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Kiblawi R, Zoeller C, Zanini A, Kuebler JF, Dingemann C, Ure B, Schukfeh N. Laparoscopic versus Open Pediatric Surgery: Three Decades of Comparative Studies. Eur J Pediatr Surg 2022; 32:9-25. [PMID: 34933374 DOI: 10.1055/s-0041-1739418] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Despite its wide acceptance, the superiority of laparoscopic versus open pediatric surgery has remained controversial. There is still a call for well-founded evidence. We reviewed the literature on studies published in the last three decades and dealing with advantages and disadvantages of laparoscopy compared to open surgery. MATERIALS AND METHODS Studies comparing laparoscopic versus open abdominal procedures in children were searched in PubMed/MEDLINE. Reports on upper and lower gastrointestinal as hepatobiliary surgery and on surgery of pancreas and spleen were included. Advantages and disadvantages of laparoscopic surgery were analyzed for different types of procedures. Complications were categorized using the Clavien-Dindo classification. RESULTS A total of 239 studies dealing with 19 types of procedures and outcomes in 929,157 patients were analyzed. We identified 26 randomized controlled trials (10.8%) and 213 comparative studies (89.2%). The most frequently reported advantage of laparoscopy was shorter hospital stay in 60.4% of studies. Longer operative time was the most frequently reported disadvantage of laparoscopy in 52.7% of studies. Clavien-Dindo grade I to III complications (mild-moderate) were less frequently identified in laparoscopic compared to open procedures (80.3% of studies). Grade-IV complications (severe) were less frequently reported after laparoscopic versus open appendectomy for perforated appendicitis and more frequently after laparoscopic Kasai's portoenterostomy. We identified a decreased frequency of reporting on advantages after laparoscopy and increased reporting on disadvantages for all surgery types over the decades. CONCLUSION Laparoscopic compared with open pediatric surgery seems to be beneficial in most types of procedures. The number of randomized controlled trials (RCTs) remains limited. However, the number of reports on disadvantages increased during the past decades.
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Affiliation(s)
- Rim Kiblawi
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Christoph Zoeller
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany.,Department of Pediatric Surgery, University Hospital Munster, Munster, Nordrhein-Westfalen, Germany
| | - Andrea Zanini
- Department of Pediatric Surgery, Chris Hani Baragwanath Hospital, Johannesburg, South Africa
| | - Joachim F Kuebler
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Carmen Dingemann
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Benno Ure
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Nagoud Schukfeh
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
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2
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Grant HM, Banever GT, Moriarty KP, Pepper VK, Tashjian DB, Tirabassi MV. Return of the Banana Knife: An Alternative Instrument for Laparoscopic Pyloromyotomy. J Laparoendosc Adv Surg Tech A 2021; 31:1455-1459. [PMID: 34783264 DOI: 10.1089/lap.2021.0370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: When the disposable arthroscopic banana knife (Linvatec, Largo, FL) became unavailable, many pediatric surgeons adapted the use of spatula tip cautery for laparoscopic pyloromyotomy; however, reusable arthroscopic knives remain readily available and are well suited to the procedure. Methods: We compared laparoscopic pyloromyotomy with a reusable arthroscopic banana knife (Sklar, West Chester, PA; catalog no. 45-6050) to those using spatula tip cautery at a single institution between September 1, 2012, and December 31, 2019. Mann-Whitney U test was used to compare operative time, room time, and time to discharge between groups. Results: Overall, 109 patients underwent pyloromyotomy for hypertrophic pyloric stenosis during the study time period. Of these, 12 were open and one was undertaken with the Storz pyloromyotomy knife, so these were excluded. A total of 74 (77.1%) laparoscopic cases with spatula tip cautery and 22 (22.9%) with the banana knife were included. Mean age at the time of surgery was ∼37 days. The majority of patients in each group were white, male, and full term. The most common comorbid conditions were reactive airway disease and neonatal abstinence syndrome. There were no significant differences in operative time (P = .61), room time (P = .41), or time from surgery to discharge (P = .26) between procedures using the banana knife and those using the cautery spatula tip. There were no perforations or recurrences. Conclusion: Our findings suggest that the reusable banana knife is a safe and effective alternative to spatula tip cautery for laparoscopic pyloromyotomy, with no difference in operative time, time from surgery to discharge, or complications.
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Affiliation(s)
- Heather M Grant
- Department of Surgery, UMass Medical School-Baystate, Springfield, Massachusetts, USA.,Institute for Healthcare Delivery and Population Science, UMass Medical School-Baystate, Springfield, Massachusetts, USA.,Presented as a video abstract at the International Pediatric Endosurgery Group Annual Meeting 2021
| | - Gregory T Banever
- Department of Surgery, UMass Medical School-Baystate, Springfield, Massachusetts, USA.,Baystate Children's Hospital, Springfield, Massachusetts, USA.,Presented as a video abstract at the International Pediatric Endosurgery Group Annual Meeting 2021
| | - Kevin P Moriarty
- Department of Surgery, UMass Medical School-Baystate, Springfield, Massachusetts, USA.,Baystate Children's Hospital, Springfield, Massachusetts, USA.,Presented as a video abstract at the International Pediatric Endosurgery Group Annual Meeting 2021
| | - Victoria K Pepper
- Baystate Children's Hospital, Springfield, Massachusetts, USA.,Presented as a video abstract at the International Pediatric Endosurgery Group Annual Meeting 2021
| | - David B Tashjian
- Department of Surgery, UMass Medical School-Baystate, Springfield, Massachusetts, USA.,Baystate Children's Hospital, Springfield, Massachusetts, USA.,Presented as a video abstract at the International Pediatric Endosurgery Group Annual Meeting 2021
| | - Michael V Tirabassi
- Department of Surgery, UMass Medical School-Baystate, Springfield, Massachusetts, USA.,Baystate Children's Hospital, Springfield, Massachusetts, USA.,Presented as a video abstract at the International Pediatric Endosurgery Group Annual Meeting 2021
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3
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van den Bunder FAIM, van Heurn E, Derikx JPM. Comparison of laparoscopic and open pyloromyotomy: Concerns for omental herniation at port sites after the laparoscopic approach. Sci Rep 2020; 10:363. [PMID: 31941898 PMCID: PMC6962153 DOI: 10.1038/s41598-019-57031-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 12/03/2019] [Indexed: 12/13/2022] Open
Abstract
Pyloromyotomy is a common surgical procedure in infants with hypertrophic pyloric stenosis and can be performed with a small laparotomy or laparoscopically. No specific complications have been documented about one of the approaches. We aim to study (severity of) complications of pyloromyotomy and to compare complications of both approaches. Children undergoing pyloromyotomy between 2007 and 2017 were analyzed retrospectively. Complication severity was classified using the Clavien-Dindo classification. We included 474 infants (236 open; 238 laparoscopic). 401 were male (85%) and median (IQR) age was 33 (19) days. There were 83 surgical complications in 71 patients (15.0%). In the open group 45 infants (19.1%) experienced a complication vs. 26 infants in the laparoscopic group (10.5%)(p = 0.013). Severity and quantity of postoperative complications were comparable between both groups. Serosal tears of the stomach (N = 19) and fascial dehiscence (N = 8) occurred only after open pyloromyotomy. Herniation of omentum through a port site occurred only after laparoscopy (N = 6) and required re-intervention in all cases. In conclusion, the surgical complication rate of pyloromyotomy was 15.0%. Serosal tear of the stomach and fascial dehiscence are only present after open pyloromyotomy and omental herniation after laparoscopy respectively. The latter complication is underestimated and requires attention.
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Affiliation(s)
- Fenne A I M van den Bunder
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Department of Pediatric surgery, Amsterdam, 1100 DD, The Netherlands.
| | - Ernest van Heurn
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Department of Pediatric surgery, Amsterdam, 1100 DD, The Netherlands
| | - Joep P M Derikx
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Department of Pediatric surgery, Amsterdam, 1100 DD, The Netherlands
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4
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Ismail I, Elsherbini R, Elsaied A, Aly K, Sheir H. Laparoscopic vs. Open Pyloromyotomy in Treatment of Infantile Hypertrophic Pyloric Stenosis. Front Pediatr 2020; 8:426. [PMID: 32984197 PMCID: PMC7475708 DOI: 10.3389/fped.2020.00426] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 06/19/2020] [Indexed: 11/13/2022] Open
Abstract
Background/Purpose: Laparoscopic pyloromyotomy gained wide popularity in management of pyloric stenosis with contradictory results regarding its benefits over classic open approach. This study aimed at comparing both regarding their safety, efficiency, and outcome. Methods: This is a prospective randomized controlled study performed from April 2017 to April 2019. It included 80 patients, divided randomly into two groups, where laparoscopic pyloromyotomy was performed in group A and open pyloromyotomy in group B. Both groups were compared regarding operative time, post-operative pain score, time required to reach full feeding, hospital stay, complications, and parents' satisfaction. Results: Median operative time was 21 min in group A vs. 30 min in group B (P = 0). Pain Assessment in Neonates scores were generally higher in group B with more doses of analgesics required (P = 0). Mean time needed to reach full feeding was 15.2 and 18.8 h in groups A and B, respectively (P = 0). Median hospital stay was 19 h in group A and 22 h in group B (P = 0.004). Parents' satisfaction also was in favor of group A (P = 0.045). Although no significant difference was reported between both groups regarding early and late complications, some complications such as mucosal perforation and incomplete pyloromyotomy occurred in the laparoscopic group only. Conclusion: Laparoscopic pyloromyotomy was found superior to open approach regarding faster operative time, less need of analgesics, easier development of oral feeding, shorter hospital stay, and better parents' satisfaction. Yet, there are still some concerns about the safety and efficiency of this procedure over open technique.
