Pyloromyotomy For Hypertrophic Pyloric Stenosis Research Articles

A small lump in the abdomen

A 20-year-old man presented to the emergency department with a small painful swelling located in the midline of the epigastric region. His medical history included asthma and extramucosal pyloromyotomy for hypertrophic pyloric stenosis when he was a baby. His vital signs were normal. Abdominal ultrasound (US) showed a small hypoechoic formation located in the subcutaneous adipose tissue that penetrated into the abdominal cavity through an orifice of about 7 mm in the linea alba.

Return of the Banana Knife: An Alternative Instrument for Laparoscopic Pyloromyotomy.

Background: When the disposable arthroscopic banana knife (Linvatec, Largo, FL) became unavailable, many pediatric surgeons adapted the use of spatula tip cautery for laparoscopic pyloromyotomy; however, reusable arthroscopic knives remain readily available and are well suited to the procedure. Methods: We compared laparoscopic pyloromyotomy with a reusable arthroscopic banana knife (Sklar, West Chester, PA; catalog no. 45-6050) to those using spatula tip cautery at a single institution between September 1, 2012, and December 31, 2019. Mann-Whitney U test was used to compare operative time, room time, and time to discharge between groups. Results: Overall, 109 patients underwent pyloromyotomy for hypertrophic pyloric stenosis during the study time period. Of these, 12 were open and one was undertaken with the Storz pyloromyotomy knife, so these were excluded. A total of 74 (77.1%) laparoscopic cases with spatula tip cautery and 22 (22.9%) with the banana knife were included. Mean age at the time of surgery was ∼37 days. The majority of patients in each group were white, male, and full term. The most common comorbid conditions were reactive airway disease and neonatal abstinence syndrome. There were no significant differences in operative time (P = .61), room time (P = .41), or time from surgery to discharge (P = .26) between procedures using the banana knife and those using the cautery spatula tip. There were no perforations or recurrences. Conclusion: Our findings suggest that the reusable banana knife is a safe and effective alternative to spatula tip cautery for laparoscopic pyloromyotomy, with no difference in operative time, time from surgery to discharge, or complications.

A Rare Entity: Case Report of Recurrent Hypertrophic Pyloric Stenosis

Introduction: Hypertrophic pyloric stenosis (HPS) is well known in pediatric surgery and has good outcomes after pyloromyotomy.1 Emesis in the immediate postoperative period occurs in 40% of patients with HPS and is attributed to gastroparesis from prolonged gastric distention.2 Emesis presenting weeks to months after pyloromyotomy prompts an evaluation that often yields pathology unrelated to HPS. Because recurrent HPS is rare, making this diagnosis highlighted the importance of practicing broad differential diagnoses, ruling out most common causes, and including obscure etiologies. Clinical Findings: A 3-week-old male born after full-term gestation with a history of HPS underwent an uncomplicated laparoscopic pyloromyotomy. He had an uneventful initial recovery but then presented with recurrent projectile nonbilious emesis 7 weeks postoperatively. Between presentations, the patient consistently tolerated feeds and gained weight. Informed consent was obtained. Clinical Course: The patient was evaluated with an abdominal ultrasound, which revealed a hypertrophic pyloric channel, and an upper gastrointestinal contrast (UGI) study, which showed a partial gastric outlet obstruction. He underwent laparoscopy, which revealed a thickened pyloric channel, prompting a repeat pyloromyotomy. Postoperatively, his diet was advanced, and he was discharged on postoperative day 1. Conclusions: Emesis after pyloromyotomy for HPS is common and usually self-limited. Recurrent emesis after normal feeding for weeks or months often yields a diagnosis unrelated to HPS. However, if other more common causes of emesis are excluded, then recurrent HPS can be evaluated with abdominal ultrasound and an UGI study. Once diagnosed, laparoscopic repeat pyloromyotomy is an appropriate treatment option.

Laparoscopic pyloromyotomy for congenital hypertrophic pyloric stenosis: Our experience with twenty cases.

