Contemporary management of pyloric stenosis

Case Report: Gas in the esophagus, stomach wall and portal vein with congenital hypertrophic pyloric stenosis

Background

CHPS dramatically affects infant growth and development and can even cause aspiration resulting from esophageal reflux. There is potential danger. CHPS is common, while CHPS with gas in the stomach wall and portal vein is rare. Gas in the stomach wall and portal vein are often the key features of more serious disease. It can be easily mistaken as a serious disease when patients with CHPS have gas in the stomach wall and portal vein.

Case presentation

A 56-day-old baby was hospitalized for aspiration pneumonia after vomiting without bile for 20 days. Compared with vomiting, which is the most common symptom, pneumonia tends to attract more attention. Because of pneumonia, a chest CT scan was performed and revealed massive gas accumulation in the walls of the esophagus, stomach, and portal vein. Therefore, NEC was considered first and was treated conservatively for one week. However, the vomiting continued, and CHPS was confirmed by ultrasound. The delay in CHPS diagnosis was due to insufficient recognition of the signs of gas accumulation. Because of inexperience and lack of knowledge about CHPS with gastrointestinal pneumatosis, physicians failed to make an early accurate diagnosis. Case 2 was a 29-day-old male who was admitted to the hospital with vomiting without bile. He was examined by ultrasound, which revealed gas in the stomach wall and portal vein after admission to the hospital. No peritonitis was found after a detailed and comprehensive physical examination. Emergency life-threatening diseases such as NEC were quickly ruled out. He received surgery as soon as possible and had an uneventful recovery with no complications.

Conclusion

CHPS may present with gas in the gastric or esophageal wall and portal vein, which is not a contraindication to surgery.

Perioperative Hypoxemia and Postoperative Respiratory Events in Infants with Hypertrophic Pyloric Stenosis

BACKGROUND

 Normalization of metabolic alkalosis is an important pillar in the treatment of infantile hypertrophic pyloric stenosis (IHPS) because uncorrected metabolic alkalosis may lead to perioperative respiratory events. However, the evidence on the incidence of respiratory events is limited. We aimed to study the incidence of peroperative hypoxemia and postoperative respiratory events in infants undergoing pyloromyotomy and the potential role of metabolic alkalosis.

MATERIALS AND METHODS

 We retrospectively reviewed all patients undergoing pyloromyotomy between 2007 and 2017. All infants received intravenous fluids preoperatively to correct metabolic abnormalities close to normal. We assessed the incidence of perioperative hypoxemia (defined as oxygen saturation [SpO2] < 90% for > 1min) and postoperative respiratory events. Additionally, the incidence of difficult intubations was evaluated. We performed a multivariate logistic regression analysis to evaluate the association between admission or preoperative serum pH values, bicarbonate or chloride, and peri- and postoperative hypoxemia or respiratory events.

RESULTS

 Of 406 included infants, 208 (51%) developed 1 or more episodes of hypoxemia during the perioperative period, of whom 130 (32%) experienced it during induction, 43 (11%) intraoperatively, and 112 (28%) during emergence. About 7.5% of the infants had a difficult intubation and 17 required more than 3 attempts by a pediatric anesthesiologist. Three patients developed respiratory insufficiency and 95 postoperative respiratory events were noticed. We did not find a clinically meaningful association between laboratory values reflecting metabolic alkalosis and respiratory events.

CONCLUSIONS

 IHPS frequently leads to peri- and postoperative hypoxemia or respiratory events and high incidence of difficult tracheal intubations. Preoperative pH, bicarbonate, and chloride were bad predictors of respiratory events.

Vomiting, Pyloric Mass, and Point-of-Care Ultrasound: Diagnostic Test Accuracy for Hypertrophic Pyloric Stenosis-A Meta-Analysis

BACKGROUND

Hypertrophic pyloric stenosis is a common cause of nonbilious vomiting in infants younger than 6 months. Its history, physical examination, and point-of-care ultrasound (POCUS) have not been compared for their diagnostic test accuracy.

OBJECTIVE

The aim of this systematic review was to quantify and compare the diagnostic test accuracy of a history of vomiting, a pyloric mass on palpation, and POCUS.

METHODS

We performed three searches of the literature from 1977 to March 2022. We evaluated bias using the QUADAS-2 (Quality Assessment Tool for Diagnostic Accuracy-2) tool. We performed a bivariate analysis.

