Review Scandinavian Journal of Surgery 95: 11–16, 2006

PyloRoPlasty foR benign gastRic outlet obstRuction –

indications and techniques

K. søreide1, M. g. sarr2, J. a. søreide1,3

Departments of Surgery,
1 Stavanger University Hospital, Stavanger, Norway
2 Mayo Clinic College of Medicine, Rochester, MN, USA
3 Department of Surgical Sciences, University of Bergen, Bergen, Norway

abstRact

the understanding of peptic ulcer disease (Pud) etiology, and improvements in treat-
ment during the last two decades, has dramatically decreased the once so frequently
performed procedures for Pud and its complications. benign gastric outlet obstruction
may, however, still require operative intervention when non-operative treatment fails.
today, surgeons in training, and even practicing surgeons, may have limited operative
experience with procedures required to alleviate an obstructed pylorus. our aim of this
paper is to review the techniques (the heineke-Mikulicz and finney pyloroplasties, and
modifications) and indications for pyloroplasty in the modern surgical era.
Key words: Gastric outlet obstruction; pyloroplasty; benign disease; surgical techniques; indications

INTRODUCTION longer belong in the category of frequently performed

Before the 1980s, operative therapy played a central
role in the treatment of patients with complicated
peptic ulcer disease. Not only did operative treat-
ment aim to relieve the cause of ulcer (i.e. by means
of neural ablation; vagotomy and/or by a decrease in
hormonal [gastrin] drive; antrectomy), operative in-
tervention was also performed frequently in emer-
gency settings (perforation and bleeding) and for late
sequela (gastric outlet obstruction, GOO) (1–4).
However, the introduction of antisecretory medica-
tions (H2 receptor inhibitors and proton-pump in-
hibitors), the 1984 landmark discovery that infection
with H. pylori contributes to peptic ulcer disease (5),
and the evolution of endoscopic interventional tech-
niques have altogether changed dramatically the
paradigm of treatment and the current role of surgi-
cal therapy (6). Operations for peptic ulcer disease no
Correspondence:
Jon Arne Söreide, M.D.
Department of Surgery
Stavanger University Hospital, Stavanger, Norway
N - 4068 Stavanger, Norway
Email: jon.soreide@kir.uib.no
elective procedures in alimentary surgery, and junior
surgeons may thus be relatively unfamiliar with the
techniques available.
Still, operative intervention for benign gastric out-
let obstruction is required after failed endoscopic
treatment (7) for a various number of indications, in-
cluding peptic ulcer disease (8), hypertrophic pyloric
stenosis (9), and other more rarely encountered dis-
orders (10). The aim of this paper is to review the
techniques and indications for pyloroplasty in the
modern surgical era.
ETIOLOGY OF BENIGN GASTRIC OUTLET
OBSTRUCTION
Although this review discusses primarily benign gas-
tric outlet obstruction (GOO), the reader should re-
member that any obstruction of the gastric outlet may
harbor an underlying malignancy (11), and proper
investigation to exclude this possibility should be ini-
tiated before choosing the surgical procedure, espe-
cially when the obstruction involves the distal antrum
proximal to the pylorus or the proximal duodenum
distal to the duodenal bulb.
12 K. Søreide, M. G. Sarr, J. A. Søreide
Complicated peptic ulcer is still regarded the most
frequent cause of benign GOO and currently accounts
for 5 to 8% of ulcer-related complications (1). How-
ever, although GOO caused by peptic ulcer disease
has decreased by up to 46% over the past 20 years
(6–12), operations for GOO continue to be performed
currently at an annual rate of about 1–3 per 100,000
(13).
With the marked decrease in elective gastric sur-
gery for peptic ulcer disease, and especially vagoto-
my and pyloroplasty, the procedure of pyloroplasty
is performed much less commonly. Although usually
related to peptic ulcer disease and its complications
(obstruction, bleeding, or perforation), a pyloroplasty
may be considered for other (rare) disorders causing
stenosis in the pyloric area, including chronic ulcer-
ation, related to the use of aspirin and non-steroidal
anti-inflammatory drugs (NSAIDs) (1,13), primary
hypertrophic pyloric stenosis in adults (11,14,14), pro-
gressive systemic sclerosis (10), and during opera-
tions for gastric replacement of the esophagus or
when a vagotomy is necessitated by the resective pro-
cedure (16).
PRESENTATION OF GASTRIC OUTLET
OBSTRUCTION
For whatever cause, GOO usually presents as nausea,
vomiting, and early satiety. Generally, it develops in-
sidiously over weeks or months, but on occasion may
develop acutely from a pyloric channel ulcer. Chro-
nic vomiting may leave the patient in a dehydrated,
hypochloremic, hypokalemic alkalosis. Treatment by
nasogastric suction and intravenous fluids should be
