Ultrasonographic serial measurements of the morphologic resolution of the pylorus after Ramstedt pyloromyotomy for infantile hypertrophic pyloric stenosis

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.

High-Resolution Ultrasound Study of Morphological Changes of the Pylorus in the Postoperative Cases of Infantile Hypertrophic Pyloric Stenosis

Aims:

The aim of this study was to find & compare the pyloric Canal Length (CL), Pyloric muscle thickness (MT) by using the High Resolution Ultrasonography (HRUS) in Preoperative & postoperative period (after Ramstedt Pyloromyotomy) for Infantile Hypertrophic Pyloric Stenosis (IHPS).

Methods:

From January 2018 to June 2019, we have performed HRUS for 40 patients of clinically diagnosed cases of IHPS. & Ultrasonography machine: Phillips HD 7 machine & Alpinion E-CUBE with 3-12MHz linear probe, 3.5-5 MHz curvilinear probe and 5-7.5 MHz sector probe were used. The sonographic criteria for positive IHPS are Pyloric muscle thickness (MT) > 3 mm, pyloric Canal length (CL) >14 mm. Postoperative MT & CL at 2 month, 4 month & 6 month were determined and results were analysed with the preoperative pyloric parameters. Statistical analysis used: Mean and standard deviation of values were obtained by using Microsoft excel and statistical significance was analysed by regression study of grouped variables showing p – value by Microsoft excel.

Results:

Pyloric parameters (MT & CL ) gradually attain normal values over months and 80 % of patients showed resolution of pyloric MT & CL values by 6 months. MT assessment shows statistical significance at six months scan ( p- value <0.05).

Conclusions:

Serial postoperative HRUS in IHPS cases show gradual ( mostly by 6 months) resolution of pyloric parameters ( MT & CL ) to normal. MT appears to be a consistent parameter for serial assessment.

Guidelines of the Italian Society of Videosurgery (SIVI) in Infancy for the minimally invasive treatment of Hypertrophic Pyloric Stenosis in neonates and infants

The most appropriate treatment for the infantile Hypertrophic Pyloric Stenosis (HPS) is still debated. The non-surgical conservative treatment with oral or intravenous administration of atropine does not enjoy a widespread appreciation for several factors (...).

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.

Imaging findings in infants with recurrent vomiting after pyloromyotomy: a pictorial review

Hypertrophic pyloric stenosis (HPS) is a common entity with an incidence of 2-4 per 1000 live births. Current definitive treatment is with pyloromyotomy, which is usually performed laparoscopically. The procedure is generally well tolerated with resolution of the patient's symptoms. In a small percentage of patients, however, there is recurrent vomiting which warrants further investigation. In this pictorial review, the expected post-operative appearance of the pylorus will be described, and the imaging findings and clinical course of two patients with recurrent vomiting after pyloromyotomy will be presented.

The ins and outs of pyloromyotomy: what we have learned in 35 years

PURPOSE/BACKGROUND

The aim of the study is to evaluate a large series of infantile hypertrophic pyloric stenosis (IHPS) patients treated by one pediatric surgeon focusing on their diagnostic difficulties and complications.

METHODS

From July 1969 to December 2003 (inclusive), the charts of 791 infants with IHPS were retrospectively reviewed.

RESULTS

There were 647 (82%) males and 144 (18%) females; mean age was 38 days, median 51 (range 7 days-10 months). When ultrasonography (US) was routinely used (1990), the age at diagnosis decreased to <40 days. The mean weight before and after routine US was 3.2 kg, median 3 (range 1.5-6). Twenty-five (3.1%) were premature at diagnosis, mean age 49 days, median 56, (range 1-3 months) and mean weight 2.5 kg, median 2.3 (range 1.5-3.2). Eighty-one (10%) had a positive family history. Forty-four (5%) were non-Caucasians. Seventy-five (9 %) had other medical conditions, anomalies and/or associated findings. Sixty (7%) patients had abnormal preoperative electrolytes. Ten (1.2%) pylorics occurred after newborn operations. Of the entire total (791) who were treated, there were 13 (1.7%) not operated on. All operations were done open initially through one of two right upper quadrant incisions, and then through an upper midline incision under general endotracheal anesthesia; 14 (1.7 %) had concomitant procedures. Prophylactic antibiotics (from 1982) decreased the wound infection rate to 3.9%. There were a total of 87 (10%) complications which included 9 (1.1%) intraoperative, (including mistaken diagnoses) 78 (9%) postoperative: 59 (2%) early (<1 month) and 19 (2.4%) late (>1 month). The 13 (1.6%) postoperative transfers (12 from non-pediatric surgeons) had 16 (18%) complications (including 1 death); five (33%) requiring reoperation (4 incomplete, 1 perforation). There were two deaths.

CONCLUSIONS

IHPS should be considered in any vomiting infant. US allows earlier diagnosis. Serious complications are uncommon and avoidable, but recognizable and easily corrected. Higher surgeon volume of pyloromyotomies (>14 per year) is associated with fewer complications.

Sonogram before and after pyloromyotomy: the pyloric ratio in infantile hypertrophic pyloric stenosis

BACKGROUND

Sonography is used to diagnose infantile hypertrophic pyloric stenosis, but Little information is available about the appearance of postoperative sonographs. The purpose of this study was to evaluate the morphology of the pylorus in association with an obstruction before and after pyloromyotomy.

METHODS

Pyloric length, diameter, muscle thickness and intermuscular space were measured sonographically at diagnosis and daily after pyloromyotomy until discharge in 12 infants with infantile hypertrophic pyloric stenosis. The ratios of pyloric wall thickness and intermuscular space to the entire pyloric diameter were measured.

RESULTS

The pylorus still appeared hypertrophied after pyloromyotomy on the sonograms. The traditional measurement of linear dimensions of the pylorus was not significantly changed from the preoperative values by the time of discharge, except for muscle thickness. The intermuscular space increased from 4.8+/-0.8 mm preoperatively to 7.3+/-2.1 mm by postoperative day 3 (p=0.10). Lowe's pyloric ratio at diagnosis was a mean of 0.32, decreasing to 0.29 on postoperative day 3 and 0.29 on the day of discharge (p=0.82). The alternative pyloric ratio increased significantly by postoperative day 2 (0.24+/-0.09 on day 2 vs. 0.11+/-0.07 preoperatively, p=0.02).

CONCLUSION

The pyloric ratio appears to be a reliable parameter in evaluating the regression of pyloric stenosis after pyloromyotomy, and also aids in the diagnosis of pyloric stenosis.