Indications for Distal Gastrectomy in Peptic Ulcer Disease

Primary Indications

The World Journal of Emergency Surgery recommends distal gastrectomy for peptic ulcer disease in cases of large gastric perforations near the pylorus, gastric corpus perforations, suspicious malignancy, and refractory bleeding that cannot be managed by endoscopic or angiographic interventions 1
Large perforations (≥2 cm) are an indication for distal gastrectomy, particularly when located near the pylorus or in the gastric corpus, where simple repair may be inadequate 1
Suspected malignancy is an indication for distal gastrectomy, when ulcers have suspicious features requiring histopathological examination 1
Refractory bleeding is an indication for distal gastrectomy, when endoscopic and angiographic interventions fail to control hemorrhage 2
Gastric outlet obstruction from chronic fibrotic disease causing stenosis is an indication for distal gastrectomy 3

Hemodynamic stability is crucial for patient selection, as the patient's condition must allow for a more extensive procedure than simple repair 1, 4
Patient classification, with Class A or B patients being better candidates than Class C patients, is important for selecting patients for distal gastrectomy 1
Perforation characteristics, including size, location, and chronicity, influence the decision to perform distal gastrectomy 4

For perforated peptic ulcer, small perforation (<2 cm) can be treated with simple or double layer suture with or without omental patch, while large perforation (≥2 cm) requires distal gastrectomy, especially near pylorus or in gastric corpus 1
For bleeding peptic ulcer, first-line treatment is endoscopic treatment attempts, second-line is angiographic embolization if available, and third-line is surgical intervention, with distal gastrectomy preferred over simple oversewing for gastric ulcers 2, 5, 6

The extent of resection in standard distal gastrectomy involves removal of approximately two-thirds of the stomach 7
D1 lymphadenectomy is typically sufficient for benign disease 7

Helicobacter pylori testing is recommended for all patients, with treatment if positive 2
Proton pump inhibitor therapy should be continued post-operatively 2

Distal gastrectomy carries higher mortality than simple repair, especially in elderly or unstable patients 4
Delayed diagnosis increases mortality, with every hour of delay from admission to surgery associated with 2.4% decreased probability of survival 4