RESULTS

From 5369 citations, we identified 14 studies meeting our inclusion criteria. We quantified three diagnostic elements: POCUS, a pyloric mass on palpation, and vomiting. We identified five studies that analyzed POCUS, which included 329 patients. POCUS had a sensitivity of 97.7% (95% confidence interval (CI) 93.1-99.3%) and a specificity of 94.1% (95% CI 88.7-97.1%) for detecting pyloric stenosis. We identified six studies that analyzed the presence of a pyloric mass, which included 628 patients. The palpation of a pyloric mass had a sensitivity of 73.5% (95% CI 62.6-82.1%) and a specificity of 97.5% (95% CI 93.8-99.0%). We identified four studies that analyzed vomiting, which included 355 patients. Vomiting had a sensitivity of 91.3% (95% CI 82.1-96.0) and a specificity of 60.8% (95% CI 8.5-96.3). Both POCUS and palpation of a pyloric mass had a high positive likelihood ratio (LR+: 17 and 33, respectively). The LR+ for vomiting was 5.0.

CONCLUSIONS

Both POCUS and palpable mass had high specificity and positive LR, whereas vomiting provided the lowest diagnostic test measures.

Hypertrophic Pyloric Stenosis in an Adolescent Girl: An Atypical Presentation of an Unexpected Disease

Hypertrophic pyloric stenosis is a common cause of vomiting in the first few weeks of life, but in rare cases, it may occur in older subjects with a major risk of delayed diagnosis and complications. We describe the case of a 12-year-and-8-month-old girl who presented to our department for epigastric pain, coffee-ground emesis, and melena, which arose after taking ketoprofen. An abdomen ultrasound showed thickening (1 cm) of the gastric pyloric antrum, while upper-GI endoscopy documented esophagitis and antral gastritis with a non-bleeding pyloric ulcer. During her hospital stay, she had no further episodes of vomiting and was therefore discharged with a diagnosis of "NSAIDs-induced acute upper gastrointestinal tract bleeding". After 14 days, following recurrence of abdominal pain and vomiting, she was hospitalized again. At endoscopy, pyloric sub-stenosis was found, abdominal CT showed thickening of large gastric curvature and pyloric walls, and an Rx barium study documented delayed gastric emptying. On suspicion of idiopathic hypertrophic pyloric stenosis, she underwent Heineke-Mikulicz pyloroplasty with resolution of symptoms and restoration of a regular caliber of the pylorus. Hypertrophic pyloric stenosis, although occurring rarely in older children, should be taken into account in the differential diagnosis of recurrent vomiting at any age.

Nationwide trends of laparoscopic pyloromyotomy in patients with infantile hypertrophic pyloric stenosis in Germany: A slow path forward

Since its introduction, laparoscopic pyloromyotomy (LP), has become increasingly popular in many countries. We have noticed an attenuated trend in Germany. The aim of this study was to analyse the distribution of open and LP in Germany. The national database of administrative claims data of the Institute for the Remuneration System in Hospitals (InEK) was analysed regarding numbers of patients with pyloromyotomy in the years 2019-2021. The German quality reports of the hospitals of 2019 and 2020 were analyzed regarding the number of procedures performed per hospital and pediatric surgical department. A total of 2050 patients underwent pyloromyotomy. The incidence of hypertrophic pylorus stenosis (HPS) was 699 and 657 patients in 2019 and 2021, respectively. Regarding age, 31.1% were admitted before 28 days of age. LP gradually increased from 216 patients (30.9%) in 2019 to 239 patients (36.4%) in 2021. Thirty-three laparoscopic operations (4.8%) were converted to an open approach. In 24 of all patients, there was an injury to the stomach, in 20 patients to the duodenum, needing repair with sutures. Analysis of the quality reports indicated that 44% of pediatric surgical departments performed LP. Although LP has became more prevalent in Germany recently, about two thirds of patients still undergo an open procedure.