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Affiliation(s)
- Ibrahim Ismail
- Pediatric Surgery Department, Mansoura University Chlidren Hospital, Mansoura University, Mansoura, Egypt
| | - Radi Elsherbini
- Pediatric Surgery Department, Mansoura University Chlidren Hospital, Mansoura University, Mansoura, Egypt
| | - Adham Elsaied
- Pediatric Surgery Department, Mansoura University Chlidren Hospital, Mansoura University, Mansoura, Egypt
| | - Kamal Aly
- Pediatric Surgery Department, Mansoura University Chlidren Hospital, Mansoura University, Mansoura, Egypt
| | - Hesham Sheir
- Pediatric Surgery Department, Mansoura University Chlidren Hospital, Mansoura University, Mansoura, Egypt
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Kozlov Y, Kovalkov K, Smirnov A. Gastric Peroral Endoscopic Myotomy for Treatment of Congenital Pyloric Stenosis—First Clinical Experience. J Laparoendosc Adv Surg Tech A 2019; 29:860-864. [DOI: 10.1089/lap.2018.0803] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Affiliation(s)
- Yury Kozlov
- Department of Pediatric Surgery, Irkutsk Municipal Pediatric Clinical Hospital, Irkutsk, Russia
- Department of Pediatric Surgery, Irkutsk State Medical Academy of Continuing Education, Irkutsk, Russia
- Department of Pediatric Surgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Konstantin Kovalkov
- Department of Pediatric Surgery, Kemerovo Clinical Pediatric Hospital No5, Kemerovo, Russia
| | - Alexander Smirnov
- Department of Endoscopy, The First Saint-Petersburg State Medical University Named of Acad. I.P. Pavlov, Saint Petersburg, Russia
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Developmental outcome at 3 years of age of infants following surgery for infantile hypertrophic pyloric stenosis. Pediatr Surg Int 2019; 35:357-363. [PMID: 30402682 DOI: 10.1007/s00383-018-4408-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/30/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE The study compared neurodevelopmental outcome at 3 years of age of infants with infantile hypertrophic pyloric stenosis (IHPS) who underwent pyloromyotomy with healthy control infants in New South Wales, Australia. METHODS Infants with IHPS as well as controls were recruited between August 2006 and July 2008. Developmental assessments were performed using the Bayley scales of infant and toddler development (version III) (BSITD-III) at 1 and 3 years of age. RESULTS Of the 43 infants originally assessed at 1 year, 39 returned for assessment at 3 years (90%). The majority were term infants (77%). Assessments were also performed on 156 control infants. Infants with IHPS scored significantly lower on four of the five Bayley subsets (cognitive, receptive and expressive language and fine motor) compared to control infants. Analysis of co-variance showed statistically significant results in favour of the control group for these four subsets. CONCLUSION Compared with the outcomes at 1 year, infants with IHPS at 3 years of age continue to score below controls in four of the BSITD-III subscales. This suggests they should have developmental follow-up with targeted clinical intervention. There is a need for further studies into functional impact and longer term outcomes.
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7
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Recurrent pyloric stenosis and definitive operative management with repeat pyloromyotomy. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2019. [DOI: 10.1016/j.epsc.2018.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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8
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Laparoscopic pyloromyotomy in infantile hypertrophic pyloric stenosis using a myringotomy knife. ANNALS OF PEDIATRIC SURGERY 2018. [DOI: 10.1097/01.xps.0000527071.00638.44] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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9
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Laparoscopic pyloromyotomy for hypertrophic pyloric stenosis: a survey of 407 children. Pediatr Surg Int 2018; 34:421-426. [PMID: 29411105 DOI: 10.1007/s00383-018-4235-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/30/2018] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Pyloromyotomy is the standard care for hypertrophic pyloric stenosis. The traditional approach for this procedure is a right upper quadrant transverse incision, although other "open" approaches, such as circumumbilical or periumbilical incision have been described. The more recent approach used is laparoscopic pyloromyotomy (LP), but experience feedback is still debated and its benefits remain unproven. The aim of this study was to make a review of all our LP procedures with an objective evaluation according to the literature. METHODS A retrospective analysis of all the LPs performed in one University Children's Hospital between 1 January 1996, and 30 December 2015 was realized. Information regarding the patient's status, intraoperative and postoperative data was analyzed. RESULTS 407 patients were included in this study. The mean operative time of the overall procedure was 24 ± 13 min, which significantly increased with the length of the pyloric muscle (p = 0.004) and significantly impacted the full feeding time (p = 0.006). 3.4% required conversion to an open procedure during the LP. We observed a significant correlation between conversion for mucosal perforation and weight loss (p = 0.04) and between conversion for mucosal perforation and preoperative weight (p = 0.002). A redo procedure was indicated in 3.7%, for incomplete pyloromyotomy each time. The mean postoperative hospital length of stay for all procedures was 1.6 ± 0.8 days. There were no inflammatory scars. None had incisional hernias or wound dehiscence. DISCUSSION LP procedure appeared to be as quick as the open procedure. Our results were similar to others series for intraoperative complications. According to operative time, this technique does not have an impact on operative room utilization. Vomiting duration at presentation in HPS does not seem to have a significant impact on postoperative outcomes. LP procedure causes little pain during the postoperative period. No wound complications were registered.
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10
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Hukeri A, Gupta A, Kothari P, Dikshit V, Kekre G, Patil P, Kulkarni A, Pawar A. Our experience of laparoscopic pyloromyotomy with ultrasound-guided parameters. J Minim Access Surg 2018; 15:51-55. [PMID: 29582798 PMCID: PMC6293670 DOI: 10.4103/jmas.jmas_193_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Traditional management of infantile Hypertrophic Pyloric Stenosis is open pyloromyotomy after initial adequate resuscitation of the patient. From 1991, laparoscopic approach is considered feasible and safe. Today, diagnosis of hypertrophic pyloric stenosis is made most often made by ultrasound. With use of ultrasound-guided parameters (length of pyloric tumour and thickness of pyloric tumour), we could avoid ‘incomplete pyloromyotomy’ and ‘mucosal perforation’ (most common complications in laparoscopic approach) to achieve 100% adequacy and safety in laparoscopic pyloromyotomy.
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Affiliation(s)
- Aboli Hukeri
- Department of Paediatric Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
| | - Abhaya Gupta
- Department of Paediatric Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
| | - Paras Kothari
- Department of Paediatric Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
| | - Vishesh Dikshit
- Department of Paediatric Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
| | - Geeta Kekre
- Department of Paediatric Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
| | - Prashant Patil
- Department of Paediatric Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
| | - Apoorva Kulkarni
- Department of Paediatric Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
| | - Arjun Pawar
- Department of Paediatric Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
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11
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Recurrent pyloric stenosis: a form of the incomplete pyloromyotomy. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2018. [DOI: 10.1016/j.epsc.2017.09.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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12
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Henderson L, Hussein N, Patwardhan N, Dagash H. Outcomes During a Transition Period from Open to Laparoscopic Pyloromyotomy. J Laparoendosc Adv Surg Tech A 2017; 28:481-485. [PMID: 29265912 DOI: 10.1089/lap.2017.0366] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Previous studies suggest that laparosopic pyloromyotomy may have some benefits over an open approach. We examined our results during a transition period from open to laparoscopic pyloromyotomy to see whether these benefits are sustained during the learning curve. METHODS This is a retrospective case note review of all patients undergoing pyloromyotomy at a tertiary institution for a 5-year period (2010-2015). Data are presented as median (range). Statistical analysis was performed with Fisher's exact and Student's t-test. RESULTS A total of 185 pyloromyotomies were performed, with data available for 90 open and 60 laparoscopic procedures. Duration of surgery was 42 (16-102) minutes for open and 28 (14-97) minutes for laparoscopic procedures (P = .0001). Total paracetamol requirements were 23.5 (0-169.4) mg/kg for open and 13.9 (0-95.3) mg/kg for laparoscopic cases (P = .008). No postoperative analgesia was required for 23 open and 29 laparoscopic patients (P = .005). Complications in the open group included incomplete pyloromyotomy (n = 1) and wound infection (n = 4); complications in the laparoscopic group included incisional hernia (n = 1), omental port-site herniation (n = 2), and suspected perforation with conversion to open procedure, although no perforation was found (n = 1; P = 1.000). CONCLUSION Our results suggest that when the laparoscopic technique is first introduced, overall complication rates are not statistically higher, and operative times and analgesia requirements are significantly shorter, despite the learning curve.
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Affiliation(s)
- Lucy Henderson
- 1 Department of Paediatric Surgery, Leicester Children's Hospital , Leicester, United Kingdom
| | | | - Nitin Patwardhan
- 1 Department of Paediatric Surgery, Leicester Children's Hospital , Leicester, United Kingdom
| | - Haitham Dagash
- 1 Department of Paediatric Surgery, Leicester Children's Hospital , Leicester, United Kingdom
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13
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The surgical management of malrotation: A Canadian Association of Pediatric Surgeons survey. J Pediatr Surg 2017; 52:853-858. [PMID: 28189453 DOI: 10.1016/j.jpedsurg.2017.01.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 01/23/2017] [Indexed: 11/22/2022]
Abstract
PURPOSE Some surgeries are now performed almost exclusively via a laparoscopic approach to enhance recovery and reduce postoperative complications. This survey explored institutional and individual physician practice patterns of the surgical management of malrotation. METHODS All 2015 Canadian Association of Pediatric Surgeons annual meeting attendees were invited to complete an anonymous prepiloted survey. Descriptive statistics were calculated. RESULTS The response rate was 35% (150 distributed, 52 returned). Most institutions (39.5%) saw on average 5-10 cases of malrotation per year. Most respondents (54.2%) indicated that the laparoscopic (LL) and open Ladd's (OL) procedures were equal surgical approaches for stable patients. Respondents were nearly equally divided (47.9% yes; 44.7% no) with respect to whether an LL procedure led to a higher risk of postoperative volvulus. Of those who answered yes, most indicated that an increased risk of postoperative volvulus was because of an inadequate widening of mesentery (45.8%), reduced "beneficial" postoperative adhesions (29.2%), or both (16.7%). 100% of respondents who perform an OL as their standard procedure indicated that there was a higher risk of postoperative volvulus with LL procedure. Only 1/8 who performed a LL as a standard approach routinely performed an appendectomy. CONCLUSION There remain polarized views on the best surgical approach to malrotation yet a persistent belief in the reduction in postoperative adhesions in leading to a postoperative volvulus with LL procedures. Collaboration to permit long-term follow-up of a large cohort may help develop guidelines for the operative management of malrotation. LEVEL OF EVIDENCE Level V.
