It was a very common problem in southern India pts come quite late.There is a gradual change in the development of DU,I mean the incidence has dropped significantly and the freely available H2receptor antagonists and PPIs further contributed the decline of cicatrized ulcers.Consequently I get to operate one or two cases in a year (Lap TV+GJ).I remember during my training in UK during open Highly selective vagatomy,we used to dilate the pylorus using Tubb's dilator invariably they stenose in a short period.One perforation occurred.endoscopic dilatations were done for a small number ,the end result is the same as above unless it is not cicatrized.So our practice is not to to dilate a cicatrized pylorus.

Much obliged Dr. Prasanna Kumar Reddy for valuable detailed answer.

It seems that no role of endoscopic dilatation for those cases, in addition to  that , it is hazardaous, it may cause perforation, so, surgery is amust.

Dr.Taha,

The pure scar pylorostenosis is one of the rariest entitiy these days, and seems have ever been as such. According to our city district database, there have been 1998 cases of the peptic ulcer disease enrolled for the last 6 years. Among that population, there were 11 cases of the reverse inflammative stenosis of the pyloro-bulbar chanel treated successfully with rutine medication, and the only one case of the real scar stenosis of the gastric outlet in an elderly woman (what takes 0.05% from the total). That very case demanded to be operated upon because the endoscopic dilation failed. However, the Jaboulay procedure+truncal vagotomy was performed that followed the uneventful recovery.

As for the Roux-en-Y GES, this way seems to be oversophisticated technique to solve a relatively small challenge. I dare to suppose that there have been complications, haven't they? Would you explain the reason to perform that?

Thanks Dr. Andrey Borodach for your answer,

In Egypt, i realized that there is a higher incidence of cicatrized DU with GOO, but there is no data base or statistics that  confirms the incidence. Egypt is a developing country, and many poor patients can not even buy the expensive medical treatment for enough time. Surprisingly, one patient aged 17 years old!!! 

Truncal  vagotomy supposed to decrease the incidence of stomal ulcer.

Roux-en Y gastro-jejunostomy supposed to decreased reflux of bile to stomach and prevents biliary gastritis.

I see your point, Dr.Taha,

However, I've got a couple of questions to ask:

1) What is the criterium (criteria) to take a given GOO as unreversable?

2) Have you any remote follow-up data according to the patients after the Roux reconstruction? Are they all right?

With your permission, I would add later a short review concerning the history of the surgical treatment of the peptic ulcer disease including the role of bile reflux and its absence. The history is seemingly thouroghly forgotten these days.

There is not the ideal operation, unfortunately...

I do not pretend that what I have written here is an exhousting review on the matter. It is just a humble attempt to thinking about its possible historical perspective.

1. The role of the insufficient duodenal alkalic defence in the DU pathogenesis

The first surgical model of peptic ulcer disease might be worked out by prof.Pavlov’s experimental physiologic school. In that model, the small intestine loop was implanted between gastrostoma and skin to exclude the alcalic action of the duodenal contents. The chronic ulcer developed on the intestinal side of the gastrojejunal stoma. Another ‘classic’ model of peptic ulcer disease was developed by F.C.Mann and C.S.Williamson in 1923. It was also based upon elimination of the alkalic action of the duodenal contents [Mann F.C.& Williamsom C.S. The experimental production of peptic ulcer // Annals of Surgery, 1923, vol.77; 4:409-22]. The latter article was splendidly illustrated in the style typical for these Mayo clinic’s authors. Interestingly, a similar procedure was invented again for the morbid obesity treatment by N.Scopinaro et al., 1998, that reported as complicated up to 5% incidence rate of the peptic ulcer during the follow-up period [Marceau P., Biron S. Current Malabsorption Procedures: Biliopancreatic Diversion. In: Obesity Surgery, 1st Ed., ed. Martin, Louis F. McGraw-Hill 2004. 363 P.; Biliopancreatic Diversion and Duodenal Switch in: Schwartz's Principles of Surgery, 9th Ed. McGraw-Hill NY 2010, 2336 P.]. 

