Laparoscopic Pyloromyotomy Research Articles

Impact of Standardized Postoperative Feeding Regimen After a Laparoscopic Pyloromyotomy Utilizing a Computirized Provider Order Entry Order Set

Impact of Standardized Postoperative Feeding Regimen After a Laparoscopic Pyloromyotomy Utilizing a Computirized Provider Order Entry Order Set

Hypertrophic Pyloric Stenosis Following Repair of Esophageal Atresia and Tracheo-Esophageal Fistula

Two cases of hypertrophic pyloric stenosis (HPS) developed after a few weeks of repair of an esophageal atresia and tracheo-esophageal fistula (EA&TEF). Both cases were dealt successfully with laparoscopic pyloromyotomy.

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Background and aims: Sugammadex was synthesized as a selective reversal agent for the neuromuscular blocking agent, rocuronium. Several authors have reported the use of sugammadex and rocuronium in infants, but there have been few reports of its use for laparoscopic pyloromyotomy. Aims: The aim of this study was to investigate the relationship between the dose of sugammadex and rocuronium, time to extubation both after the end of surgery and after administration of sugammadex for laparoscopic pyloromyotomy in infants with hypertrophic pyloric stenosis. Methods: This study was approved by the institutional review board. The data was collected retrospectively from 8 consecutive laparoscopic pyloromyotomy procedures in infants with hypertrophic pyloric stenosis between May 2012 and April 2013. Results: At the time of surgery, the median age was 33 days (range 15–84) and the weight was 3.7 kg (2.9–5.1). The median duration of surgery was 29.5 minutes (23–46). The median doses of sugammadex and rocuronium were 2.2 (1.7–11.3) and 0.83 mg/kg (0.48–2.12), respectively. The time to extubation after surgery was 16 minutes (6–62), and the time to extubation after administration of sugammadex was 10 minutes (5–60). Greater doses of sugammadex were directly associated with greater doses of rocuronium (p=0.013, r2=0.67). Greater doses of sugammadex and rocuronium were associated with longer times to extubation after surgery (p=0.0016, r2=0.83; p=0.0019, r2=0.82) and longer times to extubation after administration of sugammadex (p=0.0037, r2=0.78; p=0.0014, r2=0.84), respectively. Conclusions: Greater doses of sugammadex and rocuronium were related to a longer time to extubation after the end of surgery.

Laparoscopic pyloromyotomy: comparing the arthrotomy knife to the Bovie blade

BackgroundLaparoscopic pyloromyotomy was performed at our institution using an arthrotomy knife until it became unavailable in 2010. Thus, we adapted the use of the blunt Bovie tip, which can be used with or without electrocautery to perform the myotomy. This study compared the outcomes between using the arthrotomy knife versus the Bovie blade in laparoscopic pyloromyotomies. Materials and methodsRetrospective review was performed on all laparoscopic pyloromyotomy patients from October 2007 to September 2012. Arthrotomy knife pyloromyotomy patients were compared with those performed with the Bovie blade. Patient demographics, diagnostic measurements, electrolyte levels, length of stay, operative time, and complications were compared. ResultsA total of 381 patients were included, with 191 in the arthrotomy group and 190 in the Bovie blade group. No significant differences existed between groups in age, weight, gender, pyloric dimensions, electrolyte levels, or length of stay. Mean operative times were 15.8 ± 5.6 min with knife and 16.4 ± 5.3 min for Bovie blade (P = 0.24). In the arthrotomy knife group, there was one incomplete pyloromyotomy and one omental herniation. There was one wound infection in each group. Readmission rate was greater in the arthrotomy knife group (5.7%) versus the Bovie blade group (3.1%). ConclusionsThe Bovie blade appears to offer no objective disadvantages compared with the arthrotomy knife when performing laparoscopic pyloromyotomy.

