What are the surgical steps for pyloric exclusion?

Pyloric Exclusion Surgical Steps

Pyloric exclusion is performed through an anterior gastrostomy to suture the pylorus closed with absorbable material, optionally followed by gastrojejunostomy, with the goal of temporarily diverting gastric contents while allowing spontaneous pyloric reopening after duodenal healing. 1, 2

Surgical Technique

Access and Exposure

• Perform a standard laparotomy with Kocherisation of the duodenum to fully expose the injury and pylorus 3
• Complete mobilization of the duodenum is essential to assess the full extent of injury before proceeding with pyloric exclusion 1

Duodenal Repair First

• Repair the duodenal injury primarily using 3/0 polydioxanone suture (PDS) in a tension-free transverse fashion after removing all devitalized tissue 1, 3
• Place a nasogastric tube for proximal gastric decompression 1
• Consider reinforcing complex repairs with a jejunal serosal patch sutured over the primary repair using 3/0 PDS (serosa to serosa only) 3

Pyloric Exclusion Procedure

• Create an anterior gastrostomy incision in the body of the stomach 3
• Through this gastrostomy, identify the pylorus from inside the stomach 2, 4
• Suture the pylorus closed using absorbable suture material—polydioxanone (PDS) is superior to polyglycolic acid (PGA) for reliable spontaneous reopening at 3-4 weeks 2, 5
• The controlled reopen suture technique involves placing absorbable sutures that will dissolve to allow pyloric patency to resume 2
• Close the anterior gastrostomy using a GIA stapling device or hand-sewn closure 3

Gastrojejunostomy Decision

• Gastrojejunostomy can be omitted if the duodenal repair does not compromise the lumen and the patient's physiology is stable 2
• When gastrojejunostomy is performed, create a standard Roux-en-Y or loop gastrojejunostomy to divert gastric contents 4
• Vagotomy is not routinely required and adds unnecessary operative time in the trauma setting 2

Drainage

• Place external drains near the duodenal repair site to control potential leaks 1
• Periduodenal drain placement is recommended for WSES class III injuries (AAST grades III-V) 1

Critical Technical Points

Suture Material Selection

• Use polydioxanone (PDS) rather than polyglycolic acid (PGA) for pyloric closure—PDS reliably allows pyloric reopening at 3-4 weeks, while PGA may result in prolonged closure 5
• PDS maintains tensile strength for approximately 4-6 weeks before complete absorption, matching the duodenal healing timeline 5

Avoiding Complications

• The pyloric exclusion itself should be quick and simple, taking only minutes to perform 2, 4
• Avoid excessive tissue handling or tight suture placement that could cause ischemia 2
• Do not perform vagotomy unless specifically indicated, as it increases operative time and complications without benefit 2

Common Pitfalls

Overuse of the Procedure

• Current evidence shows pyloric exclusion does not reduce duodenal fistula rates or mortality compared to primary repair alone, and is associated with longer hospital stays 6
• The WSES guidelines note that definite indications for pyloric exclusion remain controversial, with several studies showing no improvement in morbidity or mortality 1
• Consider pyloric exclusion only for WSES class III or higher duodenal injuries (AAST grades III-V) where primary repair alone may be insufficient 1

Technical Errors

• Using non-absorbable suture material (polypropylene) will prevent spontaneous pyloric reopening and necessitate endoscopic or surgical intervention 5
• Inadequate Kocherisation may miss posterior duodenal injuries or prevent adequate assessment of injury severity 3
• Performing pyloric exclusion in damage control situations adds unnecessary operative time when the patient's physiology is deranged 1

Postoperative Management Failures

• Failure to maintain nasogastric decompression can increase pressure on repair sites 1
• Not monitoring drain output for duodenal fistula (increased output, fever, leukocytosis) can delay recognition of complications 7
• Gastric suture line complications including marginal ulcers occur in approximately 3-5% of cases and require surveillance 4, 6

Expected Outcomes

• Pyloric patency returns in approximately 94% of patients examined 21 days or more after operation when absorbable sutures are used 4
• Duodenal fistula rates of 2.2-5.5% are reported, though these are not significantly different from primary repair alone 4, 6
• Marginal ulceration occurs infrequently (approximately 3-4% of cases) when gastrojejunostomy is performed 4