The most effective treatment for gastric and duodenal ulcers that do not heal with systematic and standardized drug therapy, or for gastric ulcers suspected to be cancerous (i.e., recalcitrant ulcers), or for gastric and duodenal ulcers with complications such as pyloric obstruction, gastric perforation, or gastric bleeding, is to perform a major gastrectomy. A major gastrectomy is the removal of the distal 2/3 of the stomach, so it is also called a distal major gastrectomy. Why is it necessary to remove the distal 2/3 of the stomach for ulcers? Will it affect the digestive function if so much of the stomach is removed? Can’t less be removed? This is a question that patients are often confused about. To answer and understand these questions, we must first understand the physiological functions of the stomach and its functional divisions. Figure 1: The general anatomical pattern of the stomach As shown in the figure, the stomach is located in the upper left abdomen and is divided into two mouths, two curves, and two walls, front and back. The entrance of the stomach is called the cardia, which is connected upward to the esophagus, and the exit of the stomach is called the pylorus, which is connected downward to the duodenum. The upper edge of the stomach is called the lesser curvature of the stomach and the lower edge is called the greater curvature of the stomach. And it is divided into four regions, which are the cardia, the bottom of the stomach, the body of the stomach and the pylorus; the pylorus is divided into two parts, the left side is called the pyloric sinus, also called the gastric sinus, and the right side is called the pyloric duct. The gastric body and the gastric sinus at the junction of the lesser curvature is called the gastric angle. The anatomical regions of the gastric mucosa are different, and their cellular distribution and respective physiological functions are also different. The main physiological functions of the stomach: the stomach has five main physiological functions. 1. admission and storage of food. 2. digestion and absorption: mechanical and chemical digestion of food through the peristalsis of the stomach and its secretion of gastric acid, pepsin synergy, etc. (can be considered as primary digestion). 3. transport and emptying function: the initial digestion and grinding of food into the duodenum and jejunum, for further digestion and absorption. 4. 4. defense function: the mucosal barrier of the stomach, gastric acid, secretory immunoglobulin lgG, lgA and lymphoid tissue, etc., can prevent the invasion of pathogenic bacteria and foreign bodies. 5. secretion function: the stomach can secrete gastric acid (hydrochloric acid), pepsin, gastrin, gastric actin, growth inhibitor, etc. The most important of these is the secretion of gastric acid (hydrochloric acid), pepsin, gastrin, gastrin, etc. Among them, the most important is the secretion of gastric acid and pepsin, which are indispensable biochemicals for food digestion. Gastric acid (i.e. hydrochloric acid) is produced by the wall cells of the gastric mucosa. If hydrochloric acid is secreted excessively, it causes damage to the gastric mucosa under the joint action of pepsin and causes ulceration of the local gastric mucosa, which is the basic mechanism for the formation of gastric and duodenal ulcers. This is the basic mechanism for the formation of gastric and duodenal ulcers. It is really a case of “success and failure”! In recent years, the conditionally pathogenic bacterium Helicobacter pylori was also found to take advantage of this situation and participate in the destructive activities of the gastric mucosa. Figure 2: Our surgically removed giant gastric ulcer Most of the hydrochloric acid-secreting mural cells of the gastric mucosa are distributed in the distal 2/3 region of the stomach (Figure 3); in addition, the G cells of the gastric mucosa in the gastric sinus secrete gastrin, which causes the secretion of gastric acid through the neurohumoral reflex. Furthermore, gastric and duodenal ulcers almost always occur in the distal 2/3 of the stomach. Figure 3: Distribution of mural cell areas in the gastric mucosa that secrete gastric acid The rationale for surgery for gastric and duodenal ulcers with surgical indications requires removal of the distal 2/3 of the stomach. The distal gastrectomy can kill several birds with one stone: 1. it removes most of the gastric acid-secreting mural cells of the gastric mucosa and significantly reduces gastric acid secretion, which eliminates the main risk factor for the formation of gastric and duodenal ulcers; 2. it removes the gastrin-secreting G cells of the mucosa of the gastric sinus and eliminates the accomplices of gastric acid secretion; 3. most importantly, it removes the ulcer lesion and relieves the ulcer of cancer, bleeding, perforation and The risk of complications such as ulcer cancer, bleeding, perforation and pyloric obstruction is eliminated. On the contrary, if the extent of gastrectomy is not enough and only half or part of the stomach is removed, there will be more residual mucosal cells that secrete gastric acid, which will cause recurrence of ulcers in the residual stomach and ulcers in the gastrointestinal anastomosis (clinically called anastomotic ulcers), as well as bleeding, which strictly speaking means that the operation is a failure. The effect of major gastrectomy on human digestive function is temporary, after surgery, you can start to eat less and more meals (4-5 times a day), and gradually transition from whole liquid food to semi-liquid food and general food, after the major distal gastrectomy, about 1/3 of the remaining residual stomach will grow to close to the original normal size after one year of surgery, and gradually restore normal digestive function. Therefore, there is no need to worry about the large gastric resection. Therefore, there is no need to worry that the digestive function of the body will be affected after the major gastrectomy.