By incision of the pyloric muscle and plastic reconstruction

Pyloroplasty Jon Arne Söreide, MD, PhD, FACS and Kjetil Söreide, MD By incision of the pyloric muscle and plastic reconstruction of the pyloric channel, pyloroplasty facilitates gastric emptying when the gastric outlet is obstructed either mechanically by ulcer, stenosis, or hypertrophy, or functionally by antropyloric vagotomy. First described by Heineke in 1886 and by Mikulicz in 1888, the Heineke-Mikulicz technique is still considered the principal pyloroplasty operation favored by most surgeons. Nevertheless, several modifications and some alternative techniques have been introduced during the last century (Fig 1). INDICATIONS Traditionally, pyloroplasty was performed following selective or truncal vagotomy in the surgical treatment of peptic ulcer disease with pyloric stenosis. 1,2 The need for pyloroplasty in the absence of mechanical pyloric obstruction has been a matter of discussion for many years. 3-5 During emergency surgery for a bleeding duodenal ulcer, clear exposure of the offending ulcer is important, and access to control the bleeding site is mandatory. Closure of the duodenotomy is completed by performing a pyloroplasty to prevent stenosis at the level of the duodenotomy. 6 Caution should be undertaken to perform a pyloroplasty when the pyloric area is severely distorted or inflamed as a result of the ulcer disease. With the marked decrease in gastric surgery for peptic ulcer disease, pyloroplasty has become a much less common procedure. Although most commonly related to peptic ulcer disease and its complications (ie, obstruction, bleeding or perforation), a pyloroplasty may be considered in other rare situations, including Crohns disease, 7 progressive systemic sclerosis, 8 and during operations when gastric replacement of the esophagus is necessary and a vagotomy (vagectomy) is necessitated by the resective procedure. 9,10 From the Division of Gastroenterologic Surgery, Dept. of Surgery, Rogaland Central Hospital, University of Bergen, Institute of Surgical Sciences, Stavanger, Norway. Address reprint requests to Professor Jon Arne Söreide, MD, PhD, FACS, Dept. of Surgery, Rogaland Central Hospital, POB 8100, N-4068 Stavanger, Norway; e-mail: jon.soreide@kir.lib.no. 2003 Elsevier Inc. All rights reserved. 1524-153X/03/0502-0016$30.00/0 doi:10.1053/otgn.2003.35366 GENERAL CONDITIONS To make the operation technically feasible, the anterior surface of the pylorus should be minimally involved and the duodenum sufficiently mobile. Occasionally, a pyloroplasty can also be performed in the presence of an anterior ulcer if the tissue surrounding the ulcer is minimally involved. There are two basic types of pyloroplasty: the Heineke- Mikulicz and the Finney procedures. The Jaboulay pyloroplasty is really a gastroduodenostomy; the incision does not extend through the pylorus. In addition, several important modifications of the standard procedures have been described; we will address these as well. Heineke-Mikulicz Pyloroplasty A longitudinal incision is placed through the pylorus, extending from the distal antrum to the proximal duodenum. By closing this incision transversely, the outlet diameter of the pylorus is increased. The duodenum is mobilized by a Kocher maneuver, and the pylorus identified (Fig 2). The pyloric veins of Mayo may aid its identification, as does its palpable thickening appreciated by transmural inspection. Scarring on the anterior surface of the pylorus should be minimal, and mobilization of the duodenum is necessary to facilitate the pyloroplasty. Between two traction sutures placed about 1 cm apart on the anterior surface of the pylorus, a longitudinal incision is made, extending about 3 cm onto the antrum and a similar distance onto the duodenum (Fig 2). The total length should not exceed 5 to 7 cm. The incision is created by diathermy, which also affords hemostasis. Careful inspection of the stomach and the duodenum for bleeding ulcer or point of obstruction is mandatory. If pyloric stenosis is present, the initial entry into the gut lumen could be made either in the duodenum or in the stomach, because the obstructed lumen in the pyloric region may be eccentrically placed. Use of a grooved director or narrow tipped clamp passed into the pylorus from the initial distal antrotomy will facilitate the appropriate placement of the pylorotomy. If bleeding from an associated gastric or duodenal ulcer is encountered, a transfixion suture (polydioxone, PDS 3 0 or 2 0 silk) may be necessary. Various techniques have been designed to accomplish closure of the incision. The longitudinal incision is closed transversely by rostral and caudal distraction of the re- Operative Techniques in General Surgery, Vol 5, No 2 (June), 2003: pp 65-72 65

