Is There a Relation Between Pyloric Muscle Thickness and Clinical and Laboratory Data in Infants with Hypertrophic Pyloric Stenosis?

Utility of Pyloric Length Measurement for Detecting Severe Metabolic Alkalosis in Infants with Hypertrophic Pyloric Stenosis

Purpose

Infantile hypertrophic pyloric stenosis (IHPS) is a common gastrointestinal disease in neonates and hypochloremia metabolic alkalosis is a typical laboratory finding in affected patients. This study aimed to analyze the clinical characteristics of infants with IHPS and evaluate the association of clinical and laboratory parameters with ultrasonographic findings.

Methods

Infants diagnosed with IHPS between January 2017 and July 2022 were retrospectively evaluated.

Results

A total of 67 patients were included in the study. The mean age at diagnosis was 40.5±19.59 days, and the mean symptom duration was 11.97±9.91 days. The mean pyloric muscle thickness and pyloric canal length were 4.87±1.05 mm and 19.6±3.46 mm, respectively. Hyponatremia and metabolic alkalosis were observed in five (7.5%) and 36 (53.7%) patients, respectively. Serum sodium (p=0.011), potassium (p=0.023), and chloride levels (p=0.015) were significantly lower in patients with high bicarbonate levels (≥30 mmol/L). Furthermore, pyloric canal length was significantly higher in patients with high bicarbonate levels (p=0.015). To assess metabolic alkalosis in IHPS patients, the area under the receiver operating characteristic curve of pyloric canal length was 0.910 and the optimal cutoff value of the pyloric canal length was 23.5 mm.

Conclusion

We found a close association between laboratory and ultrasonographic findings of IHPS. Clinicians should give special consideration to patients with pyloric lengths exceeding 23.5 mm and appropriate fluid rehydration should be given to these patients.

Open Versus Laparoscopic Pyloromyotomy for Pyloric Stenosis-A Systematic Review and Meta-Analysis

INTRODUCTION

Infantile hypertrophic pyloric stenosis is treated by either open pyloromyotomy (OP) or laparoscopic pyloromyotomy (LP). The aim of this meta-analysis was to compare the open versus laparoscopic technique.

METHODS

A literature search was conducted from 1990 to February 2021 using the electronic databases MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. Primary outcomes were mucosal perforation and incomplete pyloromyotomy. Secondary outcomes consisted of length of hospital stay, time to full feeds, operating time, postoperative wound infection/abscess, incisional hernia, hematoma/seroma formation, and death.

RESULTS

Seven randomized controlled trials including 720 patients (357 with OP and 363 with LP) were included. Mucosal perforation rate was not different between groups (relative risk [RR] LP versus OP 1.60 [0.49-5.26]). LP was associated with nonsignificant higher risk of incomplete pyloromyotomy (RR 7.37 [0.92-59.11]). There was no difference in neither postoperative wound infections after LP compared with OP (RR 0.59 [0.24-1.45]) nor in postoperative seroma/hematoma formation (RR 3.44 [0.39-30.43]) or occurrence of incisional hernias (RR 1.01 [0.11-9.53]). Length of hospital stay (-3.01 h for LP [-8.39 to 2.37 h]) and time to full feeds (-5.86 h for LP [-15.95 to 4.24 h]) were nonsignificantly shorter after LP. Operation time was almost identical between groups (+0.53 min for LP [-3.53 to 4.59 min]).

CONCLUSIONS

On a meta-level, there is no precise effect estimate indicating that LP carries a higher risk for mucosal perforation or incomplete pyloromyotomies compared with the open equivalent. Because of very low certainty of evidence, we do not know about the effect of the laparoscopic approach on postoperative wound infections, postoperative hematoma or seroma formation, incisional hernia occurrence, length of postoperative stay, time to full feeds, or operating time.

Open versus laparoscopic pyloromyotomy for pyloric stenosis

BACKGROUND

Infantile hypertrophic pyloric stenosis (IHPS) is a disorder of young children (aged one year or less) and can be treated by laparoscopic (LP) or open (OP) longitudinal myotomy of the pylorus. Since the first description in 1990, LP is being performed more often worldwide.

OBJECTIVES

To compare the efficacy and safety of open versus laparoscopic pyloromyotomy for IHPS.

SEARCH METHODS

We conducted a literature search on 04 February 2021 to identify all randomised controlled trials (RCTs), without any language restrictions. We searched the following electronic databases: MEDLINE (1990 to February 2021), Embase (1990 to February 2021), and the Cochrane Central Register of Controlled Trials (CENTRAL). We also searched the Internet using the Google Search engine (www.google.com) and Google Scholar (scholar.google.com) to identify grey literature not indexed in databases.

SELECTION CRITERIA

We included RCTs and quasi-randomised trials comparing LP with OP for hypertrophic pyloric stenosis.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened references and extracted data from trial reports. Where outcomes or study details were not reported, we requested missing data from the corresponding authors of the primary RCTs. We used a random-effects model to calculate risk ratios (RRs) for binary outcomes, and mean differences (MDs) for continuous outcomes. Two review authors independently assessed risks of bias. We used GRADE to assess the certainty of the evidence for all outcomes.

