Pyloric Exclusion in Modern Acute Care Surgery: A Selective Salvage Strategy for Complex Duodenal Pathology

Background Pyloric exclusion (PEX) was initially described for duodenal fistula and complex ulcer disease. It was adopted in trauma surgery as an adjunct to primary repair of complicated duodenal injuries. However, its use in the non-trauma population has remained uninvestigated in recent years. Its current role as a highly selective operation for complex duodenal pathology remains ambiguous in the acute care surgery population. The aim of this study was to assess indications and outcomes of PEX in the acute care surgery population. Methods Patients that underwent pyloric exclusion in the NSQIP database between 2005 and 2021 were identified. Risk factors and outcomes were also extracted. Univariate logistic regression (LR) analysis was used to compare outcomes by surgical indication. Multivariate LR analysis adjusting for timing of operation (emergent vs non-emergent), age, and medical comorbidity was also used to compare outcomes. Results 117 patients were identified during the study period. The most common indication for PEX was ulcer (n = 32, 50.8%) and neoplastic disease (n = 24, 22.4%). Pyloric exclusion was performed emergently 84.4% of the time for ulcers and 8.3% of the time for neoplastic disease. On univariate analysis, complications were more common for ulcer vs neoplastic disease [71.9% vs 33.3%, OR = 5.11 (95% CI: 1.6-16.1), P < 0.01] and for emergent vs non-emergent surgery [69.4% vs 45.9%, OR = 2.67 (95% CI: 5.9-1.2), P < 0.01]; however, this was not re-demonstrated on multivariate analysis. Conclusion Pyloric exclusion is rarely performed in acute care surgery. It is most often performed for ulcer and neoplastic pathology, with outcomes dependent on clinical urgency.