Finney's pyloroplasty in chronic pyloric obstruction.
Vagotomy with a drainage procedure has been generally accepted as the surgery of choice for chronic duodenal ulcer with pyloric obstruction, Due to the inherent advantages of a pyloroplasty over a gastro-jejunostomy the former is usually preferred as a drainage procedure. We have been doing a Weinberg's modification of HeinekeMikulicz pyloroplasty with truncal vagotomy for several years. The disadvantages that were encountered were: (i) In cases of chronic pyloric obstruction with a large atonic stomach, the patients used to have a very large aspirate which continued for a long period post-operatively (800 to 1200 ml of aspirate for 7 to 8 days post-operatively). Hence these patients had to be maintained on intravenous fluids for a longer time. This delayed the mobilisation of the patient, increased the incidence of thrombophlebitis, increased chest complications and lastly increased the overall expenditure; and (ii) In a few cases with an extremely narrow pylorus, a HeinekeMikulicz pyloroplasty would not have been possible. Hence a gastro-jejunostomy had to be resorted to inspite of its inherent disadvantages.
Because of these problems, 15 cases of chronic duodenal ulcer with pyloric obstruction were treated with truncal vagotomy and Finney's pyloroplasty and the results assessed.
Fifteen cases of chronic duodenal ulcer with pyloric obstruction who presented to a general surgical unit of K.E.M. Hospital were selected for the study.
The diagnosis was based on
(i) Clinical history and physical examination.
(ii) Response to slow continuous milk drip through a nasogastric tube. Epigastric pain relieved by this treatment with progressively diminishing quantities of gastric aspirates was considered to be due to peptic ulcer with pyloro-spasm while constant or increasing quantities of gastric aspirate was taken as evidence of organic pyloric obstruction. The cases falling in the latter category only are included in this series.
(iii) Barium studies of the upper gastro-intestinal tract.
The indication for surgery in all the 15 cases was chronic pyloric obstruction. The patients were submitted to a truncal vagotomy and Finney's pyloroplasty.
Post-operatively, the patients were kept on intravenous fluids and the nasogastric tube was continuously aspirated. As soon as the patients had evidence of peristaltic activity in the form of (a) decreasing volume of gastric aspirate (b) passage of flatus or/and stools, and (c) return of peristaltic sounds, they were given test feeds. The naso-gastric tube was clamped and the patients were given 30 ml of water orally every hour. Before the 5th feed (i.e. at the end of 4 hours which is roughly the normal gastric emptying time) the naso-gastric tube was aspirated and if the aspirate was less than 60 ml, the test feeds were considered to have been tolerated. The naso-gastric tube was then removed, intravenous fluids were discontinued and the patient was given liquid diet and subsequently full diet.
There were 11 males (73.33%) and 4 females (26.67%) in this study group. Their age distribution is shown in [Table 1].
The duration of symptoms varied from 1 to 20 years, the average duration being 4.7 years. Seven cases had clinical evidence of pyloric obstruction in the form of a palpable stomach and succussion splash. Of these, 4 patients had a very large overnight residue. The remaining 8 cases had radiological evidence of duodenal ulcer with pyloric obstruction. Four of these cases had a large stomach as seen on barium studies. Exploratory laparotomy revealed evidence of chronic duodenal ulcer with pyloric obstruction in all 15 cases.
Seven cases had a moderately large stomach and 1 case had a very large stomach. Two patients had post-bulbar stenosis. In all other cases the lumen of the pylorus was very small and, a HeinekeMikulicz pyloroplasty would not have been possible. A large and adequate stoma was obtained in all the 15 cases after Finney's pyloroplasty.
