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We have reported two cases of double pylorus or duplicated pyloric channel as an unusual complication of peptic ulcer disease. It is usually noted as an incidental finding on x-ray films or at endoscopy. Double pylorus seems to be an acquired lesion arising from gastric ulceration and does not necessarily require surgical correction.
OBJECTIVE: A prospective randomized multicenter study was performed to assess whether the results of pylorus-preserving pancreaticoduodenectomy (PPPD) equal those of the standard Whipple (SW) operation, especially with respect to duration of surgery, blood loss, hospital stay, delayed gastric emptying (DGE), and survival. SUMMARY BACKGROUND DATA: PPPD has been associated with a higher incidence of delayed gastric emptying, resulting in a prolonged period of postoperative nasogastric suctioning. Another criticism of the pylorus-preserving pancreaticoduodenectomy for patients with a malignancy is the radicalness of the resection. On the other hand, PPPD might be associated with a shorter operation time and less blood loss. METHODS: A prospective randomized multicenter study was performed in a nonselected series of 170 consecutive patients. All patients with suspicion of pancreatic or periampullary tumor were included and randomized for a SW or a PPPD resection. Data concerning patients' demographics, intraoperative and histologic findings, as well as postoperative mortality, morbidity, and follow-up up to 115 months after discharge, were analyzed. RESULTS: There were no significant differences noted in age, sex distribution, tumor localization, and staging. There were no differences in median blood loss and duration of operation between the 2 techniques. DGE was observed equally in the 2 groups. There was only a marginal difference in postoperative weight loss in favor of the standard Whipple procedure. Overall operative mortality was 5.3%. Tumor positive resection margins were found for 12 patients of the SW group and 19 patients of the PPPD group (P < 0.23). Long-term follow-up showed no significant statistical differences in survival between the 2 groups (P < 0.90). CONCLUSIONS: The SW and PPPD operations were associated with comparable operation time, blood loss, hospital stay, mortality, morbidity, and incidence of DGE. The overall long-term and disease-free survival was comparable in both groups. Both surgical procedures are equally effective for the treatment of pancreatic and periampullary carcinoma.
A case of double pylorus with a chronic ulcer in one of the two channels is described. The patient, a middle-aged man with active rheumatoid arthritis, required partial gastrectomy to allow continued treatment of the arthritis with anti-inflammatory drugs. Detailed histological examination of the surgical specimen revealed features consistent with intramural penetration of an ulcer across the pyloric ring, resulting in a gastro-duodenal fistula. The findings provide further support for the hypothesis that the double pylorus is an acquired lesion, which occurs as an uncommon complication of chronic peptic ulcer.
The competence of the pylorus was studied in 13 normal volunteers and nine dyspeptic patients by means of a radiological technique involving intubation of the duodenum. The pylorus was found to be competent in most normal individuals and in fewer than half of the dyspeptic patients. However, on smoking a cigarette, appreciable increase in duodenogastric reflux was seen in nine out of the 13 normal volunteers and in seven out of the nine dyspeptic patients. Such induced pyloric incompetence and the resultant regurgitation of duodenal juices may explain the increased incidence of gastritis and gastric ulceration in heavy smokers.
A case of acquired double pylorus, incident to peptic ulcer disease, is described. Fiberoptic gastroscopy confirmed a scarred antrum, a shallow prepyloric ulcer and a pylorus consisting of two large openings divided by a septum. The duodenum was visualized through each channel. This appearance probably represents a pyloroduodenal fistula caused by penetration of a prepyloric ulcer into the duodenum.
A two-marker technique was used to determine duodenogastric reflux in fasting dogs with normal or surgically modified gastroduodenal junctions. All nine dogs had an esophagostomy for gastric marker perfusion. The duodenal marker was given via a duodenal fistula. In two dogs a Heineke-Mikulicz pyloroplasty was performed, and in four dogs extramucosal circular pylorectomy was performed in addition. The mean fasting duodenogastric reflux rate in dogs with a normal pylorus was 1.1 +/- 0.5 (SE) ml/10 min; after pyloroplasty it was 1.6 +/- 0.3 ml/10 min (P greater than 0.1), and after pylorectomy it was 1.5 +/- 0.4 ml/10 min (P greater than 0.1). Simultaneous intraduodenal manometry revealed no relation between the interdigestive myoelectric complex and reflux. The marker technique for the measurement of reflux was validated by pharmacologically induced reflux. Subcutaneous injection of 0.1 mg of apomorphine increased the reflux rate tenfold. A transpyloric tube increased reflux rate fivefold. It is concluded that, in the fasting dog, phenomena such as retropulsive peristalsis are determinants of duodenogastric reflux and not the presence or absence of the pylorus and normal interdigestive motility.
