Mena Boules, MD, Ricard Corcelles, MD, PhD, Esam Batayyah, MD, John Rodriguez, MD, Matthew Kroh, MD
Department of General Surgery, Cleveland Clinic Main Campus, Cleveland, Ohio (all authors).
Introduction: Adult idiopathic hypertrophic pyloric stenosis (AIHPS) is a rare entity. The most common clinical symptom is abdominal distention relieved by vomiting. There are several treatment modalities for relief of the pyloric obstruction.
Case Description/Technique: A 43-year-old woman presented with a long history of epigastric pain, nausea, vomiting, and bloating, which appeared to be caused by functional dyspepsia. She also reported severe postprandial epigastric pain that was thought to be secondary to peptic ulcer disease (PUD). She had lost 7 kg, leading to a poor nutritional status. Further investigation by upper gastrointestinal endoscopy demonstrated moderate stenosis at the pylorus. After discussion, she elected to undergo laparoscopic Heineke-Mikulicz pyloroplasty. The patient was placed supine, and entrance into the peritoneal cavity was obtained with a 5-mm optical trocar. The pylorus was clearly identified and was visibly thickened. Two 2-0 silk stay sutures were placed. Gastrotomy was made with a harmonic scalpel, and the pylorus was cut. The pylorus was reconstructed horizontally by using the Heineke-Mikulicz technique. Finally, a second layer of interrupted 2-0 silk sutures was placed.
Discussion: The etiology of AIHPS remains unclear. In a case report, Zarineh et al. classified AIHPS into two main types: primary and secondary. Several factors are important in establishing the diagnosis. The approaches include endoscopic dilation, gastrojejunostomy, partial gastrectomy, and pyloromyotomy with or without pyloroplasty. Despite the technical difficulty, operative procedures such as the Heineke-Mikulicz pyloroplasty have shown favorable results. Currently, laparoscopic pyloroplasty may represent a reasonable, less invasive option for this rare condition.
Key Words: Heineke-Mikulicz pyloroplasty, Hypertrophic pyloric stenosis, Pyloric obstruction.