Gut, 1970, 11, 358-362

Radiological anatomy after pyloroplasty

D. K. M. TOYE, J. F. K. HUTTON, AND J. ALEXANDER WILLIAMSFrom the General Hospital, Birmingham

SUMMARY The radiological anatomy of the pyloro-duodenal area after pyloroplasty isdescribed. The deformity produced by pyloroplasty is shown in the patient with a normalpylorus and duodenum and in the patient with a duodenal ulcer and stenosis. From a studyof 24 asymptomatic patients after pyloroplasty it is possible to recognize the radiologicalfeatures that indicate a successful operation.

In the United Kingdom vagotomy and pyloro-plasty is fast becoming the most popular operationin the treatment of chronic duodenal ulceration.While most patients are cured, approximately10% continue to complain of some form ofindigestion. When the patient has continueddyspepsia, clinicians usually suspect that eitherthe operation has failed to cure the ulcer or

that the pyloroplasty drainage has been in-effective; they then turn to radiologists forhelp in confirming their suspicions. However,radiologists have been reluctant to play a majorrole in the evaluation of these patients, partlybecause they have accepted the view that radiologycan play no part in the evaluation of duodenalulcer activity and partly because it was thoughtimpossible to exclude ulceration in the presence

of pyloroduodenal deformity. Further difficultiesarose from lack of familiarity with the post-operative anatomy, particularly in those patientswithout complications. The present study is anattempt to clarify the changes in anatomy broughtabout by a Heineke-Mickulicz pyloroplasty andto indicate the radiological features of a successfuloperation.

The Effect of Pyloroplasty on the NormalPyloric Canal

THEORETICAL EFFECTThe simplest form of pyloroplasty and the one

still most widely used (Heineke-Mikulicz pyloro-plasty) involves a longitudinal incision in theline of the gut 2 to 5 cm either side of the pylorus.The upper and lower edges of the centre of thisincision are then drawn apart and the proximaland distal ends brought together in the centreso that the incision is closed in the transverseaxis of the bowel. The effect of drawing the endsof the incision towards the centre is to producea pouch at the site ofthe suture line and so tractionon the longitudinal muscle fibres at either end ofthe incision. This traction produces a constrictionor 'sling' proximal and distal to the pouch.This theoretical anatomical model is shown inFig. 1 and should lead to four structures thatwe might expect to recognize radiologically.Proceeding from the antrum distally, these

D R

Fig. 1 Diagram of theoretical landmarks to beexpected on radiographs after pyloroplasty.PP = Pouches D = Duodenal constrictionR = Ridge A = Antral constriction

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Radiological anatomy after pyloroplasty

Fig. 2a Photograph ofplaster cast ofpyloro-duodenal channel after postmortem pyloroplasty.Anterior view showing position of suture line, pouches,and slings. The position of the ridge was identifiedon the posterior aspect.

Fig. 2b Radiographs ofpyloroplasty channel inpostmortem specimen. The channel is partly filledwith barium and clearly shows the four structuresdescribed in Figutre 1.

are: (1) the antral constriction; (2) a pouch atthe site of the suture line which will continue onits posterior aspect; (3) a ridge or bar formed bythe ring of pyloric muscle; and, distally (4) theduodenal constriction. Furthermore, it followsthat, in theory, the longer the pyloroplastyincision the greater will be the size of the pouchand the greater the degree of constriction pro-duced by the sling effect.

CADAVER STUDYThe theoretical hypothesis was tested by a post-mortem study in which a pyloroplasty was per-formed on a normal duodenum. This area wasthen filled with barium and a radiograph taken.It was finally filled with plaster of Paris and a castformed. Examination of the cast and its compari-son with the radiograph supported by theanatomical description previously proposed(Figures 2a and b).

CLINICAL STUDYSix patients were studied in whom a Heineke-Mikulicz pyloroplasty had been performed ona duodenum that was previously radiologicallyand anatomically normal. These patients hadhiatus hernia (3), gastric ulcer (2), and nodemonstrable gastric disease (1). The patientswere all asymptomatic at the time of study afterpyloroplasty.The radiological findings after pyloroplasty

in these patients again confirmed the expectationsfrom the theoretical model (Figures 3a and b).

