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Lu C, Marcin J, Staab V. Atropine as an Adjunct in the Management of Pediatric Patients With Hypertrophic Pyloric Stenosis: A Single Institution Experience and Review of the Literature. Cureus 2024; 16:e65363. [PMID: 39071076 PMCID: PMC11279068 DOI: 10.7759/cureus.65363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2024] [Indexed: 07/30/2024] Open
Abstract
Infantile hypertrophic pyloric stenosis (IHPS) is a condition whereby there is a thickening of the pyloric muscle, leading to obstruction of the gastric outflow. Typically present within three to five weeks of life, it presents as postprandial non-bilious projectile vomiting. Commonly, a pyloromyotomy is the gold standard to relieve the obstruction. However, in a subset of patients not amenable to undergo surgery or anesthesia, or for postoperative persistent or recurrent obstruction, atropine may offer an alternative treatment. A retrospective review was performed on pediatric patients with hypertrophic pyloric stenosis utilizing the electronic medical record. Data included were demographics, workup data, treatment, outcomes, and symptom resolution. Approval was obtained by the institutional review board of the host institution. Five pediatric patients, with an average age of 2.1 months, received atropine treatment for IHPS. The average time to reach full feeds since the initiation of atropine was approximately four days. Three of the five patients were successfully managed with IV atropine, which was then transitioned to oral atropine and tapered off as outpatients, leading to the resolution of symptoms. The remaining two patients were considered failures of medical management and subsequently required surgery. Atropine use as an alternative treatment for IHPS may be considered when patients are not able to undergo surgery or anesthesia or have recurrent or persistent obstructive symptoms postoperatively. In this limited study, atropine was found to be safe and effective. Randomized controlled studies may lend additional merit to this therapy in the future.
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Affiliation(s)
- Charles Lu
- Department of Pediatric Surgery, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, USA
| | - John Marcin
- Department of Pediatric Surgery, Hackensack Meridian Health School of Medicine, Nutley, USA
| | - Victoriya Staab
- Department of Pediatric Surgery, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, USA
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Mendenhall ET, Rakes L, Vernor J, Anderson M, Flesher S. Successful management of pylorospasm with atropine in a failure-to-thrive neonate case report. SAGE Open Med Case Rep 2024; 12:2050313X241236334. [PMID: 38444696 PMCID: PMC10913498 DOI: 10.1177/2050313x241236334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 02/14/2024] [Indexed: 03/07/2024] Open
Abstract
Pylorospasm is an elusive diagnosis that can mimic the presentation of pyloric stenosis. There is limited discussion regarding its management in neonates with few case reports describing the use of antispasmodic agents. The following case reviews this management in a unique neonate. A 2-month-old female presented with persistent nonbilious, nonbloody emesis and failure-to-thrive. A thorough workup was performed due to its pronounced persistence while inpatient. Pyloric ultrasounds remained negative for pyloric stenosis; however, an upper gastrointestinal (GI) study was significant for pylorospasm. The workup also revealed hypothyroidism. Antispasmodic therapy with atropine was pursued as she was not a surgical candidate. Patient tolerated IV atropine therapy well with quick resolution of emesis and successfully transitioned to oral atropine therapy, displaying continued weight gain with exclusive oral feeds. This case displays a unique presentation of pylorospasm with successful management utilizing IV and oral atropine therapy in a neonate with failure-to-thrive and concomitant hypothyroidism.
