Pyloroplasty

Updated: Oct 14, 2015
  • Author: Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS; Chief Editor: Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS  more...
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Overview

Background

Pyloroplasty is almost never performed alone. In almost all cases, it is performed as an adjunct to another procedure (most commonly vagotomy). It can be performed on a diseased (narrowed or thickened) or normal pylorus.

Pyloroplasty completely destroys the pyloric sphincter and drains the stomach into the duodenum. At the same time, however, it results in rapid emptying of the stomach into the duodenum (causing dumping) and allows reflux of duodenal contents back into the stomach (causing bile gastritis).

There are several types of pyloroplasty, as follows:

  • Heineke-Mikulicz pyloroplasty involves a longitudinal incision across the pylorus that is closed transversely; this is the most commonly performed pyloroplasty
  • Jaboulay pyloroplasty involves a side-to-side gastroduodenostomy without pylorus incision
  • Finney pyloroplasty also involves a side-to-side gastro-duodenostomy but with pylorus incision

Pyloric dilatation and pyloromyotomy are lesser variants of pyloroplasty. Gastrojejunostomy and antrectomy (approximately 50% of distal portion of stomach) are alternatives to pyloroplasty.

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Indications

Pyloroplasty is most commonly performed as a gastric drainage procedure that is adjunctive to vagotomy for peptic ulcer disease (truncal and selective vagotomy, which denervate the pylorus and requires pyloric drainage; highly selective vagotomy spares the pylorus and does not require a drainage procedure). With the availability of H2-receptor anatgonists (H2RA) and proton pump inhibitors (PPIs), elective indications for surgery for peptic ulcer disease have, however, decreased.

In addition, pyloroplasty can be performed as the first step in the surgical control of a bleeding duodenal ulcer and rarely for perforated duodenal ulcer.

Pyloroplasty is also performed as an adjunct to inadvertent vagotomy in esophagectomy and proximal gastrectomy. However, pyloroplasty as an adjunct to inadvertent vagotomy in patients undergoing esophagectomy is being questioned, and some surgeons do not perform it. [1, 2] Endoscopic balloon dilatation of the pylorus is an alternative to surgical pyloroplasty. [3]

Rare indications include pyloric atresia in infants and gastroparesis in elderly patients. A retrospective study by Mancini et al found pyloroplasty to be highly effective for management of refractory gastroparesis. [4]

In elective situations, vagotomy is performed first, followed by pyloroplasty. In an emergency (bleeding and perforation), the pylorus is handled first, and vagotomy follows.

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Contraindications

Heineke-Mikulicz pyloroplasty should not be performed in presence of chronic duodenal ulcer with extensive fibrosis, scarring, and induration (Jaboulay pyloroplasty may be performed).

Pyloroplasty is not performed alone; it should be performed in combination with vagotomy (truncal or selective).

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Technical Considerations

Anatomy

The stomach wall consists of outer serosa (the visceral peritoneum), a thick layer of (smooth) muscles arranged in three layers (outer longitudinal, middle circular [which forms the pylorus] and inner oblique [unique to stomach]); submucosa, which contains a rich network of blood vessels; and the innermost mucosa, which consists of lamina propria, muscularis mucosa, and columnar epithelium. The mucosa and submucosa are thrown into several longitudinal folds called rugae.

Best practices

Pyloroplasty is generally superior to gastrojejunostomy (the other drainage procedure), in that it is more physiologic (ie, it maintains the normal gastroduodenal continuity). In contrast, gastrojejunostomy bypasses the duodenum and causes less bile reflux.

Pyloroplasty should not be performed in the presence of fibrosed and scarred pyloroduodenum in chronic duodenal ulcer.

In making the incision, it must be remembered that the wall is thick in the antropylorus but thin in the duodenum.

Pyloromyotomy and pyloric dilatation are lesser gastric drainage options than pyloroplasty. During pyloromyotomy, electrocautery is avoided in deeper parts to avoid an inadvertent opening of the mucosa.

Complication prevention

The incision across the pylorus should be of adequate length on both (stomach and duodenum) sides. A single-layer approach decreases the amount of inversion, as well as the risk of narrowing and gastric outlet obstruction.

In the performance of pyloromyotomy, care should be exercised to avoid opening of the duodenal (and, less commonly, gastric) mucosa.

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