Pyloroplasty

Pyloroplasty widens the pyloric channel to relieve gastric outlet obstruction or to facilitate gastric emptying after truncal vagotomy. Historical indications — vagotomy and pyloroplasty for peptic ulcer disease — have largely disappeared with the advent of proton pump inhibitors and H. pylori eradication. Modern indications include benign pyloric stenosis (from chronic ulceration, caustic injury, or surgery), gastric outlet obstruction from a fixed peptic ulcer, gastroparesis refractory to medical therapy (where pyloroplasty or pyloromyotomy may be considered), and as a drainage procedure after intentional truncal vagotomy.

Pyloroplasty is also performed during esophagectomy when truncal vagotomy is unavoidable as part of the proximal gastric mobilization, to prevent post-vagotomy gastric stasis. Some surgeons perform routine pyloroplasty (or pyloromyotomy) during esophagectomy; others perform it selectively or rely on endoscopic balloon dilation postoperatively if obstruction develops.

Workup includes upper endoscopy with biopsy to rule out malignancy (an obstructing distal stomach mass is gastric cancer until proven otherwise), upper GI contrast study to characterize the obstruction, and nutritional assessment. Patients with chronic gastric outlet obstruction are often malnourished, dehydrated, and have metabolic alkalosis with hypokalemia from chronic vomiting. Correction of electrolyte abnormalities and nutritional repletion (often with TPN preoperatively) reduce operative morbidity.

The Heineke-Mikulicz is the simplest and most common pyloroplasty. A longitudinal incision is made through the pylorus, beginning 2 cm proximal and extending 2 cm distal, through the full thickness of the muscular wall. The incision is then closed transversely, converting the long-axis incision into a wider short-axis closure that increases the pyloric diameter. Closure is typically two layers — full-thickness absorbable suture followed by seromuscular interrupted sutures.

Technical pitfalls include excessively long incision (which makes transverse closure difficult and predisposes to leak), inadequate transverse closure (which negates the widening effect), and failure to recognize a chronic ulcer at the operative site that may require local excision.

The Finney pyloroplasty is essentially a side-to-side gastroduodenostomy. The first part of the duodenum and the antrum are mobilized via Kocher maneuver. A U-shaped incision is made spanning the pyloric channel, opening the antrum on one limb and the proximal duodenum on the other. The posterior wall is sewn first, then the anterior wall, creating a large gastroduodenal anastomosis around the divided pylorus.

Finney is appropriate when the pyloric channel is too narrow or deformed for adequate Heineke-Mikulicz, and provides a larger drainage opening at the cost of additional dissection.

The Jaboulay pyloroplasty is a side-to-side gastroduodenostomy in which the pyloric channel itself is bypassed rather than incised. A long anastomosis is created between the antrum and the proximal duodenum without dividing the pylorus. This is useful when the pyloric channel is severely scarred or inflamed and cannot be safely incised.

The nasogastric tube is typically left in place until gastric function returns (often 24–72 hours). Diet is advanced gradually with attention to symptoms of delayed gastric emptying, which is the most common functional complication. Prokinetic agents (metoclopramide, erythromycin) may be helpful. Most patients tolerate a regular diet within 5–7 days.

Operative complications include leak from the suture line (presenting with fever, leukocytosis, and abdominal pain in the first week — managed with reoperation, drainage, and broad-spectrum antibiotics), bleeding, and inadvertent injury to nearby structures. Postoperative complications include dumping syndrome (especially if vagotomy is added), bile reflux gastritis (because the pylorus no longer functions as a competent valve), gastric atony from vagal disruption, and recurrent gastric outlet obstruction from stricture at the pyloroplasty.

Dumping is the most clinically relevant late complication. Early dumping (within 30 minutes of eating) presents with abdominal cramping, diarrhea, and vasomotor symptoms from rapid fluid shifts as hyperosmolar gastric contents enter the small bowel. Late dumping (1–3 hours postprandial) results from reactive hypoglycemia after rapid carbohydrate absorption. Management is dietary: small, frequent, low-carbohydrate meals with separation of solids from liquids.

Examiners commonly test the recognition that gastric outlet obstruction in an adult is gastric cancer until proven otherwise (mandating endoscopic biopsy), the choice among Heineke-Mikulicz, Finney, and Jaboulay based on local conditions, and the recognition and management of dumping syndrome after vagotomy and pyloroplasty.