gastric chief cells lining the wall of the stomach. These cells produce a digestive enzyme called pepsin that, when overproduced, can thin the layer of mucus otherwise protecting the stomach.

A vagotomy is usually done along with an antrectomy as an open laparotomy or laparoscopic surgery. Recovery times are similar to those for a gastrectomy.

Pyloroplasty

Pyloroplasty is a surgery used to widen the opening at the lower part of the stomach, called the pylorus. It specifically targets the pyloric sphincter, the ring of smooth muscle that helps to regulate the flow of food and prevents the reflux of acid from the stomach to the duodenum.

There are several techniques that can be used for pyloroplasty. The most common is the Heineke-Mikulicz technique which widens the pylorus by making a vertical cut, pinching the cut horizontally, and suturing the wound shut in that position.

Pyloroplasty can be performed laparoscopically or as an open surgery. It is almost never performed by itself and is most commonly paired with vagotomy. Recovery and a return to normal activities should take four to six weeks.

Stomach Ulcer Surgery Risks and Complications

Stomach ulcer surgery can cause immediate complications or may result in delayed digestive issues. Some immediate complications are due to unplanned surgical events, while delayed problems are generally related to structural changes that are an inherent part of the therapeutic procedure.

Operative complications can include infection, bleeding, a new perforation, or an injury to the esophagus, stomach, or small intestine.

These issues may cause:

• Pain
• Fever
• Nausea
• Vomiting
• Hematemesis (vomiting blood)
• Hematochezia (blood in the stool)
• Dizziness

Excessive postoperative inflammation can cause gastrointestinal obstruction, with pain, abdominal distension (swelling of the abdomen), severe constipation, and vomiting.

Who Shouldn’t Get Stomach Ulcer Surgery?

There are several issues that may prevent you from having peptic ulcer surgery:

• You may not be able to undergo surgery if your stomach ulcer is very large or not repairable with surgery.
• Sometimes a chronic illness, like Crohn's disease, can make you susceptible to recurrent ulcers, and surgical treatment may not be a definitive therapeutic approach.
• Additionally, if you have a severe illness, like cancer, you might not be able to tolerate the surgery; this could be a contraindication to having the procedure.

Purpose of the Procedure

Peptic ulcers can cause pain, stomach discomfort, abdominal cramps, decreased appetite, hematemesis, gastrointestinal bleeding, iron deficiency anemia (a type of red blood cell deficiency), and malnutrition.

Generally, the condition can be effectively treated with medication and lifestyle changes, rather than with surgical intervention. Smoking and alcohol use can contribute to stomach ulcers, and stopping these habits can help an ulcer heal. Sometimes dietary modifications, like avoiding spicy foods, can help control symptoms.

Treatments for gastric ulcers include proton pump inhibitors (PPIs) and antibiotics to eradicate Helicobacter pylori, a bacteria that is commonly associated with stomach ulcers.

Surgical management may be needed for complications of peptic ulcer disease or for treatment of a stomach ulcer that doesn't improve despite conservative management.

Issues that may warrant surgical intervention for the treatment of peptic ulcer disease include:

• Perforation: An ulcer can form a hole in the wall of the stomach. This is a life-threatening complication that results in the leaking of digestive juices, food, and bacteria from the stomach into the abdominal cavity. A perforated ulcer causes sudden, severe stomach pain, and it can result in a fever, profuse bleeding, dangerous blood chemistry abnormalities, and loss of consciousness.
• Bleeding: A bleeding ulcer may manifest with blood in the stool (it can appear bright red or black) and/or hematemesis. It can be painful or painless. Typically, a bleeding ulcer is treated with endoscopic repair, and if the bleeding is profuse and sudden, emergency surgery may be needed.
• Gastric outlet obstruction: Gastric outlet obstruction is a rare complication of stomach ulcers that causes swelling or scarring. These issues narrow the stomach so that its contents can't pass through. Symptoms include vomiting and abdominal pain. Gastric outlet obstruction may be relieved with an upper endoscopy or with a surgical procedure, and the ulcer would be treated at the same time.
• Refractory or recurrent disease: Stomach ulcers that don't improve or that worsen despite non-surgical treatment may require surgical intervention. Resistant, non-healing ulcers can be caused by a disease that produces gastric fluid, like Zollinger-Ellison syndrome, or by the erosion of the stomach lining due to gastric cancer.

These issues can cause persistent and serious health problems. Stomach ulcer surgery would be done to alleviate your symptoms and prevent consequences to your overall health.