initiated, and malnutrition should be addressed ap-
propriately when present. Depending on the under-
lying cause of obstruction, the availability and feasi-
bility of endoscopic intervention, and the metabolic
and nutritional state of the patient, time should be
taken to restore the patient’s nutritional needs by ini-
tiating pre-operative total parenteral nutrition to de-
crease the risk of postoperative complications. His-
torically, almost all patients with GOO eventually
required operative therapy (17).
TREATMENT FOR GASTRIC OUTLET
OBSTRUCTION
“If anyone should consider removing half of
my good stomach to cure a small ulcer in my
duodenum, I would run faster than he.”
Charles H. Mayo, 1865–1939
Endoscopic balloon dilatation is performed currently
with initial success in a high number of patients with
benign GOO. However, data on long-term sympto-
matic improvement are lacking1, and at least one
third may still require operative therapy (7, 8). Fur-
thermore, endoscopic dilatation may not be equally
effective for all types of GOO, such as H. pylori-nega-
tive GOO (18, 19).
Thus, surgical intervention remains an important
treatment modality for patients with benign GOO,
either as primary treatment or after failed endosco-
pic balloon dilatation. Options for surgical treatment
include highly selective vagotomy (HSV) with some
form of pyloroplasty, truncal vagotomy with pyloro-
plasty or gastroenterostomy, or truncal vagotomy
with antrectomy. However, evidence for overall su-
periority of one procedure over the other is not well-
defined; recurrence of ulcer disease is more common
with vagotomy alone (10–20%) compared to vagoto-
my and antrectomy, but the potential for postgastrec-
tomy sequelae make antrectomy a less attractive op-
tion.
The only randomized, controlled trial (‘level I evi-
dence’) on surgical treatment of benign GOO report-
ed to date proposed HSV with gastrojejunostomy as
the treatment of choice in patients with GOO second-
ary to duodenal ulcer (20). The 90 patients were ran-
domized to undergo one of three alternative opera-
tive procedures: HSV and gastrojejunostomy (Group
1), HSV and Jaboulay gastroduodenostomy (Group
2), or selective vagotomy with antrectomy (Group 3).
The three groups had no differences in postoperative
course (however, one patient in Group 2 died due to
postoperative acute pancreatitis). Gastric acid reduc-
tion was similar initially in all groups. At follow-up
after a mean of 98 months (range 30–156 months),
long-term Visick scores were better (p < 0.01) for
Group 1 when compared to Group 2, but did not dif-
fer significantly compared to Group 3. The authors
recommended HSV with gastrojejunostomy for be-
nign GOO. However, the results are based on small
numbers, and are yet to be duplicated by others.
Currently, the timing and role of endoscopic dilata-
tion versus operative therapy for benign GOO re-
mains unsettled (3). In fact, when looking into recent
surgical texts, one finds parochial support for any of
the surgical procedures ranging from truncal vagot-
omy with drainage to vagotomy and antrectomy.
When feasible (i.e. no severe scarring at the pylorus)
we believe that, in addition to vagotomy, pyloroplas-
ty alone is the safest, easiest, and least physiologi-
cally disruptive of the alternatives in restoring a pa-
tent gastric outlet; in addition, pyloroplasty is less
problematic than gastrojejunostomy (with its atten-
dant risks of stomal ulcer, bile reflux, and duodenal
bypass) or antrectomy (with its risks of postgastrec-
tomy sequelae), given today’s medical options to
treat the hyperacidic secretion. If the GOO is caused
by an antral ulcer, however, distal gastrectomy should
be the operation of choice.
GENERAL CONDITIONS AND INDICATIONS
FOR PERFORMING A PYLOROPLASTY
Traditionally, pyloroplasty was carried out in re-
sponse to a selective or truncal vagotomy in the sur-
gical treatment of peptic ulcer disease with pyloric
stenosis (21). The need for pyloroplasty in the ab-
sence of mechanical pyloric obstruction has been a
matter of discussion for many years (22); however,
most surgeons carry out some form of drainage pro-
 Pyloroplasty for benign gastric outlet obstruction – indications and techniques
Fig. 1. Incisions made for the three most com-
monly performed pyloroplasties. Heineke-
Mikulicz (1A), Finney (1B), and Jaboulay
(1C). (Modified and reprinted from reference
25, with permissions from Elsevier).
cedure (pyloroplasty, pyloromyotomy, gastroente-
rotomy) when a vagotomy is performed as an anti-
secretory therapy or when required by gastroesopha-
geal resection.
During emergency surgery for a bleeding duode-
nal ulcer, clear exposure of the offending ulcer is im-
portant, and access to control the bleeding site is
mandatory. Closure of the proximal longitudinal duo-
denotomy by incorporating it into a pyloroplasty is a
rapid and safe procedure in a setting where time is
