Step 1: Surgical Anatomy

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  Pyloroplasty consists of dividing the pyloric muscle and reconstructing the pyloric channel to improve gastric emptying. Following truncal vagotomy, impairment of gastric tone results in gastric stasis and requires that a drainage procedure be performed.

  
  
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  To perform a pyloroplasty, ideally the anterior surface of the pylorus should have minimal fibrosis and scarring. Mobilization of the duodenum is key in order to make the operation technically feasible. If an anterior duodenal ulcer is present, the pyloroplasty incision can be modified to encompass the ulcer, still making the operation possible.

  
  
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  A Heineke-Mikulicz pyloroplasty consists of a longitudinal incision through the pylorus from the distal antrum to the proximal duodenum. This incision is closed transversely to increase the diameter of the pyloric channel.

Step 2: Preoperative Considerations

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  Pyloroplasty has the advantages of ease of performance, avoidance of the difficult duodenal stump, and less dissection compared to an antrectomy. It ensures drainage of the gastric antrum following vagotomy and does not alter the continuity of the gastrointestinal tract.

  
  
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  For many years, pyloroplasty combined with vagotomy was considered a second option behind vagotomy and antrectomy for peptic ulcer disease due to the higher rate of failure (10% to 15%). However, with the advent of proton-pump inhibitor therapy to treat recurrences, it has become the preferred procedure in the emergent situation.

  
  
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  In operations for bleeding duodenal or prepyloric ulcers, pyloroplasty is ideal if the duodenum has been opened to control bleeding.

  
  
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  In the acute setting, a nasogastric tube should be placed to confirm upper gastrointestinal bleeding and to prevent aspiration. Upper endoscopy is helpful for diagnosis and potentially allows for endoscopic control of bleeding, obviating the need for an operation.

  
  
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  In patients with chronic peptic ulcer disease, nutritional status should be optimized by enteral or parenteral means. It can take several days to correct nutrition and electrolytes in the patient with long-standing gastric-outlet obstruction.

  
  
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  Preoperative preparation consists of deep vein thrombosis prophylaxis and antibiotics. Many of these patients have been on long-term proton-pump inhibitor therapy, thereby altering the acidity and bacterial flora of the gastric lumen. Preoperative antibiotics should consist of first- or second-generation cephalosporins.

Step 3: Operative Steps