Pylorus Exclusion

PYLORUS EXCLUSION, as an operation complementing gastroenterostomy, was proposed by Eiselsberg in 1895 for cancer of the pyloric part; the operation consists of transversely cutting the stomach to the left (toward the cardia) from the neoplasm and hermetically sealing both ends (see the figure) and is performed in the following manner: within the limits of healthy walls, a segment is separated, and by applying clamps on both sides of the incision line, the stomach is cut; after this, both ends are hermetically sealed. The purpose of the operation is to eliminate the irritating effect of food masses; therefore, exclusion was considered indicated for tumors causing bleeding or severe pain. Nevertheless, precisely in cases of cancer, Eiselsberg's operation was rarely applied, as it in itself represents a significant complication of gastroenterostomy. Pylorus exclusion found much greater application in pyloric and duodenal ulcers. For the first time for these indications, exclusion was applied before Eiselsberg by Doyen (1893) in a simple form: constricting sutures are applied in two rows to the pyloric part—first in the transverse, then in the longitudinal direction. The goal pursued by pylorus exclusion in ulcers is to place the ulcer outside of mechanical and chemical irritations and thus promote its more rapid healing; at the same time, the danger of bleeding and perforation is reduced, and the painful symptom is eliminated.

Exclusion of ulcers was practiced by many surgeons up to the most recent times, during which the technique of the operation underwent numerous variations. One of the most common methods was the application of a circular ligature followed by covering it with a serosal suture; observations showed that after such ligatures, the patency of the pylorus is soon restored due to the ligature being cut through into the intestinal cavity, and the exclusion is temporary. Bier, before applying a circular ligature, crushes the stomach wall with Doyen's crusher and ties the groove with a silk or catgut thread, followed by covering with a serosal suture, but this modification also does not guarantee against the subsequent restoration of pyloric patency. More reliable in this regard is the tightening with strips of living tissue—fascia, cut from the sheath of the rectus muscles (Wilms, Bogolyubov), or the round ligament of the liver, which are not cut through but take root in the walls of the stomach. It should be noted that such ligatures do not provide complete pyloric obstruction, and part of the gastric contents passes into the duodenum. Girard produces narrowing of the pylorus in the following manner: a transverse incision is made on the anterior wall of the stomach from the lesser to the greater curvature through the thickness of the seromuscular layer, the edges of the incision are pulled to the right and left, after which the upper edge is sutured to the lower; in other words, the operation is analogous to pyloroplasty but is performed in reverse. The application of pylorus exclusion in all its forms for ulcers of the stomach and duodenum, according to subsequent observations, revealed one negative aspect: statisticians (Haberer, Clairmont, Sokolov) established the fact that pylorus exclusion predisposes to the development of secondary peptic ulcers at the anastomosis or in the jejunum (up to 20-27% of cases according to some authors). The explanation for this must be seen in the fact that after pylorus exclusion, the physiological reflex that causes the secretion of pancreatic juice and occurs only after the acidic gastric contents penetrate into the duodenum is disrupted (I. P. Pavlov). The main role in neutralizing gastric acid belongs precisely to the pancreatic juice. These observations have discredited the value of pylorus exclusion for ulcers, and at present this operation has lost its significance and has almost fallen out of use. A specific indication for pylorus exclusion consists of cases of persistent fistulas of the duodenum.

V. D. Protorskii.