The famous gastric surgeon S.Yudin in his review of peptic ulcer surgery performed in the 1920-30s, reported that due to the decrease of the alkalic action of the duodenal contents, the stomal ulcer developed in 10% of cases after retrocolic gastrojejunostomy; in 30% after gastrojejunostomy with the Braun entero-enterostomy; in 50% after diversion of the pylorus according to Eiselberg; and in 80% after Roux-Y-shaped gastrojejunostomy after complete diversion of the pylorus. Similar results were obtained after the Roux-Y-shaped procedure in white rats. The stomal ulcer developed in 72.7% of the animals in 10 months after the operation [Arlt G, Schumpelick V, Riechert B, Kloppel G. / The ulcer risk in reflux preventive gastric operations. An experimental study // Scand J Gastroenterol Suppl 1984;92 125-128; Schumpelick V, Arlt G, Riechert B, Klapdor R. / Ulcer risk of reflux-preventing reconstruction following stomach resection - an animal experiment study // Z Gastroenterol 1984;22(11):630-643].

Another method of surgical modeling of the duodenal ulcer was ligation of the common bile duct produced in pigs with mortality being 70% due to perforation of the ulcer rapidly developing [Terblanche J, van Hoorn-Hickman R. / The prevention of peptic ulceration by highly selective vagotomy in a new peptic ulcer experimental model: the bile duct-ligated pig // Surgery. 1978; 84(2):206-211]. 

https://en.wikipedia.org/wiki/Sergei_Yudin_(surgeon)

Benign duodenal stenosis following DU is a difficult and demanding issue for both patients and doctors. Fortunately, duodenal ulcer incidence has been declining over the last 2 decades due to successful H pylori eradication, however DU complication rates do not follow similarly, at least at the western countries. Based on our patient age, comorbitities etc, we have to discriminate between an edematous and fibrotic stenosis witch is the usual cause of a recalcitrant DU stenosis. As ballon dilatation usually is not a long lasting technique it would be more promising a self expandable retrievable metal stent, especially covered. This is  followed by an over 90% placement success rate, durability of at least a year, however migration rate is unacceptably high of 45%. Price is a hot issue but honestly i cannot help.  So, for an older patient this could be a bridge before final decisions. Younger patients as the one you mentioned is a difficult decision as there is not enough evidence based knowledge. I personally would give him a chance with SEMS explaining the option of a further permanent surgical treatment.

Gastrointestinal Endoscopy, Volume 59, Issue 5, April 2004, Page P153

Hyo Jung Kim, Jong-Jae Park, Chang Don Kang, Sung-Joon Lee, Jin Yong Kim, Jong Eun Yeon, Jae Seon Kim, Kwan Soo Byun, Young-Tae Bak, Chang Hong Lee                 

I have no experience of GOO stenting, but this idea seems to be doubtful taking in mind what results obtained from the similar technique use for other reasons. It might be useful for the prophylaxis of cicatrification if not the highest incidence of the stent migration after the oedema has been solved. If the decompensated scar stenosis has already occured, the stenting is hardly possible and would be just waisting of the valuable time.

It is commonly known that the epidermis has had some limited potential of the edge regeneration that does not exceed approximately 5 cm (a little more than 2 inches). So, if the wound width is larger than this it will be the indication for skin grafting. On the other hand, to the best of my knowledge, nobody has ever made similar investigations concerning the healing capacity of mucosal linings of any digestive organ, from the oesophageus (chemical burns' management and Barrett metaplasia resection better outcome perspectives) to the ulcers and other alterations of the stomach, duodenum, and colon.

Endoscopic dilatation in this specific clinical scenario does not afford long-term benefit and surgery is required in majority

In my opiniin surgical intervention is the best 

I agree with John Robotis. Balloon dilatation have an high incidence of recurence, so the best option for these cases is SEMS placement. Further surgical treatments will be taken into account according to age, comorbidities and clinical response

In my opinion there is no one best treatment. I prefer to approach the patient with the least invasive initial treatment and if there is a failure then moved to more definitive therapy. In most cases I will initially perform through the scope balloon dilation, which often requires multiple dilations of successively increasing diameters. If there is recurrence especially with control of acid secretion, I think placement of a coated SEM to allow gradual continuous dilation over time is a good option at this point, especially as it can be removed. Having failed these options, of course salvage therapy with surgery is always effective.