Purpose:Laparoscopic pyloromyotomy for hypertrophic pyloric stenosis has become quite popular over the past decade. There have been many modifications in the technique initially described by Alain et al. in 1991. We describe our experience of the laparoscopic procedure performed in twenty cases.Materials and Methods:This study includes twenty patients of pyloric stenosis who underwent laparoscopic pyloromyotomy from March 2017 to March 2020. All the infants had classical clinical symptoms and abdominal ultrasound confirming the diagnosis of pyloric stenosis. Two 3-mm ports and one 5-mm port were used. The duodenum was grasped to stabilise the olive; a stab knife cut to 10 mm and mounted on a needle holder was introduced through the 3-mm trocar in the left hypochondrium to perform the myotomy, and subsequently, the myotomy was spread with a 5-mm Maryland forceps. Feeding was started 6 h postoperatively.Results:Twenty patients with congenital idiopathic pyloric stenosis underwent laparoscopic pyloromyotomy by this technique. The average operating time was 42 min. There were no peri- or post-operative complications. The post-operative hospital stay ranged between 36 h and 54 h.Conclusion:Laparoscopic pyloromyotomy using a stab knife mounted on a needle holder is a technically feasible, safe and effective surgical procedure for pyloric stenosis.

Differences in Outcomes Based on Sex for Pediatric Patients Undergoing Pyloromyotomy

BackgroundMales and females are known to have varied responses to medical interventions. Our study aimed to determine the effect of sex on surgical outcomes after pyloromyotomy. Materials and methodsUsing the Kids' Inpatient Database for the years 2003-2012, we performed a serial, cross-sectional analysis of a nationally representative sample of all patients aged <1 y who underwent pyloromyotomy for hypertrophic pyloric stenosis. The primary predictor of interest was sex. Outcomes included mortality, in-hospital complications, cost, and length of stay. Regression models were adjusted by race, age group, comorbidity, complications, and whether operation was performed on the day of admission with region and year fixed effects. ResultsOf 48,834 weighted operations, 81.8% were in males and 18.2% were in females. The most common reported race was white (47.3%) and most of the patients were ≥29 days old (72.5%). There was no difference in the odds of postoperative complications, but females had a significantly longer length of stay (incidence rate ratio, 1.28; 95% confidence interval [95% CI], 1.18-1.39; P ≤ 0.01), higher cost (5%, 95% CI, 1.02-1.08; P ≤ 0.01), and higher odds of mortality (odds ratio, 3.26; 95% CI, 1.52-6.98; P ≤ 0.01). ConclusionsOur study demonstrated that females had worse outcomes after pyloromyotomy compared with males. These findings are striking and are important to consider when treating either sex to help set physician and family expectations perioperatively. Further studies are needed to determine why such differences exist and to develop targeted treatment strategies for both females and males with pyloric stenosis.

Implementation of a Quality Control System for Laparoscopic Pyloromyotomy in Hypertrophic Pyloric Stenosis: Hurdles and Pitfalls.

In 2011, we implemented a new video-based system for quality control of laparoscopic pyloromyotomy. More than 3 years later, we evaluated how the implementation had gone and assessed its usability in predicting postoperative outcomes. Four key point images or short video-segments were to be recorded perioperatively: prepyloromyotomy, parallel-mobility testing, perforation testing, and postpyloromyotomy. Data of all 134 patients undergoing laparoscopic pyloromyotomy from September 2011 to December 2014 were analyzed retrospectively. Five pediatric surgeons independently assessed the anonymized operative images for predicting reoperation and time to full-enteral feeding. The percentage of operations during which images were recorded increased from 45% in 2012 to 75% in 2014. Over the study period, one or more images were recorded in 89 of the 134 (66%) patients. In only 17 of 89 patients (19%), all four images were documented. The key point images or videos were made for prepyloromyotomy in 49%, parallel-mobility testing in 85%, perforation testing in 42%, and postpyloromyotomy in 94% of 89 patients. Five patients (3.7%) were reoperated for incomplete pyloromyotomy (N = 4) or mucosal perforation (N = 1). Images were recorded during the first operation in four of the five reoperated patients. The need of reoperation was correctly predicted for two of the four patients. Full-enteral feeding within 24 hours was correctly predicted for 67% of the patients (range: 47-88%). The increase in recorded images over the years is promising. The implementation of the quality control system did not contribute to a significant decrease in the complication rate, which was already very low. Still, reoperation or a protracted postoperative course could only be predicted with moderate accuracy from the operative images, therefore, for now the use of perioperative images in a medicolegal setting should be advised against. Improved compliance with image recording and better instructions for evaluating the images might improve the usefulness of perioperative images in, e.g., telementoring, education, and medicolegal practice.

