What are the types of pyloplasty?

Types of Pyloplasty

The three main types of pyloplasty are Heineke-Mikulicz (most common), Finney, and Jaboulet procedures, with Heineke-Mikulicz being the standard technique for most clinical scenarios requiring pyloric drainage.

Classical Pyloplasty Techniques

Heineke-Mikulicz Pyloplasty

• This is the most commonly performed pyloplasty technique, involving a longitudinal incision through the pylorus that is then closed transversely to widen the pyloric channel 1, 2, 3
• The technique is analogous to the "Fenger-plasty" described in urologic literature, where a longitudinal incision is closed in a Heineke-Mikulicz fashion 4
• This approach is preferred when the stomach is used as an esophageal substitute after esophagectomy, serving as a drainage procedure 1
• The procedure is technically straightforward and can be performed quickly, making it suitable for most clinical situations requiring pyloric drainage 3

Finney Pyloplasty

• This technique involves creating a side-to-side gastroduodenostomy by folding the pylorus and creating a U-shaped anastomosis 1
• It provides a wider drainage channel compared to Heineke-Mikulicz but requires more extensive mobilization of the duodenum 2

Jaboulet Pyloplasty

• This is a side-to-side gastroduodenostomy performed without dividing the pylorus 1
• The technique bypasses rather than widens the pyloric channel 2

Modern Endoscopic Alternative: Gastric Per-Oral Endoscopic Myotomy (G-POEM)

Technical Approach

• G-POEM represents an endoscopic pyloric drainage technique that involves submucosal tunneling and myotomy of the pylorus, similar to peroral endoscopic myotomy (POEM) for achalasia 5, 1
• A 1.5- to 2-cm mucosal incision is made, followed by submucosal tunneling close to the muscularis propria until the pyloric ring is fully exposed with limited extension into the duodenal bulb 5
• Complete myotomy of the pylorus is performed and carried out 2 cm proximally into the antrum 5
• Mucosal closure can be performed using endoclips or an endoscopic suturing device 5

Variations in G-POEM Technique

• Most operators favor a greater-curvature approach, though a lesser-curvature approach has been described with similar outcomes (pyloromyotomy is more challenging with the lesser-curve approach) 5
• A "double myotomy" technique involves performing two pyloromyotomy incisions at the index G-POEM, which was found superior to single myotomy at 6-month follow-up in one study 5
• The addition of a second incision is not technically challenging and does not markedly prolong procedure time, though additional long-term data are needed 5

Clinical Outcomes and Indications

G-POEM Efficacy

• Clinical success rates of 77.5% at 4 years have been reported, with diabetic gastroparesis showing the best long-term outcomes (89% success rate) 1
• Pooled analyses show reduction in post-procedure GCSI scores and improved gastric emptying, with 6.8% overall adverse events 1
• At 12 months, clinical success was achieved in 56% with GCSI score <2 observed in 68% of patients 5

Indications for Pyloric Drainage Procedures

• Refractory gastroparesis with severe gastric emptying delay who have failed standard medical therapies, particularly diabetic gastroparesis 1
• Esophageal reconstruction when the stomach is used as an esophageal substitute 1
• Large gastric perforations near the pylorus or gastric outlet obstruction from chronic fibrotic disease 3

Important Clinical Considerations

Expertise Requirements

• G-POEM should only be performed at tertiary care centers by a team of experts with extensive experience in treating refractory gastroparesis 1
• Surgical pyloplasty should be performed by experienced surgeons, particularly when using laparoscopic approaches 2

Treatment Algorithm for Refractory Gastroparesis

• First-line: Anti-emetic agents and neuromodulators based on predominant symptoms 1
• Second-line: Consider G-POEM or surgical pyloroplasty for severe cases, particularly diabetic gastroparesis 1
• Last resort: Partial or total gastrectomy only after all available therapies have been exhausted 1

Common Pitfalls

• Avoid performing pyloric drainage procedures in patients on chronic opioids, as opioids worsen gastroparesis 1
• Ensure proper patient selection with documented gastric emptying delay using appropriate methodology 1
• G-POEM adverse events include abdominal pain, inadvertent mucosotomy, capnoperitoneum, bleeding, and gastric ulceration 5