Diagnostic Accuracy of Acid-Base Status in Infants with Hypertrophic Pyloric Stenosis

Background: Hypertrophic pyloric stenosis is a condition in newborns in which the hypertrophic pyloric muscle causes gastric obstructive symptoms of progressive vomiting leading to hypochloremic hypokalemic metabolic alkalosis. The main aim of the research was to assess whether, based on the acid-base status, we can distinguish newborns who vomit due to pylorostenosis, compared with newborns who vomit for other unspecific reasons. Methods: The electronic records of patients in the hospital information system treated under the diagnosis Q40.0 (Congenital hypertrophic pyloric stenosis) (n = 69/included in the study = 53) in the period from 1 January 2014 to 1 January 2022 were reviewed retrospectively. For the purposes of the control group, the electronic records of patients treated in the emergency department with a diagnosis of R11.0 (Nausea and vomiting) (n = 53) without an established cause were randomly reviewed. In addition to the main aim, other research outcomes were to determine differences between groups in the following variables: duration of symptoms, family history, birth (preterm, term, post-term), birth weight, weight during examination, difference between birth weight and weight during an examination, type of vomiting, the thickness of the muscle wall and its length, and to calculate whether there is a correlation between the thickness and length of the pylorus muscle and the duration of vomiting in relation to variables from acid-base status. Results: In relation to the variables of interest between the groups, statistically significant differences were observed in the duration of symptoms (Mdn 4 vs. 2 days, p = 0.002), weight at examination (Mean 3880 vs. 4439 g, p = 0.001), difference in weight between birth and examination (Mean 374 vs. 1010 g, p < 0.0001), and type of vomiting (explosive 45 vs. 22, p = 0.023). In the acid-base status between the groups, a statistically significant difference was recorded for pH (Mdn 7.457 vs. 7.422, p < 0.0001), bicarbonate (Mdn 25 vs. 23 mmol/L, p = 0.000), total carbon dioxide (Mdn 25 vs. 24 mmol/L, p = 0.011), base excess (Mdn 0.8 vs. −1.3 mmol/L, p = 0.000), potassium (Mdn 5 vs. 5.3 mmol/L, p = 0.006), ionized calcium (Mdn 1.28 vs. 1.31 mmol/L, p = 0.011), and glucose (Mdn 4.5 vs. 4.9 mmol/L, p = 0.007). Regardless of the group, the correlations between the duration of vomiting (r = 0.316, p = 0.021 vs. r = 0.148, p = 0.290) and the thickness (r = 0.190, p = 0.172) and length (r = 0.142, p = 0.311) of the pylorus muscle in relation to pH did not exist or were weak. Conclusions: In a world where radiological methods are not equally available everywhere, with promising acid-base indicators, prospective multicenter studies and meta-analyses must be pursued in the future in order not to miss the possible much greater diagnostic potential of acid-base status.

Neonates undergoing pyloric stenosis repair are at increased risk of difficult airway management: secondary analysis of the NEonate and Children audiT of Anaesthesia pRactice IN Europe

BACKGROUND

Hypertrophic pyloric stenosis in otherwise healthy neonates frequently requires urgent surgical procedure but anaesthesia care may result in respiratory complications, such as hypoxaemia, pulmonary aspiration of gastric contents, and postoperative apnoea. The primary aim was to study whether or not the incidence of difficult airway management and of hypoxaemia in neonates undergoing pyloric stenosis repair was higher than that in neonates undergoing other surgeries.

METHODS

Data on neonates and infants undergoing anaesthesia and surgery for pyloric stenosis were extracted from the NEonate and Children audiT of Anesthesia pRactice In Europe (NECTARINE) database, for secondary analysis.

RESULTS

We identified 310 infants who had anaesthesia for surgery for pyloric stenosis. Difficult airway management (more than two attempts at laryngoscopy) was higher in children with pyloric stenosis when compared with the entire NECTARINE cohort (7.9% [95% confidence interval {CI}, 5.22-11.53] vs 4.4% [95% CI, 1.99-6.58]; relative risk [RR]=1.81 [95% CI, 1.21-2.69]; P=0.004), whereas transient hypoxaemia with oxygen saturation <90% was comparable between the two cohorts. Postoperative complications occurred in 16 children (5.6%) within the 30-day follow-up. No mortality was reported at 30 and 90 days.

CONCLUSIONS

Children undergoing surgery for pyloric stenosis had a higher incidence of difficult intubation compared with the entire NECTARINE cohort.

CLINICAL TRIAL REGISTRATION

NCT02350348.

