Surgery STAT: Pyloroplasty for gastric outflow emptying (2024)

A Y-U pyloroplasty is a great technique for treating this condition-when done with the utmost care and precision.

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Surgery STAT: Pyloroplasty for gastric outflow emptying (1)Surgery STAT: Pyloroplasty for gastric outflow emptying (2)

Surgery STAT: Pyloroplasty for gastric outflow emptying (3)

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In patients with a partial gastric outflow obstruction, metoclopramide and cisapride may increase gastric contractions and emptying. But when medical management fails, surgically increasing the diameter of the pyloric lumen is indicated. The surgical options for treating gastric outflow obstruction include Fredet-Ramstedt, pyloro­myotomy, Heineke-Mikulicz pyloroplasty and the preferred Y-U pyloroplasty.

However, if these procedures are performed incorrectly, they are difficult to correct. And the potential side effects from surgical complications can be costly. For example, the surgery may need to be repeated if the lumen is not opened enough or incisional dehiscence occurs, or additional therapy for areas of gastric necrosis will add to the expense and a patient's morbidity. Consider the following guidelines for performing a Y-U pyloroplasty with the utmost care and precision.

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Master the fine points

As with any gastrointestinal surgery, packing off the area will limit contamination from spillage. Also, complete sponge counts should also be performed routinely.

Mentally draw and center the “Y” over the pylorus. All three arms should be equal in length. The base of the Y should appear along the ventral side of the pylorus toward the duodenum. The orad arms of the Y should course along the lesser and greater curvatures but stay just medial of large gastric vessels. These arms must diverge enough to avoid necrosis of the tip of the stomach flap but not too far apart as to cause excess damage to gastric vessels. Use full-thickness stay sutures throughout the procedure to minimize the handling of tissue edges with forceps.

Starting over the pylorus, make the first full-thickness incision with a No. 15 blade and extend it 1 to 2 cm, depending on the size of the animal. I prefer to start the incision with my blade but continue the cut with baby Metzenbaum scissors. If you are using curved scissors, make sure the natural angle of the blades does not draw the incision off midline. I place a 3-0 or 4-0 stay suture at the end or along this incision for better manipulation (Figure 1).

Surgery STAT: Pyloroplasty for gastric outflow emptying (4)Surgery STAT: Pyloroplasty for gastric outflow emptying (5)

Surgery STAT: Pyloroplasty for gastric outflow emptying (6)

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Figure 1: The base of the Y is aborad to the pylorus. Note the stay suture to help with surgical manipulation. (All surgical photos courtesy of Dr. Jennifer Wardlaw.)

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Once you've made the base of the Y, create the first arm along the lesser curvature. The arm needs to be cranial enough to create a wide tongue of stomach wall but not too near the curvature to result in excess bleeding (Figures 2A and 2B). Using suction and stay sutures will help minimize spillage while the stomach is open.

Surgery STAT: Pyloroplasty for gastric outflow emptying (7)Surgery STAT: Pyloroplasty for gastric outflow emptying (8)

Surgery STAT: Pyloroplasty for gastric outflow emptying (9)

Figure 2A: The first arm of the Y is started toward the lesser curvature.

Surgery STAT: Pyloroplasty for gastric outflow emptying (10)Surgery STAT: Pyloroplasty for gastric outflow emptying (11)

Surgery STAT: Pyloroplasty for gastric outflow emptying (12)

Figure 2B: It continues until it is about the same length as the base of the Y (2B).

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Make the final arm of the Y in a similar manner along the greater curvature (Figure 3). I use sometimes use a stay suture or a Babcock forceps to help provide tension on the stomach wall while making this final incision. This avoids jagged bites of tissue from the scissors due to tissue movement, creating a much cleaner line of closure once the procedure is finished.

Surgery STAT: Pyloroplasty for gastric outflow emptying (13)Surgery STAT: Pyloroplasty for gastric outflow emptying (14)

Surgery STAT: Pyloroplasty for gastric outflow emptying (15)

Figure 3: The last arm of the “Y” is made along the greater curvature and is as long as the other two branches. Tension with either a stay suture or Babcock forceps (as pictured) will help avoid jagged edges and make this a smooth, controlled cut.

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Finish strong

Start the closure of the Y-U with a simple interrupted suture, taking the point of the flap that has been created and connecting it to the base of the Y, aborad to the pylorus. This appositional suture helps ensure that the Y's arms are the right size, the diameter of the pylorus has been widened and the closure is symmetrical. If there is too sharp of a point at the end, trim this piece to allow for better apposition of the ends.

Once this full-thickness suture is in place, I prefer to close the stomach wall with a simple continuous suture pattern. Simple interrupted stitches can also be used, but the seal is not as watertight. Before the last few milli­meters of the Y-U is closed, I insert my finger into the incision, through the pylorus, to ensure that there is not inverted mucosa blocking the lumen and that the lumen is wider than it was preoperatively. Then I finish closing the incision (Figure 4).

Surgery STAT: Pyloroplasty for gastric outflow emptying (16)Surgery STAT: Pyloroplasty for gastric outflow emptying (17)

Surgery STAT: Pyloroplasty for gastric outflow emptying (18)

Figure 4: A closed Y-U with two stay sutures used intraoperatively to aid in manipulation and lumen palpation.

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Finally remove the stay sutures (Figure 5). At this point, inspect the entire incision to ensure that no leakage can occur, that minimal mucosa is seen everting from the incision and that proper apposition has been achieved. Local lavage, abdominal lavage, sponge count and instrument changes should be performed to combat contamination. If biopsies are indicated or pyloric mucosal resection is necessary, the Y-U allows for this as well as widening the diameter of the pylorus.

