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INDICATIONS

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These procedures may be used when the vagus innervation of the stomach has been interrupted either by truncal vagotomy, selective vagotomy, or division of the vagus nerves associated with esophagogastric resection and re-establishment of esophagogastric continuity. The pyloroplasty ensures drainage of the gastric antrum following vagotomy and, therefore, partially eliminates the antral phase of gastric secretion. It does not alter the continuity of the gastrointestinal tract and decreases the possibility of marginal ulceration occasionally seen after gastrojejunostomy. Pyloroplasty carries a low surgical morbidity and mortality rate because of its technical simplicity. Two types of pyloroplasty are commonly used: the Heineke–Mikulicz pyloroplasty (figure a) and the Finney pyloroplasty (figure b). Pyloroplasty should be avoided in the presence of a marked inflammatory reaction or severe scarring and deformity on the duodenal side of the gastric outlet. Under these circumstances, the Jaboulay procedure (figure c) should be considered or a gastroenterostomy located within 3 cm of the pylorus on the greater curvature. Gastrin levels should be determined. The Jaboulay reconstruction should be considered when a long incision is made in the anterior wall of the duodenum during the search for very small mucosal gastrinomas.

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HEINEKE–MIKULICZ PYLOROPLASTY

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The pylorus is identified with the pyloric vein as the landmark. A Kocher maneuver (Chapter 26) is then carried out to mobilize the duodenum for good exposure and relaxation of tension on the subsequent transverse suture line. Traction sutures of 00 silk are placed and tied at the superior and inferior margins of the pyloric ring for anatomic orientation. Efforts should be made to include the pyloric vein in these sutures in order to partially control the subsequent bleeding. A longitudinal incision is made approximately 2 to 3 cm on each side of the pyloric ring through all layers of the anterior wall (figure 1). In the presence of marked deformity, it may be advisable to incise the midportion of the duodenum and then, with a hemostat directed up through the constricted pyloric canal as a guide, make the incision in the midportion of the pylorus, across the midportion of the anterior duodenal wall, and across the midpoint of the pyloric wall into the gastric side. Bleeding is controlled with electrocautery.

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Traction on the angle sutures draws the longitudinal incision apart until it becomes first diamond shaped (figure 1) and then transverse (figure 2). Active bleeders tend to occur in the divided duodenal wall and in the region of the divided pyloric sphincter. Inverting sutures of interrupted silk are passed through all layers to approximate the mucosa. Some prefer a one-layer closure (figure 2) in order to minimize the encroachment on the pyloric lumen resulting from the inversion that follows a two-layer closure. The one-layer, the Gambee suture, is shown in cross section. This is placed in four passes, with the second and ...

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