Infantile hypertrophic pyloric stenosis: long-term audit from a general surgical unit

Is there any benefit with pantoprazole treatment in infantile hypertrophic pyloric stenosis?

CONTEXT

Previous studies demonstrated faster correction of metabolic derangement associated with hypertrophic pyloric stenosis with pre-operative intravenous (IV) histamine-2 receptor antagonists.

AIMS

We investigated if similar outcomes are achieved with IV pantoprazole, a proton-pump inhibitor (PPI), including the subgroup of delayed presenters in the South African setting.

SETTINGS AND DESIGN

A 5-year retrospective record review (January 2014-December 2018) compared the rate of metabolic correction in patients with hypertrophic pyloric stenosis at two tertiary centres.

SUBJECTS AND METHODS

One centre routinely administers IV pantoprazole (1 mg/kg daily) preoperatively (PPI group) and the other does not (non-PPI group). Fluid administration, chloride supplementation and post-operative emesis were evaluated.

STATISTICAL ANALYSIS

Spearman's rank correlation coefficient was used to calculate statistical significance for discrete dependent variables. Continuous variables were compared between the groups using the Student t-test. Fisher's exact contingency tables were used to classify categorical data and to assess the significance of outcome between two treatment options. P < 0.05 was considered statistically significant.

RESULTS

Forty-two patients received IV pantoprazole and 24 did not. The mean time of metabolic correction was 8 h shorter in the PPI group (P = 0.067). Total pre-operative chloride administration correlated to the rate of metabolic correction in both cohorts (P < 0.0001). Profound hypochloraemia (chloride <85 mmol/l) was corrected 23 h faster in the PPI group (P < 0.004). Post-operative emesis was noted: 0.45 episodes/patient in the PPI group and 0.75 episodes/patient in the non-PPI group (P = 0.01).

CONCLUSIONS

Pre-operative IV pantoprazole administration showed a faster correction of metabolic derangements, and in profound hypochloraemia, the correction occurred substantially faster in the PPI group. Post-operative emesis was significantly less frequent in the PPI group.

Treating idiopathic hypertrophic pyloric stenosis with sequential therapy: A clinical study

AIM

The aim of this study was to explore the efficacy and safety of treating idiopathic hypertrophic pyloric stenosis with sequential therapy (ST).

METHODS

From January 2010 to June 2013, 49 children with idiopathic hypertrophic pyloric stenosis were divided into two groups to accept either atropine ST (ST group, n = 26) or laparoscopic surgery (operation group, n = 23). The remission rate of vomiting, complications, hospital stay and medical expenditure were compared between the two groups. The body weight and the thickness of the pyloric muscle at 6 months after the treatments were also compared.

RESULTS

The remission rate of vomiting was lower in the ST group (88.5%; 23/26) than in the operation group (100%, 23/23). The difference in the incidence rate of complications, body weight and pyloric muscle thickness was not statistically significant between the two groups. However, the hospital stay was significantly longer, while the medical expenditure was significantly lower in the ST group than in the operation group.

CONCLUSIONS

Atropine ST is safe, effective and cost-effective as compared with operation; however, the efficacy of ST is lower than operation.

Pyloric stenosis--postoperative care on a nonsurgical ward

BACKGROUND

Recent progress has been made in the care of infants with hypertrophic pyloric stenosis (HPS), including earlier operative intervention and shorter hospital length of stay (LOS), which is attributable to expedited postoperative feeding protocols developed and implemented by surgeons. We hypothesized that patients with HPS admitted to a unit that is co-managed by nonsurgeon providers postoperatively have a longer LOS than those on the surgical ward.

MATERIALS AND METHODS

We reviewed the medical records of infants who underwent pyloromyotomy for HPS at a single institution from April, 2009-July, 2013.

RESULTS

A total of 259 patients underwent pyloromyotomy (35 female; 13.5%), 205 (79%) were admitted to the surgical ward; 46 had a planned neonatal intensive care unit (NICU) admission (18%) and were co-managed with the neonatology team. Eight (3%) had an unplanned NICU admission and were excluded from the analysis. The groups did not differ in terms of sex, age, serum electrolytes at presentation, or time between surgeon evaluation and operative intervention. Surgical ward patients had longer preoperative symptom duration. Operative time was longer in the NICU patients. Comparing the two groups, there was no difference in postoperative apnea, hypoxic, or bradycardic episodes. NICU patients achieved ad libitum feeds later than floor patients (2.0 versus 1.4 d; P = 0001) and had a longer postoperative LOS (2.2 versus 1.6 d; P = 0.0012).