Feasibility of laparoscopic pyloromyotomy under spinal anesthesia

BackgroundMost agents used for GA are considered to be neurotoxins and affect developing brains in experimental models, leading to a push for spinal anesthesia (SA). There are no reports of laparoscopic pyloromyotomy (LP) performed under SA. We present our experience with LP and SA and discuss feasibility. MethodsA retrospective analysis was performed on a consecutive series of patients who underwent an LP. An ‘intent to treat’ analysis was utilized, and GA was compared to SA. Data regarding patient characteristics, operative intervention, complications, and postoperative course were collected. ResultsTwelve cases had attempted SA for the LP, 9 were successful. During the same time, 12 cases underwent LP under GA. We found no difference for length of procedure, time to the first feed, or the postoperative LOS. The time to leave the OR after conclusion of the procedure was significantly shorter for the SA group (14min vs. 28min, p<0.001). There were no complications from the SA, however three cases had to be converted to GA. ConclusionsIt is feasible and safe to perform laparoscopic pyloromyotomy under spinal anesthesia. Given the increasing concern over the use of GA in infants, consideration may be given to use of SA for LP.

Single-site umbilical laparoscopic pyloromyotomy in neonates less than 21-day old

Single-site umbilical laparoscopic pyloromyotomy for hypertrophic pyloric stenosis in neonates <3-week old has rarely been reported in the literature. This article reports our initial experience with this procedure. Overall, 13 cases of hypertrophic pyloric stenosis occurred in neonates <3-week old from January 2010 to April 2013 in our hospital. All neonates were treated by a single-site laparoscopic procedure. A 5-mm trocar and endoscope were introduced through an incision in the center of the umbilicus, and two 3-mm working instruments were inserted directly into the abdomen via separate lateral fascial stab incisions in the umbilical fold, and a single-site umbilical laparoscopic pyloromyotomy was then performed. The procedure was performed in 13 infants (12 male) with mean age of 17.3 days. The average length of the operation was 26 min. The mean postoperative hospital stay was 4.5 days. All patients were discharged home on full feeds. Follow-up examinations were scheduled 2 to 6 weeks after discharge, and no postoperative complications were noted in any of the patients. These cases had shorter and thinner pylori than their older counterparts. However, the laparoscopic procedure was safe and feasible, with good postoperative results and excellent cosmesis. Surgeons should have a firm foundation of advanced minimal access surgical skills prior to attempting the procedure.

Comparison of Arthrotomy Knife to Bovie Blade in Performing the Myotomy during Laparoscopic Pyloromyotomy

Comparison of Arthrotomy Knife to Bovie Blade in Performing the Myotomy during Laparoscopic Pyloromyotomy

Comparison of Pyloromyotomy with Supraumbilical Incision and Laparoscopic Pyloromyotomy for Hypertrophic Pyloric Stenosis Performed by a Single Surgeon

Purpose: Hypertrophic pyloric stenosis (HPS) is known to be one of the most common cause of surgery for infants and pyloromyotomy was considered to the standard treatment. There has been an ongoing debate about whether laparoscopic pyloromyotomy (LP) or open pyloromyotomy (OP) is the best option for treating HPS. The aim of this study is to evaluate safety and effectiveness of LP by comparing the clinical results of both surgical strategies performed by single surgeon. Methods: Between January 2000 and December 2013, 60 patients who underwent pyloromyotomy at Asan Medical Center performed by a surgeon were followed: open-supraumbilical incision (n=36) and LP (n=24). The parameters included sex, age and body weight at operation. Clinical outcomes included operation time, time to full feeding, postoperative hospital stay, and postoperative complications. Results: There were no significant differences in characteristics, postoperative hospital stay between the two groups. Time to full feeding was shorter in LP (OP 24.5 hours vs. LP 19.8 hours; p=0.063). In contrast, the mean operation time was longer in LP (OP 37.5 minutes vs. LP 43.5 minutes; p=0.072). Complications such as perforation of mucosal layer (OP 1 vs. LP 0) and wound problems (OP 2 vs. LP 0) were found to be not worse in laparoscopic group as compared with open group. Conclusion: There has no difference both laparoscopic and open-supraumbilical incision in terms of postoperative hospital stay, time to full feeds and frequency of complications.

Laparoscopic pyloromyotomy: Lessons learnt in our first 101 cases.