Is all-cause readmission an appropriate performance measure for pediatric surgeons? A case study in pyloromyotomy

IntroductionAll cause readmissions are used as a surrogate metric for quality of care for both hospitals and physicians, and are considered in pay for performance initiatives. However, the integrity of using all cause readmissions as a benchmark for surgical outcomes has received little attention. Pyloromyotomy for hypertrophic pyloric stenosis is considered a safe pediatric surgical procedure with few complications or readmissions. The incidence of in hospital complications has been reported, however the rate of readmissions and specifically the proportion of readmissions related to surgical complications have not been previously reported. MethodsData were abstracted from the longitudinally linked Office of Statewide Health Planning and Development data from the State of California from 1995 to 2009, allowing patient tracking across all hospitals and years within California. Inclusion criteria were primary procedure code of pyloromyotomy, a diagnosis code of hypertrophic pyloric stenosis, and no prior record of any in-hospital admission. ResultsA total of 1900 patients were identified: 16.8% girls, 31.7% whites, 5.1% blacks, and 58.2% Hispanics. The median length of stay was 2days (IQR 2–3days). The in-hospital complication rate was 5.16% and overall complication rate was 6.84%; there were no deaths. The rate of 30-day all-cause readmission was 4.01%, with a median of 0% across hospitals (IQR 0%–1.1%); and 13.2% of readmissions occurred at a different hospital. Surgically-related readmission rate was 2.16%. Surgically-related readmission comprised 36% readmissions at 30days, but only 13% readmissions overall. The top three primary diagnoses on readmission were respiratory infections (43%), nonrespiratory infections (14%) and other nonsurgical GI indications (14%). All-cause readmissions at 60days, 90days, 180days, and 1year were 5.8%, 7.3%, 10.4%, and 13.7%, respectively. ConclusionThirty-day readmission for a surgical complication occurs in 1 of 50 patients undergoing a pyloromyotomy for hypertrophic pyloric stenosis but for all causes is twice as likely, 1 in 25 patients. All-cause readmission is an inadequate measure for the quality of surgical care and the performance of pediatric surgeons.This is a Prognostic Study with Level II Evidence.

Prematurity Affects Age of Presentation of Pyloric Stenosis.

Term infants with hypertrophic pyloric stenosis (HPS) typically present between 4 and 6 weeks. There is limited consensus, however, regarding age of presentation of premature infants. We aim to determine if there is an association between the degree of prematurity and chronological age of presentation of HPS. A total of 2988 infants who had undergone a pyloromyotomy for HPS were identified from the 2012 and 2013 NSQIP-P Participant Use Files. Two hundred seventeen infants (7.3%) were born prematurely. A greater degree of prematurity was associated with an older chronological age of presentation ( P < .0001). Prematurity was significantly associated with an increase in overall postoperative morbidity, reintubation, readmission, and postoperative length of stay. When clinicians evaluate an infant with nonbilious emesis with a history of prematurity, they should consider pyloric stenosis if the calculated postconceptional age is between 44 and 50 weeks. When counseling families of premature infants, surgeons should discuss the increased incidence of postpyloromyotomy morbidity.

