Pyloroplasty

Overview

Pyloroplasty is a surgical procedure designed to modify the pylorus, the muscular valve at the bottom of the stomach that regulates the passage of food into the small intestine. This procedure may be required to widen the pylorus if food is struggling to pass through. It can also be employed to reconstruct the pylorus if it has been altered or damaged by another procedure.

Pyloroplasty can be performed using either open or laparoscopic surgical techniques. Laparoscopic surgery, a minimally invasive option, involves smaller incisions compared to traditional open surgery. Both procedures are conducted under general anesthesia, so you will be asleep and free from pain throughout the operation.

Reasons for undergoing the procedure

If your pylorus is not functioning properly or you are experiencing issues with gastric emptying, pyloroplasty can be beneficial. Conditions that may necessitate pyloroplasty include:

Peptic ulcer disease

In severe cases of peptic ulcer disease, elective surgery may be necessary. If you experience recurring bleeding ulcers or ulcers that do not heal, your doctor might recommend a vagotomy. This procedure involves cutting some of the nerves to the stomach to reduce stomach acid and help decrease ulcers. However, it also impacts the nerve that controls the pylorus, the valve between the stomach and small intestine. As a result, if you undergo a vagotomy, a pyloroplasty will be required to permanently keep the pylorus open, allowing food to pass through.

Ulcers can also require emergency surgery. For example, a swollen ulcer or one with scar tissue can obstruct the pylorus, while an actively bleeding ulcer or one that has perforated the gastrointestinal wall may need immediate surgical intervention. If the ulcer is located in the duodenum, the surgeon may need to make an incision in the pylorus to access it. Following this, a pyloroplasty might be needed to reconstruct the pylorus.

Gastroparesis

Gastroparesis is a condition marked by partial paralysis of the stomach muscles, including the pylorus, resulting in impaired gastric motility and delayed gastric emptying. In severe cases, this can lead to chronic nausea and vomiting, making eating difficult. If other treatments prove ineffective, your doctor may recommend a pyloroplasty to open the pylorus.

Gastroesophageal resection

Surgery on your esophagus or stomach may sever the vagus nerve, which controls the opening and closing of the pylorus. As a result, you might need a pyloroplasty to keep the pylorus open.

Pyloric stenosis

Pyloric stenosis predominantly affects newborns and is rare in adults. It causes the walls of the pylorus to thicken, which narrows and obstructs the outlet. Newborns with pyloric stenosis typically require pyloroplasty to allow them to feed without vomiting.

Risks

General risks

Like any abdominal surgery, pyloroplasty carries certain general risks. These concerns include:

• Infection.
• Bleeding.
• Blood clots.
• Damage to adjacent organs.
• A leak from the repair.

Dumping syndrome

Pyloroplasty carries the specific risk of developing dumping syndrome, a common but typically temporary side effect of stomach surgery. Dumping syndrome occurs when the stomach empties its contents too quickly into the small intestine, the opposite issue of delayed gastric emptying, which might have been the reason for the pyloroplasty.

Dumping syndrome has two phases, each with distinct symptoms, and you may experience one or both phases. Early dumping syndrome happens shortly after eating and can cause nausea, stomach cramps, and diarrhea. Late dumping syndrome occurs a few hours after eating when blood sugar levels drop rapidly, leading to symptoms such as weakness, heart palpitations, flushing, and faintness.

After pyloroplasty, up to 40% of people may have mild symptoms of dumping syndrome, and up to 10% may experience more severe symptoms. These symptoms usually subside over time. In the meantime, dietary changes can often help manage them. Your doctor will discuss strategies to avoid or manage dumping syndrome and may prescribe medication if necessary.

Bile reflux

Surgery that modifies your pyloric valve can result in the backflow of small intestine contents into your stomach if the valve no longer closes properly. This backwash includes bile, which can be harsh on the stomach lining if it refluxes. Excessive bile reflux may lead to inflammation (gastritis) or erosion of the stomach lining.

During the procedure

Different conditions call for different types of pyloroplasty operations.

• Heineke-Mikulicz pyloroplasty. The Heineke-Mikulicz technique is the most often used kind of pyloroplasty. The ring of muscle that opens and closes your pylorus, known as the pyloric sphincter, is severed lengthwise by the surgeon. Next, they use crosswise stitches to reattach it, causing the muscle to relax and the diameter to enlarge.
• Pyloromyotomy (Ramstedt pyloroplasty). For newborns with pyloric stenosis, this modified pyloroplasty is the recommended course of treatment. It can occasionally be used in place of the Heineke-Mikulicz procedure for people suffering from gastric outlet obstruction or gastroparesis. Your surgeon preserves the mucosa, or inner lining of your stomach, while cutting through some but not all of the pylorus’ layers. The mucosa extends through the cut, increasing the space inside the pylorus.
• Pyloric dilation. During this process, an upper endoscopy is performed by a doctor who specializes in scope operations. An instrument is inserted via your mouth to dilate (expand) your pylorus without causing any cuts.
• Jaboulay/Finney pyloroplasty. Jaboulay and Finney pyloroplasties are rare procedures. Both involve bypassing the pylorus and establishing a new connection between the stomach and the duodenum (gastroduodenostomy). If your pylorus has too much scar tissue or inflammation for it to be treated adequately, they can be required. The Jaboulay procedure entirely bypasses the pylorus, whereas the Finney method involves making an incision in the pylorus to create the new outlet.

After the procedure

After your surgeon opens your gastric outlet, they will close all of your incisions to complete the procedure. If you undergo laparoscopic surgery, you may be able to return home the same day. However, with open abdominal surgery, you might need to stay in the hospital for a few days and will have a larger wound. Initially, you may be fed through a vein or a feeding tube and won’t be able to eat solid food.

Outcome

Most individuals recover quickly from pyloroplasty, especially when it is performed laparoscopically. Most people can return to their regular activities and diet within a few weeks. However, if dumping syndrome occurs, dietary adjustments may be needed to manage symptoms, which could persist for few months.

Pyloroplasty is highly effective for treating gastroparesis and gastric outlet obstruction, with success rates approaching 90%. Additionally, when performed as part of a broader procedure, pyloroplasty effectively prevents pyloric obstruction.