CONCLUSIONS

Patients with HPS admitted to the NICU postoperatively had a longer time to full feeds and hospital LOS. The reduction in LOS between hospital wards may be improved with implementation of a hospital-wide postoperative protocol for patients with HPS.

Current trends in the diagnosis and treatment of pyloric stenosis

AIM

We hypothesized that recent trends towards earlier diagnosis of hypertrophic pyloric stenosis continued throughout the early part of the 21st century.

METHODS

We reviewed the medical records of patients with HPS at a single institution during two periods: 1/03-12/05 and 4/09-7/13.

RESULTS

A total of 433 patients with hypertrophic pyloric stenosis who underwent pyloromyotomy were included (modern cohort = 259; historic = 174). The two cohorts did not differ in terms of age, weight, or median time from symptom onset to physician (5 vs 6.5 days; p = 0.3) or surgeon (7 days for both) evaluation. The percentage of patients who presented late (>7 days of symptoms) (27 % modern vs 25 % historic; p = 0.15) or with an elevated serum bicarbonate (22 % for both; p = 0.8) did not change over time. There was a shift to laparoscopic procedures: 99 % modern vs 57 % historic (p < 0.0001) with no associated change in operative length (28 vs. 27 min; p = 0.06), or operative (3 % for both, p = 0.8) or respiratory (4 vs 2 %, p = 0.4) complications.

CONCLUSION

Most infants with hypertrophic pyloric stenosis are diagnosed early, prior to significant electrolyte abnormalities; however, continued improvement in awareness is necessary given that a fourth of patients are diagnosed after over 1 week of symptoms.

Rapid correction of metabolic alkalosis in hypertrophic pyloric stenosis with intravenous cimetidine: preliminary results

PURPOSE

Pyloromyotomy has been the treatment of choice for hypertrophic pyloric stenosis (HPS) for the past century. In most HPS cases, there is mild metabolic alkalosis, which requires intravenous fluid resuscitation with 5% dextrose/normal saline for 1-2 days. However, in some cases, due to a delay in diagnosis, alkalosis becomes severe and a much longer resuscitation period (5-10 days) is required to normalize serum pH. Metabolic alkalosis of HPS results from excessive vomiting of hydrochloric acid; and therefore if its production is reduced, serum pH can be normalized faster. In this study, the use of intravenous cimetidine (CM) in a small number of infants with HPS is presented.

METHODS

Over a 28-month period, 32 HPS cases, including a sub-group of 17 infants (aged 7-9 weeks) with arterial pH >7.60, were admitted to a tertiary referral unit. Four infants in this sub-group were treated with standard resuscitation fluids for 4 days prior to intravenous CM, while 12 infants received CM immediately. Intravenous CM (10 mg/kg) was given at twice daily until arterial pH was less than 7.50. In one case, intravenous omeprazole at 0.1 mg/kg was given instead of CM.

RESULTS

In all 17 cases, CM treatment or omeprazole therapy (for 12-48 h) reduced pH to less than 7.50, thus allowing for Ramstedt pyloromyotomy the same day. These patients were allowed oral feeding on the following day and were discharged at 1-3 post-operative days. No complications due to CM (or omperazole) treatment were observed.

CONCLUSION

Intravenous CM administration can rapidly normalize severe metabolic alkalosis in HPS patients. As a result, pyloromyotomy can be performed sooner reducing both hospital stay and costs.

Determinants of good outcome in pyloric stenosis

Good outcome following pyloromyotomy for pyloric stenosis is dependent on the training of the surgeon, availability of a specialist paediatric anaesthetist, and the quality of preoperative correction of fluid and electrolyte abnormalities. Complications (including death, inadvertent duodenal perforation, incomplete pyloromyotomy, wound dehiscence and infection), higher hospital costs and increased length of hospital stay are all more likely to occur when the pyloromyotomy is performed by a surgeon who has had no speciailist paediatric surgical training.

Medical treatment of infantile hypertrophic pyloric stenosis: should we always slice the "olive"?

BACKGROUND/PURPOSE

Laparoscopic pyloromyotomy has recently gained wide acceptance as the optimum treatment of infantile hypertrophic pyloric stenosis (IHPS). However, medical treatment may be superior to laparoscopic surgery in invasiveness. The efficacy of our regimen of intravenous atropine therapy for IHPS was assessed in comparison with surgical treatment.

METHODS

Medical treatment was initially chosen for 52 (61%) of 85 infants with IHPS at our institute between 1996 and 2004. Atropine was given intravenously at 0.01 mg/kg 6 times a day before feeding. When vomiting ceased and the infants were able to ingest 150 mL/kg per day of formula after stepwise increases in the feeding volume, they were given 0.02 mg/kg atropine 6 times a day orally, and the dose was decreased stepwise.