Minimally Invasive Surgery in Neonatal Patients: A Review

Laparoscopic and thoracoscopic surgery have gradually become accepted diagnostic and therapeutic modalities in the management of neonatal surgical conditions. In the hands of experienced surgeons, minimally invasive surgery (MIS) has reduced the need for open procedures. In children younger than 1 year, the advantages of MIS are evident in avoiding the sequelae of open surgery. MIS has shown outcomes comparable to those with open surgery. The recent literature in the PubMed database was reviewed, using the keywords “minimally invasive surgery,” “neonatology,” “pediatric surgery,” “laparoscopy,” and “thoracoscopy.” The review included retrospective and institutional reports of MIS published since January 2000.The results were used to develop a review of the current state of MIS in the neonatal population. The use of minimally invasive techniques in neonatal surgical conditions was successful in the hands of experienced surgeons. Some procedures currently performed include gastrostomy, pyloromyotomy for hypertrophic pyloric stenosis, gastroesophageal reflux surgery, the Ladd procedure for intestinal malrotation, colonic pull-through procedures for Hirschsprung disease and other anorectal malformations, repair of diaphragmatic eventration and congenital diaphragmatic hernia, duodenal atresia, esophageal atresia/tracheoesophageal fistula, pulmonary lobectomy, surgery for necrotizing enterocolitis, and ligation of patent ductus arteriosus. Further formal training of surgeons in these techniques and the development of new and improved instrumentation can reduce the rates of open surgery and its sequelae in the neonatal population.

Is there any correlation between radiologic findings and eradication of symptoms after pyloromyotomy in hypertrophic pyloric stenosis?

Background:Hypertrophic pyloric stenosis (HPS) is one of the most common gastrointestinal disorders during early infancy, with an incidence of 1-2:1000 live births in the world. In this study, we aimed to investigate the correlation between radiologic findings and eradication of symptoms after pyloromyotomy in HPS.Materials and Methods:One hundred and twenty-five (102 boys and 23 girls) patients with suspected infantile HPS were treated surgically by Ramstedt pyloromyotomy between March 21, 2004 and March 20, 2014 at paediatric surgery ward of Tabriz Children's Hospital, Iran. The demographic features, clinical findings, diagnostic work-up, operation type and postoperative specifications of the patients were studied retrospectively.Results:Male to female ratio was 4:1. The patients were 16-90 days of old and the mean age was 39 ± 1.42 days. The range of pyloric canal length was 7.60-29.00 mm and the mean length was 19.54 ± 3.42 mm. Pyloric muscle diameter was 2.70-9.00 mm, and the mean diameter was 4.86 ± 1.14 mm. Seventy-two percent of patients had episodes of vomiting after operation. Mean time of persistence of vomiting after pyloromyotomy was 15.73 ± 0.15 h. Mean discharge time was 55.22 ± 0.08 h. Radiologic findings did not show any significant correlation with persistence of vomiting or discharge time.Conclusion:The present study revealed that radiographic findings could not predict postoperative symptom eradication after pyloromyotomy in HPS.

A Modified Umbilical Incision for Laparotomy in Newborns and Small Infants

Purpose: A modified upper abdominal incision through the umbilicus has previously been described by one of the authors (Salakos) for performing pyloromyotomy in hypertrophic pyloric stenosis. The advantages were easier access to the peritoneal cavity, and better cosmetic results compared with epigastric transverse or midline incisions. Methods: Using the same umbilical incision, a wider incision in the aponeurotic fascia following the skin incision lines has been added, thus allowing better access to the abdominal contents, and enabling an easier exteriorization of the bowel. Results: This surgical approach was used in 23 babies- mean gestational age 34 ± 5.28 weeks and mean birth body weight 1980 ± 1048g. The mean age at the time of surgery was 12 ± 30 days. Indications for surgery included: necrotizing enterocolitis or its complications (n=9), small bowel perforation (n=3), malrotation (n=3), meconial ileum (n=2), intestinal dysmotility due to prematurity (n=2), intestinal atresia (n=2), gastric perforation (n=1), and omphalomesenteric duct remnants causing obstruction (n=1). Six patients were left with an ileostomy. Wound infection occurred in 3 cases and there was no dehiscence. Conclusions: We have extended the use of a modified open umbilical access to manage a broader range of surgical conditions in neonates and infants achieving good exposure and cosmetic appearance.

Management and Outcome of Mucosal Injury During Pyloromyotomy--An Analytical Survey Study.