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Abstract
Complications related to general pediatric surgery procedures are a major concern for pediatric surgeons and their patients. Although infrequent, when they occur the consequences can lead to significant morbidity and psychosocial stress. The purpose of this article is to discuss the common complications encountered during several common pediatric general surgery procedures including inguinal hernia repair (open and laparoscopic), umbilical hernia repair, laparoscopic pyloromyotomy, and laparoscopic appendectomy.
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Affiliation(s)
- Maria E Linnaus
- Department of Surgery, Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, Arizona 85016
| | - Daniel J Ostlie
- Department of Surgery, Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, Arizona 85016.
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15
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Linnaus ME, Langlais CS, Johnson KN, Notrica DM. Top to Bottom: A New Method for Assessing Adequacy of Laparoscopic Pyloromyotomy. J Laparoendosc Adv Surg Tech A 2016; 26:934-937. [PMID: 27532616 DOI: 10.1089/lap.2016.0303] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Hypertrophic pyloric stenosis is a commonly encountered pediatric surgical issue. Initially treated with open surgical techniques, many pediatric surgeons have adopted the minimally invasive approach using laparoscopy. However, some concerns exist that the rate of incomplete pyloromyotomy is elevated in laparoscopy. We propose a new technique to assess the adequacy of laparoscopic pyloromyotomy. METHODS Adequacy of laparoscopic pyloromyotomy was assessed by confirming that the top of the serosa on one side of the pylorus has adequate freedom to reach the bottom of the muscle on other side. A retrospective review of patients undergoing laparoscopic pyloromyotomy confirmed by this method from March 2012 to January 2016 was conducted. Demographics, laboratory values on admission, and postoperative outcomes were collected. Descriptive statistics was utilized. RESULTS Thirty-three patients were included. Median age was 30 days (interquartile range [IQR]: 24, 47). Median pylorus length and thickness were 19 mm (IQR 17.3, 21) and 4.5 mm (IQR: 4.0, 4.8), respectively. Median time to first full feed was 8.5 hours (IQR: 6.6, 15.6). Twenty-three (69%) patients had postoperative emesis. Median length of stay postoperation was 26.5 hours (IQR: 21.1, 44.7). There were no reoperations for incomplete pyloromyotomy and no infections. On follow-up, 1 patient had prolonged postoperative emesis that resolved without further intervention and 1 patient on peritoneal dialysis before surgery had an incisional hernia that required operation in the setting of bilateral inguinal hernias. CONCLUSION In a small series, the top to bottom assessment appears to confirm adequacy of pyloromyotomy.
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Affiliation(s)
- Maria E Linnaus
- 1 Division of Pediatric Surgery , Phoenix Children's Hospital, Phoenix, Arizona.,2 Department of Surgery, Mayo Clinic Hospital , Phoenix, Arizona
| | - Crystal S Langlais
- 1 Division of Pediatric Surgery , Phoenix Children's Hospital, Phoenix, Arizona
| | - Kevin N Johnson
- 3 Department of Pediatric Surgery, Mott Children's Hospital, University of Michigan , Ann Arbor, Michigan
| | - David M Notrica
- 1 Division of Pediatric Surgery , Phoenix Children's Hospital, Phoenix, Arizona.,2 Department of Surgery, Mayo Clinic Hospital , Phoenix, Arizona
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16
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Iwanaka T, Yamataka A, Uemura S, Okuyama H, Segawa O, Nio M, Yoshizawa J, Yagi M, Ieiri S, Uchida H, Koga H, Sato M, Soh H, Take H, Hirose R, Fukuzawa H, Mizuno M, Watanabe T. Pediatric Surgery. Asian J Endosc Surg 2015; 8:390-407. [PMID: 26708583 DOI: 10.1111/ases.12263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 08/21/2015] [Accepted: 08/21/2015] [Indexed: 12/25/2022]
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17
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Vahdad MR, Nissen M, Semaan A, Klein T, Palade E, Boemers T, Troebs RB, Cernaianu G. Can a simplified algorithm prevent incomplete laparoscopic pyloromyotomy? J Pediatr Surg 2015; 50:1544-8. [PMID: 25783316 DOI: 10.1016/j.jpedsurg.2014.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Accepted: 12/02/2014] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study is to analyze an algorithm intended to prevent incomplete pyloromyotomy in 3-port laparoscopic (3TP) and laparoendoscopic single-site (LESS-P) procedures in a teaching hospital. METHODS We defined the pyloroduodenal and pyloroantral junctions as anatomical margins prior pyloromyotomy by palpating and coagulating the serosa with the hook cautery instrument. Incomplete pyloromyotomies, mucosa perforations, serosa lacerations, and wound infections were recorded for pediatric surgical trainees (PST) and board-certified pediatric surgeons (BC). RESULTS We reviewed the medical files of 233 infants, who underwent LESS-P (n=21), 3TP (n=71), and open pyloromyotomy (OP, n=141). No incomplete pyloromyotomies occurred. In contrast to OP, mucosa perforations did not occur in the laparoscopic procedures during the study period (6.38% vs. 0%, P=.013). OP had insignificantly more serosal lacerations (3.5% vs. 1.4%, P=.407). There was no difference in the rate of wound infections between OP and laparoscopic procedures (2.8% vs. 4.3%, P=.715). In the latter, all wound infections were associated with the use of skin adhesive. CONCLUSIONS This algorithm helps avoiding incomplete laparoscopic pyloromyotomy during the learning curve and in a teaching setting. It is not risky to assist 3TP and LESS-P to PST as this led to a decreased rate of mucosa perforations without experiencing incomplete pyloromyotomies.
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Affiliation(s)
- M Reza Vahdad
- Department of Pediatric Surgery and Pediatric Urology Kliniken der Stadt Köln GmbH, Kinderkrankenhaus Amsterdamer Strasse 59, 50735 Koeln, Germany.
| | - Matthias Nissen
- Department of Pediatric Surgery, Marienhospital Herne, Ruhr-University of Bochum, Widumerstr. 8, 44627 Herne, Germany.
| | - Alexander Semaan
- Department of Pediatric Surgery and Pediatric Urology Kliniken der Stadt Köln GmbH, Kinderkrankenhaus Amsterdamer Strasse 59, 50735 Koeln, Germany.
| | - Tobias Klein
- Department of Pediatric Surgery and Pediatric Urology Kliniken der Stadt Köln GmbH, Kinderkrankenhaus Amsterdamer Strasse 59, 50735 Koeln, Germany.
| | - Emanuel Palade
- Department of Surgery, University Hospital Luebeck, Ratzeburger Allee 160, 23538 Lübeck, Germany.
| | - Thomas Boemers
- Department of Pediatric Surgery and Pediatric Urology Kliniken der Stadt Köln GmbH, Kinderkrankenhaus Amsterdamer Strasse 59, 50735 Koeln, Germany.
| | - Ralf-Bodo Troebs
- Department of Pediatric Surgery, Marienhospital Herne, Ruhr-University of Bochum, Widumerstr. 8, 44627 Herne, Germany.
| | - Grigore Cernaianu
- Department of Pediatric Surgery, University Hospital Luebeck, Ratzeburger Allee 160, 23538 Lübeck, Germany.
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Handu AT, Jadhav V, Deepak J, Aihole JS, Gowrishankar, Narendrababu M, Ramesh S, Srimurthy K. Laparoscopic pyloromyotomy: Lessons learnt in our first 101 cases. J Indian Assoc Pediatr Surg 2014; 19:213-7. [PMID: 25336803 PMCID: PMC4204246 DOI: 10.4103/0971-9261.142009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Aim: To analyze our experience with laparoscopic pyloromyotomy for infantile hypertrophic pyloric stenosis for the lessons that we learnt and to study the effect of learning curve. Materials and Methods: This is a retrospective analysis of case records of 101 infants who underwent laparoscopic pyloromyotomy over 6 years. The demographic characteristics, conversion rate, operative time, complications, time to first feed and post-operative hospital stay were noted. The above parameters were compared between our early cases (2007-2009) (n = 43) and the later cases (2010-2013) (n = 58). Results: 89 male and 12 female babies ranging in age from 12 days to 4 months (mean: 43.4 days) were operated upon during this period. The babies ranged in weight from 1.8 to 4.7 kg (mean: 3.1 kg). Four cases were converted to open (3.9%): three due to mucosal perforations and one due to technical problem. The mean operative time was 45.7 minutes (49.7 minutes in the first 3 years and 43.0 minutes in the next 3 years). There were 10 complications-4 mucosal perforations, 5 inadequate pyloromyotomies and 1 omental prolapse through a port site. All the complications were effectively handled with minimum morbidity. In the first 3 years of our experience the conversion rate was 9.3%, mucosal perforations were 6.9% and re-do rate was 2.3% as compared to 0%, 1.7% and 6.9%, respectively, in the next 3 years. Mean time for starting feeds was 21.4 hours and mean post-operative hospital stay was 2.4 days. Conclusion: Laparoscopic pyloromyotomy is a safe procedure with minimal morbidity and reasonable operative times. Conversion rates and operative times decrease as experience increases. Our rate of inadequate pyloromyotomy was rather high which we hope to decrease with further experience.