Aim:To analyze our experience with laparoscopic pyloromyotomy for infantile hypertrophic pyloric stenosis for the lessons that we learnt and to study the effect of learning curve.Materials and Methods:This is a retrospective analysis of case records of 101 infants who underwent laparoscopic pyloromyotomy over 6 years. The demographic characteristics, conversion rate, operative time, complications, time to first feed and post-operative hospital stay were noted. The above parameters were compared between our early cases (2007-2009) (n = 43) and the later cases (2010-2013) (n = 58).Results:89 male and 12 female babies ranging in age from 12 days to 4 months (mean: 43.4 days) were operated upon during this period. The babies ranged in weight from 1.8 to 4.7 kg (mean: 3.1 kg). Four cases were converted to open (3.9%): three due to mucosal perforations and one due to technical problem. The mean operative time was 45.7 minutes (49.7 minutes in the first 3 years and 43.0 minutes in the next 3 years). There were 10 complications-4 mucosal perforations, 5 inadequate pyloromyotomies and 1 omental prolapse through a port site. All the complications were effectively handled with minimum morbidity. In the first 3 years of our experience the conversion rate was 9.3%, mucosal perforations were 6.9% and re-do rate was 2.3% as compared to 0%, 1.7% and 6.9%, respectively, in the next 3 years. Mean time for starting feeds was 21.4 hours and mean post-operative hospital stay was 2.4 days.Conclusion:Laparoscopic pyloromyotomy is a safe procedure with minimal morbidity and reasonable operative times. Conversion rates and operative times decrease as experience increases. Our rate of inadequate pyloromyotomy was rather high which we hope to decrease with further experience.

Postoperative emesis after laparoscopic pyloromyotomy in infantile hypertrophic pyloric stenosis

This study aimed to determine the causes of postoperative emesis (PE) in neonates with infantile hypertrophic pyloric stenosis (IHPS) after laparoscopic pyloromyotomy (LP). Retrospective review of the hospital database for infants with IHPS managed between 2000 and 2010 was performed. Relevant data were collected from the clinical records in the Medocs(®) system and used for statistical analysis. During the 10-year period, 95 patients with IHPS were identified and 43 (36 boys and seven girls) fulfilled the inclusion criteria. PE occurred in 21 infants (48.8%), of which nine presented with manifestations of enteric infections, with confirmed diagnosis in four. PE was significantly higher in the fast track feeding protocol (FTFP) group 12/15 compared with the conventional slow feeding protocol (CSFP) group 8/21 (p = 0.019). Gastro-oesophageal reflux (GER) confirmed by 24-h impedance monitoring was responsible for PE in three. Operative revision for suspected incomplete pyloromyotomy was performed in five infants. However, incomplete myotomy could only be confirmed in two infants during surgery. Postoperative emesis in IHPS after LP requires careful evaluation as it can be a result of enteric viral infections, aggressive feeding protocols or GER. Decisions to perform reoperations for incomplete myotomy after LP due to PE are challenging.

Ergonomic laparoscopic spreader for infantile hypertrophic pyloric stenosis

Laparoscopic pyloromyotomy (LP) for Infantile Hypertrophic Pyloric Stenosis (IHPS) is associated with an increased risk of mucosal tears or incomplete myotomy when compared with open myotomy. Keeping these risks in mind, a new ergonomically designed spreader for LP was developed and investigated in IHPS. The new Pyloric Spreader was designed as a 3.5 mm instrument specifically for minimal access application taking into consideration the specific needs of LP. LP was performed using this spreader in 25 infants with IHPS during a 5-year period from 2006-2012. After incising the pylorus using an arthrotomy knife blade, the spreader could be inserted with ease in the pyloric muscle slit and permitted spreading of the pyloric muscle without any circular tears. The axial handle attached to the spreader enable a wide and controlled muscular spreading without mucosal injuries or incomplete spreads. Two infants underwent surgical revision due to recurrent vomiting; however no signs of incomplete myotomy were evident and the vomiting which subsequently subsided was attributed to the preoperative administration of Rotavirus vaccines in these infants. The newly designed Pyloric Spreader offers a new ergonomically designed instrument with a flat tip for easy placement in the pyloric muscle slit, broad instrument surface to avoid circular muscle tears, rounded tip edges to prevent mucosal injuries, wide spreading capability for optimal muscle spread and an axial handle for better hand ergonomic for LP in IHPS.