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Affiliation(s)
- Eric T Mendenhall
- Department of Pediatrics, Marshall University, Joan C Edwards School of Medicine, Huntington, WV, USA
| | - Lauren Rakes
- Department of Pediatrics, Marshall University, Joan C Edwards School of Medicine, Huntington, WV, USA
| | - Jamie Vernor
- Department of Pediatrics, Marshall University, Joan C Edwards School of Medicine, Huntington, WV, USA
| | - Madison Anderson
- Department of Pediatrics, Marshall University, Joan C Edwards School of Medicine, Huntington, WV, USA
| | - Susan Flesher
- Department of Pediatrics, Marshall University, Joan C Edwards School of Medicine, Huntington, WV, USA
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Stewart S, Cruz-Centeno N, Marlor DR, St Peter SD, Oyetunji TA. Bridging the Gap: Pediatric General Surgery for the Pediatrician. Pediatr Rev 2023; 44:632-643. [PMID: 37907417 DOI: 10.1542/pir.2022-005894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
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The Safety and Effectiveness of Laparoscopic Pyloromyotomy Using 3-mm Electrocautery Hook versus Open Surgery for Treatment of Hypertrophic Pyloric Stenosis in Infants. CHILDREN-BASEL 2021; 8:children8080701. [PMID: 34438592 PMCID: PMC8392573 DOI: 10.3390/children8080701] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 08/12/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The standard of treatment for infants with hypertrophic pyloric stenosis is still pyloromyotomy. Recently, in most of the pediatric surgery centers laparoscopic pyloromyotomy has become popular. The aim of the present study is to compare the outcomes of treatment in infants with hypertrophic pyloric stenosis between traditional open approach and laparoscopic pyloromyotomy using 3-mm electrocautery hook. METHODS A total of 125 infants, 104 (83.2%) males, with median age 33 (interquartile range, IQR 24, 40) days, who underwent pyloromyotomy because of hypertrophic pyloric stenosis, between 2005 and 2021, were included in the retrospective study. Of that number 61 (48.8%) infants were allocated to the open group and 64 (51.2%) to the laparoscopic group. The groups were compared in regards to time to oral intake, duration of surgery, the type and rate of complications, rate of reoperations, frequency of vomiting after surgery, and the length of hospital stay. RESULTS No differences were found with regards to baseline characteristics between two investigated groups. Laparoscopic approach was associated with significantly better outcomes compared to open approach: shorter duration of surgery (35 min (IQR 30, 45) vs. 45 min (40, 57.5); p = 0.00008), shorter time to oral intake (6 h (IQR 4, 8) vs. 22 h (13.5, 24); p < 0.00001), lower frequency of postoperative vomiting (n = 10 (15.6%) vs. n = 19 (31.1%)), and shorter length of postoperative hospital stay (3 days (IQR 2, 3) vs. 6 days (4.5, 8); p < 0.00001). In regards to complications and reoperation rates, both were lower in the laparoscopic pyloromyotomy group but the differences were not statistically significant (p = 0.157 and p = 0.113, respectively). The most common complication in both groups was mucosal perforation (open group, n = 3 (4.9%); laparoscopic group, n = 2 (3.1%)) followed by wound infection in open group, n = 3 (4.9%). No cases of wound infection were recorded in the laparoscopic group. CONCLUSION Open and laparoscopic pyloromyotomy are equally safe and effective in treatment of hypertrophic pyloric stenosis. Laparoscopic technique is associated with faster recovery, shorter duration of surgery and shorter duration of hospital stay.
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Ono S, Takenouchi A, Terui K, Yoshida H, Terui E. Risk factors for unsuccessful atropine therapy in hypertrophic pyloric stenosis. Pediatr Int 2019; 61:1151-1154. [PMID: 31520503 DOI: 10.1111/ped.14009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 07/17/2019] [Accepted: 09/10/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND I.v. atropine (IA) for infantile hypertrophic pyloric stenosis (IHPS) is a good alternative to pyloromyotomy but has not been broadly accepted. The lower success rate is one of the greatest disadvantages of IA. We investigated the risk factors for unsuccessful results following IA for IHPS. METHODS Medical records of patients with IHPS who were admitted to Kimitsu Chuo Hospital between 2002 and 2016 and were initially given atropine sulfate were retrospectively reviewed. Atropine was given i.v. (0.1 mg/kg/day in eight divided doses). Oral feeding of milk was started with a small amount and increased in a stepwise fashion to full feed. IA therapy was defined as unsuccessful in the presence of projectile vomiting more than three times a day or intolerance to a predetermined amount of milk. RESULTS Of the 48 patients with IHPS, 33 patients were successfully treated with IA and 15 patients needed surgical intervention. On univariate analysis the risk factors for unsuccessful IA therapy were younger age, lower bodyweight, and shorter duration of symptoms before diagnosis. On multivariate analysis age at diagnosis < 30 days was the only significant risk factor for unsuccessful IA therapy (OR, 5.7 l P = 0.03). CONCLUSIONS Age at diagnosis < 30 days is a risk factor for unsuccessful IA therapy in IHPS. This might be considered when IA therapy is used for neonates with IHPS.