66 Söreide and Söreide 1 Pyloroplasty incisions: (A) Heineke-Mikulicz, (B) Finney, (C) Moschel, and (D) Jaboulay

Pyloroplasty 67 2 Gastroduodenotomy for Heineke-Mikulicz pyloroplasty

68 Söreide and Söreide 3 Finney pyloroplasty traction sutures. Of importance is that the outlet diameter is kept sufficient. A one-layer closure (Weinberg modification of the Heineke-Mikulicz pyloroplasty) is most frequently employed (Fig 2C and 2D), although a two-layer closure may be preferred by some surgeons (Fig 2E). Whichever method is used, the suture should pass through all layers with meticulous approximation of the separate serosal and mucosal layers. Our personal preference is a single layer with continuous absorbable suture (poliglecaprone, Monocryl 3 0 or4 0). Finney Pyloroplasty By extending the incision of the pyloric area onto the stomach and first portion of the duodenum, a Finney pyloroplasty (ie, a gastroduodenostomy with incision of the pylorus) can be completed (Fig 3). This technique is especially well suited for a J-shaped stomach in which the pylorus may be retracted and fixed rostrally, making a Heineke-Mikulicz pyloroplasty tenuous. The duodenum should be widely Kocherized and partially detached from the gastro-hepatic ligament to facilitate the descending duodenum to be laid alongside the greater curvature of the distal antrum. Adjacent gastric and duodenal walls are first united by means of a seromuscular suture (poliglecaprone Monocryl, 3 0 or 4 0), from above downwards, closing the angle between the pylorus. A traction suture is placed in the superior margin of the pyloric ring, a second one placed on the duodenal wall about 10 cm

Pyloroplasty 69 4 Moschel pyloroplasty distal to the pyloric ring, and, a third placed on the greater curvature of the stomach 10 cm proximal to the pylorus. With diathermy, a full thickness incision is made along the inverted horseshoe-shaped line which runs from the gastric antrum 4 to 5 cm proximal to the pylorus curving through the duodenal bulb and down the descending duodenum. Care should be taken to stop any bleeding. Again, initial entry into the lumen could be either in the antrum or the duodenum. To close the incision, the posterior adjacent walls are approximated by means of a continuous seromuscular suture (poliglecaprone Monocryl, 3 0), starting at the superior end of the pylorotomy. This suture is continued through the inferior gastroduodenal angle, to proceed

70 Söreide and Söreide onto the anterior wall of the gastroduodenostomy until a safe and well-approximated closure forms the anterior part of the pyloroplasty. From a personal point of view, one or two additional single seromuscular sutures to support the anastomosis at the inferior gastroduodenal angle may ease the surgeon s mind that night. Jaboulay pyloroplasty. This procedure is not a true pyloroplasty, because the pylorus is not incised (see Fig 1). Indeed, separate antrotomy and duodenotomy incisions are necessary. However, the aim of, and the indication for, this operation is to increase the luminal size of the gastric outlet, and the Jaboulay modification will in principal be performed by following the steps described in the Finney procedure but without necessarily opening the pyloric ring. Modifications of Standard Procedures Judd pyloroplasty. This operation includes excision of an anterior ulcer with removal of the anterior twothirds of the pyloric sphincter. This and other modifications of the two standard pyloroplasties (Heineke-Mikulicz and Finney pyloroplasty) are generally considered more of historic interest, since our present understanding of duodenal ulcer disease does not support the need for excision of the ulcer. Recurrent stenosis tended to occur more frequently after the Judd pyloroplasty, due to the larger amount of tissue removed with the failure to assure and maintain an adequate pyloroplasty. Moschel pyloroplasty. Using a Y-shaped incision, with the base of the Y extending through the pylorus onto the duodenum and the arms of the Y onto the antrum, this technique was designed to maintain an adequate blood supply to the advancement flap of the antrum. The antral flap is then sutured to the duodenum, generally using a one-layer closure (Fig 4). STAPLING TECHNIQUES Surgical stapling techniques have also been employed to perform a modified Heineke-Mikulicz pyloplasty (Fig 5) and a Jaboulay pyloroplasty (Fig 6). Transverse closure of a longitudinal pylorotomy can be accomplished using a linear stapler. Similarly, an antroduodenostomy can be accomplished using a gastrointestinal stapler, the arms of which are introduced through separate antrotomy and duodenotomy creating a stapled side-to-side anastomosis (Fig 6). The possible benefits in comparison to standard techniques, however, remain to be shown. Recently, further technical developments, including laparoscopic approaches have been introduced. 11,12 Given that general laparoscopic skills and experience are present, this approach may have its place in some patients. 5 Stapled Heineke-Mikulicz pyloroplasty COMMENTS AND CONCLUSION Providing that the duodenal area is not severely inflamed and scarred, pyloroplasty is usually a safe and technically

