Pyloroplasty Eric Monnet Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO, USA
21.1 Indications the rest of the abdominal cavity with laparotomy
sponges and towels to minimize contamination. The Pyloroplasty and pyloromyotomy have been recom- pyloric antrum is palpated to identify the extent of the mended to release a benign gastric outflow obstruction. hypertrophy. Pyloric hypertrophy can be the result of muscular hyper- Stay sutures are placed on the duodenum and the trophy, mucosal hypertrophy, or both (Bellenger et al. body of the stomach (Figure 21.1). A partial thickness 1990). Brachycephalic breeds seems to be more at risk incision over the serosa is made with a #15 blade to than any other breeds for pyloric hypertrophy (Poncet et outline the Y incision. The black arrows and the four al. 2005). If neoplasia is suspected as the cause of the out- letters highlight the Y‐shaped incision (Figure 21.2a). flow obstruction, either a Billroth I or II, or a Roux-in Y Then the full‐thickness incision is made from the are more appropriate (Chapters 19 and 20). Endoscopic proximal duodenum over the pylorus into the stomach. evaluation of the pylorus is recommended before surgery This incision should be centered over the pylorus and with needle aspiration to further document the nature of extend 3–4 cm on each side (Figure 21.2b). Then two the obstruction. incisions are performed in the stomach from the end of Several techniques of pyloroplasty have been the first incision, parallel to the lesser and greater described: Heineke–Mikulicz pyloroplasty, the Finney curvature. This creates a U‐shaped flap in the pyloric pyloroplasty and the Y‐U pyloroplasty (Ali et al. 2019). antrum (Figure 21.3a). The pyloric mucosa is biopsied. The Y‐U pyloroplasty is more likely the technique most If mucosal hypertrophy is present, the mucosa and commonly used in dogs (Bright et al. 1988). This submucosa can be resected 360° at the level of the technique has been shown to decrease gastric emptying pylorus to increase the diameter of the pylorus (Figure time without increasing the risk of duodenogastric 21.3a). Before starting the resection of the mucosa and reflux in normal dogs (Bright et al. 1988). The Heineke– submucosa it is recommended to place stay sutures in Mikulicz pyloroplasty has been used in the treatment of the mucosa on the side of the duodenum (Figure 21.3a dogs with gastric dilatation volvulus (Greenfield et al. and b). The resection is completed partial thickness 1989). The pyloroplasty increased the complication rate (Figure 21.3c). The mucosa from the duodenum and the and did not affect long‐term outcome of dogs with stomach are sutured with a 4‐0 monofilament absorbable gastric dilatation volvulus. suture in a continuous pattern with the knots in the wall of the duodenum (Figure 21.3d). Then the tip of the U flap created in the pyloric antrum is advanced and sutured to most distal point of 21.2 Technique the incision in the duodenum (Figure 21.2c). Simple interrupted full‐thickness sutures are used to complete 21.2.1 Y-U Pyloroplasty the closure of both arms of the U‐shaped flap (Figure After a midline incision and an abdominal explora- 21.2d). A monofilament absorbable suture size 4‐0 is tion the stomach and the duodenum are isolated from used for the closure.
incision is 4–5 cm. The incision is then closed in a per-
pendicular fashion with full‐thickness simple inter- rupted sutures changing the longitudinal incision into a perpendicular suture line. A monofilament absorbable suture size 4‐0 is used for the closure. This technique increases the diameter of the pylorus.
21.2.3 Pyloromyotomy A Fredet–Ramstedt pyloromyotomy is indicated for a muscular hypertrophy of the pyloric region. A partial thickness incision center over the pylorus is made over 4 cm. The incision is through only the serosa and the muscularis region. When the incision is completed the submucosa and the mucosa are bulging through the Figure 21.1 incision. If the lumen of the stomach or the duodenum are entered during the procedure, the mucosa‐submu- 21.2.2 Other Pyloroplasty cosa are closed with simple interrupted suture with 4‐0 For the Heineke–Mikulicz pyloroplasty a full‐thickness monofilament absorbable suture. The omentum can be incision centered over the pylorus is made in the proxi- patched in the myotomy site. The serosa and the muscu- mal duodenum and the stomach. The total length of the laris layers are left open.
(a) (b)
(c) (d)
Figure 21.2 21.4 Complication 157
(a) (b)
(c) (d)
Figure 21.3
21.3 Tips surgery. A jejunostomy tube could be used to bypass the
surgical site and feed a patient that is still vomiting in the The Y‐U pyloroplasty is most commonly performed in dogs post‐operative period. A jejunostomy tube through a with mucosal hypertrophy in the pyloric region because it gastrostomy tube is appropriate for those cases. has been shown to be associated with less biliary reflux in the stomach (Bright et al. 1988). If the hypertrophy is too severe, a Billroth I can be performed. If the disease process 21.4 Complications is infiltrative toward the duodenum a Billroth II or a Roux‐en‐Y should be attempted (Chapter 22). In the immediate post‐operative period dogs are moni- The tip of the U flap from the pyloric antrum should tored for signs of septic peritonitis. Dogs can eat orally be rounded to avoid necrosis of a narrow tip. immediately after surgery unless they are still vomiting The closure of the U flap is better performed with sim- because of gastritis. Ondansetron, omeprazole, and ple interrupted sutures than with a continuous suture to sucralfate are used after surgery to reduce the gastritis avoid the formation of dog ears on each side. The author and the risk of vomiting. likes to divide each side of the U flap in half and keep Prognosis of dogs with benign pyloric hypertrophy is adding sutures by dividing each segment by half. excellent. They may be nauseated because of duodeno‐ Usually feeding tubes are not required for the post‐ gastric reflux; however, the Y‐U pyloroplasty has been operative support of those patients. However, a gastros- shown to be associated with minimal reflux (Bright et tomy tube could be useful to keep the stomach al. 1988). It is not known if a very distended stomach decompressed after surgery and administer medications. because of chronic pyloric obstruction will regain nor- A gastrostomy tube could be useful to keep the stomach mal size and function. Metoclopramide is recommended decompressed in the post‐operative period, especially if in the post‐operative period to stimulate peristalsis in the stomach is very distended and flaccid at the time of the stomach. 158 21 Pyloroplasty
Dogs that had chronic vomiting gastritis and period with sucralfate and omeprazole for at least esophagitis should be treated in the post‐operative 10 days.
R eferences
Ali, A. et al. (2019). Surgery of peptic ulcer disease. In: Greenfield, C.L. et al. (1989). Significance of the Heineke– Shackelford’s Surgery of the Alimentary Tract (eds. C.J. Mikulicz pyloroplasty in the treatment of gastric Yeo et al.), 673–701. Philadelphia: Elsevier. dilatation‐volvulus: a prospective clinical study. Vet. Bellenger, C.R. et al. (1990). Chronic hypertrophic pyloric Surg. 18 (1): 22–26. gastropathy in 14 dogs. Aust. Vet. J. 67 (9): 317–320. Poncet, C.M. et al. (2005). Prevalence of gastrointestinal Bright, R.M. et al. (1988). Y‐u antral flap advancement tract lesions in 73 brachycephalic dogs with upper pyloroplasty in dogs. Compend. Contin. Educ. Pract. Vet. respiratory syndrome. J. Small Anim. Pract. 46 (6): 10 (2): 139–144. 273–279.