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Affiliation(s)
- Sachie Ono
- Department of Pediatric Surgery, Kimitsu Chuo Hospital, Kisarazu City, Chiba, Japan
| | - Ayako Takenouchi
- Department of Pediatric Surgery, Kimitsu Chuo Hospital, Kisarazu City, Chiba, Japan
| | - Keita Terui
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, Chiba City, Chiba, Japan
| | - Hideo Yoshida
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, Chiba City, Chiba, Japan
| | - Elena Terui
- Department of Pediatric Surgery, Kimitsu Chuo Hospital, Kisarazu City, Chiba, Japan
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Al-Mayoof AF, Doghan IK. Late onset Infantile Hypertrophic Pyloric Stenosis. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2018. [DOI: 10.1016/j.epsc.2017.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Anesthesia for Hypertrophic Pyloric Stenosis. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Pandita A, Sharma D, Murki S, Oleti TP, Leelakumar V. Transient neonatal myasthenia gravis with infantile hypertrophic pyloric stenosis: coincidence or causation? Trop Doct 2017; 48:164-165. [PMID: 29099348 DOI: 10.1177/0049475517734117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | - Deepak Sharma
- 2 Consultant Neonatology, NIMS Hospital, Jaipur, India
| | - Srinivas Murki
- 3 Cheif Neonatologist, Fernandez Hospital, Hyderabad, India
| | | | - Vallamsetty Leelakumar
- 5 Consultant, Pediatric Surgery, Suraksha Children's Hospital, Tarnaka, Hyderabad, India
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Taghavi K, Powell E, Patel B, McBride CA. The treatment of pyloric stenosis: Evolution in practice. J Paediatr Child Health 2017; 53:1105-1110. [PMID: 29148193 DOI: 10.1111/jpc.13736] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 12/04/2016] [Accepted: 01/12/2017] [Indexed: 01/28/2023]
Abstract
Over the last hundred years, idiopathic hypertrophic pyloric stenosis has undergone an evolution in treatment, with subsequent improvements in outcome. Initially, it was treated by physicians with antispasmodics and various alternative feeding and resuscitation modalities. The evolution of surgical approaches led to a revolution in outcome, from almost certain death to complete cure. The progression of surgical and medical treatments is reviewed in this article until, ultimately, Ramstedt's pyloromyotomy is reached. This distilled operation has remained the gold-standard procedure for over a century.
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Affiliation(s)
- Kiarash Taghavi
- Department of General Surgery, Hutt Hospital, Lower Hutt, New Zealand
| | - Emma Powell
- Department of Vascular Surgery, Wellington Hospital, Wellington, New Zealand
| | - Bhaveshkumar Patel
- Surgical Team: Infants, Toddlers, Children (STITCh), Lady Cilento Children's Hospital, Brisbane, Queensland, Australia
| | - Craig A McBride
- Surgical Team: Infants, Toddlers, Children (STITCh), Lady Cilento Children's Hospital, Brisbane, Queensland, Australia
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Adverse Events and Resource Utilization After Spinal and General Anesthesia in Infants Undergoing Pyloromyotomy. Reg Anesth Pain Med 2017; 41:532-7. [PMID: 27281725 DOI: 10.1097/aap.0000000000000421] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND OBJECTIVES Interest in spinal anesthesia (SA) is increasing because of concern about the long-term effects of intravenous (IV) and inhaled anesthetics in young children. This study compared SA versus general anesthesia (GA) in infants undergoing pyloromyotomy. METHODS Between 2000 to 2013, the University of Vermont Medical Center almost exclusively used SA for infant pyloromyotomy surgery, whereas Columbia University Medical Center relied on GA. Outcomes included adverse events (AEs) within 48 hours of surgery, operating room (OR) time, and postoperative length of stay (LOS). Regression was used to evaluate the association between anesthesia technique and outcomes, accounting for demographic and clinical covariates. RESULTS We studied 218 infants with SA at the University of Vermont Medical Center and 206 infants with GA at Columbia University Medical Center. In the SA group, 96.3% of infants had adequate initial analgesic levels, but 35.8% required supplemental IV or inhaled anesthetic agents. Compared with GA, the risk of AEs in SA (adjusted odds ratio, 0.60; 95% confidence interval [CI], 0.27-1.36) did not significantly differ, but SA was associated with shorter OR times (17.5 minutes faster; 95% CI, 13.5-21.4 minutes) and shorter postoperative LOS (GA is 1.19 times longer; 95% CI, 1.01-1.40). CONCLUSIONS Infants undergoing pyloromyotomy with SA had shorter OR times and postoperative LOS, no significant differences in AE rates, and decreased exposure to IV and inhaled anesthetics, although SA infants often still required supplemental anesthetics. Whether these differences result in any long-term benefit is unclear; further studies are needed to determine the risk of rare AEs, such as aspiration.