Evaluation of a fluid resuscitation protocol for patients with hypertrophic pyloric stenosis

INTRODUCTION

We previously developed an institutional, evidence-based fluid resuscitation protocol for neonates with infantile hypertrophic pyloric stenosis (HPS) based on the severity of electrolyte derangement on presentation. We aim to evaluate this protocol to determine its efficacy in reducing the number of preoperative lab draws, time to electrolyte correction, and overall length of stay.

METHODS

A single center, retrospective review of 319 infants with HPS presenting with electrolyte derangement from 2008 to 2020 was performed; 202 patients managed pre-protocol (2008-2014) and 117 patients managed per our institutional fluid resuscitation algorithm (2016-2020). The number of preoperative lab draws, time to electrolyte correction, and length of stay before and after protocol implementation was recorded.

RESULTS

Use of a fluid resuscitation algorithm decreased the number of infants who required four or more preoperative lab draws (20% vs. 6%) (p < .01), decreased median time to electrolyte correction between the pre and post protocol cohorts (15.1 h [10.6, 22.3] vs. 11.9 h [8.5, 17.9]) (p < .01), and decreased total length of hospital stay (49.0 h [40.3, 70.7] vs. 45.7 h [34.3, 65.9]) (p < .05).

CONCLUSION

Implementation of a fluid resuscitation algorithm for patients presenting with hypertrophic pyloric stenosis decreases the frequency of preoperative lab draws, time to electrolyte correction, and total length of hospital stay. Use of a fluid resuscitation protocol may decrease discomfort through fewer preoperative lab draws and shorter length of stay while setting clear expectations and planned intervention for parents.

LEVEL OF EVIDENCE

III - Retrospective comparative study.

Gastrointestinal Emergencies in Neonates: A Review Article

Numerous emergencies that are life-threatening might present in the newborn period of life. Thus, physicians need an in-depth understanding of such circumstances in order to treat critically ill neonates. Identification of these illnesses and choosing the appropriate course of action, which includes patient stabilization, differential diagnosis based on laboratory and imaging results, and well-guided therapy, are the responsibility of the emergency department staff. The most typical diagnoses in this kind of situation are severe bacterial infections, congenital heart illness, gastrointestinal crises (including malrotation with midgut volvulus, necrotizing enterocolitis, etc.), respiratory problems, neurologic abnormalities, and child abuse. Reviewing the most prevalent ailments of a severely unwell newborn in the emergency room is the major goal of this review article. In developing countries, neonatal mortality rates are a crucial determinant of their development. Management of emergencies especially in neonates can be very difficult and fatal if misdiagnosed. In this article, we will be discussing neonatal gastrointestinal (GI) emergencies.

Diagnostic accuracy of palpation and ultrasonography for diagnosing infantile hypertrophic pyloric stenosis: a systematic review and meta-analysis

Objective:

Although infantile hypertrophic pyloric stenosis (IHPS) is a well-known disease, there is no systematic review regarding the optimal diagnostic strategy. We conducted a systematic review and meta-analysis to obtain diagnostic accuracy of all methods to diagnose IHPS.

Methods:

According to the Preferred Reported Items for Systematic Reviews and Meta-Analysis guidelines, we searched MEDLINE and Embase to identify studies reporting sensitivity and specificity of all methods used to diagnose IHPS. Inclusion criteria were infants with suspicion of/or diagnosed with IHPS who underwent pyloromyotomy or had clinical follow-up. A random-effects model was used to obtain pooled estimates of sensitivity, specificity and area under the receiver operating characteristic curve.

Results:

After screening 5364 studies, we included 43 studies with in total 6085 infants (n = 4241 IHPS; n = 1844 controls). The diagnostic sensitivity of palpation ranged from 10.0 to 93.4% and decreased over time. Different parameters for ultrasonography were found. Most used parameters were pyloric muscle thickness (PMT) ≥ 3 mm (pooled sensitivity 97.6% and specificity 98.8%), PMT ≥ 4 mm (pooled sensitivity 94.0% and specificity 98.0%) or a combination of PMT ≥ 4 mm and/or pyloric canal length ≥16 mm (pooled sensitivity 94.0% and specificity 91.7%). The AUC showed high diagnostic accuracy (0.997, 0.966 and 0.981 respectively), but large heterogeneity exists. Due to the large differences in cut-off values no meta-analysis could be conducted for pyloric canal length and pyloric diameter.

