A 52-year-old man with a 10-year history of duodenal ulcer disease presents to the emergency department with sudden-onset severe epigastric pain radiating to the back, followed by vomiting. On examination, he is in acute distress with a rigid, board-like abdomen and rebound tenderness. Vital signs show BP 95/55 mmHg, HR 118/min, RR 22/min. Upright chest X-ray reveals free air under the diaphragm. He is resuscitated with IV fluids and broad-spectrum antibiotics. After stabilization, what is the most appropriate surgical management?
A 48-year-old man with a 15-year history of gastric ulcer disease presents with persistent epigastric pain and early satiety despite 8 weeks of PPI therapy (omeprazole 40 mg daily). Upper endoscopy shows a 2 cm ulcer in the gastric antrum with clean base and no signs of malignancy. Serum gastrin is 45 pg/mL (normal <100), and H. pylori serology is negative. He has no NSAID use. After confirming compliance and ruling out malignancy, what is the most appropriate next step in management?
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