Pyloroplasty 71 6 Stapled Jaboulay pyloroplasty

72 Söreide and Söreide easy operation. However, the advantage of facilitating gastric emptying is also accompanied by some disadvantages. The rapid emptying of liquids and solids due to destruction of the pyloric sphincter in association with a vagotomy may cause symptoms such as dumping and diarrhea. In addition, some patients may suffer from reflux alkaline gastritis due to reflux of duodenal fluid into the stomach. With the decreasing incidence of peptic ulcer disease as well as the virtual disappearance of truncal vagotomy, the need for a pyloroplasty is vanishing. REFERENCES 1. Rachlin L: Vagotomy and Heineke-Mikulicz pyloroplasty in the treatment of pyloric stenosis. Am Surg 36(4):251 253, 1970 2. Cade D, Allan D: Long term follow-up of patients with gastric ulcers treated by vagotomy, pyloroplasty and ulcerectomy. Br J Surg 66(1):46 47, 1979 3. Aeberhard P, Walther M: Results of a controlled randomized trial of proximal gastric vagotomy with and without pyloroplasty. Br J Surg 65(9):634 636, 1978 4. Gutierrez de la Pena C, Marquez R, Fakih F, Dominguez-Adame E, Medina J: Simple closure or vagotomy and pyloroplasty for the treatment of a perforated duodenal ulcer: comparison of results. Dig Surg 17(3):225 228, 2000 5. Chan V, Reznick R, O Rourke K, Kitchens J, Lossing A, Detsky A: Meta-analysis of highly selective vagotomy versus truncal vagotomy and pyloroplasty in the surgical treatment of uncomplicated duodenal ulcer. Can J Surg 37(6):457 464, 1994 6. Brolin R, Stremple J: Emergency operation for upper gastrointestinal hemorrhage. Am Surg 48(7):302 308, 1982 7. Taor RE: Adult hypertrophic pyloric stenosis and Crohn s disease. Proc R Soc Med 69(3):228, 1976 8. Hirakata M, Akizuki M, Okano Y, et al: Pyloric stenosis in a patient with progressive systemic sclerosis. Clin Rheumatol 7(3):394 397, 1988 9. Fok M, Cheng SW, Wong J: Pyloroplasty versus no drainage in gastric replacement of the esophagus. Am J Surg 162(5):447 452, 1991 10. Law S, Cheung MC, Fok M, Chu KM, Wong J: Pyloroplasty and pyloromyotomy in gastric replacement of the esophagus after esophagectomy: a randomized controlled trial. J Am Coll Surg 184(6):630 636, 1997 11. Ng JW, Yeung GH: Laparoscopic vagotomy and open pyloroplasty for bleeding duodenal ulcer not controlled endoscopically. Surg Laparosc Endosc 8(2):127 131, 1998 12. Danikas D, Geis W, Ginalis E, Gorcey S, Stratoulias C: Laparoscopic pyloroplasty in idiopathic hypertrophic pyloric stenosis in an adult. [In Process Citation]. JSLS 4(2):173 175, 2000