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Pyloric Stenosis. Anesthesiology 2017. [DOI: 10.1007/978-3-319-50141-3_55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Cubas RF, Longshore S, Rodriguez S, Tagge E, Baerg J, Moores D. Atropine: A Cure for Persistent Post Laparoscopic Pyloromyotomy Emesis? J Neonatal Surg 2017; 6:2. [PMID: 28083488 PMCID: PMC5224753 DOI: 10.21699/jns.v6i1.485] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 11/06/2016] [Indexed: 11/27/2022] Open
Abstract
Background: Atropine has been used as a successful primary medical treatment for hypertrophic pyloric stenosis. Several authors have reported a higher rate of incomplete pyloromyotomy with the laparoscopic approach compared to open. In this study, we evaluated the use of atropine as a medical treatment for infants with emesis persisting greater than 48 hours after a laparoscopic pyloromyotomy.
Materials and Methods: We performed a retrospective chart review of infants receiving a laparoscopic pyloromyotomy between November 1998 and November 2012. Infants with emesis that persisted beyond 48 hours postoperatively were given 0.01mg/kg of oral atropine 10 minutes prior to feeding. Infants remained inpatient until they tolerated two consecutive feedings without emesis.
Results: 965 patients underwent laparoscopic pyloromyotomy; 816 (84.6%) male and 149 (15.4%) female. Twenty-four (2.5%) received oral atropine. The mean length of stay for patients who received atropine was 5.6 ± 2.6 days, an average of 3 additional days. They were discharged home with a one-month supply of oral atropine. Follow up evaluation did not reveal any complications from receiving atropine. The median follow up was 21 days. None returned to the operating room for incomplete pyloromyotomy. There were 17 (1.8%) operative complications in our series; 9 mucosal perforations, 2 duodenal perforations, and 6 conversions to open for equipment failure or poor exposure. There were 4 (0.4%) post-operative complications: 2 episodes of apnea requiring reintubation and 2 incisional hernias that required a second operation. There were no deaths.
Conclusion: Oral atropine is a viable treatment for persistent emesis after a pyloromyotomy and reduces the need for a second operation due to incomplete pyloromyotomy.
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Affiliation(s)
- Robert Frank Cubas
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Shannon Longshore
- Division of Pediatric Surgery, Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Samuel Rodriguez
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Edward Tagge
- Division of Pediatric Surgery, Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Joanne Baerg
- Division of Pediatric Surgery, Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Donald Moores
- Division of Pediatric Surgery, Loma Linda University Children's Hospital, Loma Linda, CA, USA
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Wu SF, Lin HY, Huang FK, Chen AC, Su BH, Li CI, Lin HC. Efficacy of Medical Treatment for Infantile Hypertrophic Pyloric Stenosis: A Meta-analysis. Pediatr Neonatol 2016; 57:515-521. [PMID: 27215474 DOI: 10.1016/j.pedneo.2016.02.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 01/21/2016] [Accepted: 02/21/2016] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Infantile hypertrophic pyloric stenosis (IHPS) is a common disease in infancy. Pyloromyotomy is universally considered the treatment for IHPS; however, oral or intravenous atropine has been reappraised for the treatment of IHPS in the past 20 years. We investigated the efficacy of atropine in the medical management of IHPS by using meta-analysis and investigated the sonographic changes of the pyloric canal, as well as the efficacy and adverse effects of atropine. METHODS Information was retrieved from PubMed, Ovid, and MEDLINE. The efficacy and adverse effects of atropine treatment for IHPS were reviewed using the standard process of meta-analysis. RESULTS Eleven articles were obtained. Five reports showed that 77 of 110 (70%) infants who were administered oral atropine benefitted by the induced remission of IHPS. Six reports showed that 288 of 345 (83.5%) patients who were treated initially with intravenous atropine then changed to oral atropine showed beneficial effects and had no serious side effects. Time to pyloric muscle normalization ranged from 5 weeks to 15 months. CONCLUSION The study results indicate that atropine is a possible alternative treatment for IHPS, particularly in infants with major concurrent disease, and is safe without obvious side effects.
