How is GOO caused by PUD surgically managed?
- GOO can result from an acute exacerbation of PUD in the setting of chronic pyloric and duodenal scarring.
- Classically, patients with GOO present with nausea, emesis, early satiety, and weight loss. Although radiologic contrast studies are useful in evaluation, upper endoscopy is critical to rule out a malignant cause of the obstruction.
- Although in H. pylori –positive patients a trial of medical management may be successful, operative intervention is necessary in more than 75% of patients presenting with GOO. The two main goals of surgery are to relieve the obstruction and to perform a definitive ulcer operation.
- Truncal vagotomy and antrectomy with Billroth II reconstruction is performed if the duodenal stump can be safely closed. If the stump cannot be closed, a tube duodenostomy is left in place for control of secretions until the stump closes by secondary intention.
- An alternative is to perform a truncal vagotomy and pyloroplasty, which often requires the Finney pyloroplasty or Jaboulay gastroduodenostomy because of severe scarring.
- Truncal vagotomy and gastrojejunostomy may be performed if the severe scarring precludes an adequate drainage procedure via the duodenum. In patients with a prolonged history of obstruction, postoperative gastric atony can be expected, so placement of a gastrostomy tube may be helpful in postoperative care.
- Also, the nutritional status of the patient should be taken into account (albumin < 3 mg/dL is associated with higher rates of morbidity and mortality) and a feeding jejunostomy at the time of the operation may be deemed necessary.
