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Pyloroplasty
Definition
Pyloroplasty is a surgical procedure in which the pylorus valve at the lower portion of
the stomach is cut and resutured, relaxing and widening its muscular opening (pyloric
sphincter) into the duodenum (first part of the small intestine). Pyloroplasty is a
treatment for patients at high risk for gastric or peptic ulcer disease (PUD).
Purpose
Pyloroplasty surgery enlarges the opening through which stomach contents are
emptied into the intestine, allowing the stomach to empty more quickly. A
pyloroplasty is performed to treat the complications of PUD or when medical
treatment has not been able to control PUD in high-risk patients.
Description
Peptic ulcer disease develops when there is an imbalance between normal conditions
that protect the lining (mucosa) of the stomach and the intestines and conditions that
disrupt normal functioning of the lining. Protective factors include the water-soluble
mucosal gel layer, the production of bicarbonate in the lining to balance acidity, the
regulation of gastric acid (stomach acid) secretion, and blood flow in the lining. The
aggressive factors that work against this protective gastric-wall system are excessive
acid production, H. pylori bacterial infection, and a reduced blood flow (ischemia) in
the mucosal lining. These aggressive factors can cause inflammation and ulcer
development. A peptic ulcer is a type of sore or hole (perforation) that forms on the
lining of the stomach (gastric ulcer) or intestine (duodenal ulcer), when the lining has
been eaten away by stomach acid and digestive juices. Peptic ulcers can be primary,
caused by H. pylori infection, or secondary, caused by excess acid production, stress,
use of medications, and other underlying
In a pyloroplasty, an incision is made in the area that connects the stomach to
the duodenum (small intestine), called the pylorus (A). The pylorus is divided
laterally (B), and then stitched longitudinally (C and D), allowing for a larger
connection. ( Illustration by GGS Inc. )
Conditions that disrupt the gastric environment. Although H. pylori is believed to
cause the majority of all ulcers, not all people infected with it develop ulcers. In highrisk individuals, the bacteria more readily disturb the balance between good factors
and destructive factors, upsetting the protective function of the stomach and intestine
lining. An ulcer develops when the lining can no longer protect the organs. Secondary
ulcers are usually found in the stomach; primary ulcers can be in the stomach or
intestine.
Other factors that contribute to mucosal inflammation and ulceration include:
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alcohol and caffeine use
non-steroidal anti-inflammatory drugs (NSAIDs)
aspirin
cigarette smoking
exposure to certain irritating chemicals
emotional disturbances and prolonged stress
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traumatic injuries and burns
respiratory failure
blood poisoning
critical illnesses that create imbalances in body chemistry
Symptoms of gastric or peptic ulcer include burning pain, nausea, vomiting, loss of
appetite, bloating, burping, and losing weight.
When PUD is diagnosed or high risk established, medical treatment will begin to treat
H. pylori infection if present and to restore balanced conditions in the mucosal lining.
Any underlying condition may be treated simultaneously, including respiratory
disorders, fluid imbalance, or stomach and digestive disorders. Medications may be
prescribed to help correct gastric disturbances and control gastric acid secretion.
Certain drugs that are prescribed for other conditions, especially NSAIDs, may be
discontinued if they are known to cause inflammation. Adult patients may be advised
to discontinue alcohol and caffeine use and to stop smoking.
When medical treatment alone is not able to improve the conditions that cause PUD, a
pyloroplasty procedure may be recommended, particularly for patients with stress
ulcers, perforation of the mucosal wall, and gastric outlet obstruction. The surgery
involves cutting the pylorus lengthwise and resuturing it at a right angle across the cut
to relax the muscle and create a larger opening from the stomach into the intestine.
The enlarged opening allows the stomach to empty more quickly. A pyloroplasty is
sometimes done in conjunction with a vagotomy procedure in which the vagus nerves
that stimulate stomach acid production and gastric motility (movement) are cut. This
may delay gastric emptying and pyloroplasty will help correct that effect.
Diagnosis
Diagnosis begins with an accurate history of prior illnesses and existing medical
conditions as well as a family history of ulcers or other gastrointestinal (stomach and
intestines) disorders. A complete history and comprehensive diagnostic testing may
include:
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location, frequency, duration, and severity of pain
vomiting and description of gastric material
bowel habits and description of stool
all medications, including over-the-counter products
appetite, typical diet, and weight changes
family and social stressors
alcohol consumption and smoking habits
heart rate, pulse, and blood pressure
chest examination and x ray, if necessary
palpation (touch) of the abdomen
rectal examination and stool testing
pelvic examination in sexually active females
examination of testicles and inguinal (groin) area in males
testing for the presence of Helicobacter pylori
complete blood count and blood chemistry profile
urinalysis
imaging studies of gastrointestinal system (x ray, other types of scans)
biopsy of stomach lining using a tube-like telescopic instrument (endoscope)
Preparation
Before surgery, standard preoperative blood and urine tests will be performed and
various x rays may be ordered. The patient will not be permitted to eat or drink
anything after midnight the night before the procedure. When the patient is admitted
to the hospital, cleansing enemas may be ordered to empty the intestine. If nausea or
vomiting are present, a suction tube may be used to empty the stomach.
Aftercare
The patient will spend several hours in a recovery area after surgery where blood
pressure, pulse, respiration, and temperature will be monitored. The patient's
breathing may be shallower than normal because of the effect of anesthesia and the
patient's reluctance to breathe deeply and experience pain at the site of the surgical
incision. The patient will be shown how to support the site while breathing deeply or
coughing, and will be given pain medication as needed. Fluid intake and output will
be measured. The operative site will be observed for any sign of redness, swelling, or
wound drainage. Intravenous fluids are usually given for 24–48 hours until the patient
is gradually permitted to eat a special light diet and as bowel activity resumes. About
eight hours after surgery, the patient may be allowed to walk a little, increasing
movement gradually over the next few days. The average hospital stay, dependent
upon the patient's overall recovery status and any underlying conditions, ranges from
six to eight days.
Risks
Potential complications of this abdominal surgery include excessive bleeding, surgical
wound infection, incisional hernia, recurrence of gastric ulcer, chronic diarrhea, and
malnutrition. After the surgery, the surgeon should be informed of an increase in pain,
and of any swelling, redness, drainage, or bleeding in the surgical area. The
development of headache, muscle aches, dizziness, fever, abdominal pain or swelling,
constipation, nausea or vomiting, rectal bleeding, or black stools should also be
reported.
Normal results
Complete healing is expected without complications. Recovery and a return to normal
activities should take from four to six weeks.
Morbidity and mortality rates
Successful treatment of Helicobacter pylori has improved morbidity and mortality
rates, and the prognosis for PUD, with proper treatment and avoidance of causative
factors, is excellent. Pyloroplasty is rarely performed in primary ulcer disease.
Morbidity and mortality are higher in patients with secondary ulcers because of
underlying illness that complicates both PUD and surgical treatment.