Peptic ulcer disease-related gastric outlet obstruction - does surgery still play a role?

Gastric outlet obstruction (GOO) due to peptic ulcer disease (PUD) has seen a global decline, with endoscopic management now considered first-line therapy. Modern surgeons have limited exposure to PUD GOO, with a lack of recent literature and contemporary guidelines to aid in surgical decision-making. This study aims to review a cohort of PUD GOO patients with specific focus on those needing surgical intervention.

All patients managed for PUD GOO at a single South African centre over a four-year period were included. Those requiring surgery were sub-analysed and multivariate analysis performed to identify factors associated with increased morbidity.

A total of 84 PUD GOO patients were included. Forty-five were selected for endoscopic balloon dilatation (EBD), with only 21 (46.7%) successfully managed with EBD. Thirteen patients required only medical therapy, eight were selected for upfront surgery and 18 patients were managed with stenting. A total of 31 patients (36.9%) required surgery, with 33 separate operations performed (12 resections and 21 bypass operations). The surgical procedure performed was the only variable shown to be significantly associated with postoperative morbidity, with both pyloroplasty and partial gastrectomy having higher complication rates when compared to gastro-jejunal bypass (50.0% and 66.7% vs 5.6%, OR:17.0 and 8.5, p = 0.016 and p < 0.001 respectively).

In our setting obstructed PUD often requires surgical management. The choice of surgical procedure should be individualised. Due to the multifactorial complexity of these patients, they are best managed in multidisciplinary team settings with input from dieticians, endoscopists and surgeons.