The Effect of Pyloroplasty on AbnormalAnatomy

When the normal anatomy of the pyloroduodenalarea is distorted by fibrosis, ulceration, andoedema the radiological anatomy after pyloro-plasty will differ from that after pyloroplastyon the normal pylorus.

CLINICAL STUDYEighteen patients were studied after vagotomyand Heineke-Mikulicz pyloroplasty for demon-strable duodenal ulceration or deformity due tochronic ulcer disease. At the time of study afterpyloroplasty all patients were free of symptomsand all have since remained cured of ulcerdyspepsia.

In these patients, in whom there was originallyan ulcer crater but very little deformity, thepostoperative radiological pattern appeared simi-lar to that seen in those patients with pyloro-plasty on the normal pylorus described above.However, when there had been gross duodenal

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D. K. M. Toye, J. F. K. Hutton, and J. Alexander Williams

FIGC. 3a. FIG. 3b.

Fig. 3 Normal pyloroplasty appearances.(a) Note the antral sling and the ridge across thepyloroplasty pouches. The stomach is emptyingrapidly into the small bowel and the antrum appearsbowed upwards.(b) Pouches are present above and below the channeland the duodenum sling is well demonstrated.

deformity or oedema, variations from thispattern were observed.

OutlineSome pouching was always seen at the pyloro-plasty. However, the inferior or superior pouchwas sometimes absent, depending on whetherthe pyloroplasty incision had passed along thelower or upper border of the first part of theduodenum. When the posterior wall of theduodenum was fixed as a result of scarring, themobile stomach was pulled distally over theduodenum and the pouch was sometimes seendistal to the pyloric bar.

Mucosal patternThe clear demonstration of the mucosal patternin the pyloroduodenal area is of particularimportance in patients after pyloroplasty butis not always easy to achieve. In 24 asympto-matic patients studied after pyloroplasty a

satisfactory mucosal pattern was achieved in 19(79 %) at the first attempt. This percentage couldbe improved by repeating the more difficultexaminations.The new lines of traction created by the pyloro-

plasty produce a straightening in the mucosalfolds. It would be expected that the folds onthe posterior wall would run in the transverseaxis of the bowel and those on the anteriorwall would be drawn along the long axis ofthe bowel. Superimposition of anterior andposterior folds occasionally gives a criss-crossappearance in the mucosal pattern. This mightsuggest the radiation of folds from the chroniculcer and lead to an erroneous diagnosis ofrecurrent ulceration (Figure 4).

Disappearance of the ulcer craterIt is accepted radiological teaching that it isimpossible to evaluate radiologically the healingof a duodenal ulcer. However, after pyloroplastyand when a posterior ulcer was previouslydemonstrated it may be possible to show that themucosa of the posterior wall is now intact andso infer healing of the ulcer (Figure 5).

In our series of 18 patients with duodenalulcer studied after pyloroplasty there were 10 inwhom an active posterior wall ulcer had been de-monstrated before operation and in eight ofthese it was now possible to demonstrate thepresence of a normal mucosal pattern on the

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Fig. 4 Mucosal reliefof the channel. The foldsapparently converge and the resultant density mayat first sight be mistaken for an ulcer crater. Thisappearance is due to superimposition of anterior andposterior folds. (Note also markers at either end ofridge.)

posterior wall. In a further five patients whohad preoperative duodenal scarring but noulcer crater, the postoperative radiographsshowed a normal mucosal pattern in the pyloro-plasty channel. The postoperative barium studiesdid not give sufficiently clear definition to permitevaluation in three.

Free drainage and the absence of retentionThe 'sphincteric' effect of the pyloric muscleis abolished by pyloroplasty and if the pyloro-plasty is successful there should be no restinggastric juice in a stomach of normal size. Inall our patients the postoperative examin-ation showed that there was no appreciableresidue, a normal sized stomach, and a rapidpassage of barium into the duodenum (Fig. 3).

Discussion

Others who have studied the radiological appear-ances of the pyloro-duodenal area after pyloro-plasty have described the characteristic pouchdeformity (Burhenne, 1964; Riach, 1968). It hasbeen pointed out that cine-radiographic studiesdemonstrate that these pouches exhibit muscularmovement and can therefore be differentiatedfrom recurrent ulcer craters. (Bloch and Wolf,1965; Gleeson and Ellis, 1968). All these authorshave stressed the difficulties in diagnosing recur-rent ulceration.

