Overview
Definition:
The Heineke-Mikulicz pyloroplasty is a surgical procedure involving longitudinal incision of the pylorus followed by transverse closure, widening the gastric outlet
It is primarily indicated for relieving gastric outlet obstruction (GOO) due to benign etiologies, including strictures secondary to corrosive ingestion.
Epidemiology:
Corrosive ingestion is more common in developing countries, often due to accidental or intentional ingestion of strong acids or alkalis
Stricture formation requiring surgical intervention can occur in 2-10% of severe corrosive injuries
The Heineke-Mikulicz procedure is one of several options for GOO management in such cases.
Clinical Significance:
Corrosive gastric injury leading to pyloric stricture causes significant morbidity, including intractable vomiting, malnutrition, and electrolyte disturbances
Timely and effective surgical management, such as Heineke-Mikulicz pyloroplasty, is crucial for restoring gastrointestinal continuity and improving the patient's quality of life and nutritional status.
Clinical Presentation
Symptoms:
Progressive postprandial nausea and vomiting, often non-bilious
Early satiety and abdominal fullness
Weight loss and anorexia
Epigastric pain or discomfort
Dehydration and reduced urine output
Electrolyte abnormalities.
Signs:
Visible gastric peristalsis
Abdominal distension, particularly in the epigastrium
Succussion splash on abdominal palpation
Signs of dehydration: dry mucous membranes, decreased skin turgor
Cachexia in chronic cases
Vital sign abnormalities related to dehydration and electrolyte imbalance.
Diagnostic Criteria:
Diagnosis of GOO due to corrosive injury is based on a history of corrosive ingestion, characteristic symptoms and signs, confirmed by upper GI endoscopy and imaging
Endoscopic findings include luminal narrowing, inflammation, ulceration, and fibrotic stricture at the pylorus or duodenum
Barium meal may show delayed gastric emptying and a dilated stomach.
Diagnostic Approach
History Taking:
Detailed history of the ingested substance (acid/alkali, quantity, time of ingestion)
Symptoms of dysphagia, odynophagia, chest pain, or abdominal pain
Duration and progression of symptoms
Previous GI surgeries or medical conditions
Nutritional status and weight loss
Red flags: severe abdominal pain, signs of perforation, hematemesis, melena.
Physical Examination:
Thorough abdominal examination looking for distension, tenderness, masses, and auscultation for bowel sounds
Assessment of hydration status
Examination of oral mucosa for corrosive burns
General examination to assess nutritional status and for signs of systemic illness.
Investigations:
Complete blood count (anemia, leukocytosis)
Serum electrolytes, urea, creatinine (dehydration, renal compromise)
Liver function tests
Endoscopy: essential for grading the severity of corrosive injury and assessing the extent and nature of the stricture
Barium swallow/meal: shows delayed gastric emptying, dilated stomach, and the caliber of the stricture
CT scan: may be useful to rule out perforation or assess extraluminal complications.
Differential Diagnosis:
Peptic ulcer stricture
Gastric malignancy
Gastric bezoars
Post-surgical strictures (e.g., after vagotomy, antrectomy)
Crohn's disease affecting the pylorus
Irritable bowel syndrome (if symptoms overlap).
Surgical Management
Indications:
Symptomatic gastric outlet obstruction refractory to conservative management
Inability to tolerate oral intake
Severe and persistent vomiting
Significant weight loss
Evidence of progressive gastric dilation on imaging
Pyloric stricture that cannot be endoscopically dilated.
Procedure Steps:
The Heineke-Mikulicz pyloroplasty involves an anterior longitudinal incision through the pyloric muscle, extending a few centimeters onto the stomach and duodenum
The incision is then closed transversely using sutures, creating a wider stoma
This procedure is typically performed laparoscopically or as an open surgery.