The nasogastric aspirate at the end of 24 hours after surgery varied from 72 ml to 631 ml with an average of 377 ml. The total aspirate during the next 24 hours varied from 90 ml to 630 ml. The mean aspirate was 389 ml. On the 3rd postoperative day (i.e. at the end of 48 hours after surgery), 5 patients (33%) tolerated the test feeds. The remaining 10 patients had a mean aspirate of 376 ml. On the 4th postoperative day (at the end of 72 hours after surgery), 8 more patients (53% ) tolerated the test feeds. The remaining 2 patients had an aspirate of 550 ml and 332 ml respectively. These 2 patients tolerated the test feeds on the 5th post-operative day (96 hours after surgery). Intravenous fluids were stopped. at the latest on the 5th day (96 hours after surgery).
There was no evidence of any chest complication. One patient had mild thrombophlebitis. One patient developed moderate haematemesis on the 2nd postoperative day but this could be controlled by conservative management. As the anastomosis had been done with interrupted sutures, the bleeding was thought to be from the anastomosic line. After this, all further anostamoses were done with continuous sutures and no complications were seen. There was no other complication except for an occasional case of superficial wound infection.
The follow-up of the 15 patients varied from 6 to 18 months. All the patients are asymptomatic and none of them have any significant disturbance in their digestive physiology. No patient has complained of biliary regurgitation. A routine post-operative barium study done in one patient showed that the stomach was emptying well and the stoma was large.
There was no mortality and the morbidity was negligible.
The choice for a gastric drainage procedure after truncal vagotomy rests between gastro-jejunostomy and pyloroplasty. Both these procedures have certain advantages and a few disadvantages.
The advantage of pyloroplasty is that it is a more physiological operation in that the gastro-intestinal continuity is maintained and there is no blind loop. The disadvantage is that it cannot be done in cases of chronic pyloric obstruction where the lumen of the pylorus is very small.
Gastro-jejunostomy has the advantage of providing a large stoma for the drainage of a chronically dilated, atonic stomach and the stoma is independent of the state of the pylorus. The main disadvantages of a gastro-jejunostomy have been the blind loop syndrome and the associated disturbances in the intestinal physiology. Also the incidence of postoperative intestinal obstruction is higher after gastrojejunostomy than pyloroplasty.
In cases of chronic pyloric obstruction, Finney's pyloroplasty combines the advantages of both the above procedures without the disadvantages of either.
In the present study of 15 cases of chronic pyloric obstruction the advantages of Finney's pyloroplasty that were seen were:
(1) It can be done in cases of very tight pyloric obstruction when a HeinekeMikulicz pyloroplasty would not have been possible. Most of our patients had very tight pyloric obstructions but we did not have to do a gastrojejunostomy in any of them.
(2) It gives better drainage of a grossly dilated and atonic stomach following a prolonged pyloric obstruction. In all the 15 patients the average nasogastric aspirate varied from 350, ml to 400 ml per day. Five patients (33%) could be given oral feeds, after 48 hours of surgery, 8 patients (53%) could be given oral feeds 72 hours after surgery and the remaining 2 were on liquid diet 96 hours after surgery.
In similar cases when we had done a HeinekeMikulicz pyloroplasty, the aspirate varied from 800 ml to 1200 ml per day and continued to remain high for as long as 7 to 8 days.
(3) The patients can be put earlier on oral alimentation. This permits early mobilisation and markedly reduces the problems associated with prolonged recumbency and parenteral alimentation. Furthermore, as intravenous fluids have to be administered for a shorter period, overall expenditure can thus be reduced.
In the present study, all patients had the nasogastric tube for not longer than 96 hours after surgery. No chest complications were seen.
Thus complications due to prolonged parenteral alimentation and due to nasogastric tube can be reduced by Finney's pyloroplasty.
(4) The fluid and electrolyte disturbances due to prolonged naso-gastric drainage of large quantities of gastro-intestinal secretions are avoided.
(5) Post-bulbar stenosis can also be corrected by Finney's pyloroplasty.
In the present study, Finney's pyloroplasty was done in 2 cases of post-bulbar stenosis and the results obtained were satisfactory.
We are thankful to the Dean, K.E.M. Hospital, Bombay, for allowing us to use the hospital records.