Dyspepsia surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Fahad Hasan, M.D.[2] Ajay Gade MD[3]]

Overview

Surgery has a limited, narrowly defined role in dyspepsia and is directed almost exclusively at complications of organic disease — principally peptic ulcer disease (PUD) complicated by perforation, refractory haemorrhage, or gastric outlet obstruction, rather than at functional dyspepsia (FD) itself. Contemporary guidelines, including the British Society of Gastroenterology (BSG) 2022 guideline, explicitly recommend against surgery for refractory FD given the absence of high-quality evidence of benefit and the recognised risk of iatrogenic harm. The marked decline in elective peptic ulcer surgery over recent decades reflects the success of H. pylori eradication and proton pump inhibitor therapy. Procedural interventions such as gastric peroral endoscopic myotomy (G-POEM) and gastric electrical stimulation (GES) are established only in the context of scintigraphically confirmed gastroparesis, not FD per se.

Surgery

Surgery for Complications of Peptic Ulcer Disease

Perforated peptic ulcer

• Ulcer perforation accounts for approximately 10.4% of PUD-related hospital admissions, with mortality of approximately 9%.
• Initial management: resuscitation, broad-spectrum antibiotics, NPO status, and nasogastric decompression.
• Laparoscopic omental patch repair is preferred in haemodynamically stable patients.
• Open repair is reserved for haemodynamically unstable patients or where laparoscopic expertise is unavailable.
• Gastric ulcer perforations should undergo biopsy of the perforation edge to exclude malignancy and to test for H. pylori.
• Large perforations (>2 cm) may require resection and reconstruction (Billroth I/II, Roux-en-Y gastrojejunostomy).
• Damage control surgery should be considered in patients with severe haemodynamic instability and diffuse peritonitis.

Refractory upper GI bleeding

• Surgery is reserved for failure of endoscopic haemostasis (typically after two attempts) when angiographic embolization is unavailable or has failed.
• Operative options include oversewing of a bleeding duodenal ulcer via duodenotomy with ligation of the gastroduodenal artery.

Gastric outlet obstruction from PUD Benign PUD-related gastric outlet obstruction is now uncommon. Stepwise approach:

1. Endoscopic balloon dilation as first-line therapy, with high technical and clinical success.
2. Temporary self-expanding metal stent placement for patients who fail dilation and are not surgical candidates.
3. EUS-guided gastroenterostomy (EUS-GE) using lumen-apposing metal stents; a 2026 network meta-analysis of 6 RCTs and 10 adjusted cohort studies (1,585 patients) found lower reintervention rates, higher clinical success, shorter hospitalisation, and faster time to oral intake versus enteral stenting and surgical gastrojejunostomy.
4. Surgical gastrojejunostomy or pyloroplasty for patients failing endoscopic interventions.

Intractable peptic ulceration

Surgery for medically refractory PUD is exceedingly rare. Before considering surgery, confirm H. pylori eradication, exclude ongoing NSAID use, rule out gastrinoma (Zollinger-Ellison syndrome), and ensure compliance with maximal-dose PPI therapy. If surgery is indicated, truncal vagotomy with pyloroplasty (feasible laparoscopically) or vagotomy with Roux-en-Y gastrojejunostomy remain options; the current role of vagotomy is significantly limited, and highly selective vagotomy is no longer considered a preferred elective approach given technically demanding surgery and high recurrence rates.

Functional Dyspepsia: Surgery Should Be Avoided

Multiple guidelines and expert reviews state that surgery should not be performed for FD.

• No high-quality evidence supports any surgical procedure for FD.
• Fundoplication is not indicated for FD. Post-fundoplication functional GI complaints (dysphagia, gas-bloat syndrome, delayed gastric emptying) are reported in a substantial proportion of patients, with up to 50% experiencing at least one new GI symptom, and can worsen symptoms in patients with FD misdiagnosed as GERD.
• The BSG guideline recommends that failure of medical therapy in FD should prompt referral for psychological therapy, not surgical consultation.