MAIN RESULTS

The electronic database search resulted in a total of 434 records. After de-duplication, we screened 410 independent publications, and ultimately included seven RCTs (reported in 8 reports) in quantitative analysis. The seven included RCTs enrolled 720 participants (357 with open pyloromyotomy and 363 with laparoscopic pyloromyotomy). One study was a multi-country trial, three were carried out in the USA, and one study each was carried out in France, Japan, and Bangladesh. The evidence suggests that LP may result in a small increase in mucosal perforation compared with OP (RR 1.60, 95% CI 0.49 to 5.26; 7 studies, 720 participants; low-certainty evidence). LP may result in up to 5 extra instances of mucosal perforation per 1,000 participants; however, the confidence interval ranges from 4 fewer to 44 more per 1,000 participants. Four RCTs with 502 participants reported on incomplete pyloromyotomy. They indicate that LP may increase the risk of incomplete pyloromyotomy compared with OP, but the confidence interval crosses the line of no effect (RR 7.37, 95% CI 0.92 to 59.11; 4 studies, 502 participants; low-certainty evidence). In the LP groups, 6 cases of incomplete pyloromyotomy were reported in 247 participants while no cases of incomplete pyloromyotomy were reported in the OP groups (from 255 participants). All included studies (720 participants) reported on postoperative wound infections or abscess formations. The evidence is very uncertain about the effect of LP on postoperative wound infection or abscess formation compared with OP (RR 0.59, 95% CI 0.24 to 1.45; 7 studies, 720 participants; very low-certainty evidence). The evidence is also very uncertain about the effect of LP on postoperative incisional hernia compared with OP (RR 1.01, 95% CI 0.11 to 9.53; 4 studies, 382 participants; very low-certainty evidence). Length of hospital stay was assessed by five RCTs, including 562 participants. The evidence is very uncertain about the effect of LP compared to OP (mean difference -3.01 hours, 95% CI -8.39 to 2.37 hours; very low-certainty evidence). Time to full feeds was assessed by six studies, including 622 participants. The evidence is very uncertain about the effect of LP on time to full feeds compared with OP (mean difference -5.86 hours, 95% CI -15.95 to 4.24 hours; very low-certainty evidence). The evidence is also very uncertain about the effect of LP on operating time compared with OP (mean difference 0.53 minutes, 95% CI -3.53 to 4.59 minutes; 6 studies, 622 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

Laparoscopic pyloromyotomy may result in a small increase in mucosal perforation when compared with open pyloromyotomy for IHPS. There may be an increased risk of incomplete pyloromyotomy following LP compared with OP, but the effect estimate is imprecise and includes the possibility of no difference. We do not know about the effect of LP compared with OP on the need for re-operation, postoperative wound infections or abscess formation, postoperative haematoma or seroma formation, incisional hernia occurrence, length of postoperative stay, time to full feeds, or operating time because the certainty of the evidence was very low for these outcomes. We downgraded the certainty of the evidence for most outcomes due to limitations in the study design (most outcomes were susceptible to detection bias) and imprecision. There is limited evidence available comparing LP with OP for IHPS. The included studies did not provide sufficient information to determine the effect of training, experience, or surgeon preferences on the outcomes assessed.

Application of color Doppler ultrasound combined with Doppler imaging artifacts in the diagnosis and estimate of congenital hypertrophic pyloric stenosis

Congenital Hypertrophic Pyloric Stenosis (CHPS) is a disease condition that is caused as a result of pylorus wall hypertrophy and hyperplasia. In this study, we used color Doppler flow imaging (CDFI) and Doppler artifacts technique to observe the blood flow of hypertrophic pylorus tissue and the dynamic imaging of liquid passing through the pyloric canal in CHPS infants. 65 cases of CHPS infants and 50 infants without CHPS served as control group. We found that there were statistically significant differences between the blood flow grade of muscular layer and mucosal layer between CHPS and control infants, but no significant differences were observed in the same group. Doppler artifacts technique demonstrated the whole process of contrast agent flow through pyloric canal was directly observed in 35 of 65 subjects, and the internal diameter of the pyloric canal was 1.93 ± 0.33mm.Conclusion that CDFI combined with color Doppler artifacts technique was proved to be effective to observe the distribution feature and blood flow grade in each layer of pyloric canal in CHPS patients. This method provides the evidence for judging the degree of pyloric stenosis clinically, and furnishes the basis of therapy along with its clinical significance and good application value.

Epidemiological and clinical characteristics of 304 patients with infantile hypertrophic pyloric stenosis in Anhui Province of East China, 2012-2015

OBJECTIVE

To analyze the clinical and epidemiological features of patients with infantile hypertrophic pyloric stenosis (IHPS) so as to provide scientific evidence for diagnosis and prevention of IHPS.

METHODS

We performed a retrospective study of infants with IHPS diagnosed from 2012 to 2015 at Anhui Provincial Children's Hospital. Demographic characteristics and clinical data were collected.

RESULTS

Three hundred four patients (264 males and 40 females) were studied, of which 94.7% were full term and 75.7% were bottle fed or mixed fed; 16.8% of the patients had other congenital malformations in combination with IHPS. The proportion of IHPS cases with hyponatremia, hypokalemia, and hypochloremia was 18.4%, 12.5%, and 53.9%. A negative correlation was found between duration of disease and serum electrolytes. The mean pyloric muscle thickness, pyloric length, and diameter were 4.8 ± 0.7 mm, 19.4 ± 2.5 mm, and 13.3 ± 1.8 mm, respectively. There were significant differences in muscle thickness, pyloric length, and diameter between short (≤14 d) and long (>14 d) durations of disease. All patients underwent pyloromyotomy, and postoperative recovery was good.

CONCLUSIONS

IHPS occurs mainly in male, full-term, bottle-fed or mixed-fed infants. Patients with long duration of disease were more likely to develop electrolyte disorder and thicker muscle layer. More attention should be paid to early discovery and diagnosis, which will help to improve the curative effect and prognosis of IHPS.