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Affiliation(s)
- Abhilasha Tej Handu
- Department of Surgery, Bharti Hospital and Research Centre, Pune, Maharashtra, India
| | - Vinay Jadhav
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bangalore, Karnataka, India
| | - J Deepak
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bangalore, Karnataka, India
| | - Jayalaxmi S Aihole
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bangalore, Karnataka, India
| | - Gowrishankar
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bangalore, Karnataka, India
| | - M Narendrababu
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bangalore, Karnataka, India
| | - S Ramesh
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bangalore, Karnataka, India
| | - Kr Srimurthy
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bangalore, Karnataka, India
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Ein SH, Masiakos PT, Ein A. The ins and outs of pyloromyotomy: what we have learned in 35 years. Pediatr Surg Int 2014; 30:467-80. [PMID: 24626877 DOI: 10.1007/s00383-014-3488-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/18/2014] [Indexed: 11/26/2022]
Abstract
PURPOSE/BACKGROUND The aim of the study is to evaluate a large series of infantile hypertrophic pyloric stenosis (IHPS) patients treated by one pediatric surgeon focusing on their diagnostic difficulties and complications. METHODS From July 1969 to December 2003 (inclusive), the charts of 791 infants with IHPS were retrospectively reviewed. RESULTS There were 647 (82%) males and 144 (18%) females; mean age was 38 days, median 51 (range 7 days-10 months). When ultrasonography (US) was routinely used (1990), the age at diagnosis decreased to <40 days. The mean weight before and after routine US was 3.2 kg, median 3 (range 1.5-6). Twenty-five (3.1%) were premature at diagnosis, mean age 49 days, median 56, (range 1-3 months) and mean weight 2.5 kg, median 2.3 (range 1.5-3.2). Eighty-one (10%) had a positive family history. Forty-four (5%) were non-Caucasians. Seventy-five (9 %) had other medical conditions, anomalies and/or associated findings. Sixty (7%) patients had abnormal preoperative electrolytes. Ten (1.2%) pylorics occurred after newborn operations. Of the entire total (791) who were treated, there were 13 (1.7%) not operated on. All operations were done open initially through one of two right upper quadrant incisions, and then through an upper midline incision under general endotracheal anesthesia; 14 (1.7 %) had concomitant procedures. Prophylactic antibiotics (from 1982) decreased the wound infection rate to 3.9%. There were a total of 87 (10%) complications which included 9 (1.1%) intraoperative, (including mistaken diagnoses) 78 (9%) postoperative: 59 (2%) early (<1 month) and 19 (2.4%) late (>1 month). The 13 (1.6%) postoperative transfers (12 from non-pediatric surgeons) had 16 (18%) complications (including 1 death); five (33%) requiring reoperation (4 incomplete, 1 perforation). There were two deaths. CONCLUSIONS IHPS should be considered in any vomiting infant. US allows earlier diagnosis. Serious complications are uncommon and avoidable, but recognizable and easily corrected. Higher surgeon volume of pyloromyotomies (>14 per year) is associated with fewer complications.
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Blinman T, Ponsky T. Pediatric minimally invasive surgery: laparoscopy and thoracoscopy in infants and children. Pediatrics 2012; 130:539-49. [PMID: 22869825 DOI: 10.1542/peds.2011-2812] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
This article discusses the potential benefits and challenges of minimally invasive surgery for infants and small children, and discusses why pediatric minimally invasive surgery is not yet the surgical default or standard of care. Minimally invasive methods offer advantages such as smaller incisions, decreased risk of infection, greater surgical precision, decreased cost of care, reduced length of stay, and better clinical information. But none of these benefits comes without cost, and these costs, both monetary and risk-based, rise disproportionately with the declining size of the patient. In this review, we describe recent progress in minimally invasive surgery for infants and children. The evidence for the large benefits to the patient will be presented, as well as the considerable, sometimes surprising, mechanical and physiological challenges surgeons must manage.
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Affiliation(s)
- Thane Blinman
- Children's Hospital of Philadelphia, 34th and Civic Center, Philadelphia, PA 19083, USA.
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Walker K, Badawi N, Holland AJ, Halliday R. Developmental outcomes following major surgery: what does the literature say? J Paediatr Child Health 2011; 47:766-70. [PMID: 21040073 DOI: 10.1111/j.1440-1754.2010.01867.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Relative to the wealth of information in the medical literature regarding developmental outcome for infants who have had cardiac surgery available, few studies specifically detail how those who have undergone major surgery grow and develop. The few published studies tend to be disease specific, making their results difficult to translate to a more general setting. As mortality for most infants who require surgery in infancy continues to decrease, the focus for researchers and clinicians should be on how these children will grow and develop. As parents realise that their infant will survive, this becomes their next major concern. The most common conditions requiring early major surgery have been reviewed in relation to data on infant developmental outcomes.
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Affiliation(s)
- Karen Walker
- Grace Centre for Newborn Care, The Children's Hospital at Westmead, Australia.
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Abstract
Laparoscopic pyloromyotomy was first reported 20 years ago. This technique uses a small umbilical incision and 2 small upper abdominal incisions. During the last 5 years, this approach has become the preferred technique for many pediatric surgeons in the infant who needs a pyloromyotomy. Recently, with the advent of single-site umbilical laparoscopic surgery, this approach is being used for several common pediatric conditions, including pyloric stenosis. This article will describe the single-site approach used at the Children's Hospital of Alabama and the early outcomes from its use in a relatively small group of infants. An improvement in the cosmetic appearance of the abdominal wall with the single-site approach appears to be the primary reason for its use.
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Affiliation(s)
- Carroll M Harmon
- Department of Surgery, Division of Pediatric Surgery, Children's Hospital of Alabama, Birmingham, Alabama 35233, USA.
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Abstract
The relative rarity of hypertrophic pyloric stenosis (HPS) in the developing world makes its diagnosis a challenge to many physicians. This study audits the management of HPS at a tertiary hospital in South Africa, with a view to defining its regional pattern. This is a retrospective review of records of all patients ( n = 63) managed for HPS over an eight-year period (2002–2010). The mean age at presentation was 6.2 weeks and the male/female ratio was 6:1. The majority of patients presented with non-bilious vomiting. Abdominal ultrasound had a sensitivity of 65% and 81.3% when the criteria of pyloric muscle thickness >4 mm and pyloric channel length >16 mm were used, respectively. The overall complication rate was 14.3% and the mortality rate was 0%. Despite the rarity of HPS in the Third World, the outcome of its management is favourable. However, the sensitivity of abdominal ultrasound for diagnosing HPS is low.
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Affiliation(s)
- P W Saula
- Department of Paediatric Surgery, Nelson R Mandela School of Medicine, University of KwaZulu – Natal, Private Bag 7, Congella 4013, South Africa
| | - G P Hadley
- Department of Paediatric Surgery, Nelson R Mandela School of Medicine, University of KwaZulu – Natal, Private Bag 7, Congella 4013, South Africa
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Bensard DD, Hendrickson RJ, Clark KS, Giesting KJ, Kokoska ER. Use of ultrasound measurements to direct laparoscopic pyloromyotomy in infants. JSLS 2011; 14:553-7. [PMID: 21605521 PMCID: PMC3083048 DOI: 10.4293/108680810x12924466008321] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Preoperative ultrasound measurement of pyloric length to determine laparoscopic pyloromyotomy appears to minimize the risk of incomplete pyloromyotomy. Background: Laparoscopic pyloromyotomy is associated with an increased risk of incomplete myotomy compared with open myotomy. We hypothesized that utilizing ultrasound measured length to direct laparoscopic pyloromyotomy would reduce the risk of incomplete pyloromyotomy without a concomitant increase in the risk of mucosal perforation. Methods: Infants (n=43) with hypertrophic pyloric stenosis diagnosed by ultrasound and subsequent laparoscopic pyloromyotomy over a 2-year period (December 2006 through December 2008) were studied. Pyloromyotomy length was guided by preoperative ultrasound measurements. Pyloromyotomy was considered complete if the measured length was ≥ the ultrasound measurement. Infants were followed prospectively for time to full feeding, time to discharge, and complications. Results: The cohort included 38 male and 5 female infants (age, 37±13 days; range, 17 to 72 days) who underwent ultrasound (length 1.9±0.2cm; thickness 4.4±0.9mm) and laparoscopic pyloromyotomy. Infants achieved full feeding 28±16 hours postoperatively and were discharged 34±18 hours postoperatively. No infant required reoperation for incomplete myotomy. One infant sustained mucosal perforation (2%). No patient suffered other complications. Conclusion: Preoperative ultrasound measurement of pyloric length to determine the length of laparoscopic pyloromyotomy, rather than visual cues alone, appears to minimize the risk of incomplete pyloromyotomy.
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Affiliation(s)
- Denis D Bensard
- Department of Pediatric Surgery, The Peyton Manning Children's Hospital at St. Vincent, Indianapolis, Indiana, USA.
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Lemoine C, Paris C, Morris M, Vali K, Beaunoyer M, Aspirot A. Open transumbilical pyloromyotomy: is it more painful than the laparoscopic approach? J Pediatr Surg 2011; 46:870-3. [PMID: 21616243 DOI: 10.1016/j.jpedsurg.2011.02.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Accepted: 02/11/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Open transumbilical pyloromyotomy (UMBP) and laparoscopic pyloromyotomy (LAP) have been compared on different outcomes, but postoperative pain as a primary end point had never been assessed. The aim of this study was to compare the use of analgesia in UMBP and LAP patients. METHODS Infants with hypertrophic pyloric stenosis treated by UMBP in 2008-2009 were matched with LAP-treated infants. Demographics, type and use of analgesia, and length of stay were recorded. Statistical analysis was performed using the Fisher exact test. RESULTS Each group contained 19 patients (N = 38) with comparable demographics and no comorbid condition. Bupivacaine was injected intraoperatively in all UMBP and 89% of LAP infants. There was a trend toward increased acetaminophen use in LAP infants (79% vs 58%, P = .61) in the recovery room. There was no difference in opiates use (3 UMBP vs 1 LAP, P = .60). In the ward, more UMBP patients received acetaminophen (78% vs 53%, P = .03). This difference was significant. Mean postoperative length of stay was similar in both groups. CONCLUSION Our study suggests that UMBP infants might experience more postoperative pain in the ward, without any impact on various outcomes. A prospective study with a larger sample size should be undertaken to verify these findings.