Surgical Variations:
While Heineke-Mikulicz is a specific technique, other pyloroplasties (e.g., Jaboulay, Finney) or drainage procedures like antrectomy with Billroth I anastomosis may be considered based on the extent of injury and surgeon preference
Gastric resection may be necessary for extensive mural damage or malignancy suspicion.
Alternative Procedures:
Gastric resection (antrectomy or gastrectomy) with gastroduodenostomy (Billroth I) or gastrojejunostomy (Billroth II) may be indicated for extensive strictures or if malignancy is suspected
Endoscopic balloon dilation is an option for less severe, purely fibrotic strictures but may have lower long-term efficacy in corrosive injuries compared to surgical bypass or reconstruction.
Postoperative Care
Initial Management:
Nasogastric tube decompression to rest the stomach and monitor for drainage
Intravenous fluid resuscitation and electrolyte correction
Pain management with analgesics
Antibiotic prophylaxis as per hospital protocol.
Nutritional Support:
Gradual reintroduction of oral intake, starting with clear liquids and advancing as tolerated
Parenteral nutrition may be required initially if oral intake is not feasible
Nutritional assessment and supplementation to address preoperative malnutrition.
Monitoring:
Close monitoring of vital signs, fluid balance, and electrolyte levels
Assessment of drain output if applicable
Observation for signs of complications such as leak, bleeding, or infection
Patient education regarding diet and follow-up.
Discharge Planning:
Patients are typically discharged once they can tolerate an adequate oral diet, have adequate pain control, and show no signs of complications
Follow-up appointments are scheduled to monitor recovery and nutritional status.
Complications
Early Complications:
Anastomotic leak
Bleeding from the suture line
Gastric retention
Wound infection
Ileus
Pneumonia
Deep vein thrombosis.
Late Complications:
Recurrent gastric outlet obstruction
Marginal ulceration
Dumping syndrome (more common with gastric resections, but can occur)
Adhesions leading to bowel obstruction
Nutritional deficiencies
Stricture recurrence if the underlying fibrotic process is extensive or incomplete relief.
Prevention Strategies:
Meticulous surgical technique to ensure adequate stoma size and secure anastomosis
Prophylactic antibiotics
Early mobilization
Adequate hydration and nutritional support
Careful advancement of oral intake
Long-term follow-up to detect and manage late complications.
Prognosis
Factors Affecting Prognosis:
The nature and extent of the initial corrosive injury
Promptness and success of surgical intervention
Presence of complications
Nutritional status of the patient
Adequacy of postoperative management and follow-up
Absence of malignancy.
Outcomes:
Successful Heineke-Mikulicz pyloroplasty can significantly relieve symptoms of GOO, allowing for resumption of normal oral intake and improvement in nutritional status and quality of life
However, the long-term success depends on managing the underlying fibrotic changes and preventing recurrence.
Follow Up:
Regular follow-up appointments are essential, including clinical assessment, nutritional evaluation, and periodic upper GI endoscopy to monitor for recurrence of stricture, development of marginal ulcers, or other complications
Patients should be advised on dietary modifications and to report any recurring symptoms promptly.
Key Points
Exam Focus:
Heineke-Mikulicz pyloroplasty is a longitudinal incision and transverse closure procedure to widen the pylorus
It is indicated for benign gastric outlet obstruction, including from corrosive injury
Endoscopy is crucial for diagnosis and grading
Complications include leak, bleeding, and recurrent obstruction.
Clinical Pearls:
Always inquire about the nature of the ingested corrosive agent (acid vs
alkali) as it influences tissue damage and prognosis
Endoscopy is the gold standard for assessing corrosive injuries
In corrosive strictures, consider that the fibrotic process may be ongoing, potentially leading to recurrence even after successful initial surgery.
Common Mistakes:
Underestimating the extent of corrosive damage
Performing a pyloroplasty on a severely devitalized or perforated stomach
Inadequate stoma widening leading to recurrent obstruction
Delayed surgical intervention when conservative measures fail
Insufficient postoperative nutritional support.