Robotic Heineke-Mikulicz Pyloroplasty for Pyloric Stenosis

Abstract

Pyloric stenosis resulting in gastric outlet obstruction can present with nausea, vomiting, and early satiety. Imaging including fluoroscopic upper gastrointestinal series and computed tomography can diagnose gastric outlet obstruction. Upper endoscopy is included in the work-up to visualize the extent of stenosis and to obtain a tissue biopsy. After a malignancy is ruled out, treatment involves management of underlying causes. This may include acid suppression, treatment of H. pylori, and dietary modification. Patients who fail conservative management may benefit from endoscopic therapies including pneumatic dilation and botulinum toxin injection. However, these therapies may not offer lasting symptomatic relief. Pyloroplasty can be performed with the goal of widening the pylorus to improve gastric emptying. Pyloroplasty can be accomplished through open, laparoscopic, and robotic techniques. Here we describe a robotic-assisted Heineke-Mikulicz pyloroplasty in an adult patient with benign pyloric stenosis.

Keywords

Robotic surgery; gastric outlet obstruction; pyloroplasty; minimally-invasive surgery.

Case Overview

Background

Pyloric stenosis is a common cause of gastric outlet obstruction (GOO) in adults and is most commonly caused by malignancy, closely followed by peptic ulcer disease. Hypertrophic pyloric stenosis presenting in adulthood is rare.^1, 2 Ruling out an underlying malignancy is important to offering treatment. Patients commonly present with nausea, vomiting, and early satiety.³

Focused History of Patient

Here we present a 66-year-old woman with a past medical history significant for Barrett’s esophagus, chronic obstructive pulmonary disease, hypothyroidism, and prediabetes. She presented for evaluation of an approximately 1-year history of gastric reflux, early satiety, and projectile vomiting. Due to her symptoms and a family history of Barrett’s esophagus and esophageal cancer, she underwent an upper endoscopy around the time of symptom onset, which revealed Barrett's esophagus, a hiatal hernia, and retained liquids and solids in the stomach. The pylorus could not be transversed. She was prescribed omeprazole 40 mg daily. She underwent three pyloric dilations with pneumatic dilation up to 12 mm and a botulinum toxin injection during one of the endoscopies. These resulted in minimal and short-lived symptom relief. Multiple biopsies were taken and were all negative for malignancy. Due to continued symptoms she presented for robotic-assisted pyloroplasty.

The patient had no prior abdominal surgeries. Her medications include hydrochlorothiazide, omeprazole, levothyroxine, rosuvastatin, albuterol, and fluticasone proprion-salmeterol. She is a former smoker. She has no drug allergies.

Physical Exam

Physical exam revealed a well-nourished and healthy-appearing woman. She was in no apparent distress with vital signs within normal limits. Her BMI was 28.5kg/m². Her abdomen was soft, non-distended, non-tender, with no palpable masses.   

Imaging

Fluoroscopic upper gastrointestinal (UGI) series is diagnostic for GOO but does not differentiate between underlying causes.^2, 4 Computed tomography (CT) scan of the abdomen with oral and intravenous contrast offers the advantages of better defining the anatomy of the UGI and can potentially identify an underlying malignancy.

This patient underwent a CT scan of the abdomen and pelvis with oral and IV contrast. This revealed a possible 1.2-cm exophytic lesion at the pylorus. This finding raised the concern for a possible gastrointestinal stromal tumor or thickening secondary to peptic ulcer disease. A nuclear gastric emptying study showed severely delayed gastric emptying. A fluoroscopic UGI series showed no obstruction but was significant for delayed passage of contrast through the pylorus. 

Natural History

The pylorus is composed of a thick inner layer of muscle that is contiguous with the inner layer of gastric muscle. This inner muscle layer is separate from the inner layer of muscle in the duodenum. There is also a thinner outer layer of muscle in the pylorus. These longitudinal muscle fibers are continuous from the stomach and reach the duodenum.^1, 2

Adult pyloric stenosis falls into two main categories. Primary pyloric stenosis is a rare entity and thought to be persistent hypertrophic tissue that has been present since infancy.^2, 5 Secondary pyloric stenosis is by far the most prevalent variety. Secondary pyloric stenosis is most commonly caused by malignancy and peptic ulcer disease.² In a series of 100 patients with pyloric stenosis 42% were due to malignancy and 37% due to peptic ulcer disease.¹

A stenotic or occluded pylorus prevents adequate gastric emptying. Clinical manifestations typically include nausea and vomiting, which may be projectile in nature. Early satiety may also be present. Symptoms typically occur over weeks to months. They may occur more acutely due to an ulcer within the pylorus.³ Patients may have varying levels of tolerance of oral intake. It is important to account for a patient’s nutritional and metabolic status before proceeding with any intervention as they may require resuscitation and nutritional optimization.