Procedural Interventions for Gastroparesis With Dyspeptic Symptoms

When dyspeptic symptoms (postprandial fullness, early satiation, nausea) are attributable to objectively confirmed gastroparesis (>10% retention at 4 hours on gastric emptying scintigraphy, with moderate delay defined as >20% retention), procedural options may be considered after failure of dietary and pharmacologic management. These procedures are indicated for gastroparesis, not FD.

Gastric peroral endoscopic myotomy (G-POEM)

• Two sham-controlled RCTs have demonstrated symptom improvement; in one trial (n=41), >50% reduction in Gastroparesis Cardinal Symptom Index (GCSI) at 6 months occurred in 71% after G-POEM versus 22% after sham (P=.005).
• The AGA 2025 guideline suggests against routine use of G-POEM (conditional recommendation, low-certainty evidence) but acknowledges select patients may benefit through shared decision-making.
• The AGA 2023 Clinical Practice Update suggests offering G-POEM to patients with retention >20% at 4 hours and moderate-to-severe symptoms dominated by nausea/vomiting.
• Predictors of positive outcome: shorter disease duration, nondiabetic etiology, lower BMI, and prior response to intrapyloric botulinum toxin.
• Adverse events (~7–12%) include pneumoperitoneum, pyloric channel ulceration, and dumping syndrome.
• The AGA 2025 guideline recommends against intrapyloric botulinum toxin injection for gastroparesis (conditional recommendation, low-certainty evidence), despite its historical use as a predictor of G-POEM response.

Gastric electrical stimulation (GES)

• One of two interventions (alongside G-POEM) for gastroparesis assessed in sham-controlled trials; an RCT of 38 patients showed superiority of activated over non-activated GES.
• An RCT of 38 patients showed GCSI improvement with activated versus non-activated GES (median difference −1.33; 95% CI −2.34 to −0.33; P=.01).
• Network meta-analysis found GES had the highest intermediate-term efficacy (3–36 months), while G-POEM had the greatest short-term effect.
• Adverse events include abdominal wall pain at the implant site and infection at the battery pouch.
• GES (Enterra Therapy) remains available only under an FDA Humanitarian Device Exemption (HDE), not full premarket approval, which limits insurance coverage.

Laparoscopic pyloroplasty

• Largely replaced by G-POEM.
• A study of 177 patients reported 90% had improved gastric emptying at 3 months and symptom improvement at 1 and 6 months.
• May provide additive benefit when combined with GES.

Surgery for Gastric Malignancy Presenting With Dyspepsia

When endoscopic evaluation reveals gastric malignancy as the cause of dyspeptic symptoms, management follows oncologic principles per NCCN guidelines. For malignant gastric outlet obstruction:

• Endoluminal stenting is preferred in patients with limited survival.
• Surgical gastrojejunostomy is considered when longer-term palliation is needed.
• EUS-guided gastroenterostomy is emerging as a preferred option based on 2026 network meta-analyses showing superior clinical success and lower reintervention rates.

High-Yield Clinical Pearls

• No surgery should be offered for FD; the BSG explicitly recommends against it. Failure of medical therapy should prompt psychological therapy referral, not surgical consultation.
• Before considering surgery for "refractory" peptic ulcer, always re-confirm H. pylori eradication, exclude NSAID use, rule out Zollinger-Ellison syndrome, and ensure PPI compliance.
• G-POEM and GES are gastroparesis procedures, not dyspepsia procedures; scintigraphic confirmation of delayed emptying (>10% at 4 hours) is required for diagnosis, with G-POEM candidates generally having ≥20% retention.
• Biopsy the edge of any perforated or non-healing gastric ulcer to exclude malignancy.
• Laparoscopic omental patch is now standard for perforated PUD in stable patients.

Common Pitfalls

• Performing fundoplication or other anti-reflux surgery in patients with FD misdiagnosed as GERD — this worsens symptoms in up to 50% of cases.
• Referring FD patients for G-POEM without scintigraphic evidence of gastroparesis.
• Failing to perform gastric ulcer biopsy at the time of surgical repair for perforation.
• Proceeding to surgery for "intractable" PUD without systematic exclusion of ongoing NSAID use, non-compliance, gastrinoma, or false-negative H. pylori testing.
• Conflating dyspeptic symptoms with gastroparesis — FD and gastroparesis overlap clinically but require different diagnostic and therapeutic pathways.