essential for the patient in critical condition, and es-
pecially when a vagotomy is also performed. Caution
should be undertaken when performing a pyloro-
plasty when the pyloric area is severely distorted or
inflamed as a result of ulcer disease. For benign GOO,
pyloroplasty alone creates a widely patent gastric
outlet and can be performed with low mortality and
morbidity. Dumping is rare, especially so if truncal
vagotomy is not necessary (23, 24).
To allow for a safe, standard pyloroplasty, the an-
terior surface of the pylorus should be minimally in-
volved (i.e. inflamed) and the duodenum sufficiently
mobile to permit a tension-free, transverse closure. A
pyloroplasty can also be performed in the presence
of an anterior ulcer if the tissue surrounding the ulcer
is minimally involved.
In general, two types of pyloroplasty are referred
to as ‘standard’: the Heineke-Mikulicz (Fig. 1A) and the
Finney procedures (Fig. 1B). The Jaboulay pyloroplas-
ty (Fig. 1C) is really an antroduodenostomy in that
the incision does not extend through the pylorus, but
rather the antroduodenostomy bypasses the scarred
pylorus. In addition, several modifications of the
standard procedures are available (25). Our discus-
sion will focus on the two most commonly performed
procedures--namely the Heineke-Mikulicz and Finney
pyloroplasties (Fig. 2 and 3). Alternative techniques
13
and modifications are only discussed briefly and may
be studied in more detail elsewhere (25).
THE HEINEKE-MIKULICZ PYLOROPLASTY
In principle, a longitudinal incision is placed through
the pylorus, extending from the distal antrum to the
proximal duodenum. By closing this incision trans-
versely, the outlet diameter of the pylorus is in-
creased. The procedure begins with a Kocher maneu-
ver to mobilize the first two portions of the duo-
denum. The pylorus is next localized carefully (Fig. 2).
The (pyloric) veins of Mayo may aid its identification,
as does its palpable thickening appreciated by trans-
mural palpation. Ideally, the scarring on the anterior
surface of the pylorus should be minimal and mobi-
lization of the duodenum markedly facilitates the
pyloroplasty. On occasion, the periduodenal and
peripyloric inflammation may prevent accurate iden-
tification of the pyloric channel, and consideration
should be given to abandoning the idea of a pyloro-
plasty and proceeding rather to gastroenterostomy.
(In this situation, an antrectomy may be even more
dangerous because of the attendant difficulties to be
encountered with the duodenal closure.)
The pyloroplasty begins with the placement of two
traction sutures about 1 cm apart on the anterior sur-
face of the pylorus (Fig. 2A). A longitudinal, transmu-
ral incision is made, extending about 3 cm onto the
antrum and a similar distance onto the duodenum
(Fig. 2A). The total length of the incision need not
exceed 5 to 7 cm. The incision is best created by dia-
thermy to afford hemostasis. Careful inspection of the
stomach proximally and the duodenum distally with
a probing finger for a bleeding ulcer or point of ob-
struction should also be considered mandatory. If
14 K. Søreide, M. G. Sarr, J. A. Søreide
pyloric stenosis is present, the initial entry into the
gut lumen should be made either in the duodenum
or in the antrum, because the obstructed lumen in the
pyloric region may be located eccentrically. Use of a
grooved director or narrow-tipped clamp passed into
the pylorus from the initial antrotomy will facilitate
the appropriate placement of the pylorotomy. If
bleeding from an associated gastric or duodenal ulcer
is encountered, placement of transfixion sutures is
usually easy because of the excellent exposure ob-
tained.
Various techniques have been designed to accom-
plish closure of the incision. The longitudinal incision
Fig. 2. The Heineke-Mikulicz pylo-
roplasty showing a transversally cut
incision (2A) with retraction sutures
(2B), longitudinally closure (2C)
with either one layer (Weinberg
modification; 2D) or two layers (2E).
(Modified and reprinted from refer-
ence 25, with permissions from
Elsevier).
Fig. 3. The Finney pyloroplasty with
“horseshoe” incision (3A), seromus-
cular sutures (3B), and closure (3C
& D). (Modified and reprinted from
reference 25, with permissions from
Elsevier).
is closed transversely by rostral and caudal distrac-
tion of the retraction sutures (Fig. 2B and 2C). Of
importance is that the outlet diameter is kept suffi-
cient by making a long enough pylorotomy. A one-
layer closure (Weinberg modification of the Heineke-
Mikulicz pyloroplasty) is employed most frequently
(Fig. 2D). Others use a two-layer closure, the original
Heineke-Mikulicz technique (Fig. 2E). Whichever
method is used, the sutures should meticulously ap-
proximate the separate serosal and mucosal layers
(Fig. 2C). Our personal preference is a single layer
with continuous absorbable suture (poliglecaprone