Risk of incomplete pyloromyotomy and mucosal perforation in open and laparoscopic pyloromyotomy

BackgroundDespite randomized controlled trials and meta-analyses, it remains unclear whether laparoscopic pyloromyotomy (LP) carries a higher risk of incomplete pyloromyotomy and mucosal perforation compared with open pyloromyotomy (OP). MethodsMulticenter study of all pyloromyotomies (May 2007–December 2010) at nine high-volume institutions. The effect of laparoscopy on the procedure-related complications of incomplete pyloromyotomy and mucosal perforation was determined using binomial logistic regression adjusting for differences among centers. ResultsData relating to 2830 pyloromyotomies (1802 [64%] LP) were analyzed. There were 24 cases of incomplete pyloromyotomy; 3 in the open group (0.29%) and 21 in the laparoscopic group (1.16%). There were 18 cases of mucosal perforation; 3 in the open group (0.29%) and 15 in the laparoscopic group (0.83%). The regression model demonstrated that LP was a marginally significant predictor of incomplete pyloromyotomy (adjusted difference 0.87% [95% CI 0.006–4.083]; P=0.046) but not of mucosal perforation (adjusted difference 0.56% [95% CI −0.096 to 3.365]; P=0.153). Trainees performed a similar proportion of each procedure (laparoscopic 82.6% vs. open 80.3%; P=0.2) and grade of primary operator did not affect the rate of either complication. ConclusionsThis is one of the largest series of pyloromyotomy ever reported. Although laparoscopy is associated with a statistically significant increase in the risk of incomplete pyloromyotomy, the effect size is small and of questionable clinical relevance. Both OP and LP are associated with low rates of mucosal perforation and incomplete pyloromyotomy in specialist centers, whether trainee or consultant surgeons perform the procedure.

Protocol versus ad libitum feeds after laparoscopic pyloromyotomy: A prospective randomized trial

BackgroundWe conducted a prospective, randomized trial comparing protocol to ad libitum (ad lib) feeding after laparoscopic pyloromyotomy. MethodsInfants undergoing laparoscopic pyloromyotomy were randomized to protocol versus ad lib feeding strategies. The protocol started with Pedialyte® two hours post-operative. This was repeated by another round of Pedialyte®, then two rounds of half-strength formula or breast milk, followed by two rounds of full strength formula or breast milk, followed by the home feeding regimen, at which time the patient was discharged if feeding well. The ad lib group was allowed formula or breast milk two hours after the operation and considered for discharge after tolerating three consecutive feeds. The primary outcome variable was the length of postoperative hospitalization. ResultsOne hundred fifty infants were enrolled between January 2010 and December 2011. There were no differences in patient characteristics at presentation. While the ad lib group reached goal feeds sooner than the protocol group, this did not translate into a difference in duration of postoperative hospitalization. There were more patients with emesis in the ad lib group after goal feeding was reached, but no difference in readmissions. ConclusionAd lib feeding allows patients to reach goal feeds more rapidly than protocol feeding following laparoscopic pyloromyotomy. However, this goal is usually reached beyond discharge hours, resulting in a similar duration of hospitalization.

Moving toward Laparoscopic Pyloromyotomy: An Initial Italian Experience and National Survey

Moving toward Laparoscopic Pyloromyotomy: An Initial Italian Experience and National Survey

