Pyloric Revision

What is Pylorus?

Pyloric Revision : Pylorus is the name of the anatomical site consisting of a muscle bundle at the gastric outlet, which controls the emptying of the stomach and thus acts as a “VALVE” that provides a one-way flow from the stomach to the intestine.

In what terms is the Pylorus important?

Our stomach serves as a pre-storage and (mechanical, chemical and enzymatic) digestion site for food. With a pH of 1.5-2, the stomach pH is acidic. Due to the acid pH, the stored food is also purified from the microbes it contains.

While eating, the PYLORUS remains closed, which allows the stomach to perform its functions. The average residence time of food in the stomach is 2-4 hours. The stomach contents that are mechanically, enzymatically and chemically digested during this period are called CHYMUS. Once the CHYMUS is formed, a stimulus is sent from the stomach to the brain and 50-75 cc of chymus is transferred to the duodenum every 3-5 minutes through the emptying contraction movements of the stomach and simultaneous opening of the PYLORUS. This allows the intestines to function without any strain due to the slow passage of stomach contents into the duodenum. However, this controlled gastric emptying is only possible with a functional pylorus. In case the pylorus fails to close and open, i.e. to perform the VALVE function, the STOMACH becomes completely or partially unable to perform the functions of storing, disinfecting its contents, transferring the contents to the duodenum in a controlled manner, digesting (mechanical-chemical-enzymatic) and preventing the contents of the duodenum from escaping back into the STOMACH.

Satiety is achieved through two mechanisms. The first is a rise in blood sugar, but this produces a weak satiety. The second, on the other hand, is the pressure exerted by the food on the stomach wall, which requires the pylorus to be closed and the stomach to be full. The feeling of satiety caused by the pressure exerted by the stomach contents on the stomach wall creates a potent satiety.

Complete or partial dysfunction of the pylorus can lead to the followings:

• As there will be a constant leak from the stomach, a potent satiety may never be achieved, and the pressure-induced satiety is short-lived due to leakage.
• The vast majority of carbohydrates (sugar, flour, fruit, etc.) are absorbed in the first 90-100 cm of our small intestine, which is about 8 meters long. Uncontrolled gastric emptying causes sudden and excessive spikes in blood sugar, pushing the limits of our insulin capacity. And this leads to a feeling of tiredness and sleepiness after meals. The blood sugar, which spikes, drops just as quickly when confronted with the insulin response. And this manifests itself as hunger 2 hours after meals.
• The duodenal contents can flow back through this opening into the stomach. And this leads to “Alkaline Reflux Gastritis”. Duodenal contents have a basic pH. In the duodenum, the bile duct opens 8-10 cm after the gastric outlet. Therefore, it is the bile content of a basic nature that flows back into the stomach. The bile content that leaks into the stomach causes a burn in the stomach.
• As foods cannot reside in the stomach long enough, they cannot be purified from microbial content, resulting in more frequent intestinal infections.
• As the stomach becomes unable to digest (mechanically-chemically-enzymatically) food adequately, some foods are malabsorbed, leading to intestinal discomfort.

How can you find out if the Pylorus is normal?

Under normal conditions, endoscopic examination does not show any bile content in the stomach. However, the presence of bile content in the stomach suggests an impaired PYLORIC function. If the endoscopic examination shows that the pylorus is completely closed and there is no bile content in the stomach, or if the pylorus closes completely when mild mechanical stimulation is applied around the pylorus with the tip of the endoscopy device, this pyloric structure is called NORMOTONIC PYLORUS (pylorus functioning normally).

However, if endoscopic examination shows that there is bile content in the stomach or if the pylorus closes only partially upon mild mechanical stimulation around the pylorus with the tip of the endoscopy device, it is called HYPOTONIC PYLORUS (a pylorus with poor function), and if it does not close at all despite mechanical stimulation, it is called ATONIC PYLORUS (a non-functioning pylorus).

Studies have shown that the prevalence of atonic and hypotonic pylorus in people with a BMI of 20-25 kg/m2 is 5-10%, while this figure rises to 60-65% in people with a BMI over 40 kg/m2.

In the presence of which findings is Pyloric Dysfunction suspected?

• Severe feeling of tiredness and sleepiness after meals
• Immediate hunger 1.5-2 hours after eating
• Not getting full despite eating much
• A feeling of sour stomach after 3-4 hours of not eating anything
• Excessive abdominal bloating after a meals
• Dyspepsia
• Frequent intestinal infections
• Excessive intestinal gas

What is Pyloric Revision?

This method was first introduced in the medical literature by Assoc. Prof. Dr. Murat KANLIÖZ. The physiopathological processes of the PYLORUS in relation to obesity, blood sugar regulation and “Alkaline Reflux Gastritis” have also been introduced to the literature by Assoc. Prof. Dr. Murat KANLIÖZ (1).

Pyloric revision is a surgical procedure performed to close the opening by endoscopically injecting filler into the dysfunctional ATONIC or HYPOTONIC pylorus, to improve the functionality of the pylorus and thus to reduce uncontrolled escape from the stomach and to prevent the backflow of bilious intestinal contents into the stomach.

Does Pyloric Revision require any preliminary preparation?

Yes, it is. If the patient who will undergo the procedure is taking any blood thinners (aspirin, coraspin, coumadin, etc.), he/she should stop taking them 5 days before the procedure. It is important that there are no food residues in the stomach in order to obtain a sufficiently clean image during the procedure, so oral intake of any liquid-solid food and medication should be avoided 12 hours before the procedure.

How is Pyloric Revision performed?

Following the necessary preliminary preparations of the patient, a vascular access is established following fasting for 12 hours, then the patient is slightly anesthetized under the supervision of an anesthesiologist in the standard endoscopy ward in the hospital, and while the patient is asleep with normal breathing and without feeling anything, the endoscopy device is inserted through the mouth to reach the stomach, and the procedure is performed. Patients who are endoscopically found to have an ATONIC or HYPOTHONIC pylorus undergo pyloric revision with filler injections around the pylorus during the same session, thus making the pylorus functional.

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