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Affiliation(s)
- Caroline Lemoine
- Division of Pediatric Surgery, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
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Muensterer OJ, Chong AJ, Georgeson KE, Harmon CM. The Cross-technique for single-incision pediatric endosurgical pyloromyotomy. Surg Endosc 2011; 25:3414-8. [PMID: 21487868 DOI: 10.1007/s00464-011-1677-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Accepted: 03/10/2011] [Indexed: 01/03/2023]
Abstract
BACKGROUND Single-incision pediatric endosurgical (SIPES) pyloromyotomy is frequently used for the treatment of hypertrophic pyloric stenosis at our center. Our initial SIPES approach mirrored the conventional, triangulated laparoscopic pyloromyotomy. Because an increased number of perforations were noted on our initial analysis, a more straightforward Cross-technique SIPES pyloromyotomy was developed. This study compares the current Cross-technique SIPES pyloromyotomy to the previous standard SIPES operation. METHODS The Cross-technique entails grasping the antrum with the surgeon's left hand instrument, retracting toward the left lower quadrant, and thereby orienting the pylorus obliquely toward the right upper quadrant. The serosal incision and muscular spreading is accomplished using a right-hand instrument that crosses over the left hand grasper. Demographic variables, operative times, estimated blood loss (EBL), complications, conversion rate, and postoperative length of stay were compared. RESULTS Twenty-nine Cross-technique patients were compared with 23 in the standard group. The Cross-technique was faster than the standard procedure (21 ± 5 vs. 27 ± 12 min, p = 0.03) and EBL was lower (1.3 ± 0.5 vs. 1.7 ± 0.6 ml, p = 0.02). There were two mucosal perforations requiring conversions to triangulated 3-access-site laparoscopy in the standard, and one conversion to open surgery in the Cross-technique group. Patients who underwent cross-technique pyloromyotomy weighed less (3.6 ± 0.6 vs. 4.0 ± 0.5 kg, p = 0.012), but there were no differences in age, gender ratio, conversion rate, or length of stay. There was one postoperative wound infection in the cross-technique, but none in the standard group. No patients required reoperation. All participating surgeons felt that the cross-technique was more ergonomic and easier to perform than the standard SIPES technique. CONCLUSIONS The Cross-technique appears superior to standard SIPES pyloromyotomy and should be preferentially used for single-incision endosurgical pyloromyotomy for hypertrophic pyloric stenosis.
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Affiliation(s)
- Oliver J Muensterer
- Department of Surgery, Children's Hospital of Alabama, University of Alabama, Birmingham, AL, USA.
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Bertozzi M, Prestipino M, Nardi N, Appignani A. Preliminary experience with a new approach for infantile hypertrophic pyloric stenosis: the single-port, laparoscopic-assisted pyloromyotomy. Surg Endosc 2010; 25:2039-43. [PMID: 21136088 DOI: 10.1007/s00464-010-1505-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2010] [Accepted: 11/12/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Ramstedt pyloromyotomy is still the procedure of choice for infantile hypertrophic pyloric stenosis; however, the best way to approach the pylorus is debated. Recent literature reports many comparisons between various open approaches and laparoscopic one. The purpose of this preliminary experience is to show a new approach to infantile hypertrophic pyloric stenosis: single-port, laparoscopic-assisted pyloromyotomy. METHODS Nineteen infants underwent single-port laparoscopic-assisted pyloromyotomy. The approach to the abdominal cavity is performed through a right circumbilical incision, and then a 12-mm trocar is inserted. After the pneumoperitoneum is established, an operative telescope is introduced. Once the telescope is inserted, the pylorus is easily located, and then grasped and exteriorized via the umbilical incision. At this point, conventional Ramstedt pyloromyotomy is performed. Once the pylorus is reintroduced in the abdomen, a new pneumoperitoneum is created to control mucosal integrity and hemostasis. A retrospective statistical analysis was performed to compare patients who underwent this technique to others approached by the same team with right upper quadrant incision or right semicircular umbilical skin-fold incision. RESULTS In all 19 cases, adequate pyloromyotomy was performed in a good ranging time without any intra- or post-operative complications, achieving excellent early cosmetic results. CONCLUSIONS The feasibility of single-port, laparoscopic-assisted pyloromyotomy obtained in this small sample suggests that this procedure could be an excellent alternative to open or laparoscopic pyloromyotomy as long as it acts as intermediary between the two techniques.
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Affiliation(s)
- Mirko Bertozzi
- Clinica Chirurgica Pediatrica, Università degli Studi di Perugia, Ospedale S. Maria della Misericordia, S. Andrea delle Fratte, 06100, Perugia, Italy.
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Walker K, Halliday R, Holland AJA, Karskens C, Badawi N. Early developmental outcome of infants with infantile hypertrophic pyloric stenosis. J Pediatr Surg 2010; 45:2369-72. [PMID: 21129547 DOI: 10.1016/j.jpedsurg.2010.08.035] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2010] [Accepted: 08/12/2010] [Indexed: 11/19/2022]
Abstract
PURPOSE The study aimed to compare the developmental outcome of infants with infantile hypertrophic pyloric stenosis (IHPS) who underwent pyloromyotomy with healthy control infants in New South Wales (NSW), Australia. METHODS Infants diagnosed with IHPS requiring surgical intervention were enrolled prospectively between August 1, 2006, and July 31, 2008. Healthy control infants were enrolled in the same period. The children underwent a developmental assessment at 1 year of age (corrected) using the Bayley Scales of Infant and Toddler Development (Version III). RESULTS Of 52 infants with IHPS who were enrolled, 43 had developmental assessments. Most (90.6%) were term infants (>36 weeks gestation) with a median birth weight of 3237.8 g. Two infants (8%) had an associated birth defect, and survival was 100%. Developmental assessments were also performed on 211 control infants. Infants with IHPS scored significantly lower on the cognitive, receptive language, fine motor, and gross motor subscales compared to the control infants. CONCLUSIONS This unique study found lower than expected developmental scores for infants after surgery for IHPS than for healthy control infants. These findings raise concerns over the potential impact of IHPS and its surgical treatment. Further studies, including continuing developmental review to determine whether these differences persist and their functional importance, should be performed.
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Affiliation(s)
- Karen Walker
- Grace Centre for Newborn Care, The Children's Hospital at Westmead, Discipline of Paediatrics and Child Health, Sydney Medical School, The University of Sydney, New South Wales 2145, Australia.
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Muensterer OJ. Single-incision pediatric Endosurgical (SIPES) versus conventional laparoscopic pyloromyotomy: a single-surgeon experience. J Gastrointest Surg 2010; 14:965-8. [PMID: 20405233 DOI: 10.1007/s11605-010-1199-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2010] [Accepted: 03/31/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pyloromyotomy by single-incision pediatric endosurgery (SIPES) is a new technique that leaves virtually no appreciable scar. So far, it has not been compared to conventional laparoscopic (CL) pyloromyotomy. This study compares the results of the first 15 SIPES pyloromyotomies of a surgeon to his last 15 CL cases. METHODS Data were collected on all SIPES pyloromyotomies. Age, gender, operative time, estimated blood loss, conversion/complication rate, and outcome in the SIPES patients were compared to the CL cohort. RESULTS There was no difference in age, weight, gender, blood loss, or hospital stay. A trend toward shorter operating time was found in the CL group (21.7 +/- 9.9 versus 30.3 +/- 15.8, p = 0.08, 95%CI 20.9-39.7 min). Two mucosal perforations occurred in the SIPES cohort. Both cases were converted to conventional laparoscopy, the defect was repaired, and both patients had an uncomplicated postoperative course. There were no wound infections or conversions to open surgery. Parents were uniformly pleased with the cosmetic results of SIPES. CONCLUSION SIPES pyloromyotomy may have a higher perforation rate than the CL approach. If recognized, a laparoscopic repair is feasible. Improved cosmesis must be carefully weighed against the potentially increased risks of SIPES versus conventional laparoscopic pyloromyotomy.
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Affiliation(s)
- Oliver J Muensterer
- Division of Pediatric Surgery, Children's Hospital of Alabama, Department of Surgery, University of Alabama at Birmingham, 1600 7th Avenue South, ACC 300, Birmingham, AL 35233, USA.
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Vegunta RK, Rawlings AL, Jeziorczak PM. Methylene blue: a simple marker for intraoperative detection of gastroduodenal perforations during laparoscopic pyloromyotomy. Surg Innov 2009; 17:11-3. [PMID: 20038507 DOI: 10.1177/1553350609357055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION We studied the feasibility of using methylene blue (MB) as a marker to detect mucosal perforations during laparoscopic pyloromyotomy using in vitro and in vivo animal models. MATERIALS AND METHODS MB was initially tested in pig stomachs in vitro. Information gathered from these experiments was then used to test the marker during experimental live piglet laparoscopic surgery. RESULTS MB stained the gastric mucosa blue; this tint could be seen through the intact mucosal layer exposed via myotomy. Dye extravasation was seen during laparoscopic surgery with mucosal perforations of 1.2 mm and greater with or without air insufflation of the stomach. Air extravasation was seen with perforations of 2.0 mm and greater. CONCLUSION Full strength 1% MB dye instilled into the gastric lumen can potentially be used as a marker for detection of mucosal perforations of 1.2 mm or greater during laparoscopic pyloromyotomy.
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Affiliation(s)
- Ravindra K Vegunta
- University of Illinois College of Medicine at Peoria and Children's Hospital of Illinois at OSF St Francis Medical Center, Peoria, IL, USA.
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Perger L, Fuchs JR, Komidar L, Mooney DP. Impact of surgical approach on outcome in 622 consecutive pyloromyotomies at a pediatric teaching institution. J Pediatr Surg 2009; 44:2119-25. [PMID: 19944219 DOI: 10.1016/j.jpedsurg.2009.02.067] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2009] [Revised: 02/09/2009] [Accepted: 02/10/2009] [Indexed: 11/27/2022]
Abstract
PURPOSE The aim of this study is to compare the outcome of 3 different approaches to pyloromyotomy in a large single institution series. METHODS Records of consecutive patients undergoing pyloromyotomy for an 8-year period were reviewed. Patients' age, sex, weight, operating time, length of stay, number of emeses, and complications were recorded. Variables were compared between right upper quadrant (RUQ), umbilical (UMB), and laparoscopic (LAP) approaches. RESULTS Six hundred twenty-two patients were included in the study. Operating time was significantly shorter for LAP and RUQ compared to UMB. Length of stay did not differ between the groups. There were fewer episodes of emesis in the LAP group. There was a trend toward a higher rate of complications in UMB group. CONCLUSION Outcomes after pyloromyotomy are institution dependent and cannot be generalized. Patient safety is the first concern, followed by patient comfort and cosmesis. Laparoscopic pyloromyotomy can be as fast and efficient as open, without an increased rate of complications, with excellent cosmetic results, and less analgesic requirement. If skill and experience to replicate good outcomes of laparoscopy are not available, open pyloromyotomy is a safer technique. The UMB approach is an alternative method to achieve good cosmesis without laparoscopy in the hands of a surgeon proficient in this method.