Laparoscopic pyloromyotomy, the tail of the learning curve

The debate whether laparoscopic pyloromyotomy (LP) is superior to open pyloromyotomy (OP) remains actual. A recent review showed no benefit between the LP or OP, but in the studied randomized, controlled trials the learning curve was not addressed. Comparing LP including the learning curve with OP after the learning curve is questionable. In previous research, the learning curve of LP was analyzed. It was concluded that the plateau was reached after 35 procedures with a steep decrease in complications when comparing before and after 35 procedures. This study was designed to retrospectively analyze the results obtained in HPS patients after the learning curve in LP has been reached. The results will be compared with results of OP in HPS patients in the same period. A retrospective analysis in 106 OP and 57 LP was performed from September 2008 to June 2012. The overall complication rate in the OP group was significantly higher than in the LP group (18% vs. 3.5%, p = 0.012). Also there was a higher major complication rate in the OP group (10.4% vs. 1.7%, p = 0.045). The median time to operate was with 28.5 min in OP and 30.0 min in LP (not significant), whereas the LOS was 2 days in both groups (not significant). In this study, a further decline in overall and major complications after the learning curve is seen in the LP group, the tail of the learning curve. The debate whether LP is superior to OP is not finished as long as it is not clear whether the minimally invasive operation is beyond the initial or tail of the learning curve.

Carbon dioxide gas pneumoperitoneum induces minimal microcirculatory changes in neonates during laparoscopic pyloromyotomy

Little is known about the direct effect of pneumoperitoneum (PP) on microcirculation and its influence on the quality of tissue perfusion. This study aimed to investigate the intraoperative effects of carbon dioxide (CO2) gas PP on microcirculation density and perfusion in neonates receiving laparoscopic surgery for hypertrophic pyloric stenosis. In a single-center observational study, the oral microcirculation in 12 neonates receiving laparoscopic pyloromyotomy was investigated. Intraoperative hemodynamic parameters, intermittent buccal mucosa capillary density measurements (pre- and postoperative), and continuous intraoperative sublingual microcirculation measurements (i.e., vessels with a diameter <25 μm) of total vessel density, perfused vessel density, proportion of perfused blood vessels, blood vessel diameters (BVd), and microvascular flow index were obtained before (at baseline), during, and after PP insufflation for all patients using sidestream dark-field imaging for the duration of the complete surgical procedure. With the exception of a significantly elevated end-tidal CO2 (34 ± 4-40 ± 8 mmHg; p < 0.05 vs before [baseline], one-way analysis of variance [ANOVA]) during intraoperative insufflation, no significant differences were found between time points for the intraoperative hemodynamic parameters. Pre- and postoperative buccal capillary density showed no significant changes in mucosal perfusion. Analysis of continuous intraoperative sublingual microcirculation parameters exhibited a statistically significant increase in BVd during insufflation (8.8 ± 2.4-9.3 ± 2.5 μm; p < 0.05, one-way ANOVA) and a significant decrease after exsufflation (8.2 ± 2.3 μm; p < 0.01 vs during insufflation and p < 0.05 vs baseline, one-way ANOVA, respectively). No other significant differences were found between time points for the remaining microcirculatory parameters. The installation of CO2 gas PP during laparoscopic pyloromyotomy procedures regulates microcirculatory perfusion by inducing changes in microvascular diameters but does not alter microcirculation density in neonates.

Laparoscopic Versus Open Pyloromyotomy for Hypertrophic Pyloric Stenosis

Purpose: Hypertrophic pyloric stenosis (HPS) is a common condition affecting infants that causes severe projectile non-bilious vomiting in the first few months of life. Although open pyloromyotomy is the standard treatment for HPS, recently, the laparoscopic approach has rapidly been adopted by pediatric surgeons. The aim of this study is to determine the efficacy and safety of laparoscopic pyloromyotomy by comparing the clinical results of laparoscopic and open pyloromyotomy. Methods: Between January 2007 and September 2012, a cohort of 69 children who underwent pyloromyotomy at Seoul National University Children’s Hospital were followed; open pyloromyotomy (OP, n=56) and laparoscopic pyloromyotomy (LP, n=13). A retrospective analysis of patient’s characteristics and clinical outcomes in patients with open or laparoscopic pyloromyotomy for HPS was performed. The evaluated characteristics included gestational age, sex, birth weight, age and weight at operation. Clinical outcomes included operation time, length of hospital stay, time to postoperative full feeds without vomiting, number of postoperative vomiting and complications. Results: There were no significant differences in characteristics, length of hospital stay and time to postoperative full feeds without vomiting between the two groups. Incidence of postoperative vomiting in the LP group was significantly lower than that in the OP group (OP: 5.07±4.60 vs. LP: 2.00±2.16, p=0.035). In contrast, the operation time was longer, following the LP group (OP: 26.30±9.95 vs. LP: 44.15± 19.56, p＜0.001). Complications such as perforation of mucosal layer (OP: 2 vs. LP 1, p＞0.999) and wound problems (OP: 4 vs. LP 1, p＞0.999) were found to be similar in both groups. Conclusion: Both open and laparoscopic pyloromyotomy are safe procedures for the management of hypertrophic pyloric stenosis. Incidence of vomiting was statistically superior in the laparoscopic group. In addition, postoperative complications were fewer in this group. However, an improvement in the operation time will be needed for the future development of laparoscopic pyloromyotomy.