Different approaches of dealing with mucosal injury during pyloromyotomy for hypertrophic pyloric stenosis have been described. There is, however, no consensus on the best technique to use. We conducted a survey among International Pediatric Endosurgery Group (IPEG) members on their experience of mucosal injuries during pyloromyotomy, the way in which these were handled, any modification in subsequent postoperative care, and impact on outcome. A confidential survey was sent to IPEG members querying demographic data, number of pyloromyotomies performed, operative approach, incidence of mucosal injury, intraoperative management, and postoperative consequences. Statistical analysis was performed to determine factors associated with complications and outcome. In total, 231 mucosa injuries were included in the study. Of these, 93% were noticed intraoperatively. Cases were nearly equally distributed between laparoscopic (49%) and open (51%) procedures, and the risk of mucosal injuries was no different between the two. Most surgeons addressed mucosal perforation with primary mucosal repair (70%), whereas a minority (27%) performed full-thickness closure, rotation, and repyloromyotomy in a different quadrant. Common alterations in management included delay in feeding (84%), longer hospital stay (30%), and contrast study before feeding (12%). The vast majority of patients had no adverse sequelae after a mucosal injury (96%), but three patients underwent re-operation. No correlations were found between repair method and complications. Mucosal injuries that are noticed and addressed intraoperatively resulted in few complications, regardless of the repair method. Among the queried surgeons, primary mucosal repair is the current standard of care. Primary mucosal repair is equivalent to full-thickness closure in terms of complications and outcome.

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

Credits: Study data were collected and managed using REDCap electronic data capture tools hosted at the Children’s Foundation Research Institute - Biomedical Informatics Core and the University of Tennessee Health Science Center (Harris et al., 2009). Research Electronic Data Capture is a secure, Web-based application designed to support data capture for research studies, providing (a) an intuitive interface for validated data entry, (b) audit trails for tracking data manipulation and export procedures, (c) automated export procedures for seamless data downloads to common statistical packages, and (d) procedures for importing data from external sources. Introduction Various feeding regimens are used for infants after pyloromyotomy for hypertrophic pyloric stenosis (HPS). A few studies have shown that standardized feeding regimens (SFRs) can decrease length of hospital stay. In January 2010, a freestanding academic children’s hospital converted to Computerized Provider Order Entry (CPOE), and standard order sets were implemented. A postoperative order set was devised for patients with HPS, and an SFR was specified. Purpose The aim of this study was to measure impact of a CPOE-driven SFR on postoperative length of stay (LOS) after laparoscopic pyloromyotomy. Methods A retrospective review of patients admitted with HPS who underwent laparoscopic pyloromyotomy from July 2007 to October 2009 (pre-CPOE) and from April 2010 to July 2012 (post-CPOE) at a free-standing academic children’s hospital was conducted. LOS was defined as the time from surgery to time discharge orders were written. Results There was no difference in the LOS between the pre- and post-CPOE groups. There was also no difference in the time from surgery to time discharge criteria were met between the two groups. No differences in frequency of emesis, 30-day readmit, or complication rates were seen. Physician compliance to use of CPOE SFR was 99.3%. Conclusions Design and implementation of a CPOE order set for the postoperative care of patients after pyloromyotomies utilizing an SFR did not impact the postoperative LOS. However, it can be used to produce consistent care without significantly increasing complication rates or 30-day readmits.

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.

Infantile Hypertrophic Pyloric Stenosis - A Rare Cause of Hepatoportal Venous Gas

Hepatic portal venous gas (HPVG) is usually associated with necrotizing enterocolitis or bowel ischemia in infants but it’s a rare finding with hypertrophic pyloric stenosis (HPS). In such cases, portal venous gas is a benign incidental finding and does not advocate any delay in the surgical treatment. We report this atypical case of 3 weeks old male infant with HPS having portal venous gas that was detected on abdominal ultrasound. Our patient with a history of term delivery was brought to the pediatric department of Combined Military Hospital Lahore on 25th of November, 2013 with complaints of vomiting and constipation for the last 4 days. Physical examination showed that the infant was lethargic and mildly dehydrated with soft and non-tender abdomen. Baseline blood tests revealed metabolic alkalosis with hemoglobin and total leukocyte count within normal limits. Plain xray abdomen showed a distended stomach with no signs of gut obstruction. Abdominal ultrasonography revealed a severely thickened and lengthened pylorus suggestive of hypertrophic pyloric stenosis. Moreover, ultrasound also showed multiple echogenic foci diffusely involving the both lobes of otherwise normal sized liver. Moving air bubbles were also detected in the extra and intra hepatic portal and splenic veins on dynamic scanning confirming the presence of portal venous gas. The infant underwent Ramstedt’s pyloromyotomy for HPS. The infant showed a steady recovery and ultrasonography performed at 2nd post op day detected no signs of gas within the hepato portal veins.