Withhold food for 12 to 24 hours after surgery, and then introduce small, easily digested soft food. Small meals are recommended for at least 14 days.

Surgery STAT: Pyloroplasty for gastric outflow emptying (19)Surgery STAT: Pyloroplasty for gastric outflow emptying (20)

Surgery STAT: Pyloroplasty for gastric outflow emptying (21)

Figure 5:The Y-U before abdominal wall closure. Note the wide base of the stomach portion of the pyloroplasty.

Surgery STAT: Pyloroplasty for gastric outflow emptying (2024)

FAQs

Surgery STAT: Pyloroplasty for gastric outflow emptying? ›

Pyloroplasty completely destroys the pyloric

pyloric
The pylorus is the furthest part of the stomach that connects to the duodenum. It is divided into two parts, the antrum, which connects to the body of the stomach, and the pyloric canal, which connects to the duodenum.
https://en.wikipedia.org › wiki › Pylorus
sphincter and drains the stomach continuously into the duodenum. At the same time, however, it results in rapid emptying of the stomach into the duodenum (causing dumping) and allows reflux of the duodenal contents back into the stomach (causing bile gastritis).

What is pyloroplasty surgery for gastroparesis? ›

The symptoms of gastroparesis are due to the stomach not emptying normally. Pyloroplasty decompresses the stomach into your small intestine (the direction food is supposed to flow) rather than up your esophagus (heartburn) and out your mouth (nausea and vomiting).

What is the surgery for gastric outflow obstruction? ›

The most common surgical procedures performed for GOO related to PUD are vagotomy and antrectomy, vagotomy and pyloroplasty, truncal vagotomy and gastrojejunostomy, pyloroplasty, and laparoscopic variants of the aforementioned procedures.

How successful is pyloroplasty surgery? ›

As a solution for gastroparesis and gastric outlet obstruction, pyloroplasty surgery has excellent results, with reported success rates of close to 90%.

How long does it take to recover from a pyloroplasty? ›

Most people recover quickly and completely. The average hospital stay is 2 to 3 days. It's likely you can slowly begin a regular diet in a few weeks.

What is the best surgery for gastroparesis? ›

Gastric peroral endoscopic myotomy (G-POEM) is a minimally invasive procedure to relieve symptoms of gastroparesis. In patients with this condition, the valve between the stomach and small intestine (pyloric sphincter) is unusually tight, preventing the stomach contents from emptying fully into the intestine.

What is the new surgery for gastroparesis? ›

G-POEM is a minimally invasive procedure that is done in an operating room. You are put to sleep for this procedure with general anesthesia. This procedure takes around an hour and a half to complete. Endoscopic surgery uses an endoscope, a long, flexible tube to reach the surgical site.

What is the surgery for gastric emptying? ›

G-Poem is a gastric perioral endoscopic myotomy and is a surgery where the pyloric muscle is cut by a surgeon to enable the opening of the pyloric muscle. This may help improve gastric emptying in a minority of patients.

What is the difference between gastric outlet obstruction and gastroparesis? ›

A key differential for GOO is gastroparesis, where patients have delayed gastric emptying and have similar clinical features to GOO, However, gastroparesis is caused by neuromuscular dysfunction and there is no mechanical obstruction present.

What is the surgery for gastric dumping? ›

Depending on your situation, surgical procedures to treat dumping syndrome may include reconstructing the pylorus or surgery to reverse gastric bypass surgery.

Does pyloroplasty help with weight loss? ›

Weight loss was reduced by pyloroplasty (P = 0.037), thoracotomy (P = 0.0071), and the Clavien–Dindo classification 0–II (P = 0.029). Weight changes were unrelated to dissection field, reconstruction route, anastomosis technique, and thoracic duct preservation (all Ps > 0.05).

What is the mortality rate for pyloroplasty? ›

The mortality of vagotomy and pyloroplasty for a massively bleeding ulcer (11%) was less than that following subtotal gastrectomy (21%). The mortality of elective vagotomy and pyloroplasty was 1%.

What is the alternative to pyloroplasty? ›

Endoscopic balloon dilatation of the pylorus is an alternative to surgical pyloroplasty. Intraoperative botulinum toxin (BT) injection has been used to treat delayed gastric emptying (DGE) following esophagectomy.

What are the benefits of pyloroplasty? ›

Pyloroplasty is a type of surgery that widens the opening at the bottom of the stomach. It's often used to treat gastrointestinal conditions that haven't responded to other treatments. It can be done using either traditional open surgery methods or laparoscopic techniques.

Does gastroparesis go away after surgery? ›

Reports of gastroparesis symptoms following procedures like sleeve gastrectomy and Nissen fundoplication have been published. Most of these cases spontaneously resolved, and literature showed prolonged postoperative gastroparesis (lasting longer than 3–4 weeks) to be a rare entity.

What procedure is commonly performed with a pyloroplasty? ›

A cut is made lengthwise to make your pylorus wider. This is the most common type of pyloroplasty. Jaboulay pyloroplasty. In this procedure, your doctor will create a new connection between your stomach to your small intestine (duodenum) without cutting into your pylorus.

How long does post surgical gastroparesis last? ›

In a series of 615 patients who underwent laparoscopic Nissen fundoplication, all had symptoms of delayed gastric emptying during the first three postoperative months. Yet by one year , symptoms suggestive of gastroparesis, e.g., bloating and flatulence, had resolved in greater than 90% of patients [2].

What is a successful treatment for gastroparesis? ›

Prokinetic medications are drugs that promote gastric emptying and are an important part of managing gastroparesis. Two commonly used medications are: Erythromycin: This medicine induces forceful contractions, stimulating gastric emptying of both solid and liquid foods.

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