Abstract
Infantile hypertrophic pyloric stenosis is treated by either open pyloromyotomy (OP) or laparoscopic pyloromyotomy (LP). The aim of this meta-analysis was to compare the open versus laparoscopic technique. A literature search was conducted from 1990 to February 2021 using the electronic databases MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. Primary outcomes were mucosal perforation and incomplete pyloromyotomy. Secondary outcomes consisted of length of hospital stay, time to full feeds, operating time, postoperative wound infection/abscess, incisional hernia, hematoma/seroma formation, and death. Seven randomized controlled trials including 720 patients (357 with OP and 363 with LP) were included. Mucosal perforation rate was not different between groups (relative risk [RR] LP versus OP 1.60 [0.49-5.26]). LP was associated with nonsignificant higher risk of incomplete pyloromyotomy (RR 7.37 [0.92-59.11]). There was no difference in neither postoperative wound infections after LP compared with OP (RR 0.59 [0.24-1.45]) nor in postoperative seroma/hematoma formation (RR 3.44 [0.39-30.43]) or occurrence of incisional hernias (RR 1.01 [0.11-9.53]). Length of hospital stay (-3.01h for LP [-8.39 to 2.37h]) and time to full feeds (-5.86h for LP [-15.95 to 4.24h]) were nonsignificantly shorter after LP. Operation time was almost identical between groups (+0.53min for LP [-3.53 to 4.59min]). On a meta-level, there is no precise effect estimate indicating that LP carries a higher risk for mucosal perforation or incomplete pyloromyotomies compared with the open equivalent. Because of very low certainty of evidence, we do not know about the effect of the laparoscopic approach on postoperative wound infections, postoperative hematoma or seroma formation, incisional hernia occurrence, length of postoperative stay, time to full feeds, or operating time.
Highlights
Infantile hypertrophic pyloric stenosis is treated by either open pyloromyotomy (OP) or laparoscopic pyloromyotomy (LP)
The RCT by Hall et al was stopped after the second interim analysis with 180 recruited patients showing a significant difference between treatment arms in the primary outcomes: the time to full feeds and the length of hospital stay were shorter in patients who underwent LP.[27]
Applying the aforementioned method on pooled data for incomplete pyloromyotomy and need for reoperation resulted in an effect estimate favoring the open approach over the LP for both outcomes (POR 8.06; 95% confidence interval (CI) 1.61-40.46)
Summary
Infantile hypertrophic pyloric stenosis is treated by either open pyloromyotomy (OP) or laparoscopic pyloromyotomy (LP). Minimal invasive surgery has developed a lot with common, and highly specialized surgical procedures performed laparoscopically.[11,12,13,14] At present, most specialized centers use the laparoscopic access route for pyloromyotomy, which was first described in 1990.15 Whether laparoscopic pyloromyotomy (LP) is superior to open pyloromyotomy (OP) has been debated and reviewed by many pediatric surgeons.[8,16,17,18] The laparoscopic technique in general and for IHPS seems to provide a better cosmetic result and a faster recovery from surgery.[9,19] Other advantages of the laparoscopic approach over the open technique might consist in shorter time until return to oral full feed and shorter postoperative length of stay, possibly at the expense of higher rates of incomplete myotomy.[20] Gastric outlet obstruction causes vomiting leading to electrolyte disturbances, dehydration, and failure to thrive.[5,6] The gold standard in treatment of IHPS consists of a longitudinal seromuscular incision along the entire length of the hypertrophic muscle resulting the unharmed mucosa to bulge through the incision.[7,8,9] Laparoscopic surgery was developed by Kurt Semm in the 1980s.10 Since minimal invasive surgery has developed a lot with common, and highly specialized surgical procedures performed laparoscopically.[11,12,13,14] At present, most specialized centers use the laparoscopic access route for pyloromyotomy, which was first described in 1990.15 Whether laparoscopic pyloromyotomy (LP) is superior to open pyloromyotomy (OP) has been debated and reviewed by many pediatric surgeons.[8,16,17,18] The laparoscopic technique in general and for IHPS seems to provide a better cosmetic result and a faster recovery from surgery.[9,19] Other advantages of the laparoscopic approach over the open technique might consist in shorter time until return to oral full feed and shorter postoperative length of stay, possibly at the expense of higher rates of incomplete myotomy.[20]
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