What are the primary goals of care and their timeline after a patient undergoes Pyloric Exclusion, Gastrostomy, Retrograde Duodenostomy, and Feeding Jejunostomy for duodenal ulcer perforation repair?

Goals of Care After Pyloric Exclusion, Gastrostomy, Retrograde Duodenostomy, and Feeding Jejunostomy for Duodenal Ulcer Perforation

The primary goals after this damage control procedure are to maintain gastric decompression, ensure adequate nutrition via the feeding jejunostomy, monitor for duodenal fistula formation, and allow spontaneous pyloric reopening while preventing recurrent ulceration. 1, 2

Immediate Postoperative Period (Days 0-7)

Gastric Decompression Management

• Maintain nasogastric tube patency for proximal gastric decompression to reduce pressure on the duodenal repair site and prevent gastric outlet obstruction from the pyloric exclusion 2
• Monitor gastrostomy tube output and function as an alternative decompression route 3
• Keep patient nil per os (NPO) to minimize gastric secretions entering the repaired duodenum 2

Nutritional Support

• Initiate enteral feeding via the feeding jejunostomy within 24-48 hours if hemodynamically stable, as enteral nutrition is preferred over parenteral nutrition and reduces complications 1
• If enteral feeding is not tolerated or contraindicated, provide total parenteral nutrition (TPN) to meet caloric requirements 1, 2
• The jejunostomy allows nutritional needs to be met while bypassing the damaged duodenum 3

Drain Management and Leak Surveillance

• Monitor external drainage output near the duodenal repair site closely for increased volume, bilious content, or enteric material indicating duodenal fistula 2
• Watch for clinical signs of leak: fever, leukocytosis, abdominal pain, and sepsis 2
• If duodenal fistula develops, continue NPO status, maintain TPN, and ensure adequate external drainage 2

Early Recovery Period (Weeks 1-4)

Monitoring for Complications

• Assess for gastric suture line complications including leak from the pyloric closure site or gastric outlet obstruction 2
• Continue surveillance for intra-abdominal abscess formation or peritonitis 1
• Monitor for signs of intestinal ischemia if there was concern for vascular compromise during initial surgery 1

Nutritional Advancement

• Gradually advance jejunostomy feeds as tolerated, aiming to meet 100% of caloric requirements enterally 1
• If >60% of energy needs cannot be met via the enteral route, consider supplementary parenteral nutrition 1
• Continue nutritional support until oral intake can be safely resumed 1

Ulcer Prevention Measures

• Initiate high-dose proton pump inhibitor (PPI) therapy to reduce gastric acid secretion and promote healing 4
• Test for Helicobacter pylori if not already performed, as it is a major etiologic factor alongside NSAIDs 5, 4
• If H. pylori positive, initiate appropriate antibiotic eradication therapy combined with PPI 4

Intermediate Recovery Period (Weeks 4-12)

Pyloric Reopening Assessment

• Monitor for spontaneous pyloric reopening, which typically occurs as the absorbable sutures dissolve over 4-8 weeks 2, 6
• Assess gastric emptying through clinical signs and consider contrast studies if gastric outlet obstruction symptoms persist 4
• The pyloric exclusion is temporary and designed to reopen spontaneously 2

Transition to Oral Nutrition

• Once pyloric reopening is confirmed and duodenal healing is adequate (typically 6-8 weeks), begin trial of clear liquids 7
• Advance diet gradually from liquids to soft foods to regular diet as tolerated
• Continue jejunostomy feeds as supplementation until oral intake is adequate

Risk Factor Modification

• Strictly avoid NSAIDs, as they represent one of the strongest risk factors for peptic ulcer perforation and recurrence 5, 2
• Recommend smoking cessation, as smoking is a key etiologic factor for peptic ulcer disease 5
• Avoid steroids when possible, as they are associated with increased mortality risk 5

Long-Term Management (Beyond 3 Months)

Tube Removal Timeline

• Remove feeding jejunostomy once oral intake meets >80% of nutritional requirements and patient demonstrates consistent weight maintenance (typically 8-12 weeks post-operatively)
• Remove gastrostomy tube once gastric emptying is confirmed adequate and no longer needed for decompression
• Retrograde duodenostomy drain can typically be removed once output is minimal and no evidence of persistent fistula (usually 4-8 weeks)

Definitive Ulcer Management

• Continue long-term PPI therapy, especially if H. pylori negative or if patient has risk factors for recurrence 4
• If H. pylori positive, confirm eradication with urea breath test or stool antigen test 4-6 weeks after completing antibiotic therapy 4
• Consider elective ulcer-definitive surgery (such as parietal cell vagotomy) only for uninfected patients who fail medical therapy or have recurrent perforations 4

Surveillance for Late Complications

• Monitor for delayed gastric outlet obstruction or pyloroduodenal stenosis, which can occur in 2-3% of cases 7
• Assess for recurrent ulceration, particularly if risk factor modification is incomplete 5, 2

Common Pitfalls to Avoid

• Do not attempt early oral feeding before confirming adequate duodenal healing and pyloric reopening, as this increases risk of leak and fistula formation 2
• Never allow NSAID use postoperatively, even for pain control—use alternative analgesics 5, 2
• Do not remove external drains prematurely before confirming no ongoing duodenal leak, as this can lead to intra-abdominal abscess formation 2
• Avoid delaying nutritional support—initiate jejunostomy feeds early to prevent malnutrition and promote healing 1
• Do not assume H. pylori negativity without testing—failure to eradicate H. pylori leads to high recurrence rates 5, 4

Expected Timeline Summary

• Days 0-7: NPO, gastric decompression, jejunostomy feeding, drain monitoring
• Weeks 1-4: Continue enteral nutrition, monitor for complications, initiate ulcer prevention
• Weeks 4-8: Assess pyloric reopening, begin oral intake trials if appropriate
• Weeks 8-12: Advance to full oral diet, remove tubes as appropriate
• Beyond 3 months: Long-term PPI therapy, risk factor modification, surveillance for recurrence

The overall goal is to allow the duodenal repair to heal while maintaining nutrition and preventing complications, with most patients achieving full oral intake and tube removal by 8-12 weeks post-operatively. 2, 3, 7