How to Prepare

Before your surgery, your practitioner will obtain imaging tests to help plan your procedure. This can include non-invasive tests, as well as imaging obtained with an endoscopy. You will also have blood tests, like a complete blood count (CBC) to evaluate you for anemia.

In preparation for surgery and anesthesia, you will need to have an electrocardiogram (EKG), chest X-ray, and a blood chemistry panel. Medical issues, like anemia or abnormal electrolyte levels (such as altered calcium or potassium), may need to be corrected before you can proceed with your surgery.

Your healthcare provider will also discuss the surgical technique with you and will explain whether you will have a surgical incision and a post-operative scar.

Location

An open laparotomy or laparoscopic procedure would be performed in an operating room in a hospital or surgical center.

An endoscopic surgery would be done in an operating room or a procedural suite, either of which could be in a hospital or surgical center.

What to Wear

Wear something comfortable to your surgery appointment. Make sure you have clothes that don't have a tight waist to wear on your way home.

Additionally, you might have a surgical drain if you are having laparoscopic surgery, so it is best if you wear clothes with easy access to your abdominal area (avoid a dress; consider wearing a loose shirt or one with buttons).

Food and Drink

You will need to fast from eating and drinking after midnight the night before your surgery.

Medications

Your healthcare provider may adjust some of your medications in the days or weeks before your peptic ulcer surgery. For instance, you might be directed to change the dose or stop blood thinners that you are taking. You may also need to adjust the dose of anti-inflammatory medications, diabetes medications, or treatments that you take for your peptic ulcer disease.

What to Bring

When you go to your surgery appointment, take a form of personal identification, your insurance information, and a method of payment if you are responsible for paying for some or all of the cost of your surgery.

You should also have someone with you who can take you home because you will not be able to drive for at least a few days after your surgery.

Pre-Op Lifestyle Changes

Before your surgery, your healthcare provider will advise you to avoid smoking and drinking alcohol so that your ulcer is not further irritated. You might also be instructed to avoid eating things that can exacerbate a peptic ulcer, such as spicy or acidic foods.

What to Expect on the Day of Surgery

When you go to your surgery appointment, you will register and sign a consent form. You may have some pre-operative testing before you go to the pre-surgical area. These tests may include a chest X-ray, CBC, blood chemistry panel, and urine test.

You will be asked to change into a hospital gown. You will have your temperature, blood pressure, pulse, respiratory rate, and oxygen level checked.

If you are having stomach ulcer surgery for an emergency, like a perforation, your preparation will happen quickly. You will need to have IV fluids and possibly a blood transfusion during this period.

Before the Surgery

Before your procedure is started, you will have specific preparation and anesthesia that corresponds to the type of procedure you are having.

• IV sedation: This is used for an endoscopic procedure. For this type of sedation, the anesthetic medication is injected into your IV and will make you sleepy. Your pulse, blood pressure, respiratory rate, and oxygen level will be monitored from start to finish. You might fall asleep before or during your surgery. Additionally, if you have an endoscope placed in your mouth, oral anesthetic medication (in your mouth and throat, usually via a spray) may be used to ease any discomfort.
• General anesthesia: This is used if you are having an open laparotomy or a minimally invasive laparoscopic procedure. General anesthesia involves the injection of IV anesthetic medication that would put you to sleep, decrease your sensation, and prevent you from moving. For this type of anesthesia, you would have a tube placed in your throat so you can breathe with mechanical assistance during your surgery.

If you are having an open laparotomy or a minimally invasive laparoscopic surgery, a drape will be placed over your body. A small area of your skin will be exposed where the incision will be placed. Your skin will be cleansed before the surgery starts.

These steps are not necessary before endoscopic stomach ulcer surgery.

During the Surgery

Your surgical procedure will begin after the preparation steps. The next steps will depend on which technique your surgeon is using to treat your peptic ulcer.

Endoscopic Surgery: Step by Step

If you are having an endoscopic surgery, once you are asleep, the endoscope is gently advanced through your mouth and esophagus into your stomach. You shouldn't feel any discomfort during this process.

Your healthcare provider will be able to see your ulcer and the surrounding structures on a monitor with the aid of the endoscopic camera. Surgical tools that are inserted through the endoscopic device will be used to treat and control ulcer bleeding.

Various tools, including clips, electric cautery, and injectable agents, are used to stop bleeding and prevent recurrent bleeding.

When the treatment is complete, the endoscope is removed.

Laparoscopic Surgery: Step by Step

For a laparoscopic procedure, your surgeon will make a small skin incision that is approximately 2 inches in length. Then they will cut through the peritoneum (membrane lining the abdomen) and fat that encloses your stomach and intestines. Your surgeon will cut a small opening in your stomach as well.