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Affiliation(s)
- Shu-Fen Wu
- Department of Pediatrics, China Medical University Children's Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan
| | - Hsiang-Yu Lin
- Department of Pediatrics, China Medical University Children's Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan
| | - Fu-Kuei Huang
- Department of Pediatrics, China Medical University Children's Hospital, Taichung, Taiwan
| | - An-Chyi Chen
- Department of Pediatrics, China Medical University Children's Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan
| | - Bai-Horng Su
- Department of Pediatrics, China Medical University Children's Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan
| | - Chia-Ing Li
- School of Medicine, China Medical University, Taichung, Taiwan; Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Hung-Chih Lin
- Department of Pediatrics, China Medical University Children's Hospital, Taichung, Taiwan; School of Chinese Medicine, China Medical University, Taichung, Taiwan.
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Miyata S, Cho J, Matsushima K, Fowler A, Bliss DW. Operative outcomes of infantile hypertrophic pyloric stenosis in patients with congenital heart disease. J Pediatr Surg 2016; 51:1755-1758. [PMID: 27528563 DOI: 10.1016/j.jpedsurg.2016.07.002] [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: 02/18/2016] [Revised: 05/13/2016] [Accepted: 07/02/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE This study aims to compare the outcomes of pyloromyotomy for infantile hypertrophic pyloric stenosis (IHPS) in children with and without congenital heart disease (CHD). METHODS A retrospective, single pediatric center, case-control, matched cohort study was performed over 10years. A case of IHPS with CHD was paired with control patients of IHPS without CHD, matched by age and gender. Perioperative morbidity, 30-day mortality, length of hospital stay, and hospital cost were compared. Subgroups were analyzed based on the severity of CHD and the reason for admission. RESULTS Twenty-six patients who underwent pyloromyotomy for IHPS with CHD (CHD group) were matched with 78 patients with IHPS without CHD (Non-CHD group). No 30-day mortality was identified in either group. Overall perioperative complications were not significantly different between groups (11.5% vs 5.2%, p=0.163). However, postoperative length of stay was longer in CHD group (6 vs 1days, p<0.001) and any subgroups of CHD as compared to Non-CHD group. CHD group patients admitted only for IHPS had short postoperative LOS, whereas those who developed pyloric stenosis during a hospital admission stayed longer postoperatively (1.5 vs 26.5days, p<0.001). Mean hospital costs in patients admitted for IHPS were $16,270 and $3591 for CHD group and Non-CHD group, respectively (p<0.001). CONCLUSIONS IHPS patients with CHD have prolonged postpyloromyotomy course, especially when inpatients with CHD incidentally develop IHPS.
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Affiliation(s)
- Shin Miyata
- Children's Hospital Los Angeles, Los Angeles, California, USA.
| | - Jayun Cho
- LAC+USC Medical Center, Los Angeles, California, USA
| | | | - Aaron Fowler
- Arrowhead Regional Medical Center, Colton, California, USA
| | - David W Bliss
- Children's Hospital Los Angeles, Los Angeles, California, USA
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Zakaria OM. Non-laparoscopic minimal surgical approach to pyloromyotomy: An experience from a challenged resource setting. Afr J Paediatr Surg 2016; 13:189-192. [PMID: 28051049 PMCID: PMC5154225 DOI: 10.4103/0189-6725.194672] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The aim of the study is to review the experience with the classic Ramstedt's pyloromyotomy through the RUQ approach and the circumlinear supraumbilical fold approach (circumumbilical [CU]) pyloromyotomy (an approach that combines the ease and safety of the open pyloromyotomy with the advantages of minimal invasiveness). PATIENTS AND METHODS A single centre review in a period of 12 years from January 2001 to December 2013 with the institutional ethical committee's approval, evaluating 316 pyloromyotomies based on surgical approach: RUQ (171); and CU (145). Patients' demographics, acid-base/electrolyte status on presentation, mean operative time (MOT), postoperative length of stay (LOS) at hospital, and complications were recorded. RESULTS Patients demographics, acid - base/electrolyte status on presentation; and MOT were not significantly different. The median LOS was 33 and 30 minutes for CU and RUQ, respectively, with no statistical significant difference between the two groups. One patient in the CU group had a late adhesive bowel obstruction requiring laparotomy and bowel resection. Moreover, wound infection rates did not differ significantly between the two groups (CU 3; and RUQ; 3; P = 0.15). CONCLUSIONS Pyloromyotomy is associated with a low complication rate. Cosmetically, CU is superior to the RUQ approach. Its short learning curve and the feasibility to examine the integrity of the duodenal mucosa intraoperatively may make CU a safer alternative in case of surgeons who are still practicing the RUQ approach in countries with a challenged resource settings.
