The Pyloric Sphincteric Cylinder in Health and Disease

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Chapter 32 (page 157)

Few cases of contracted pyloric sphincteric cylinder could be controlled surgically, as almost all our cases of hiatus hernia which came to operation had a transthoracic approach for the repair of the hernia. The following cases were done via an abdominal route:

Case Reports

Case 32.2. A.G.C., female aged 64 years. Ten years previously a hiatus hernia had been diagnosed radiographically. At the present examination a large, sliding hiatus hernia with free gastro-oesophageal reflux was demonstrated in the Trendelenburg position (Fig. 32.2A). A constant contraction of the sphincteric cylinder, 5.0 cm in length, was seen (Fig. 32.2B). Its walls were smooth and regular, without evidence of local mucosal destruction, a niche, filling defect or other organic lesion. Emptying of fluid barium suspension was not delayed. At operation there was a hard, tumour-like contraction in the pyloric part of the stomach, extending proximally from the pyloric ring for a distance of 5.0 cm. The contraction was of such severity that the mass appeared avascular and greyish and at first simulated a carcinoma. However, gentle massaging caused it to relax, followed immediately by recurring contraction. A pylorosplasty was done at which the muscularis externa was seen to be three times the normal thickness. The mucosa bulged through the incision and the surgeon had no doubt that it was a case of adult hypertrophic pyloric stenosis (AHPS). There was no other local lesion. The hernia was repaired and a truncal vagotomy performed. Repeat radiological examination 7 months later showed a post-pyloroplasty appearance.

Fig. 32.2 A,B. Case A.G.C. Large, sliding hiatus hernia (black arrows). Contracted pyloric sphincteric cylinder (white arrows)

It seems that, while the radiological abnormality may be unequivocal, the operative findings, as far as the pyloric part is concerned, may be of an uncertain nature, as in the following case:

Case 32.3. F.V., male aged 75 years, was admitted for mild obstructive jaundice of 10 days' duration. There had been colicky epigastric pain for the previous 5 months, as well as acidity and heartburn for years. Oral and intravenous cholecystography revealed poor concentration of the opaque medium with calculi in the gallbladder and a dilated common bile duct containing stones. (At the time sonography of the gall bladder had not been perfected). The radiological examination showed a large, irreducible hiatus hernia (Fig. 32.3). A contraction of the pyloric sphincteric cylinder, 4.5 cm in length, with a tendency toward formation of a pseudodiverticulum on its greater curvature side, was constantly present; there was no evidence of any other lesion locally or in the remainder of the stomach. The diagnosis of contracted pyloric sphincteric cylinder, resembling AHPS, in association with hiatus hernia was made. At operation a cholecystectomy was done and calculi were removed from the common bile duct. The surgeon stated that the pyloric area of the exposed stomach felt a little thicker than usual. Had his attention not been drawn to it beforehand, it is doubtful if he would have commented on it in his operative notes. No other gastric lesion was detected. Because of the patient's age, it was decided not to repair the hernia at that time. Repeat radiographic examination 5 months later showed the irreducible hiatus hernia and the contracted pyloric sphincteric cylinder to be unchanged.

Fig. 32.3. Case F.V. Large irreducible hiatus hernia (black arrow). Contracted pyloric sphincteric cylinder

In this case two points are worth noting:

  1. According to Burge (l964) pyloric and prepyloric muscle hypertrophy are only appreciated with inspection and palpation during operation in advanced cases.

  2. With modern day anaesthesia and the use of voluntary and involuntary muscle relaxants, most spastic gastric conditions are not visible at operation. In the present case pentothal, curare, nitrous oxide, oxygen and fluothane were used (followed by atropine and prostigmine.) The fluothane is regarded as a potent smooth muscle relaxant, and most anaesthetists are agreed that spastic conditions of the stomach, clearly visible at radiographic examinations in ambulant patients, will be difficult to recognize at operation when this and similar agents are used. It is conceivable that this was the state of affairs in the present case.

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