What is the treatment for pyloroplasty and what are the indications for the procedure?

Pyloroplasty: Indications and Treatment Approach

Pyloroplasty is a surgical procedure primarily indicated for patients with refractory gastroparesis, particularly those with diabetic gastroparesis who have failed medical management, and as a drainage procedure during esophageal reconstruction using a gastric conduit. 1, 2

Indications for Pyloroplasty

Refractory Gastroparesis

• Pyloroplasty may be considered for patients with severe gastroparesis who have failed standard medical therapies, particularly those with diabetic gastroparesis who show the highest frequency of clinical success (89%) 1
• Recent evidence suggests that gastric per oral endoscopic myotomy (G-POEM) or gastric per oral pyloroplasty may be effective for refractory gastroparesis, with pooled analyses showing reduction in post-procedure GCSI scores and improved gastric emptying 1, 2
• Pyloric dysfunction, including pyloric stenosis and reduced numbers of interstitial cells of Cajal, may contribute to symptoms in some patients with gastroparesis 1

Esophageal Reconstruction

• Pyloroplasty is recommended as a drainage procedure when the stomach is used as an esophageal substitute after esophagectomy 1, 3
• Randomized studies have shown that pyloroplasty significantly improves gastric emptying (T1/2: 6.6 ± 7.5 minutes with pyloroplasty vs. 24.3 ± 31.5 minutes without) and reduces complications associated with gastric outlet obstruction 3
• Patients with pyloroplasty after esophagectomy tolerate solid diet better and experience fewer symptoms with meals compared to those without drainage procedures 3

Other Indications

• Functional or mechanical gastric outlet obstruction, particularly antral dysmotility syndrome 4
• As part of colon interposition procedures 4
• During gastric resection procedures 4
• For benign gastric outlet obstruction when non-operative treatment fails 5

Surgical Techniques for Pyloroplasty

Traditional Techniques

• Heineke-Mikulicz pyloroplasty: Longitudinal incision across the pylorus with transverse closure 5, 6
• Finney pyloroplasty: U-shaped incision across the pylorus with side-to-side gastroduodenostomy 5
• One-layer vs. two-layer closure techniques: Both are equally effective and safe, with the one-layer method being simpler 7

Advanced Techniques

• Y-U advancement pyloroplasty: A broadly based U-shaped pedicle constructed from the gastric antrum is advanced into an incision in the anterior duodenum, providing maximal channel size 6
• G-POEM (Gastric Per Oral Endoscopic Myotomy): An endoscopic technique similar to POEM for achalasia, involving submucosal tunneling and myotomy of the pylorus 1
  • Should only be performed at tertiary care centers by a team of experts with extensive experience in treating refractory gastroparesis 1, 2
  • Overall adverse event rate of 6.8% 1, 2

Outcomes and Considerations

Efficacy

• For gastroparesis: G-POEM has shown clinical success rates of 77.5% at 4 years in a large retrospective study, with diabetic gastroparesis showing the best long-term outcomes 1
• For esophageal reconstruction: Pyloroplasty significantly reduces gastric emptying time and improves tolerance to solid diet 3
• For pediatric patients: Excellent catch-up weight gain occurred in over 90% of children with functional or mechanical gastric outlet obstruction 4

Complications and Considerations

• G-POEM has the theoretical potential to induce dumping syndrome, which can negatively affect food tolerance and quality of life 1
• Surgical pyloroplasty has minimal morbidity even in the absence of vagotomy 4
• The role of laparoscopic pyloroplasty is unclear due to the absence of large, well-designed trials 2
• Surgical options should be considered only after all available therapies have been exhausted, preferably at a tertiary care center 2

Treatment Algorithm for Gastroparesis

1. First-line: Medical management with prokinetics, antiemetics, and nutritional support 2
2. Second-line: Consider gastric electrical stimulation for intractable nausea/vomiting 2
3. Third-line: For refractory cases, consider G-POEM or surgical pyloroplasty, particularly for diabetic gastroparesis 1, 2
4. Fourth-line: For severe cases with nutritional compromise, consider enteral nutrition via jejunostomy tube 1, 2
5. Last resort: Partial or total gastrectomy only after all available therapies have been exhausted 1