What is the surgical approach for adult pyloric stenosis?

Surgical Management of Adult Pyloric Stenosis

For adult pyloric stenosis, endoscopic balloon dilation should be the first-line surgical approach, with open surgery reserved for cases refractory to endoscopic management or when complications occur.

Diagnostic Approach

• Confirm diagnosis with upper endoscopy to visualize the stenotic pylorus and rule out malignancy
• Assess for Helicobacter pylori infection, which is commonly associated with peptic pyloric stenosis
• Consider gastric emptying studies to quantify the degree of obstruction

Treatment Algorithm

First-Line Approach: Medical Management

1. Initial medical therapy:

   • Proton pump inhibitors (PPIs) at high doses (twice daily)
   • Gastric decompression via nasogastric tube if significant distention
   • Intravenous fluids and electrolyte correction
   • H. pylori eradication therapy if infection is present 1

2. Medical therapy has shown success in multiple studies:

   • Complete symptom resolution in 83% of patients with PPI therapy 2
   • Median duration for symptom resolution: 9 days (range 5-14 days) 2
   • H. pylori eradication resulted in resolution of peptic stenosis in 20/22 patients (91%) 1

Second-Line Approach: Endoscopic Balloon Dilation

If medical therapy fails after 2 weeks:

1. Endoscopic balloon dilation:

   • Recommended as first-line interventional therapy 3
   • Through-the-scope balloons can increase pyloric diameter from average 6mm to 16mm 3
   • High success rates for symptom relief in benign pyloric stenosis 3
   • Continue PPI therapy after dilation

2. Warning signs for endoscopic failure:

   • Need for more than two dilations indicates high risk of failure 3
   • Rapid restenosis suggests possible malignancy requiring further evaluation

Third-Line Approach: Surgical Intervention

For cases refractory to endoscopic management:

1. Surgical options:

   • Pyloroplasty (preferred for benign disease) 2
   • Gastrojejunostomy (for cases with extensive scarring)
   • Antrectomy with gastroduodenostomy (Billroth I) or gastrojejunostomy (Billroth II) for cases with suspected malignancy

2. Surgical approach considerations:

   • In hemodynamically stable patients, laparoscopic approach is preferred to reduce length of stay and morbidity 4
   • Open surgery is recommended for hemodynamically unstable patients 4

Special Considerations

Gastroparesis vs. Mechanical Obstruction

• Distinguish between mechanical pyloric stenosis and gastroparesis
• Consider G-POEM (gastric peroral endoscopic myotomy) for cases with confirmed gastroparesis 4
• G-POEM involves:
  • Submucosal bleb creation in the antrum
  • Submucosal tunneling to expose the pyloric ring
  • Myotomy of the pyloric ring
  • Closure of the mucosal incision

Complications Management

• For perforation during endoscopic procedures:

  • Immediate surgical intervention is required 4
  • Class A patients (stable, minimal contamination): primary repair or resection with primary anastomosis 4
  • Class B/C patients (unstable, significant contamination): damage control surgery with delayed anastomosis 4

• For bleeding complications:

  • Endoscopic management as first-line approach
  • Angiography with embolization for refractory bleeding
  • Surgical intervention if endoscopic and angiographic approaches fail 4

Follow-up

• Endoscopic follow-up at 2 and 6 months after treatment
• Continue PPI therapy at maintenance dose
• Monitor for symptom recurrence
• Consider repeat gastric emptying studies if symptoms persist despite endoscopically normal-appearing pylorus

Conclusion

While medical management with PPIs and H. pylori eradication has shown promising results in some studies 5, 2, 1, 6, endoscopic balloon dilation remains the first-line surgical approach for adult pyloric stenosis with surgery reserved for refractory cases or complications. This approach optimizes outcomes while minimizing morbidity and mortality associated with more invasive surgical interventions.