RESULTS

Of the 52 patients, 45 (87%) ceased projectile vomiting with treatment using intravenous (median, 7 days) and subsequent oral (median, 44 days) atropine administration. The median hospital stay was 13 days (6-36), and no significant complications were encountered during atropine therapy. The remaining 7 patients required surgery. Of 40 who underwent surgery, 4 had wound infections and 1 with hemophilia had postoperative hemorrhagic shock. The patients who underwent successful atropine therapy had body weights comparable with those who underwent surgery at the age of 1 year.

CONCLUSIONS

The high success rate of intravenous atropine therapy for IHPS suggests that this therapy is an effective alternative to pyloromyotomy if the length of the hospital stay and the necessity of continuing oral atropine medication are accepted.

Changing trends in the management of infantile hypertrophic pyloric stenosis--an audit over 11 years

BACKGROUND

This article is a follow-up to an audit performed by the Department of Surgery and published in the Irish Journal of Medical Science in 1996. This audit reviewed all cases of Infantile Hypertrophic Pyloric Stenosis (IHPS) operated on over 22 years up to 1991.

AIMS

We aim to demonstrate that radiologic investigations, namely barium meal and ultrasound, have been increasingly employed in the diagnosis of IHPS. In addition, ultrasound is now the investigation of choice.

METHODS

We have reviewed all cases of IHPS, at the same institution, over the subsequent 11 years, with reference to any radiological investigations performed. In the previous study, the diagnosis of IHPS was made clinically in 92.6% with the remainder diagnosed radiologically.

RESULTS

Over 11 years, 157 patients were diagnosed with IHPS. Male to female ratio was 4.06:1. Median age was four weeks (range 1-18 weeks).Twenty-four per cent had a barium meal, 36% had an ultrasound and 13% had both performed.

CONCLUSION

We conclude a change in practice in the management of IHPS with radiology, particularly ultrasound, playing an increasing role.

Treatment of infantile hypertrophic pyloric stenosis in a district general hospital: a review of 160 cases

BACKGROUND

Ramstedt's pyloromyotomy has long been the standard operation for the treatment of infantile hypertrophic pyloric stenosis. Controversy exists over whether this procedure can be performed safely in the district general hospital setting or whether it should be restricted to specialist pediatric units only.

METHODS

Retrospective analysis was performed on the medical records of a series of 160 infants treated by Ramstedt's pyloromyotomy by 2 surgeons in a district general hospital over 16 years.

RESULTS

There was no perioperative mortality. Oral feeding was achieved by 24 hours in 76% of infants, and there was persistent vomiting in only 3.8%. Wound discharge was encountered in 4.4% and confirmed wound infection in 1.3%. Wound dehiscence occurred in 1.9% of infants. Inadvertent mucosal perforation occurred in 19% of cases, although all cases were recognized and repaired at once with no apparent ill effects. These results are comparable with those reported from specialist pediatric units and from pediatric surgeons working within general surgical units.

CONCLUSIONS

Infantile hypertrophic pyloric stenosis can be treated safely in a district general hospital when care is provided by appropriately trained surgical, anesthetic, and pediatric staff.

Infantile hypertrophic pyloric stenosis in a regional centre

BACKGROUND

It has been suggested that only specialist paediatric surgeons should manage infantile hypertrophic pyloric stenosis (IHPS).

AIM

The aim of this retrospective study was to ascertain whether the majority of these infants might be managed in a well-equipped regional centre.

METHODS

Using the Hospital Inpatient Enquiry database, all cases of IHPS within a single administrative health region were identified over a six-year period. A chart review was performed to obtain demographic and clinical information for each patient. Reports from the Central Statistics Office were used to obtain data on population and live births for the region.

RESULTS

Seventy patients with IHPS were identified from this region from 1991 to 1996, 63 (90%) of which were treated in the region. Of the remaining seven, four were referred directly to specialised paediatric surgical hospitals because of prematurity (n = 1), low birth weight (n = 1), capillary haemangioma (n = 1) and severe metabolic derangement (n = 1) while three were assessed and treated in general hospitals outside the region. Of the 63 infants undergoing pyloromyotomy in this region, the duodenal mucosa was breached in four (6%); there were wound complications in three (5%); and one required a re-pyloromyotomy. The mean postoperative stay was eight days (range 2-42 days).

CONCLUSION

The majority of infants with IHPS may be safely managed in regional centres with transfer to specialist paediatric centres reserved for 'high risk' cases. The management of IHPS at a regional level has important implications and presents opportunities for surgical training.