Fig. 5 Disappearance of ulcer crater.(Above) Crater in duodenal cap before operation.(Below) One ofa series ofmucosal pattern films of thepyloroplasty channel showing that the crater hasdisappeared.

We believe that, with a knowledge of theexpected postoperative anatomical features andgood pictures of the mucosal pattern in thepyloro-duodenal channel, it is possible torecognize the normal and against this back-ground to evaluate the abnormal. In a subse-quent paper we will demonstrate the abnormaland assess the value of radiology in evaluatingpostoperative dypsepsia.

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References

Bloch, C., and Wolf, B. S. (1965). Gastroduodenal channel afterpyloroplasty and vagotomy: cineradiographic study. Radi-ology, 84, 43-51

Burhenne, H. J. (1964). Roentgen anatomy and terminology ofgastric surgery. Amer. J. Roentgenol., 91, 731-743

Gleeson, J., and Ellis, H. (1968). Cineradiographic studies aftervagotomy and pyloroplasty. Brit. J. Surg., 55, 385-386

Riach, I. C. F. (1968). Personal communication.

The March 1970 IssueTHE MARCH 1970 ISSUE CONTAINS THE FOLLOWING PAPERS

1960-1970: Three Editors THOMAS HUNTTwo cases of 'pancreatic cholera' with featuresof peptide-secreting adenomatosis of the pancreasW. SIRCUS, P. W. BRUNT, R. J. WALKER, W. P.SMALL, C. W. A. FALCONER, AND CHRISTINE G.THOMSON

Bio-assay evidence of abnormal secretin-likeand gastrin-like activity in tumour and blood incases of 'choleraic diarrhoea' I. G. M. CLEATOR,CHRISTINE G. THOMSON, W. SIRCUS, AND MIRANDACOOMBES

Malabsorption and subtotal villous atrophysecondary to pulmonary and intestinal tubercu-losis W. P. FUNG, K. K. TAN, S. F. YU, AND K. M.KHO

Cell loss from small intestinal mucosa: a morpho-logical study I. J. PINK, D. N. CROFT, AND B.CREAMER

IgM turnover in Crohn's disease K. BIRGERJENSEN, NIELS GOLTERMANN, STIG JARNUM, BENTWEEKE, AND HENRIK WESTERGAARD

The diagnostic value of mucosubstances in rectalbiopsies from patients with ulcerative colitis andCrohn's disease M. I. FILIPE AND IAN DAWSON

The results of ileorectal anastomosis at St Mark'sHospital from 1933-1968 W. N. W. BAKER

Sodium dependency of L-alanine absorption incanine Thiry-Vella loops BERTRAM FLESHLERAND RALPH A. NELSON

Portal hypertension caused by partial nodulartransformation of the liver M. CLASSEN, K.ELSTER, H. J. PESCH, AND L. DEMLING

Intestinal absorption of carnosine and itsconstituent amino acids in man A. M. ASATOOR,J. K. BANDOH, A. F. LANT, M. D. MILNE, ANDF. NAVAB

A study of total serum alkaline phosphataseactivity in men following partial gastrectomyJ. AMBLER, A. G. GREEN, AND C. N. PULVERTAFT

Psychiatric disorders after surgery for duodenalulcer M. C. MASON AND C. G. CLARK

Experiences with data processing to separatethe images in pancreatic scanning D. CHARLES-WORTH, H. J. TESTA, B. R. PULLAN, AND H. BRUCETORRANCE

Modification of polyethylene glycol estimationsuitable for use with small mammals J. M.BOULTER AND H. B. MCMICHAEL

Progress Report: Disorders of the myentericplexus BARBARA SMITH

Progress Report: Liver biopsy in the diagnosisof cirrhosis P. J. SCHEUER

Notes and Activities

Copies are still available and may be obtained from the PUBLISHING MANAGER,BRITISH MEDICAL ASSOCIATION, TAVISTOCK SQUARE, w.c. I. price 17s. 6D.

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