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Affiliation(s)
- Lena Perger
- Department of Surgery, University of New Mexico School of Medicine, University of New Mexico, Albuquerque, NM 87131, USA
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Sola JE, Neville HL. Laparoscopic vs open pyloromyotomy: a systematic review and meta-analysis. J Pediatr Surg 2009; 44:1631-7. [PMID: 19635317 DOI: 10.1016/j.jpedsurg.2009.04.001] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2009] [Revised: 03/31/2009] [Accepted: 04/01/2009] [Indexed: 11/19/2022]
Abstract
PURPOSE The aim of the study was to determine whether laparoscopic pyloromyotomy (LP) or open pyloromyotomy (OP) is the most effective intervention in infants with hypertrophic pyloric stenosis. METHODS A systematic review of the published literature was undertaken in February 2009. Prospective studies comparing LP and OP were selected. Age, weight, complications, duration of operation, time to full feedings, postoperative vomiting, and postoperative length of stay (LOS) data were extracted. RESULTS Six prospective studies (5 level I, 1 level II) with 625 (303 LP, 322 OP) participants met selection criteria. Combined estimates indicated that LP had a lower total complication rate (odds ratio [OR], 0.58 [0.35, 0.97]; P = .04), mostly due to a lower wound complication rate (OR, 0.42 for LP [0.20, 0.91]; P = .03). Patients who underwent LP also had shorter time to full feedings (mean difference [MD], -11.52 hours [-12.77, -10.27]; P < .00001) and shorter postoperative LOS (MD, -5.71 hours [-8.90, -2.52]; P = .0005). No statistically significant differences were noted in the rates of mucosal perforation, wound infection, postoperative emesis, or operating time. Incomplete pyloromyotomy occurred in 6 patients who underwent LP (OR, 7.74 [0.94, 63.38]; P = .06). CONCLUSIONS This meta-analysis favors the laparoscopic approach with significantly reduced rate of total complications, which is mostly due to a lower wound complication rate.
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Affiliation(s)
- Juan E Sola
- Division of Pediatric Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL 33136, USA.
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Lange R, Rey M, Fernández ED. Open vs. laparoscopic pyloromyotomy--a retrospective analysis. MINIM INVASIV THER 2009; 17:313-7. [PMID: 18942004 DOI: 10.1080/13645700802274547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Laparoscopic pyloromyotomy has obtained increasing importance in the last years. However, there is no proof of an obvious advantage of the laparoscopic over the open approach. This retrospective analysis of 157 infants with pyloromyotomies (129 open and 28 laparoscopic procedures) should settle the benefit of one of these procedures. The duration of the operation in the laparoscopic procedure was significantly shorter than in open pyloromyotomy (median 25 versus 34 min; p = 0.025). Complete oral feeding was reached after similar postoperative time in both groups, but the postoperative hospital length of stay in the laparoscopic group was significantly shorter than in the open group (3.5 versus 7 days, p = 0.008). The postoperative requirements for analgetics were low and showed no difference in both groups. In our clinic the laparoscopic pyloromyotomy was successfully introduced as standard operating procedure. There was no difference in the complication rate as compared to the open procedure. The recovery time was shorter in the laparoscopic group. A superiority of the laparoscopic pyloromyotomy over the open procedure is suggested by the ascertained data.
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Affiliation(s)
- R Lange
- Department for Surgery, Ilmtalklinik, Pfaffenhofen, Germany
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Hall NJ, Pacilli M, Eaton S, Reblock K, Gaines BA, Pastor A, Langer JC, Koivusalo AI, Pakarinen MP, Stroedter L, Beyerlein S, Haddad M, Clarke S, Ford H, Pierro A. Recovery after open versus laparoscopic pyloromyotomy for pyloric stenosis: a double-blind multicentre randomised controlled trial. Lancet 2009; 373:390-8. [PMID: 19155060 DOI: 10.1016/s0140-6736(09)60006-4] [Citation(s) in RCA: 137] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND A laparoscopic approach to pyloromyotomy for infantile pyloric stenosis has gained popularity but its effectiveness remains unproven. We aimed to compare outcomes after open or laparoscopic pyloromyotomy for the treatment of pyloric stenosis. METHODS We did a multicentre international, double-blind, randomised, controlled trial between June, 2004, and May, 2007, across six tertiary paediatric surgical centres. 180 infants were randomly assigned to open (n=93) or laparoscopic pyloromyotomy (n=87) with minimisation for age, weight, gestational age at birth, bicarbonate at initial presentation, feeding type, preoperative duration of symptoms, and trial centre. Infants with a diagnosis of pyloric stenosis were eligible. Primary outcomes were time to achieve full enteral feed and duration of postoperative recovery. We aimed to recruit 200 infants (100 per group); however, the data monitoring and ethics committee recommended halting the trial before full recruitment because of significant treatment benefit in one group at interim analysis. Participants, parents, and nursing staff were unaware of treatment. Data were analysed on an intention-to-treat basis with regression analysis. The trial is registered with ClinicalTrials.gov, number NCT00144924. FINDINGS Time to achieve full enteral feeding in the open pyloromyotomy group was (median [IQR]) 23.9 h (16.0-41.0) versus 18.5 h (12.3-24.0; p=0.002) in the laparoscopic group; postoperative length of stay was 43.8 h (25.3-55.6) versus 33.6 h (22.9-48.1; p=0.027). Postoperative vomiting, and intra-operative and postoperative complications were similar between the two groups. INTERPRETATION Both open and laparoscopic pyloromyotomy are safe procedures for the management of pyloric stenosis. However, laparoscopy has advantages over open pyloromyotomy, and we recommend its use in centres with suitable laparoscopic experience.
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Affiliation(s)
- Nigel J Hall
- UCL Institute of Child Health and Great Ormond Street Hospital, London, UK
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Affiliation(s)
- Aydin Yagmurlu
- Department of Paediatric Surgery, Faculty of Medicine, Ankara University, 06100 Ankara, Turkey
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Cozzi DA, Ceccanti S, Mele E, Frediani S, Totonelli G, Cozzi F. Circumumbilical pyloromyotomy in the era of minimally invasive surgery. J Pediatr Surg 2008; 43:1802-6. [PMID: 18926211 DOI: 10.1016/j.jpedsurg.2008.02.066] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2007] [Revised: 02/18/2008] [Accepted: 02/19/2008] [Indexed: 11/26/2022]
Abstract
BACKGROUND/PURPOSE No studies have investigated the cosmetic outcome of current approaches to pyloromyotomy in infants with hypertrophic pyloric stenosis. The purpose of this study was to evaluate the final appearance of the scar in patients undergoing circumumbilical pyloromyotomy. METHODS During a 16-year period, 86 infants underwent circumumbilical pyloromyotomy at our institution. A detailed questionnaire was created to document the family members' perceptions of the esthetic appearance of the scar. Data were collected by telephone interview and at clinic visit. In addition, cosmesis was assessed by 5 staff members who scored blindly the esthetic outcome of the scars with comparative photographs, using a categorical scale. RESULTS Fifty-seven families were tracked by telephone contact. In the family questionnaire, 100% of families reported an excellent or good scar. Of these, forty-one (72%) were available for cosmetic assessment. Follow-up ranged between 5 months and 15 years (mean, 6 years). The panel members ranked the scar, on average, as excellent or good for 90% of the patients. No assessor stated that a scar was unacceptable. Intra- and interobserver agreement was 0.72 and 0.78, respectively. CONCLUSIONS Overall satisfaction with the cosmetic outcome of circumumbilical pyloromyotomy is very high.
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Affiliation(s)
- Denis A Cozzi
- Pediatric Surgery Unit, University of Rome La Sapienza, Azienda Policlinico Umberto I, Rome, RM 00161, Italy.
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Pyloric stenosis: from a retrospective analysis to a prospective clinical trial - the impact on surgical outcomes. Curr Opin Pediatr 2008; 20:311-4. [PMID: 18475101 DOI: 10.1097/mop.0b013e3282ff0de9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Pyloric stenosis is the most common surgical condition of infants. The operative approach, however, is currently debated in the literature following the application of laparoscopic and circumumbilical techniques to facilitate the pyloromyotomy. In this review, we will examine the published data and critically evaluate the influence of prospective data in delineating truths and illuminating flaws of retrospective data on a controversial topic. RECENT FINDINGS Retrospective data are highly discordant on the influence an operative approach for pyloromyotomy has on operating time, time to goal feeds, length of stay and complications. Prospective randomized data demonstrate that when the postoperative management is controlled, the approach does not influence length of recovery in a clinically relevant manner. Prospective data also demonstrate that the operating time can be the same for the laparoscopic and open approaches with no differences in complications for centers with good laparoscopic volume. There are no prospective data to contrast the circumumbilical approach with the other approaches; however there is an inherent and obvious cosmetic advantage to the laparoscopic and circumumbilical approaches, which avoid a large epigastric incision. SUMMARY The laparoscopic approach does not appear to influence length of recovery compared to the open operation. Prospective data show the laparoscopic approach results in less postoperative pain and can be done with no increase in operating time or complications.