Using the dynamic spatial reconstructor and manometry, we measured gastric emptying, pyloric size, and antral contractile activity in three anesthetized dogs in the prone position. Our objective is to evaluate the effect of intestinal perfusion of equicaloric, neutral, and isosmolar nutrients (Maltose 32.5 mg/ml, casein hydrolysate 32.5 mg/ml, and oleic acid 15.5 mg/ml) at a constant rate of 10 ml/min in the proximal jejunum on the dynamics of the antropyloric region. Isotonic saline perfusion was used as a control solution. Test meal in the stomach was 600 ml of isotonic Gastrograffin. Antral phasic pressure activity was recorded using an antroduodenal six-channel (ports 5 mm apart) perfused probe (2 mm OD). Gastric emptying in response to intestinal perfusion of fat was significantly slower (P less than 0.02) in comparison to other nutrients or isotonic saline. There was no significant difference in the maximum or minimum pyloric diameter in response to the four intestinal perfusates. However, the pylorus was closed for a significantly longer duration (P less than 0.05) during the perfusion of fat in the upper intestine. Antral contractions were related to pyloric opening in an "antral contraction followed by pyloric opening" sequence. This study suggests that the presence of fat in the upper intestine delays gastric emptying and that this effect is regulated in part by increased resistance to flow offered by the pylorus.
BACKGROUND: Delayed gastric emptying (DGE) occurs in 14% to 61% of patients after pylorus-preserving pancreaticoduodenectomy, but its pathogenesis is unclear. We hypothesized that DGE may be due to pylorospasm secondary to vagal injuries at operation and may be preventable by the addition of pyloromyotomy. METHODS: Patients operated on consecutively between April 2000 and August 2003 were studied. Pyloromyotomy was of the Fredet-Ramstedt type combined with antroplasty. DGE-free recovery was defined as tolerance of a diet for three successive days by postoperative day 8. The symptom of nausea was used as a basis for nasogastric tube removal and diet resumption. A gastric emptying test (GET) with solid food was obtained. Patients with difficulty swallowing were fed via a feeding tube. RESULTS: There were 47 patients. Two patients were excluded because of death (n = 1) and ileus with pancreatic fistula (n = 1). Diagnoses were pancreatic cancer (n = 23), chronic pancreatitis (n = 11), ampullary cancer (n = 5), mucinous cystic neoplasm (n = 5), and duodenal villous adenoma (n = 3). Median times to nasogastric tube removal, start of liquid diet, and start of solid diet were postoperative days 2, 3, and 5, respectively. Two patients had tube feedings. Preoperative GET was abnormal in 51%, and postoperative GET was abnormal in 37%. The average length of stay was 9.5 days (median, 7 days). DGE occurred in only one patient (2.2%). There were no late complications during a 6-month follow-up. CONCLUSIONS: The addition of pyloromyotomy to pylorus-preserving pancreaticoduodenectomy is effective in preventing DGE. Results are supportive of the hypothesis that DGE may be caused by operative injuries of the vagus innervating the pyloric region.
Double pylorus is an unusual condition in which a double communication between the gastric antrum and the duodenal bulb occurs. It may be congenital, or it may be acquired complication of peptic ulcer disease. We present a case of double pylorus in a gentleman with epigastric pain and previous history of peptic ulcer disease. The relationship between Helicobacter pylori and this disease was assessed. A review of the literature, the role of associated diseases and the role of H. pylori are discussed.
The results of reconstruction of the pylorus in 12 patients with disabling diarrhoea and/or dumping after vagotomy and pyloroplasty are reported. Eight patients, primarily operated on with a truncal vagotomy and pyloroplasty, all indicated frequent diarrhoea as their principal symptom. After the reconstruction operation the stools were normalized in five, and the frequency of diarrhoea was reduced considerably in two patients. Three of four patients who had had a selective vagotomy and pyloroplasty complained of severe dumping after all kinds of food; after the reconstruction these symptoms were milder and provoked by sweets and milk only. The fourth patient with heavy diarrhoea as the principal symptom had postoperatively a slight reduction of the frequency. The operation is easy to perform, and no complication was encountered. The pathogenesis of the symptoms is discussed, and it is recommended that patients with disabling diarrhoea and/or dumping after vagotomy and pyloroplasty undergo a reconstruction of the pylorus.
Infantile hypertrophic pyloric stenosis is the most common cause for urgent abdominal surgery in infancy. The aetiology of the condition is unknown. The ontogeny of the innervation and structure of the normal infant pylorus is unknown. A variety of differing histological features have been attributed to this condition and a number of animal models have been described. The histological changes in the human condition and those in the animal models have not been quantified and statistically verified. Thus, precise comparisons cannot be made. Immunohistochemistry was the principal technique employed in this study. Using this technique, the ontogeny and structure of the normal infant pylorus have been documented. The morphological and immunohistochemical changes underlying infantile hypertrophic pyloric stenosis have been quantified for the first time and compared with the quantified changes in natural and experimental animal models of this condition.
