Pyloroplasty
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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:
Pyloric dilatation and pyloromyotomy are lesser variants of pyloroplasty. Gastrojejunostomy and antrectomy (approximately 50% of distal portion of stomach) are alternatives to pyloroplasty.
Pyloroplasty is most commonly performed as a gastric drainage procedure that is adjunctive to vagotomy for peptic ulcer disease (PUD). (Truncal and selective vagotomy 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 (H2RAs) and proton pump inhibitors (PPIs), elective indications for surgery for PUD have, however, decreased. [1]
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. [2, 3] Endoscopic balloon dilatation of the pylorus is an alternative to surgical pyloroplasty. [4]
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. [5]
In elective situations, vagotomy is performed first, followed by pyloroplasty. In an emergency (bleeding and perforation), the pylorus is handled first, and vagotomy follows.
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).
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 the 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.
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.
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.
Budzyński P, Pędziwiatr M, Grzesiak-Kuik A, Natkaniec M, Major P, Matłok M, et al. Changing patterns in the surgical treatment of perforated duodenal ulcer – single centre experience. Wideochir Inne Tech Maloinwazyjne. 2015 Sep. 10 (3):430-6. [Medline].
Gaur P, Swanson SJ. Should we continue to drain the pylorus in patients undergoing an esophagectomy?. Dis Esophagus. 2014 Aug. 27 (6):568-73. [Medline].
Datta J, Williams NN, Conway RG, Dempsey DT, Morris JB. Rescue pyloroplasty for refractory delayed gastric emptying following esophagectomy. Surgery. 2014 Aug. 156 (2):290-7. [Medline].
Swanson EW, Swanson SJ, Swanson RS. Endoscopic pyloric balloon dilatation obviates the need for pyloroplasty at esophagectomy. Surg Endosc. 2012 Jul. 26 (7):2023-8. [Medline].
Mancini SA, Angelo JL, Peckler Z, Philp FH, Farah KF. Pyloroplasty for Refractory Gastroparesis. Am Surg. 2015 Jul. 81 (7):738-46. [Medline].
Shada AL, Dunst CM, Pescarus R, Speer EA, Cassera M, Reavis KM, et al. Laparoscopic pyloroplasty is a safe and effective first-line surgical therapy for refractory gastroparesis. Surg Endosc. 2016 Apr. 30 (4):1326-32. [Medline].
Jiang G, Bai D, Qian J, Chen P, Jin S. Modified Laparoscopic Pyloroplasty During Laparoscopic Splenectomy and Azygoportal Disconnection for the Prevention of Postoperative Gastroparesis. Surg Innov. 2017 Aug. 24 (4):328-335. [Medline].
Hibbard ML, Dunst CM, Swanström LL. Laparoscopic and endoscopic pyloroplasty for gastroparesis results in sustained symptom improvement. J Gastrointest Surg. 2011 Sep. 15 (9):1513-9. [Medline].
Oezcelik A, DeMeester SR, Hindoyan K, Leers JM, Ayazi S, Abate E, et al. Circular stapled pyloroplasty: a fast and effective technique for pyloric disruption during esophagectomy with gastric pull-up. Dis Esophagus. 2011 Aug. 24 (6):423-9. [Medline].
Wu MH, Wu HH. Simple pyloroplasty using a linear stapler in surgery for esophageal cancer. Surg Today. 2013 May. 43 (5):583-5. [Medline].
Shlomovitz E, Pescarus R, Cassera MA, Sharata AM, Reavis KM, Dunst CM, et al. Early human experience with per-oral endoscopic pyloromyotomy (POP). Surg Endosc. 2015 Mar. 29 (3):543-51. [Medline].
Benias PC, Khashab MA. Gastric Peroral Endoscopic Pyloromyotomy Therapy for Refractory Gastroparesis. Curr Treat Options Gastroenterol. 2017 Oct 14. [Medline].
Kapoor VK, Ibrarullah M, Mittal BR, Sikora SS, Das BK, Kaushik SP. Functional evaluation of the intra-thoracic stomach after pyloric dilatation with Hegar’s dilators. Indian J Surg. 1995. 57:387-92.
Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS Professor of Surgical Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS is a member of the following medical societies: Association of Surgeons of India, Indian Association of Surgical Gastroenterology, Indian Society of Gastroenterology, Medical Council of India, National Academy of Medical Sciences (India), Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.
Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS Professor of General and Gastrointestinal Surgery and Senior Consultant Surgeon, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India
Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS is a member of the following medical societies: American College of Gastroenterology, American College of Surgeons, American Society of Colon and Rectal Surgeons, Royal College of Physicians and Surgeons of Glasgow, Royal College of Surgeons of Edinburgh, Royal College of Surgeons of England
Disclosure: Nothing to disclose.
Pyloroplasty
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