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Gauderer MWL. Experience with a nonlaparoscopic, transumbilical, intracavitary pyloromyotomy. J Pediatr Surg 2008; 43:884-8. [PMID: 18485959 DOI: 10.1016/j.jpedsurg.2007.12.031] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2007] [Accepted: 12/03/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND/PURPOSE Ramstedt's pyloromyotomy for hypertrophic pyloric stenosis is elegant, effective, and time-honored. Although its basic principle has not changed over the last 95 years, considerable debate exists concerning the preferred access to the pylorus and the muscle-splitting technique. Reviewed here is the experience with an approach that combines the ease and safety of the "open" pyloromyotomy with the advantages of minimal invasiveness. METHODS This series encompasses 75 consecutive, prospectively recorded pyloromyotomies. A short, curved upper umbilical rim incision is made. The linea alba is transected transversally and the abdomen entered. The pylorus is grasped with a Babcock clamp and lifted to the incision, but not delivered. Two 3:0 guy sutures are placed in the hypertrophied musculature to lift and maintain the pylorus in place. A longitudinal serosal incision is made and deepened to 1 to 3 mm. Two double-pronged skin hooks are placed, one on each partially separated edge, and gentle upward and outward traction applied until complete splitting is achieved. The mucosa is not touched by an instrument. RESULTS The age of the 75 children ranged from 9 to 89 days (mean, 40; median, 36). Their weight ranged from 2.4 to 5.4 kg (mean, 3.7 kg; median, 3.6). Fifty-seven were boys. The mean operating time was 28 minutes. The pyloric muscle splitting was performed by general surgical residents in 66. There were no mucosal injuries. Seventy-two children were discharged within 24 hours, the remaining within 48 hours. Two superficial wound infections and one suture reaction occurred. There were no recurrences. CONCLUSION Transumbilical intracavitary pyloromyotomy is a safe, reproducible procedure combining the advantages of the two most commonly employed approaches (traditional "open" and laparoscopic). Because the pylorus is not delivered, a smaller incision is used. The scar is virtually invisible. The safety of this procedure renders it well suited for the teaching setting.
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Affiliation(s)
- Michael W L Gauderer
- Division of Pediatric Surgery, Children's Hospital, Greenville Hospital System University Medical Center, Greenville, SC 29605, USA.
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Haricharan RN, Aprahamian CJ, Morgan TL, Harmon CM, Georgeson KE, Barnhart DC. Smaller scars--what is the big deal: a survey of the perceived value of laparoscopic pyloromyotomy. J Pediatr Surg 2008; 43:92-6; discussion 96. [PMID: 18206463 DOI: 10.1016/j.jpedsurg.2007.09.026] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2007] [Accepted: 09/02/2007] [Indexed: 11/26/2022]
Abstract
PURPOSE Laparoscopic and open pyloromyotomies are equally safe and effective, with the principal benefit of laparoscopy being better cosmesis. The goal of this study was to measure the perceived value of laparoscopic pyloromyotomy. METHODS Four hundred sixteen subjects (177 college freshmen, 126 first-year medical students, and 101 parents) were asked to complete a questionnaire after photographs of mature pyloromyotomy (open and laparoscopic) scars were shown to them. To measure the perceived value, subjects' willingness to pay hypothetical additional out-of-pocket expenses for their preferred operation was assessed. Data were analyzed using Cochran-Mantel-Haenszel test, t test and multivariable regression. RESULTS Four hundred four surveys were complete. Overall, 74% preferred the appearance after laparoscopy. Eighty-eight percent would pay an additional out-of-pocket amount for their daughter and 85% for their son to have the cosmetic outcome after laparoscopy. Respondents were willing to pay more for their daughters (P < .0001) and sons (P < .0001) than themselves. As expected, income level (P < .0001) influenced the willingness to pay, whereas ethnicity, education, number of children, and sex did not. CONCLUSIONS The cosmetic benefit of laparoscopic pyloromyotomy was valued by a wide demographic with 85% being willing to pay additional expenses for their children to have smaller scars.
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Affiliation(s)
- Ramanath N Haricharan
- Division of Pediatric Surgery, University of Alabama at Birmingham, Birmingham, AL 35233, USA
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Vegunta RK, Woodland JH, Rawlings AL, Wallace LJ, Pearl RH. Practice Makes Perfect: Progressive Improvement of Laparoscopic Pyloromyotomy Results, with Experience. J Laparoendosc Adv Surg Tech A 2008; 18:152-6. [PMID: 18266596 DOI: 10.1089/lap.2007.0172] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ravindra K. Vegunta
- Department of Pediatric Surgery, Children's Hospital of Illinois at OSF St. Francis Medical Center, Peoria, Illinois
| | - Jay H. Woodland
- Department of Surgery, University of Illinois College of Medicine at Peoria, Peoria, Illinois
| | - Arthur L. Rawlings
- Department of Surgery, University of Illinois College of Medicine at Peoria, Peoria, Illinois
| | - Lizabeth J. Wallace
- Department of Surgery, University of Illinois College of Medicine at Peoria, Peoria, Illinois
| | - Richard H. Pearl
- Department of Pediatric Surgery, Children's Hospital of Illinois at OSF St. Francis Medical Center, Peoria, Illinois
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Haricharan RN, Aprahamian CJ, Celik A, Harmon CM, Georgeson KE, Barnhart DC. Laparoscopic pyloromyotomy: effect of resident training on complications. J Pediatr Surg 2008; 43:97-101. [PMID: 18206464 DOI: 10.1016/j.jpedsurg.2007.09.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2007] [Accepted: 09/02/2007] [Indexed: 01/17/2023]
Abstract
PURPOSE The purpose of this study was to characterize the safety of laparoscopic pyloromyotomy and examine the effect of resident training on the occurrence of complications. METHODS Five hundred consecutive infants who underwent laparoscopic pyloromyotomy between January 1997 and December 2005 were reviewed and analyzed. RESULTS Laparoscopic pyloromyotomy was successfully completed in 489 patients (97.8%). Four hundred seventeen patients were boys (83%). Intraoperative complication occurred in 8 (1.6%) patients (mucosal perforation, 7; serosal injury to the duodenum, 1). All were immediately recognized and uneventfully repaired. Six patients (1.2%) required revision pyloromyotomy for persistent or recurrent gastric outlet obstruction. There were 7 wound complications (1.4%) and no deaths. Pediatric surgery residents performed 81% of the operations, whereas 16% were done by general surgery residents (postgraduate years 3-4). There was a 5.4-fold increased risk of mucosal perforation or incomplete pyloromyotomy when a general surgery resident rather than a pediatric surgery resident performed the operation (95% confidence interval, 1.8-15.8; P = .003). These effects persisted even after controlling for weight, age, and attending experience. CONCLUSIONS The laparoscopic pyloromyotomy has an excellent success rate with low morbidity. The occurrence of complications is increased when the operation is performed by a general surgery resident, even when directly supervised by pediatric surgical faculty.
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Affiliation(s)
- Ramanath N Haricharan
- Division of Pediatric Surgery, University of Alabama at Birmingham, Birmingham, AL 35233, USA
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Dozier K, Kim S. Vascular clamp stabilization of pylorus during laparoscopic pyloromyotomy. Pediatr Surg Int 2007; 23:1237-9. [PMID: 17909819 DOI: 10.1007/s00383-007-1913-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/27/2007] [Indexed: 10/22/2022]
Abstract
We describe a technique of grasping the pylorus during laparoscopic pyloromyotomy using a percutaneously inserted vascular clamp. The use of the vascular clamp results in better visualization and stabilization during laparoscopic pyloromyotomy.
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Affiliation(s)
- Kristopher Dozier
- Department of Surgery, University of California San Francisco-East Bay, Oakland, CA, USA
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Campbell BT, McVay MR, Lerer TJ, Lowe NJ, Smith SD, Kokoska ER. Ghosts in the machine: a multi-institutional comparison of laparoscopic and open pyloromyotomy. J Pediatr Surg 2007; 42:2026-9. [PMID: 18082701 DOI: 10.1016/j.jpedsurg.2007.08.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2007] [Accepted: 08/08/2007] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The purpose of this study was to compare laparoscopic and open pyloromyotomy using data from multiple centers in the United States. METHODS Children's hospitals that have a predominant surgical approach to pyloromyotomy were identified in the Pediatric Health Information System database. Using 2005 data, institutions were stratified into open (OPEN) and laparoscopic (LAP) groups. Patients with significant comorbid conditions were excluded. Group differences were compared using t tests and Mann-Whitney nonparametric tests for continuous variables and exact tests for categorical variables. RESULTS A total of 3 hospitals were in the LAP group (n = 207), and 4 hospitals were in the OPEN group (n = 357). The LAP group had a longer mean length of stay (LAP = 2.5 +/- 1.7, OPEN = 2.1 +/- 1.4 days; P = .02). Mean total hospital charges were similar in both groups (LAP = $11307 +/- 9499, OPEN = $11245 +/- 4841; P = .93), but there was significant skewness of the distribution for the LAP group. Nonparametric analysis demonstrated a statistically significant difference in charges (LAP median = $9727, min = $5075, max = $94323, OPEN median = $10001, min = $1614, max = $46461; P = .004). Four patients in the LAP group had charges ranging from approximately $56000 to $94000, which may have resulted from surgical complications. CONCLUSION Prolonged length of stay and skewed hospital charge data in patients undergoing laparoscopic pyloromyotomy may be the result of rare but serious complications associated with the laparoscopic approach.
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van den Ende ED, Allema JH, Hazebroek FWJ, Breslau PJ. Can pyloromyotomy for infantile hypertrophic pyloric stenosis be performed in any hospital? Results from two teaching hospitals. Eur J Pediatr 2007; 166:553-7. [PMID: 16977435 DOI: 10.1007/s00431-006-0277-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2006] [Accepted: 07/26/2006] [Indexed: 10/24/2022]
Abstract
In order to document the incidence of perioperative complications in patients with infantile hypertrophic pyloric stenosis, a descriptive cohort study was performed in two teaching hospitals in the Netherlands. One hospital specialized in pediatric surgery and the other was a general surgery teaching hospital. All consecutive infants who underwent pyloromyotomy for the diagnosis hypertrophic pyloric stenosis in both hospitals between 1998 and 2002 were included. The children were diagnosed and treated according to a standard protocol. From all charts, complications durante- and post-operationem were recorded. A total of 256 pyloromyotomies were performed. Registered perioperative complications were duodenal mucosal perforation (n=6; 2%). Perioperatively unrecognized duodenal mucosal perforation occurred four times (1%). One re-operation was performed for an incomplete pyloromyotomy (0.3%). Persistent vomiting after the operation occurred in 18 children (7%). A large majority of postoperative complications were wound infections (n=16; 6%), 12 after right upper quadrant incision and 4 after umbilical incision; most of them were treated with antibiotics and/or incision for drainage of an abscess. An incisional hernia occurred four times. Prolonged vomiting was the only postoperative complication that differed significantly between the two teaching hospitals. The overall percentages of complications were equal to complication rates in literature, and since there were no extensive differences in major complications between the two teaching hospitals in this study, we can conclude that pyloromyotomy can be performed safely in specialized centers and in general centers provided with a multidisciplinary team.