An analysis of long-term results of pylorus-preserving resections of the stomach performed on 540 patients has shown that 44 patients (8.1%) had different postgastroresectional syndromes. Operations were made on 20 patients with severe manifestations of the postgastroresectional syndromes. An analysis of the causes of complications was made as well as the substantiation of the methods of reconstructive interventions. Indications and contraindications for pylorus-preserving resections of the stomach are proposed.
Experience of operative treatment of 111 patients, operated on for big penetrating duodenal ulcer, complicated by hemorrhage, was summarized. There was proposed the method of operation performance using round hepatic ligament for tamponade of the ulcer crater and for restoration of pylorus. The advantages of pylorus preserving operations were proved.
OBJECTIVE: This experimental study of gastroantrium-cholecystostomy was designed to identify the possible use of pylorus sphincter as a substitute for Oddi sphincter. METHODS: Fifteen prairie dogs were randomized to three groups. The dogs in the control group underwent sham operation. The dogs in the first experiment group were subjected to gastroantrium-cholecystostomy and gastrojejunostomy. Meanwhile, two thin tubes were placed in stomach antrium and duodenum separately for post-operative photography. One week after operation, 20% cyctografin (10 ml) was injected into the duodenum through the relevant tube so as to check whether any backflow came out from duodenum to the bile duct. Then, 20% cyctografin (5 ml) was injected into the stomach antrium so as to demonstrate how it went from stomach antrium into duodenum. The samples of liver, stomach, stomach antrium, gallbladder and extra hepatic duct were collected for pathological examinations. The dogs of the second experiment group underwent the same operations, but the samples for pathological examination were collected four weeks after operation. RESULTS: Roentgenography showed that there was no contrast medium backflowing into the stomach antrium, and the contrast medium could flow from stomach antrium into duodenum smoothly. The results of histo-pathological examination showed that there were no obvious changes in the liver, stomach antrium and bile duct. Under light microscope, a few inflammatory cells could be seen in the gallbladder wall, and the mucosa of stomach was slightly atrophic. CONCLUSION: The gastroantrium-cholecystostomy which uses pylorus sphincter to take over the functions of Oddi sphincter can effectively prevent intestinal juice from flowing back into the bile duct.
The paper reports on the clinical observation of a patient with mechanical jaundice in which the biliary obstruction was caused by an ampulla of Vater. Cephalic duodenopancreatectomy with preservation of the pylorus was used. Distally the duodenum was excised to its intersection with the mesenteric vessels. For recovery of the digestive circuits, a loop excluded "en Y" à la Roux ascending transmesocolically was used. The anastomoses had the following stages: choledochojejunostomy (T-T) the most proximal; pancreatic-jejunal anastomosis (T-L); and the most distal, the duodeno-jejunal one (T-L). After surgery, the evolution was good, and the patient left the hospital with the wound cured. Starting from this observation, the authors discuss aspects connected with the technique of cephalic duodenopancreatectomy with or without preservation of the pylorus.
The results of treatment of 185 patients with complicated gastric and duodenal ulcer disease have been analysed. The results of operative treatment in 132 patients followed up for the period of from 1 to 7 years were studied. In gastric ulcer, resection of the stomach with preservation of the pyloric sphincter, or its reconstruction by means of the flaps taken from the antrum, is indicated; in duodenal ulcer--vagotomy, ulcer excision added by pylorus-preserving and pylorus-reconstructing methods of drainage operations.
Pylorus-preserving resections of the stomach were fulfilled in 118 patients with type I ulcers. The detected drop of the acid production in the stomach with ulcers of such localization was considered to be an indication to the removal of not more than 1/2 of the stomach. A necessary condition of pyloropreserving resection is the leaving of the pylorus zone not more than 2-3 cm. Two patients died (one from peritonitis and one from pulmonary insufficiency), 5 patients had disturbed evacuatory function of the stomach related with anastomosis. Long-term results were followed-up in 113 patients. All the patients returned to their normal activity, the pain syndrome disappeared, the dumping syndrome was absent. Complete inhibition of free hydrochloric acid was noted. There were no recurrences.
This study compares postoperative gastric emptying after pancreaticoduodenectomy with antrectomy (Whipple operation) or with preservation of the antrum and pylorus (Longmire operation). Six of eight patients with antrectomy were able to tolerate full solid feedings within ten days (a mean for the group--9.8 days). Only one of eight patients with preservation of the antrum and pylorus reached this point within ten days (a mean for the group--16 days, p less than 0.05). Average-time from operation to discharge from the hospital was seven days longer for patients in the latter group. Routine placement of a gastrostomy tube in anticipation of the prolonged need for gastric drainage reduced a potentially bothersome problem to a well-tolerated level. Although one patient had bleeding jejunal ulcers develop which required vagotomy and antrectomy one year after a Longmire operation; the long term nutritional and functional advantages of this new technique for pancreaticoduodenectomy seem to outweigh the short term costs.