MonocrylTM or polydioxanon PDSTM 3-0 or 4-0).
 Pyloroplasty for benign gastric outlet obstruction – indications and techniques
Others utilize interrupted suture approximation with
seromuscular permanent sutures (e.g. 3-0 silk). Clo-
sure by a linear stapler has been described as well.
THE FINNEY PYLOROPLASTY
The Finney pyloroplasty is especially well-suited for
a J-shaped stomach in which the pylorus may be re-
tracted and fixed rostrally, making a Heineke-Miku-
licz pyloroplasty technically difficult and tenuous. By
extending the incision of the pyloric area onto the
stomach and first portion of the duodenum, a Finney
pyloroplasty (i.e., an antroduodenostomy with inci-
sion of the pylorus) can be completed (Fig. 3). This
technique requires that the duodenum be Kocherized
widely and detached partially from its more proximal
attachments to the gastro-hepatic ligament to facili-
tate the descending duodenum to be laid alongside
the greater curvature of the distal antrum. Some mo-
bilization of the stomach (transection of gastrohe-
patic ligament and freeing up of the greater curvature
from the gastrocolic ligament) may also aid the relief
of anastomotic tension. Adjacent gastric and duode-
nal walls are first united by means of a seromuscular
suture, from above downwards, closing the angle be-
tween the pylorus (Fig. 3B). A traction suture is placed
in the superior margin of the pyloric ring, a second
one placed on the duodenal wall about 10 cm distal
to the pyloric ring, and, a third placed on the greater
curvature of the stomach 10 cm proximal to the pylo-
rus. With diathermy, a transmural incision is made
along the inverted horseshoe-shaped line which runs
from the gastric antrum 4 to 5 cm proximal to the
pylorus curving through the duodenal bulb and
down the descending duodenum (Fig. 3A). Care
should be taken to stop any bleeding, especially if the
area is inflamed or if there is an active pyloric channel
or duodenal bulb ulcer. Again, initial entry into the
lumen should be either into the antrum or the duo-
denum.
To close the antropyloroduodenotomy, the poste-
rior adjacent walls are approximated by means of a
continuous transmural suture (polyglatin Vicryl,
polydioxanon PDS, or polyglecaprone MonocrylTM
3-0 or 4-0), starting at the superior end of the pylo-
rotomy. This suture is continued through the inferior
gastroduodenal angle to proceed onto the anterior
wall of the gastroduodenostomy until a safe, well-ap-
proximated closure forms the anterior part of the py-
loroplasty. The authors prefer to put one or two ad-
ditional single seromuscular sutures (with PDS 3-0)
to support the anastomosis at the inferior gastroduo-
denal angle to ease the surgeon's mind that night;
others place a full anterior layer of seromuscular su-
tures.
ALTERNATIVE TECHNIQUES AND
MODIFICATIONS
Stapling techniques have been reported in perform-
ing a pyloroplasty. The possible benefits as compared
to standard techniques remain to be shown; also, if
15
the antrum or duodenum is very thickened and in-
flamed, use of mechanical staplers can be difficult
and unwise. Recently, further technical develop-
ments, including laparoscopic approaches have been
introduced (9, 26). Given that general laparoscopic
skills and experience are present, this approach may
offer advantages in some patients.
OTHER CONSIDERATIONS
As with any chronic intraabdominal process, if the
patient has had GOO for a long time with a dilated
stomach, one always worries about nutritional com-
promise and delayed gastric emptying. We maintain
a very low threshold for using a feeding enterostomy
(usually a needle catheter jejunostomy) (27), to per-
mit early postoperative enteral nutrition, and a de-
compressive tube gastrostomy for patient comfort.
Similarly, a Moss® tube (West Sand Lake, NY), a type
of gastrojejunostomy tube (gastric and combined je-
junal tube), which allows for a gastric decompression
as well as a means for intrajejunal feeding, may be
utilized as well, especially if prolonged postoperative
gastric stasis is of concern and/or the patient will not
tolerate well a nasogastric tube.
In summary, provided the duodenal area is not
severely inflamed and scarred, pyloroplasty is usu-
ally a safe and technically easy operation. However,
the advantage of facilitating gastric emptying may
have some disadvantages in patients after a vagoto-
my. The rapid emptying of liquids and solids due to
destruction of the pyloric sphincter and the lack of
receptive relaxation of the proximal stomach after the
vagotomy may cause symptoms such as dumping
and diarrhea. In addition, some patients may suffer
from reflux alkaline gastritis due to reflux of duode-
nal fluid into the stomach, but this is quite rare.
ACKNOWLEDGEMENTS
The authors wish to thank Deborah Frank for her
help in preparing this manuscript for publication.
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Received: November 11, 2005