What are the steps to perform a pyloroplasty?

Steps to Perform a Pyloroplasty

The standard pyloroplasty procedure involves a longitudinal incision through the pylorus followed by transverse closure to widen the pyloric channel, with the Heineke-Mikulicz technique being the most commonly performed approach.

Surgical Techniques for Pyloroplasty

Heineke-Mikulicz Pyloroplasty (Standard Technique)

1. Make a longitudinal full-thickness incision through the pylorus (approximately 4-5 cm long)
2. Extend the incision 1-2 cm into the duodenum and 2-3 cm into the gastric antrum
3. Place stay sutures at the midpoint of the incision on both sides to aid exposure
4. Close the incision transversely using interrupted sutures in one or two layers
   • One-layer closure has been shown to be as effective as two-layer technique 1
   • Ensure mucosal apposition during closure

Finney Pyloroplasty

1. Make a U-shaped incision through the pylorus
2. Create a side-to-side gastroduodenostomy
3. Close the incision to create a wider channel

Y-U Advancement Pyloroplasty

1. Create a U-shaped pedicle from the gastric antrum
2. Make an incision in the anterior duodenum
3. Advance the gastric pedicle into the duodenal incision 2
4. This technique is particularly useful in cases where standard Heineke-Mikulicz has failed

G-POEM (Gastric Peroral Endoscopic Myotomy)

For cases with confirmed gastroparesis, G-POEM may be considered as an alternative to traditional pyloroplasty:

1. Create a submucosal bleb 4-5 cm proximal to the pylorus (typically along greater curvature)
2. Make a 1.5-2 cm mucosal incision
3. Create a submucosal tunnel extending to the pyloric ring
4. Perform myotomy of the pyloric ring extending 1-3 cm into the antrum
5. Close the mucosal incision using endoscopic clips or suturing 3

Important Technical Considerations

Preoperative Assessment

• Confirm diagnosis with upper endoscopy to visualize stenotic pylorus and rule out malignancy
• Assess for Helicobacter pylori infection, which is commonly associated with peptic pyloric stenosis 4

Intraoperative Steps

1. Identify the pylorus (note the prepyloric vein of Mayo as a landmark)
2. Place stay sutures before incision to maintain orientation
3. Make the incision through avascular areas to minimize bleeding
4. Ensure complete division of all pyloric muscle fibers
5. Verify hemostasis before closure
6. Test the patency of the pyloric channel after closure

Postoperative Management

• Nasogastric tube placement is recommended until return of bowel function
• Patients may start on clear liquids once bowel function returns
• Consider proton pump inhibitor therapy to decrease acid secretion and aid healing 3
• Advance to full liquid diet for 5-7 days, then progress to small, frequent meals 3

Potential Complications and Management

• Leakage: Early disruption (within 72 hours) usually reflects technical error and may require re-exploration; later leaks may be managed conservatively 3
• Bleeding: Ensure meticulous hemostasis during the procedure
• Gastric emptying disorders: May require additional intervention if symptoms persist
• Dumping syndrome: May occur as a postoperative complication

Follow-up

• Clinical follow-up at 1-3 months post-procedure
• Consider upper GI contrast study if symptoms persist
• Monitor for symptom recurrence and consider repeat endoscopy if indicated 4

Pyloroplasty remains an effective drainage procedure for various conditions including peptic pyloric stenosis, gastroparesis, and as an adjunct to vagotomy or esophagectomy when the stomach is used as a conduit 3, 1.