Pyloroplasty
4380043640wRVU: 19.07 — Truncal or selective vagotomy with pyloroplasty43641wRVU: 19.31 — Highly selective (parietal cell) vagotomy with or without gastric drainage
[Gastroparesis / pyloric stenosis / peptic ulcer disease with gastric outlet obstruction / planned pyloroplasty for gastric drainage after vagotomy or esophagectomy]
Same
[Heineke-Mikulicz / Finney] pyloroplasty [with truncal vagotomy]
[Attending name], MD/DO
[Resident/PA name]
General endotracheal. Nasogastric tube placed.
The patient is a [age]-year-old [male/female] with [gastroparesis refractory to medical management / peptic ulcer disease with pyloric scarring and gastric outlet obstruction / undergoing truncal vagotomy requiring drainage procedure / undergoing esophagectomy requiring gastric conduit drainage]. The risks, benefits, and alternatives were discussed and informed consent was obtained.
The pylorus was [thickened and scarred / normal caliber / with active ulcer disease at the pyloric channel]. The duodenum was [mobile / adherent from prior ulcer disease / scarred]. [The stomach was [distended / decompressed via nasogastric tube preoperatively].]
The patient was positioned supine. General anesthesia was induced and a nasogastric tube was placed. A surgical timeout was performed. The abdomen was prepped and draped.
[The abdomen was entered via [midline laparotomy / right upper quadrant incision / existing incision for concurrent procedure].] The pylorus was identified and exposed. The gastroduodenal junction was assessed.
[HEINEKE-MIKULICZ PYLOROPLASTY (standard):]
A full-thickness longitudinal incision was made through the pyloric sphincter, extending [1–2 cm] onto the gastric antrum proximally and [1–2 cm] onto the first portion of the duodenum distally, centered on the pylorus. Any adhesions or scarring within the pyloric channel were divided under direct vision. The incision was then closed transversely in a single [or two] layer(s) with [interrupted 2-0 or 3-0 absorbable / Lembert sutures], converting the longitudinal opening to a transverse closure and widening the pyloric outlet. Mucosal apposition was confirmed.
[FINNEY PYLOROPLASTY (for scarred or duodenal ulcer disease):]
Given [significant pyloric scarring / penetrating duodenal ulcer / inability to achieve adequate transverse closure], a Finney pyloroplasty was performed. A U-shaped incision was made extending from the gastric antrum along the pylorus and onto the first and second portion of the duodenum, creating a wide side-to-side gastroduodenostomy. The posterior wall was approximated with [interrupted 3-0 silk Lembert sutures]. The anterior closure was completed in two layers.
[TRUNCAL VAGOTOMY (if performed):]
The esophagus was encircled at the hiatus. The anterior vagal trunk was identified along the anterior esophageal wall and a [2 cm] segment was excised and sent for pathology to confirm neural tissue. The posterior vagal trunk was identified in the posterior esophageal fat and similarly excised.
The nasogastric tube was confirmed to pass through the pyloroplasty site without obstruction. Hemostasis was confirmed. The abdomen was irrigated and closed in layers.
None
[Vagus nerve segments sent to pathology to confirm neural tissue / None]
Minimal
None / [Nasogastric tube to gravity drainage]
The patient was taken to the PACU in stable condition. NPO with nasogastric decompression initially; diet was advanced per clinical status.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: [Heineke-Mikulicz/Finney] pyloroplasty [+ truncal vagotomy]
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General; NGT placed
INDICATIONS: .PTAGE-year-old .PTSEX with *** presenting for pyloroplasty for [gastroparesis/pyloric stenosis/gastric drainage after ***]. Consent obtained.
FINDINGS: Pylorus ***. Duodenum ***.
PROCEDURE:
Supine. General anesthesia. NGT placed. Surgical timeout. [Midline laparotomy / existing incision.] Pylorus identified. [HEINEKE-MIKULICZ: Longitudinal full-thickness incision through pylorus, *** cm onto antrum and *** cm onto duodenum. Closed transversely in [1/2] layer(s) with *** sutures. Mucosal apposition confirmed.] [FINNEY: U-shaped incision antrum to D2. Posterior wall approximated Lembert sutures; anterior wall two layers.] [VAGOTOMY: Anterior vagal trunk excised *** cm, sent to path. Posterior vagal trunk excised.] NGT passes without obstruction. Hemostasis confirmed. Closed.