Trocarless laparoscopic pyloromyotomy with conventional instruments: Our experience

BACKGROUND:The incidence of hypertrophic pyloric stenosis is approximately 1–3 per 1,000 live births. Hypertrophic pyloric stenosis is seen more often in males, with a male-to female ratio of 4:1. Laparoscopic pyloromyotomy is becoming increasingly popular as the standard treatment for hypertrophic pyloric stenosis.MATERIALS AND METHODS:We describe our initial experience with laparoscopic pyloromyotomy in 16 infants using conventional laparoscopic instruments. Laparoscopic pyloromyotomy was performed through 5-mm umbilical port with 5mm 30 endoscope. Two 3-mm working instruments were inserted directly into the abdomen via separate lateral incisions.RESULTS:All patients were prospectively evaluated. The procedure was performed in 16 infants with a mean age of 36 days and mean weight of 3.1 kg. All procedures, except two, were completed laparoscopically with standard instruments. Average operating time was 28 mins, and average postoperative length of stay was 2.8 days. There were no major intraoperative and postoperative complications.CONCLUSION:Laparoscopic pyloromyotomy can be safely performed by using standard conventional laparoscopic trocarless instruments.

Consultant Versus Trainee Laparoscopic Pyloromyotomy: Is there a Difference in Outcome?

Infantile hypertrophic pyloric stenosis (IHPS) is a common cause of vomiting in infants. IHPS was a condition with significant associated mortality until 1912 when ramstedt introduced the operative procedure pyloromyotomy. Since then, mortality rates have reduced significantly owing to early recognition, correction of associated biochemical abnormalities and operative treatment. More recently, the management of IHPS has been modified by the introduction of the laparoscopic pyloromyotomy, first described almost two decades ago.

Infantile hypertrophic pyloric stenosis: Has anything changed?

The study aims to review the contemporary presentation, diagnosis and treatment of children with infantile hypertrophic pyloric stenosis (IHPS) at an Australian paediatric tertiary centre. A retrospective case review of patients with IHPS presenting to our institution between January 2004 and December 2010 was performed. Results were compared with a previous study evaluating two earlier 6-year series of patients treated between January 1984 and November 1995. Of 362 infants presenting over the current 7-year review, 84.8% were male. Mean age of admission fell from 5.9 weeks in the previous study to 5.4 weeks. An 'olive' was palpated on examination in 48%, visible peristalsis seen in 25% and 16% of patients presented with haematemesis. Diagnosis solely on clinical examination fell from 74% to 9% and was associated with a corresponding increase in use of ultrasound from 16% to 91%. The frequency of serum chloride values less than 85 mmol/L declined from 26% to 9%. A variety of open and minimally invasive surgical approaches were used with similar outcomes, although laparoscopic pyloromyotomy was associated with significantly higher rates of wound infection (χ(2) = 4.6, P = 0.03). The frequency of major complications remained low at 1%. Contemporary patients with IHPS typically present earlier with a reduction in the incidence of metabolic derangement. Diagnosis based on clinical examination alone appears uncommon, with the majority of suspected cases confirmed by ultrasound. There was no clear difference in overall outcome based on the surgical approach used, although minor variations may reflect our institution's initial experience with laparoscopic pyloromyotomy.