Conclusion:

Palpation has limited sensitivity in diagnosing IHPS. We showed that ultrasonography has highest diagnostic accuracy to diagnose IHPS and we advise to use PMT ≥ 3 mm as cut-off.

Advances in knowledge:

This is the first systematic review and meta-analysis on diagnosing IHPS, which summarizes the available literature and may be used as a guideline.

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

CONTEXT

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

AIMS

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

SETTINGS AND DESIGN

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

SUBJECTS AND METHODS

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

STATISTICAL ANALYSIS

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

RESULTS

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

CONCLUSIONS

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

The Dutch Incidence of Infantile Hypertrophic Pyloric Stenosis and the Influence of Seasons

INTRODUCTION

 Studies report contradicting results on the incidence of infantile hypertrophic pyloric stenosis (IHPS) and its association with seasons. We aim to assess the IHPS incidence in the Netherlands and to determine whether seasonal variation is present in a nationwide cohort.

MATERIALS AND METHODS

 All infants with IHPS hospitalized in the Netherlands between 2007 and 2017 were included in this retrospective cohort study. Incidence rates per 1,000 livebirths (LB) were calculated using total number of LB during the matched month, season, or year, respectively. Seasonal variation based on month of birth and month of surgery was analyzed using linear mixed model and one-way ANOVA, respectively.

RESULTS

 A total of 2,479 infants were included, of which the majority was male (75.9%). Median (interquartile range) age at surgery was 34 (18) days. The average IHPS incidence rate was 1.28 per 1,000 LB (variation: 1.09-1.47 per 1,000 LB). We did not find a conclusive trend over time in IHPS incidence. Differences in incidence between season of birth and season of surgery were not significant (p = 0.677 and p = 0.206, respectively).

CONCLUSION

 We found an average IHPS incidence of 1.28 per 1,000 LB in the Netherlands. Our results showed no changing trend in incidence and no seasonal variation.

Management of Postoperative Complications Following Common Pediatric Operations

This review discusses complications unique to pediatric surgical populations. Here the authors focus primarily on five of the most common procedures performed in children: appendectomy, central venous catheterization, pyloromyotomy, gastrostomy, and inguinal/umbilical hernia repair.

Hypertrophic Pyloric Stenosis: 10 Years' Experience with Standard Open and Laparoscopic Approach

PURPOSE

Hypertrophic pyloric stenosis (HPS) is the most common cause of gastric obstruction in newborns. Extra-mucosal pyloromyotomy can be performed through a small laparotomy or laparoscopy. The aim of this study was to compare the two surgical techniques. We also analyzed the incidence of HPS in infants in the last 10 years in relation to the demographic trend of our province.

METHODS

We analyzed all the cases of HPS treated at our Unit between January 2010 and December 2019. The data were obtained from operating systems. Data about the demographic trends, in particular, the number of births and the population residing in the province of Verona from 2010 to 2019, were also retrieved.

RESULTS

During the study period, 60 patients were treated for HPS and met the inclusion criteria. Of these, 56 males and 4 females with an average age of 38±14 days at surgery were included. No differences were found in terms of the duration of surgery, post-operative complications, duration of hospitalization, and weight at the time of surgery. The only statistically significant data was the chlorine level in cases with and without post-operative vomiting (97±3.5 vs. 102±3.3 mmol/L, p<0.05). There was a lower incidence of HPS from 2014 to 2019; however, there was no significant evidence regarding the correlation between this and the reduced birth rate recorded in the province of Verona during the same period.

CONCLUSION

Although laparoscopic pyloromyotomy is a highly complex procedure, it is a feasible alternative to the classic open technique.

Respiratory problems owing to severe metabolic alkalosis in infants presenting with hypertrophic pyloric stenosis

OBJECTIVE

Uncorrected metabolic alkalosis in infantile hypertrophic pyloric stenosis (IHPS) could lead to perioperative apnea. However, the precise incidence of preoperative respiratory problems and the association with metabolic alkalosis are unknown. Therefore, we aimed to determine the incidence of preoperative respiratory problems in IHPS and to assess the association with metabolic alkalosis.

METHODS

We retrospectively reviewed all patients diagnosed with IHPS during 2007-2017. Respiratory problems were classified as present or absent. With multivariate logistic regression we analyzed the association between bicarbonate and respiratory problems, corrected for gestational age and birth weight.