EBL: Minimal
SPECIMENS: [Vagus nerve segments to pathology / None]
COMPLICATIONS: None
DRAINS: NGT to gravity
DISPOSITION: PACU stable. NPO/NGT initially.
Signed: .ME, .MYDEGREE
.TODAYVariants
Laparoscopic Pyloroplasty
A laparoscopic approach was utilized. Four trocars were placed in the upper abdomen. The pylorus was identified and exposed laparoscopically. A longitudinal incision was made through the pylorus with hook cautery or ultrasonic shears. The closure was performed laparoscopically with interrupted [2-0 Vicryl / 3-0 Vicryl] sutures in a transverse orientation (Heineke-Mikulicz), using intracorporeal suturing technique. Mucosal closure was confirmed. The same CPT code (43800) applies for laparoscopic pyloroplasty.
Pyloroplasty as Gastric Conduit Drainage (After Esophagectomy)
Pyloroplasty was performed as a gastric drainage procedure to prevent delayed gastric emptying after esophagectomy. The pylorus was identified along the gastric conduit. A Heineke-Mikulicz pyloroplasty was performed as described. Adequate patency was confirmed by passage of the nasogastric tube and by direct digital assessment. Pyloroplasty in this context reduces the rate of delayed gastric emptying, a common complication after esophagectomy with gastric conduit reconstruction.
Charting Tips
- Document the specific technique (Heineke-Mikulicz vs Finney). The operative report must identify which drainage procedure was performed. Heineke-Mikulicz is the standard for most cases; Finney is reserved for significant pyloric scarring or penetrating duodenal ulcer where transverse closure is not feasible.
- For vagotomy with pyloroplasty (43640), send vagal trunk specimens to pathology for nerve confirmation. Document that both anterior and posterior vagal trunks were identified, a segment was excised, and the specimens were sent to confirm neural tissue. Missing the posterior trunk is the most common cause of incomplete vagotomy.
- Document pyloric patency after closure. Note that the NGT passes through the pyloroplasty site without resistance, or describe digital assessment of lumen caliber. This is important for cases where gastroparesis or delayed gastric emptying is the indication — it documents that the drainage procedure was technically adequate.
Billing Tips
- Pyloroplasty alone: 43800 (15.04 wRVU, 90-day global). Use when pyloroplasty is performed as a standalone drainage procedure — for gastroparesis, pyloric stenosis, or gastric outlet obstruction without vagotomy.
- Truncal or selective vagotomy with pyloroplasty: 43640 (19.07 wRVU, 90-day global). This is a single bundled code covering both components. Do not bill 43800 separately when vagotomy is performed. Document which type of vagotomy was performed (truncal vs selective).
- Highly selective (parietal cell) vagotomy: 43641 (19.31 wRVU, 90-day global). Parietal cell vagotomy selectively denervates the acid-secreting fundus and body while preserving antral innervation — theoretically no drainage procedure required. However, some surgeons add a drainage procedure; if performed, use 43641. Rarely performed today given PPI therapy and H. pylori eradication.
- Pyloroplasty as a gastric drainage procedure after esophagectomy: bill 43800 when pyloroplasty is performed in conjunction with esophagectomy, unless the payer bundles it. A 2025 RCT (ACS) demonstrated that routine pyloroplasty during esophagectomy significantly reduces early major complications (17.6% vs 27.1%) and improves gastric emptying — making it the current standard of care for gastric conduit drainage after esophagectomy. Some institutions report it as included in the esophagectomy CPT — verify payer policy.
- Laparoscopic pyloroplasty: use 43800 with documentation of laparoscopic technique. There is no separate laparoscopic pyloroplasty CPT; the same code is used for both open and laparoscopic approaches.
- Botulinum toxin injection to the pylorus (43210 or unlisted) is an alternative to surgical pyloroplasty for gastroparesis. It is not the same procedure and uses a different code. Document which intervention was performed.