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Affiliation(s)
- Ossama M Zakaria
- Division of Pediatric Surgery, Department of Surgery, College of Medicine, King Faisal University, Al Ahsa, KSA
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Abstract
Hypertrophic pyloric stenosis is a common surgical cause of vomiting in infants. Following appropriate fluid resuscitation, the mainstay of treatment is pyloromyotomy. This article reviews the aetiology and pathophysiology of hypertrophic pyloric stenosis, its clinical presentation, the role of imaging, the preoperative and postoperative management, current surgical approaches and non-surgical treatment options. Contemporary postoperative feeding regimens, outcomes and complications are also discussed.
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Affiliation(s)
- Matthew Jobson
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Tremona Rd, Southampton SO16 6YD, UK
| | - Nigel J Hall
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Tremona Rd, Southampton SO16 6YD, UK; Faculty of Medicine, University of Southampton, Southampton, UK.
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17
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Fan J, Shi Y, Cheng M, Zhu X, Wang D. Treating idiopathic hypertrophic pyloric stenosis with sequential therapy: A clinical study. J Paediatr Child Health 2016; 52:734-8. [PMID: 27439633 DOI: 10.1111/jpc.13184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/14/2016] [Indexed: 11/28/2022]
Abstract
AIM The aim of this study was to explore the efficacy and safety of treating idiopathic hypertrophic pyloric stenosis with sequential therapy (ST). METHODS From January 2010 to June 2013, 49 children with idiopathic hypertrophic pyloric stenosis were divided into two groups to accept either atropine ST (ST group, n = 26) or laparoscopic surgery (operation group, n = 23). The remission rate of vomiting, complications, hospital stay and medical expenditure were compared between the two groups. The body weight and the thickness of the pyloric muscle at 6 months after the treatments were also compared. RESULTS The remission rate of vomiting was lower in the ST group (88.5%; 23/26) than in the operation group (100%, 23/23). The difference in the incidence rate of complications, body weight and pyloric muscle thickness was not statistically significant between the two groups. However, the hospital stay was significantly longer, while the medical expenditure was significantly lower in the ST group than in the operation group. CONCLUSIONS Atropine ST is safe, effective and cost-effective as compared with operation; however, the efficacy of ST is lower than operation.
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Affiliation(s)
- Jianfeng Fan
- Department of Pediatric Surgery, Wuxi Children's Hospital, Wuxi, Jiangsu, China
| | - Yingzuo Shi
- Department of Pediatric Surgery, Wuxi Children's Hospital, Wuxi, Jiangsu, China
| | - Ming Cheng
- Department of Pediatric Surgery, Wuxi Children's Hospital, Wuxi, Jiangsu, China
| | - Xiaomin Zhu
- Department of Pediatric Surgery, Wuxi Children's Hospital, Wuxi, Jiangsu, China
| | - Dafeng Wang
- Department of Pediatric Surgery, Wuxi Children's Hospital, Wuxi, Jiangsu, China
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Similarities and Differences in the Epidemiology of Pyloric Stenosis and SIDS. Matern Child Health J 2013; 18:1721-7. [DOI: 10.1007/s10995-013-1417-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Almaramhy HH, Alshareif HA. Use of atropine sulfate in the treatment of infantile hypertrophic pyloric stenosis. J Taibah Univ Med Sci 2013. [DOI: 10.1016/j.jtumed.2013.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Koike Y, Uchida K, Nakazawa M, Inoue M, Kusunoki M, Tsukamoto Y. Predictive factors of negative outcome in initial atropine therapy for infantile hypertrophic pyloric stenosis. Pediatr Int 2013; 55:619-23. [PMID: 23701208 DOI: 10.1111/ped.12137] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 04/15/2013] [Accepted: 05/14/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND The predictive factors of negative outcome in initial i.v. atropine (IA) therapy of infantile hypertrophic pyloric stenosis (IHPS) are unknown. Conservative therapy for IHPS is useful for infants because it does not have the risk of surgical and anesthetic stress, but some cases of atropine therapy result in failure. This study clarified the predictive markers of negative outcome in initial atropine therapy for IHPS. METHODS Seventy-six patients with IHPS admitted from 1998 to 2011 were included in this study. The predictive risk factors of negative outcome in initial atropine therapy for IHPS were evaluated. RESULTS Thirty-one patients initially underwent non-operative therapy for IHPS during the study period. Of the 31 patients, 18 (58%) ceased projectile vomiting (PV) with IA and subsequent oral atropine. Univariate analysis showed that lack of bodyweight gain before treatment, elevated urine potassium at admission, and PV occurring ≥5 times (PV ≥5) in total for 3 days from IA initiation were predictive risk factors for negative outcome in IHPS. Multivariate analysis identified only PV ≥5 in total for 3 days after IA initiation as independently associated with failure of atropine for IHPS. CONCLUSIONS PV ≥5 in total for 3 days after IA initiation is a potential indicator of negative outcome of IA in IHPS patients. The present results provide valuable information for determining whether early surgical intervention for IHPS or initial atropine therapy is the best option.