RESULTS

We included 459 infants, of whom 23 developed preoperative respiratory problems (5.0%). Infants with preoperative respiratory problems were more often female (43.5% vs. 13.3% p = 0.001) and had significantly higher median serum levels of bicarbonate (32.0 mmol/L vs. 30.0 mmol/L), base excess (6.5 mmol/L vs. 5.3 mmol/L) and pCO2 (6.4 kPa vs. 5.9 kPa), compared to infants without respiratory problems. Multivariate analysis of serum bicarbonate and presence of respiratory problems showed an OR of 2.18 per 10 mmol/L (95% CI 1.21-4.71) (p = 0.009). The optimal bicarbonate cutoff point was 25.7 mmol/L (sensitivity 100%, specificity 13.4%).

CONCLUSION

IHPS with metabolic alkalosis potentially results in preoperative respiratory problems. A lower bicarbonate target before surgery might be recommended and respiratory monitoring should be considered.

LEVEL OF EVIDENCE

Level IV.

A Delphi Analysis to Reach Consensus on Preoperative Care in Infants with Hypertrophic Pyloric Stenosis

INTRODUCTION

 Infantile hypertrophic pyloric stenosis (IHPS) is a common gastrointestinal condition that can lead to metabolic alkalosis and, if uncorrected, to respiratory complications. A standardized approach to correct metabolic derangements and dehydration may reduce time until pyloromyotomy while preventing potential respiratory complications. Such an evidence-based policy regarding preoperative care is absent. We aim to formulate a recommendation about preoperative care for infants with IHPS using the Delphi technique.

MATERIALS AND METHODS

 The RAND/UCLA appropriateness method was used to reach international consensus in a panel of pediatric surgeons, pediatric anesthetists, and pediatricians. Statements on type and frequency of blood sampling, required serum concentrations before pyloromyotomy and intravenous fluid therapy, were rated online using a 9-point Likert scale. Consensus was present if the panel rated the statement appropriate/obligatory (panel median: 7-9) or inappropriate/unnecessary (panel median: 1-3) without disagreement according to the interpercentile range adjusted for symmetry formula.

RESULTS

 Thirty-three and twenty-nine panel members completed the first and second round, respectively. Consensus was reached in 54/74 statements (73%). The panel recommended the following laboratory tests and corresponding cutoff values prior to pyloromyotomy: pH ≤7.45, base excess ≤3.5, bicarbonate <26 mmol/L, sodium ≥132 mmol/L, potassium ≥3.5 mmol/L, chloride ≥100 mmol/L, and glucose ≥4.0 mmol/L. Isotonic crystalloid with 5% dextrose and 10 to 20 mEq/L potassium should be used for fluid resuscitation.

CONCLUSION

 Consensus is reached in an expert panel about assessment of metabolic derangements at admission, cutoff serum concentrations to be achieved prior to pyloromyotomy, and appropriate intravenous fluid regime for the correction of dehydration and metabolic derangements in infants with IHPS.

Perioperative apnea in infants with hypertrophic pyloric stenosis: A systematic review

BACKGROUND

Infantile hypertrophic pyloric stenosis (IHPS) leads to excessive vomiting and metabolic alkalosis, which may subsequently cause apnea. Although it is generally assumed that metabolic derangements should be corrected prior to surgery to prevent apnea, the exact incidence of perioperative apneas in infants with IHPS and the association with metabolic alkalosis are unknown. We performed this systematic review to assess the incidence of apnea in infants with IHPS and to verify the possible association between apnea and metabolic alkalosis.

METHODS

We searched MEDLINE, Embase, and Cochrane library to identify studies regarding infants with metabolic alkalosis, respiratory problems, and hypertrophic pyloric stenosis. We conducted a descriptive synthesis of the findings of the included studies.

RESULTS

Thirteen studies were included for analysis. Six studies described preoperative apnea, three studies described postoperative apnea, and four studies described both. All studies were of low quality or had other research questions. We found an incidence of 27% of preoperative and 0.2%-16% of postoperative apnea, respectively. None of the studies examined the association between apnea and metabolic alkalosis in infants with IHPS.

