Pyloroplasty. — Pyloroplasty is the term applied to the enlargement of a stenosed pylorus by plastic operation.
It is the operation of choice in simple non-malignant stenosis of the pylorus unless there is excessive fibroid thicken ing, recontraction of the pylorus, or pos sibly in case of excessive dilatation, when gastro-enterostomy is the preferable op eration.
The Heineke-Mikulicz operation was devised and performed independently by the surgeons whose names it bears in 1SS6-S7. According to their method, an incision is made in the long axis of the pylorus at the seat of constriction; the incision is then stretched at its middle at a right angle so as to dilate the strict tired pyloric opening, and the margin of the incision is sutured in this new position, the edges being inverted so as to bring the serous surfaces in apposi tion. The advantages over gastro-enter ostomy are its lower mortality, the ab sence of reflux of bile and pancreatic fluid into the stomach, and ultimately, in many cases, the restoration of normal pyloric action and normal gastric secre tion. The mortality varies with differ ent operators from 7 to 21 per cent.
Gastro-enterostomy.— Gastro-enteros tomy is the operation of establishing a permanent fistula between the stomach and some part of the small intestine.
Its main object is to aid in quickly and easily emptying the stomach of its contents. The operation may be abso lutely necessary to prolong life in cer tain cases of obstruction of the pylorus, and it often proves of great benefit in such conditions as gastric ulcer and ob stinate disturbance of digestion. In ma lignant diseases of the pylorus pylorec tomy is the operation of choice if the disease has not progressed too far, other wise gastro-enterostomy is indicated. In the non-malignant forms of pyloric ob struction this operation is to be pre ferred, if the stenosis is extreme, the thickening very great, or in case of re current stenosis; in other non-malignant cases pyloroplasty is the operation of choice. It has been performed with encouraging success, especially by the French surgeons, in the treatment of obstinate digestive disturbances, particu larly those associated with gastric ulcer.
Special stress laid upon the employ ment of gastrointestinal anastomosis for all varieties of pyloric stenosis, no mat ter what its cause. Gastro-enterostomy is the most frequently indicated opera tion. The anastomosis is personally pre ferred in the posterior wall at the most dependent point, a simple suture in two rows being made with an ordinary sew ing needle. The removal of the should be applied only to cases of ma lignant nature, but the simple entero anastomosis in inoperable-cancer cases is a much better surgical procedure than the formation of an artificial anus in cases of cancer of the intestines. Tuffier
(La I'resse 1\16d., Feb. 9, '9S).
Early surgical intervention is advo cated in cases of cancer of the stomach.
There are twenty instances on record of patients who have survived without re currence the removal of gastric tumors proved to be malignant after intervals varying from four to eight years. Lau donzy (Bull. de l'Acad. de MM., No. 10, '99).
When the indications are similar to those for gastrostomy—dilliculty in the onward passage of food. vomiting. pro gressive emaciation, and subnormal tem perataire—gastro-enterostonty may not lie delayed without serious risk. Even if life is not prolonged by the operation the discomfort of the patient is lunch lessened. There is somet hues a great gain in weight. The tumor sometimes entirely disappears after the operation. A posterior gastro-jejtmostomy as close to the duodenum as convenient is pre ferred, or, in the complicated eases, an anterior operation. The method is de termined by what is found on opening the abdomen, and by the extent to ' which the stomach remains mobile. Whether the food-current is isoperi staltie does not make much difference. Caird (Medical Press. May 28. 1902).
Operation. — A median incision be tween the ensiform cartilage and bilicus is generally preferred. In order that digestion and absorption be not in terfered with, it is important that the upper part of the jejunum be selected for anastomosis. The beginning of the jejunum is the only fixed part of the small intestine, and it can usually be found without much difficulty just be low the pancreas, to the left side of the vertebral column, near the root of the mesentery. A freely-movable loop of bowel should be selected, and the upper end of the bowel should be turned toward the cardia, so that the peristaltic waves of the stomach and bowel shall be in the same direction. The anasto mosis of the intestine with the anterior wall of the stomach is the easiest method of performing the operation, but in most cases, and especially if severe digestive disturbances are present, posterior gas- • tro-enterostomy, or suturing the intes tine to the posterior wall of the stomach after passing it through an opening in the gastro-colic omentum, is the prefer able operation. In any case it is de sirable to make the anastomosis at the most dependent part of the stomach near the greater curvature, to favor emptying the organ. Union may be effected by direct suture or by means of some of the numerous buttons, plates, rings, bobbins, or anastomotic forceps that have been devised for this purpose.