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Affiliation(s)
- Yuhki Koike
- Department of Pediatric Surgery, National Mie Hospital, Mie, Japan; Department of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Mie, Japan
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Takeuchi M, Yasunaga H, Horiguchi H, Hashimoto H, Matsuda S. Pyloromyotomy versus i.v. atropine therapy for the treatment of infantile pyloric stenosis: nationwide hospital discharge database analysis. Pediatr Int 2013; 55:488-91. [PMID: 23489384 DOI: 10.1111/ped.12100] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2011] [Revised: 11/03/2012] [Accepted: 02/27/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Several studies have suggested that i.v. atropine has a potential role in treating infantile hypertrophic pyloric stenosis (IHPS). It remains unclear, however, whether surgery can be replaced by i.v. therapy. METHODS Data were extracted on infants with IHPS who were treated with atropine and/or surgery, from a nationwide administrative database through 2006-2008. Patient demographic data, treatment effects and length of hospital stay were analyzed in each treatment group. RESULTS A total of 585 infants met the criteria for IHPS; 188 patients (32%) were initially treated with atropine (i.v. form, n = 180; oral form, n = 8), while 397 were treated with surgery as a first-line therapy. Of the 180 infants receiving i.v. atropine, 38 were withdrawn from medical management and subsequently underwent surgery. Thus, the overall success rate of i.v. atropine was 78.9% (142/180). Surgery had a success rate of 100%, and postoperative complications were found in 2.8% of patients (12/435). Medical management required longer hospital stay than surgery (mean, 13.5 days vs 8.0 days; P < 0.001). CONCLUSION Surgery remains the suitable standard management option for IHPS, with its high success rate, minimal complications and shorter hospital stay compared with i.v. atropine therapy.
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Affiliation(s)
- Masato Takeuchi
- Department of Pediatrics, University of Tokyo Hospital, Tokyo, Japan.
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22
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Mercer AE, Phillips R. Question 2: can a conservative approach to the treatment of hypertrophic pyloric stenosis with atropine be considered a real alternative to surgical pyloromyotomy? Arch Dis Child 2013; 98:474-7. [PMID: 23661669 DOI: 10.1136/archdischild-2013-303655] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Anita Erika Mercer
- The Hull York Medical School, John Hughlings Jackson Building, University of York, York YO10 5DD, UK.
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23
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Pazzi P, Hartman MJ, Schoeman JP. Congenital pyloric mucosal fold resulting in an antral valve outflow obstruction in a bull terrier. J Small Anim Pract 2013; 54:160-3. [PMID: 23278852 DOI: 10.1111/jsap.12002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
An under-sized three-month-old female bull terrier was referred with a history of regurgitation since three days of age. Thoracic radiographs were unremarkable, while abdominal radiographs showed a distended stomach, despite a 12 hour fast. Abdominal ultrasonography revealed gastric outflow obstruction of unclear aetiology. Coeliotomy was performed, during which an excessive mucosal fold at the pyloric antrum was excised. Histopathology of the pyloric fold revealed mild oedema and fibrosis of the mucosal tissue. The dog made a complete recovery, with resolution of regurgitation and grew to within the expected breed size. In the authors' opinion, this is the first canine report of congenital antral mucosal valve resulting in gastric outflow obstruction, and only the second report in any species.
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Affiliation(s)
- P Pazzi
- Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, University of Pretoria, Onderstepoort, 0110, South Africa
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24
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Owen RP, Almond SL, Humphrey GME. Atropine sulphate: rescue therapy for pyloric stenosis. BMJ Case Rep 2012; 2012:bcr2012006489. [PMID: 22865807 PMCID: PMC4544211 DOI: 10.1136/bcr-2012-006489] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Infantile hypertrophic pyloric stenosis (IHPS) is a common condition which presents with non-bilious vomiting and failure to thrive secondary to gastric outlet obstruction. In the UK, management is by fluid resuscitation followed by pyloromyotomy. Incomplete myotomy complicates 0.3% of cases necessitating further surgery and exposing the patient to further risk. Medical management of IHPS with antimuscarinics to promote pyloric relaxation is a well-described treatment modality that is used as first-line therapy in some countries. The use of this technique is limited by the need for extended hospital admission with parenteral nutrition administration. We describe a case of IHPS complicated by incomplete pyloromyotomy and subsequently managed successfully by atropine sulphate therapy.