CONCLUSIONS

Infants with IHPS may have a risk to develop perioperative apnea. However, the incidence rates should be interpreted with caution because of the low quality and quantity of the studies. Therefore, further studies are required to determine the incidence of perioperative apnea in infants with IHPS. The precise underlying mechanism of apnea in these infants is still unknown, and the role of metabolic alkalosis should be further evaluated.

Comparison of laparoscopic and open pyloromyotomy: Concerns for omental herniation at port sites after the laparoscopic approach

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.

Pyloric Stenosis: National Trends in the Incidence Rate and Resource Use in the United States From 2012 to 2016

OBJECTIVES

Infantile hypertrophic pyloric stenosis (IHPS) is the most common reason for abdominal surgery in infants; however, national-level data on incidence rate and resource use are lacking. We aimed to examine the national trends in hospitalizations for IHPS and resource use in its management in the United States from 2012 to 2016.

METHODS

We performed a retrospective serial cross-sectional study using data from the National Inpatient Sample, the largest health care database in the United States. We included infants aged ≤1 year assigned an International Classification of Diseases, Ninth Revision, or International Classification of Diseases, 10th Revision, code for IHPS who underwent pyloromyotomy or pyloroplasty. We examined the temporal trends in the incidence rate (cases per 1000 live births) according to sex, insurance status, geographic region, and race. We examined resource use using length of stay (LOS) and hospital costs. Linear regression was used for trend analysis.

RESULTS

Between 2012 and 2016, there were 32 450 cases of IHPS and 20 808 149 live births (incidence rate of 1.56 per 1000). Characteristics of the study population were 82.7% male, 53% white, and 63.3% on Medicaid, and a majority were born in large (64%), urban teaching hospitals (90%). The incidence of IHPS varied with race, sex, socioeconomic status, and geographic region. In multivariable regression analysis, the incidence rate of IHPS decreased from 1.76 to 1.57 per 1000 (adjusted odds ratio 0.93; 95% confidence interval 0.92-0.93). The median cost of care was $6078.30, whereas the median LOS was 2 days, and these remained stable during the period.

CONCLUSIONS

The incidence rate of IHPS decreased significantly between 2012 and 2016, whereas LOS and hospital costs remained stable. The reasons for the decline in the IHPS incidence rate may be multifactorial.

Presentation and outcomes in hypertrophic pyloric stenosis: An 11-year review

AIM

To evaluate the trend in presentation and postoperative outcomes of infants with hypertrophic pyloric stenosis (HPS) over the last decade.

METHODS

This was a multicentre retrospective study in two tertiary paediatric centres between 2005 and 2015 inclusive. Participants included 626 infants who underwent a pyloromyotomy for HPS. We collected data on presentation features (age, weight, clinical signs, blood gas results, ultrasound findings) and postoperative outcomes (length of stay (LOS), complications, time to first postoperative feed).

RESULTS

No trend was identified during the study period with regards to age, weight, biochemical findings (pH, chloride, base excess) or pre-operative ultrasound measurements. There was a downtrend in the number of palpated tumours over time, with a mean of 36% of tumours clinically palpated. Pyloric wall thickness had a moderate association with LOS in patients admitted for >8 days (correlation = 0.4752) but had a weak negative association with shorter lengths of stay (≤8 day, correlation = -0.094). Overall, median time to first feed was 7.80 h and improved yearly during the study period (hazard ratio = 1.07).

CONCLUSIONS

Patients presenting with HPS are not being identified at an earlier age or with fewer biochemical derangements, in contrast to our initial perceptions. Subsequently, biochemical derangements can still play an important role in the diagnosis of HPS, and attention needs to be given to fluid management and electrolyte correction in all patients with HPS.

Late-Onset Hypertrophic Pyloric Stenosis in a 14-Weeks-Old Full Term Male Infant

BACKGROUND

Hypertrophic pyloric stenosis is the most common cause of gastric outlet obstruction in infants, and classically presents at 2 to 6 weeks of age. Delayed presentation is an extremely rare occurrence after early infancy.

CASE REPORT

A 14-weeks-old full term male infant presented with non-bilious vomiting, dehydration and hypocloremic metabolic alkalosis. Abdominal ultrasonography revealed tubular mass 20 mm in lenght. Because of unusual age, diagnosis was confirmed with upper gastrointestinal contrast study. Laparoscopic pyloromyotomy was performed. After surgery the child was free of symptoms, had gained weight, and was tolerating a regular diet. Message: Despite the age hypertrophic pyloric stenosis should be kept in mind in any child who presents with non-bilious vomiting.