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Affiliation(s)
- Esther D van den Ende
- Department of Surgery, Haga Hospital, Red Cross Hospital/Juliana Children's Hospital, Sportlaan 600, The Hague, The Netherlands.
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Leclair MD, Plattner V, Mirallie E, Lejus C, Nguyen JM, Podevin G, Heloury Y. Laparoscopic pyloromyotomy for hypertrophic pyloric stenosis: a prospective, randomized controlled trial. J Pediatr Surg 2007; 42:692-8. [PMID: 17448768 DOI: 10.1016/j.jpedsurg.2006.12.016] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Several authors have reported on laparoscopic pyloromyotomy (LP) since the technique was originally described in 1990, but its benefits remain unproven. We performed a randomized controlled trial comparing LP to open circumumbilical pyloromyotomy (OP) for hypertrophic pyloric stenosis. METHODS In a prospective study, 102 infants with pyloric stenosis were randomly assigned to either LP (n = 50) or OP (n = 52). The primary outcome measure was the incidence of postoperative vomiting; the secondary parameters were the durations of surgery and anesthesia, surgical complications, and postoperative pain. All infants were managed according to standardized procedures regarding general anesthesia, surgical technique, postoperative analgesia, and feeding regimen. Parents, carers, and assessors responsible for the postoperative evaluation were blinded for the technique used. RESULTS There was no difference in the incidence of postoperative vomiting between the 2 groups. The overall incidence of complications was similar, but the durations of surgery and general anesthesia were significantly longer in the LP group than in the OP group (P = 10(-4) and P = .02, respectively). There were 3 cases of incomplete pyloromyotomy after laparoscopy, requiring a repeat procedure. CONCLUSIONS Laparoscopic pyloromyotomy does not decrease the incidence of postoperative vomiting, has a similar complication rate compared with the open umbilical approach, but may expose patients to a risk of inadequate pyloromyotomy.
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Affiliation(s)
- Marc-David Leclair
- Department of Paediatric Surgery, Hôpital Mère-Enfant, 44093 Nantes, France.
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Abstract
Hypertrophic pyloric stenosis (HPS) is a common condition affecting infants that presents with progressive projectile nonbilious vomiting. The pyloric portion of the stomach becomes abnormally thickened and manifests as gastric outlet obstruction. The cause is unknown. Pyloromyotomy remains the standard of treatment and outcome is excellent. This article reviews the diagnostic work up and imaging, preoperative resuscitation, the various surgical approaches used, and the effect of subspecialty training on outcomes after pyloromyotomy. Postoperative care and the variety of postoperative feeding regimens applied after pyloromyotomy are reviewed, as well as intra- and postoperative complications. Finally, medical management, in lieu of surgery, is discussed.
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Affiliation(s)
- Gudrun Aspelund
- Division of General Surgery, University of Toronto, Hospital for Sick Children, Toronto, Ontario, Canada
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Aldridge RD, MacKinlay GA, Aldridge RB. Choice of Incision: The Experience And Evolution of Surgical Management of Infantile Hypertrophic Pyloric Stenosis. J Laparoendosc Adv Surg Tech A 2007; 17:131-6. [PMID: 17362191 DOI: 10.1089/lap.2006.0525] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE This study evaluated the impact of laparoscopic pyloromyotomy since it came into use at our institution in March 1999. MATERIALS AND METHODS The recovery profiles and intraoperative and postoperative complications of 170 infants who underwent laparoscopic, semicircumumbilical incision, or right upper quadrant incision pyloromyotomies between March 1999 and April 2005 were analyzed. RESULTS Eighty-one (48%) of operations were undertaken laparoscopically, 51 (30%) by traditional right upper quadrant incision, and 38 (22%) by semicircumumbilical incision. Patient group demographics were similar across all groups. There was no significant difference in overall complication rate between procedures: laparoscopic group, 12.3% (10/81); semicircumumbilical incision group, 18.4% (7/38); and right upper quadrant incision group, 9.8% (5/51). Early in the laparoscopic series there were 2 inadequate pyloromyotomies and 2 conversions to open procedures due to perforation (n = 1) and poor visibility (n = 1). Infections were more common with open surgery: laparoscopic, 1.2% (n = 1), right upper quadrant incision, 7.8% (n = 4), and semicircumumbilical incision, 13.2% (n = 5). Operative correction was required for herniation at 3 laparoscopic incision sites (3.6%), 2 semicircumumbilical incision sites (5.3%), and 2 right upper quadrant incision sites (3.9%). Patients who underwent laparoscopy returned to full feeds faster (laparoscopic, 18.1 hours; right upper quadrant incision, 28.1 hours; and semicircumumbilical incision, 28.9 hours) (P < 0.05), required less analgesia (laparoscopic, 2.1 doses; right upper quadrant incision, 4.0 doses; and semicircumumbilical incision, 4.3 doses) (P < 0.05), and had less emesis (laparoscopic, 1.6 episodes; right upper quadrant incision, 2.9 episodes; and semicircumumbilical incision, 3.5 episodes) (P < 0.05), resulting in faster discharge (laparoscopic, 2.0 days; right upper quadrant incision, 3.1 days; and semicircumumbilical incision, 3.2 days) (P < 0.05). CONCLUSION Laparoscopic pyloromytomy is as effective and safe as open procedures and is associated with an improved recovery profile. We conclude that, where laparoscopic skills exist, laparoscopy should be the management of choice for hypertrophic pyloric stenosis.
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Affiliation(s)
- Roderick D Aldridge
- Department of Surgery, Royal Hospital for Sick Children, Edinburgh, United Kingdom
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Affiliation(s)
- Daniel J Ostlie
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
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St Peter SD, Holcomb GW, Calkins CM, Murphy JP, Andrews WS, Sharp RJ, Snyder CL, Ostlie DJ. Open versus laparoscopic pyloromyotomy for pyloric stenosis: a prospective, randomized trial. Ann Surg 2006; 244:363-70. [PMID: 16926562 PMCID: PMC1856534 DOI: 10.1097/01.sla.0000234647.03466.27] [Citation(s) in RCA: 159] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Pyloric stenosis, the most common surgical condition of infants, is treated by longitudinal myotomy of the pylorus. Comparative studies to date between open and laparoscopic pyloromyotomy have been retrospective and report conflicting results. To scientifically compare the 2 techniques, we conducted the first large prospective, randomized trial between the 2 approaches. METHODS After obtaining IRB approval, subjects with ultrasound-proven pyloric stenosis were randomized to either open or laparoscopic pyloromyotomy. Postoperative pain management, feeding schedule, and discharge criteria were identical for both groups. Operating time, postoperative emesis, analgesia requirements, time to full feeding, length of hospitalization after operation, and complications were compared. RESULTS From April 2003 through March 2006, 200 patients were enrolled in the study. There were no significant differences in operating time, time to full feeding, or length of stay. There were significantly fewer number of emesis episodes and doses of analgesia given in the laparoscopic group. One mucosal perforation and one incisional hernia occurred in the open group. Late in the study, 1 patient in the laparoscopic group was converted to the open operation. A wound infection occurred in 4 of the open patients compared with 2 of the laparoscopic patients (P = 0.68). CONCLUSIONS There is no difference in operating time or length of recovery between open and laparoscopic pyloromyotomy. However, the laparoscopic approach results in less postoperative pain and reduced postoperative emesis. In addition, there was a fewer number of complications in the laparoscopic group. Finally, patients approached laparoscopically will likely display superior cosmetic outcomes with long-term follow-up.
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Affiliation(s)
- Shawn D St Peter
- Center for Prospective Clinical Trials, Children's Mercy Hospital, Kansas City, MO 64108, USA
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Adibe OO, Nichol PF, Flake AW, Mattei P. Comparison of outcomes after laparoscopic and open pyloromyotomy at a high-volume pediatric teaching hospital. J Pediatr Surg 2006; 41:1676-8. [PMID: 17011267 DOI: 10.1016/j.jpedsurg.2006.05.051] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND/PURPOSE Laparoscopic pyloromyotomy (LP) is used widely for treatment of hypertrophic pyloric stenosis. We examined the results of pyloromyotomy at a high-volume pediatric teaching hospital to compare outcomes of laparoscopic and open pyloromyotomy (OP). METHODS We reviewed the records of all patients who underwent pyloromyotomy at our institution over a 5-year period. Data were collected regarding operative time, time to full feeds, length of hospital stay, complications, and frequency of postoperative emesis. RESULTS There were 335 pyloromyotomies: 212 laparoscopic and 123 open. Five patients in the laparoscopic group required conversion to an open procedure. There were no significant differences in operative time (LP, 30.5 minutes; OP, 32.0 minutes), time to full feeds (LP, 22.4 hours; OP, 23.5 hours), frequency of postoperative emesis (LP, 1.8; OP, 2.2), or length of hospital stay (LP, 49.3 hours; OP, 50.5 hours). There were 5 mucosal perforations in the laparoscopic group and 2 in the open group (LP, 2.3%; OP, 1.6%). There were 3 incomplete pyloromyotomies in the laparoscopic group and none in the open group. Four perforations and all incomplete myotomies occurred in the first 2 years after the laparoscopic technique was introduced at our institution. The overall complication rate was similar (LP, 3.7%; OP, 3.2%). CONCLUSIONS Laparoscopic pyloromyotomy is a safe and effective alternative to OP. There appears to be an institutional learning curve when the laparoscopic technique is introduced as reflected by slightly higher rates of mucosal injury and incomplete pyloromyotomy.
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Affiliation(s)
- Obinna O Adibe
- General, Thoracic, and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA 19104-4399, USA
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