Options for Treatment

Patients should be treated in a stepwise fashion based on a patient’s degree of symptoms and tolerance for invasive procedures. Dietary modifications with small meals and softer textures may alleviate symptoms in a portion of patients. Next, upper endoscopy may be both diagnostic and therapeutic. Balloon dilation may offer relief of symptoms but does not typically offer long-term improvement.^6, 7 Finally, there are several surgical options for treatment including pyloroplasty, pyloromyotomy, gastrojejunostomy, and distal gastrectomy.⁸

Rationale for Treatment

This patient had persistent symptoms despite repeated attempts at medical and endoscopic management. Given these failures, pyloroplasty was indicated to open the pylorus and allow for adequate gastric emptying. The surgeon chose a minimally-invasive approach.

Discussion

Here we discuss a case of a 66-year-old woman with pyloric stenosis that was refractory to medical and endoscopic management. Despite multiple endoscopic balloon dilations and injection of botulinum toxin, she remained symptomatic. Due to continued symptoms she underwent an uncomplicated robotic-assisted Heineke-Mikulicz pyloroplasty. On postoperative day two she underwent a Gastrografin swallow study, which showed no evidence of leak and passage of contrast into the duodenum. It is our practice to routinely obtain a contrast swallow study on postoperative day two or three, prior to diet initiation. She was discharged home on a full liquid diet for three days, followed by a soft diet. She tolerated this advancement well. At 3- and 6-week follow up she was recovering well with tolerance of diet advancement with the integration of cooked vegetables.

Endoscopic evaluation is an essential step for the diagnosis and treatment of GOO. The pylorus should be visualized and biopsied to determine the presence or absence of malignancy causing obstruction. As in our patient, the duodenum may be inaccessible during endoscopy depending on the extent of stenosis. Endoscopic therapies may offer some short-term symptom relief but they do not produce lasting results for many patients.⁶ Patients that fail endoscopic therapy should be referred for surgical evaluation.  

Pyloroplasty is typically carried out using the Heineke-Mikulicz or Finney techniques.³ Pyloroplasty carries less morbidity than larger operations such as gastrectomy. Considering the benign nature of this disease, less invasive and morbid treatments should be carefully considered before committing a patient to a larger surgery. Pyloroplasty can be performed using open, laparoscopic, and robotic techniques. The decision of which technique to employ largely depends on surgeon preference and comfort. The decision to perform a Heineke-Mikulicz in this case was due to surgeon preference.

The robotic-assisted approach to pyloroplasty is performed in a similar fashion to laparoscopic techniques. Patient positioning and port placements require careful consideration and planning to perform adequate exposure and reach of instruments. Ports were placed in the supraumbilical, right lateral, right mid, and left mid areas of the abdomen. The patient was placed with the right side up and in slight reverse Trendelenburg positioning. A 30-degree robotic camera was placed in the right mid-abdomen. A robotic Cadiere grasper was used to better expose the pylorus. This retraction allows for two working hands and the robotic camera, all under the control of the operating surgeon. A longitudinal incision is placed through the pylorus, extending from the distal antrum to the proximal duodenum, which was closed transversely in two layers using 2-0 V-Loc (Medtronic Minneapolis, MN) sutures. A modified Graham patch with omentum was placed to re-enforce the repair.

The first laparoscopic pyloromyotomy for pyloric stenosis was performed in 1990.⁹ Danikas et al described a laparoscopic pyloroplasty in an adult patient.⁸ Shada et al demonstrated the safety and effectiveness of a laparoscopic pyloroplasty in their series of 177 patients with gastroparesis. There were 0 conversions to laparotomy, a 1.1% leak rate, and 2.2% of patients had to return to the operating room.¹⁰

When compared to laparoscopic pyloroplasty, robotic pyloroplasty was found to have shorter operative time (90.0 min vs 122.4 min p=0.0061) and length of stay (2.7 days vs 4.0 days p=0.011). Cost was higher for robotics by $511.17 (p=0.025), but there was no difference in total cost of hospitalization. The authors attribute the decreased operative time during robotic pyloroplasty to the improved dexterity offered by the robotic platform. The fact that there was no significant difference in overall cost despite the increased cost of using the robotic platform can be attributed to the significant decrease in length of stay in the robotic group.¹¹ We agree that the improved dexterity in addition to the superior field of view makes the robotic approach ideal. 

Conclusion

Benign pyloric stenosis can be a cause of GOO in adults. Robotic-assisted Heineke-Mikulicz pyloroplasty is a safe, effective, and long-lasting treatment for benign pyloric stenosis in adults.

Equipment

This surgery was performed using the DaVinci Xi robotic platform (Intuitive Surgical, Sunnyvale, CA).

Disclosures

Nothing to disclose.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.