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Ranells JD, Carver JD, Kirby RS. Infantile hypertrophic pyloric stenosis: epidemiology, genetics, and clinical update. Adv Pediatr 2011; 58:195-206. [PMID: 21736982 DOI: 10.1016/j.yapd.2011.03.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Judith D Ranells
- Department of Pediatrics, College of Medicine, University of South Florida, 12901 Bruce B. Downs Boulevard, Tampa, FL 33612, USA
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26
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Schmedel W, Ashe L, Kuznicki K. A 24-day-old child with projectile vomiting. J Emerg Nurs 2009; 35:163-4. [PMID: 19285189 DOI: 10.1016/j.jen.2008.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2007] [Revised: 02/10/2008] [Accepted: 03/22/2008] [Indexed: 11/16/2022]
Affiliation(s)
- Wayne Schmedel
- Emergency Department, Tuality Forest Grove Hospital, Forest Grove, OR, USA.
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27
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Wang J, Waller DK, Hwang LY, Taylor LG, Canfield MA. Prevalence of infantile hypertrophic pyloric stenosis in Texas, 1999-2002. ACTA ACUST UNITED AC 2008; 82:763-7. [DOI: 10.1002/bdra.20527] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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28
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Ball V, Devita D, Angelidis M. Infant With Vomiting and Weight Loss. Ann Emerg Med 2008; 52:496, 511. [DOI: 10.1016/j.annemergmed.2008.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2008] [Revised: 02/06/2008] [Accepted: 02/26/2008] [Indexed: 10/21/2022]
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Oyachi N, Takano K, Hasuda N, Arai H, Koshizuka K, Matsumoto M. Effects of Rikkunshi-to on infantile hypertrophic pyloric stenosis, refractory to atropine. Pediatr Int 2008; 50:581-3. [PMID: 18937758 DOI: 10.1111/j.1442-200x.2008.02682.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Noboru Oyachi
- Division of Pediatric Surgery, Second Department of Surgery, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan.
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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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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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Meissner PE, Engelmann G, Troeger J, Linderkamp O, Nuetzenadel W. Conservative treatment of infantile hypertrophic pyloric stenosis with intravenous atropine sulfate does not replace pyloromyotomy. Pediatr Surg Int 2006; 22:1021-4. [PMID: 17021743 DOI: 10.1007/s00383-006-1751-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/25/2006] [Indexed: 11/29/2022]
Abstract
Pyloromyotomy as described by Weber and Ramstedt has been the standard therapy for infantile hypertrophic pyloric stenosis since the 1960's and conservative therapy has been abandoned. The objective of this study was to test the effectiveness of systemic atropine applied intravenously for 7 days as a conservative therapeutic strategy and as an alternative to primary operation. Forty-two consecutive term infants with infantile hypertrophic pyloric stenosis were enrolled in the study over a period of 5 years. After confirmation of the diagnosis they all received intravenous atropine at a dose of 0.04 mg/(kg day) and increased by 0.01 mg/(kg day) up to 0.12 mg/(kg day), given as 6-8 single doses per/day. Nine pairs of parents requested that their child should be operated before completing the 7 days of medical therapy. Surgery was necessary in 8 of the remaining 33 infants (24,.2%) who did not improve after 7 days of conservative treatment. Successful treatment with i.v. atropine sulfate was achieved only in 25/33 term infants at an average maximal dose of 0.11 mg/(kg day), without any major side effects. Intravenous atropine sulfate has been considered as a potential alternative therapeutic strategy in the treatment of infantile hypertrophic pyloric stenosis. Clinical improvement however was often not seen before the 6th or 7th day of intravenous treatment. A success rate for the conservative approach of only 75% at day 7 in our study does not favour atropine therapy, in view of success rates above 95% with surgical repair.
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Affiliation(s)
- P E Meissner
- Department of Pediatrics IV, Neonatology, Heidelberg University, Im Neuenheimer Feld 150, 69120 Heidelberg, Germany.
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