The laparoscopic device, which is equipped with surgical tools and a camera, is inserted through the opening of the skin, advanced into the peritoneum, and then the stomach where it's used to visualize the structures on a monitor.

Your surgeon will proceed with your surgery, which may include cutting a portion of your vagus nerve, cutting away the ulcer and repairing the abdomen, or patching the ulcer with healthy tissue. This process will involve the placement of sutures and control of bleeding.

After the stomach ulcer is surgically treated, your surgeon will close the peritoneum and the skin. You might have a surgical drain placed in your peritoneum or stomach and extended outside your body to collect blood and fluid as you are healing.

Open Laparotomy: Step by Step

For an open peptic ulcer surgery, your surgeon will make an incision that measures 3 to 6 inches. They will also cut through your peritoneum and into your stomach, near your peptic ulcer.

Your surgery may include resection of your ulcer and attaching your stomach opening to the opening of your small intestine, surgically closing a newly created opening in your stomach, or suturing healthy tissue to patch your ulcer.

After the repair, you may have a drain placed, and your peritoneum and skin will be closed with sutures.

Once your surgery is complete, your surgical wound will be covered with a dressing. Your anesthesia medication will be stopped, and your breathing tube will be removed. When you are medically stable and breathing well on your own, you will go to a postoperative recovery area.

After the Surgery

In the recovery area, your medical team will monitor your health, including your pain or discomfort, fluid in your drain, and whether you are passing gas. You will be assessed for signs of complications, such as hematemesis, vomiting, and severe abdominal pain.

After a few hours, you will be asked to drink clear fluids. Your medical team will ask you to slowly advance your food and drink liquids. You will need to be able to eat solid food, like a cracker without experiencing any pain or vomiting before going home.

• Barring any complications, you are likely to go home on the day of your procedure if you are having your peptic ulcer surgery endoscopically.
• An open laparotomy or laparoscopic surgery usually involves an overnight stay of one or two days.

If you develop problems (like severe pain or vomiting) as your diet is advanced, you may need further evaluation.

Before discharge, your medical team will discuss advancing your diet, pain control, and how to care for your drain and wound (if applicable). You will be given guidance regarding when to schedule follow-up appointments with your healthcare provider, as well.

Recovery

After surgery for a stomach ulcer, it will take time to fully heal. You will need to gradually advance your diet, and the pace at which to do so depends on the type of surgery you had and your tolerance for food.

For example, your healthcare provider might advise that you drink clear fluids for a given amount of time, and then advance to bland soft food when it's clear that you are tolerating the earlier step.

As a general rule of thumb, your recovery will be faster and easier after an endoscopy, and more gradual if you have had a laparoscopy, with a longer recovery if you've had an open laparotomy. The need for a drain usually corresponds with a slower recovery as well.

Any immediate postoperative complications, such as an infection or extensive swelling, can prolong full recovery.

Healing

If you have a wound and drain, you will need to make sure that you take care of them as instructed while you heal. That means keeping them dry and clean when you are bathing.

You will receive a prescription for pain medication, which should be used as directed. You might also receive a prescription medication and dietary instructions to control constipation.

Coping With Recovery

As you are recovering after surgery, you may be somewhat sore, especially if your surgery was not an endoscopic procedure. It is best not to push yourself when it comes to physical activity.

You can get up and walk, but don't run or lift heavy objects until your wound is fully healed and your drain is removed.

Long-term Care

You may need to take antacid medication if you have problems with stomach upset or heartburn. Sometimes taking medication can prevent another ulcer from developing, and your healthcare provider will advise you about this based on your risk of developing another ulcer.

Possible Future Surgeries

Generally, a stomach ulcer surgery shouldn't lead to future procedures. If you develop issues like postoperative obstruction or perforation, you could need to have another surgery to treat these problems.

Lifestyle Adjustments

After stomach ulcer surgery, you might benefit by adjusting your diet and habits for the long term. This may include continued avoidance of smoking and alcohol, as well as acidic and spicy foods.

If you have a problem with gastric motility (the movement of food through your system), your healthcare provider may advise that you eat small, frequent meals rather than large meals to avoid bloating or nausea.

Summary

Stomach ulcer surgery is used when bleeding from peptic ulcer disease cannot be controlled. The surgery may be used to cut away areas of bleeding (gastrectomy), patch a hole in the stomach (Graham patch), or severe the nerve that stimulates stomach acid production (vagotomy).

Other surgeries may be used to remove parts of the stomach that play a role in ulcer formation (antrectomy) or to prevent acid buildup by widening the channel between the stomach and the small intestine (pyloroplasty).