Prevalence and descriptive epidemiology of infantile hypertrophic pyloric stenosis in the United States: A multistate, population-based retrospective study, 1999-2010

BACKGROUND

Antecedents for infantile hypertrophic pyloric stenosis (IHPS) vary across studies; therefore, we conducted a multistate, population-based retrospective study of the prevalence and descriptive epidemiology of IHPS in the United States (US).

METHODS

Data for IHPS cases (n = 29,554) delivered from 1999-2010 and enumerated from 11 US population-based birth defect surveillance programs, along with data for live births (n = 14,707,418) delivered within the same birth period and jurisdictions, were analyzed using Poisson regression to estimate IHPS prevalence per 10,000 live births. Additional data on deliveries from 1999-2005 from seven of these programs were analyzed using multivariable logistic regression to estimate adjusted prevalence ratios (aPR)s and 95% confidence intervals (CI)s for selected infant and parental characteristics.

RESULTS

Overall, IHPS prevalence from 1999-2010 was 20.09 (95% CI = 19.87, 20.32) per 10,000 live births, with statistically significant increases from 2003-2006 and decreases from 2007-2010. Compared to their respective referents, aPRs were higher in magnitude for males, preterm births, and multiple births, but lower for birth weights <2,500 g. The aPRs for all cases increased with decreasing parental age, maternal education, and maternal parity, but decreased for parental race/ethnicity other than non-Hispanic White. Estimates restricted to isolated cases or stratified by infant sex were similar to those for all cases.

CONCLUSIONS

This study covers one of the largest samples and longest temporal period examined for IHPS in the US. Similar to findings reported in Europe, estimates suggest that IHPS prevalence has decreased recently in the US. Additional analyses supported associations with several infant and parental characteristics.

Hypertrophic pyloric stenosis following repair of oesophageal atresia and tracheo-oesophageal fistula in a neonate

Development of hypertrophic pyloric stenosis (HPS) after a few weeks of repair of an oesophageal atresia (OA) and tracheo-oesophageal fistula (TOF) is a rare condition in early infancy. Although vomiting or feeding intolerance in operated cases of OA+TOF are attributed to oesophageal stricture, gastro-oesophageal reflux and oesophageal dysmotility, it may also be caused by HPS. Herein, we report a newborn infant who had OA and TOF operation on day 2 of life and diagnosed to have HPS at 15th day of age. Even though it is a rare anomaly, HPS should be kept on mind in the presence of persistent vomiting following repair of OA.

Pyloric stenosis: an enigma more than a century after the first successful treatment

Despite hypertrophic pyloric stenosis (HPS) being one of the most frequently treated pediatric surgical conditions, its etiology remains incompletely understood. We review the diagnosis and treatment of this condition with an emphasis on the evolution of surgical techniques that led to laparoscopic pyloromyotomy, the most frequently performed technique for HPS today. In addition, we review key developments in the understanding of HPS etiology and treatment, including the postulated etiology of work-induced hypertrophy of the pylorus, its association with prokinetic macrolide antibiotics, and the emerging role of atropine sulfate as a medical treatment for HPS or a rescue treatment for incomplete myotomy.

The treatment of pyloric stenosis: Evolution in practice

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.

Late-onset hypertrophic pyloric stenosis with gastric outlet obstruction: case report and review of the literature

We report late-onset hypertrophic pyloric stenosis in a 17-year-old female. She presented with abdominal pain and an episode of upper gastrointestinal hemorrhage and subsequently developed gastric outlet obstruction. Work-up revealed circumferential pyloric thickening, delayed gastric emptying, and a stenotic, elongated pyloric channel. Biopsies showed benign gastropathy, negative for Helicobacter pylori, without eosinophilic infiltrates. Botulinum toxin injection provided limited relief. Diagnostic laparoscopy confirmed the hypertrophic pylorus and we performed laparoscopic pyloromyotomy. The patient tolerated the procedure well and had complete symptom resolution at 1-year follow-up. Hypertrophic pyloric stenosis is a rare cause of gastric outlet obstruction in adolescents and may be managed successfully with laparoscopic pyloromyotomy.