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.

The Cross-technique for single-incision pediatric endosurgical pyloromyotomy

Single-incision pediatric endosurgical (SIPES) pyloromyotomy is frequently used for the treatment of hypertrophic pyloric stenosis at our center. Our initial SIPES approach mirrored the conventional, triangulated laparoscopic pyloromyotomy. Because an increased number of perforations were noted on our initial analysis, a more straightforward Cross-technique SIPES pyloromyotomy was developed. This study compares the current Cross-technique SIPES pyloromyotomy to the previous standard SIPES operation. The Cross-technique entails grasping the antrum with the surgeon's left hand instrument, retracting toward the left lower quadrant, and thereby orienting the pylorus obliquely toward the right upper quadrant. The serosal incision and muscular spreading is accomplished using a right-hand instrument that crosses over the left hand grasper. Demographic variables, operative times, estimated blood loss (EBL), complications, conversion rate, and postoperative length of stay were compared. Twenty-nine Cross-technique patients were compared with 23 in the standard group. The Cross-technique was faster than the standard procedure (21 ± 5 vs. 27 ± 12 min, p = 0.03) and EBL was lower (1.3 ± 0.5 vs. 1.7 ± 0.6 ml, p = 0.02). There were two mucosal perforations requiring conversions to triangulated 3-access-site laparoscopy in the standard, and one conversion to open surgery in the Cross-technique group. Patients who underwent cross-technique pyloromyotomy weighed less (3.6 ± 0.6 vs. 4.0 ± 0.5 kg, p = 0.012), but there were no differences in age, gender ratio, conversion rate, or length of stay. There was one postoperative wound infection in the cross-technique, but none in the standard group. No patients required reoperation. All participating surgeons felt that the cross-technique was more ergonomic and easier to perform than the standard SIPES technique. The Cross-technique appears superior to standard SIPES pyloromyotomy and should be preferentially used for single-incision endosurgical pyloromyotomy for hypertrophic pyloric stenosis.

Microlaparoscopic pyloromyotomy in children: initial experiences with a new technique

We conducted a prospective feasibility study to evaluate the value of microlaparoscopic pyloromyotomy for hypertrophic pyloric stenosis in infants. All data were prospectively collected, and the procedures were documented by video recording. Patients were selected based on the availability of the equipment and consultant surgeons experienced in microlaparoscopy. Microlaparoscopic (exclusive use of 2-mm instruments and small-diameter scopes, 1.7-1.9 mm in diameter) pyloromyotomy was performed. All procedures were done under general anesthesia with endotracheal intubation. This study includes 21 infants, 14 boys and 7 girls (aged 3-12 weeks, average 4.8 weeks). Weight at admission averaged 4,100 g (range 3,200-5,500 g). Mean wall thickness of pyloric muscle measured by ultrasound was 4.5 mm (range 3.8-7.8 mm). Average operative time was 13 min for the consultant surgeon. Full feeding was attained on the first postoperative day in 16 infants. Postoperative length of stay averaged 87 h. Eighteen infants were re-examined to assess cosmesis. Despite the limited patient population included in this study, we conclude that use of microlaparoscopic pyloromyotomy for hypertrophic pyloric stenosis is safe and feasible, and the technique provides minimal access trauma and superior cosmesis.

Impact of spinal anesthesia for open pyloromyotomy on operating room time

Purpose When pyloromyotomy for hypertrophic pyloric stenosis (HPS) is performed under general anesthesia, metabolic abnormalities and fluid deficits coupled with residual anesthetics may increase the risk of postoperative apnea, thereby, prolonging operating room time and delaying extubation. Spinal anesthesia has been found to reduce the rate of postoperative apnea in high-risk infants. The aim of the study was to evaluate the effect of spinal vs general anesthesia on operating room time in infants undergoing open pyloromyotomy. Methods Data for 60 infants who underwent pyloromyotomy under spinal (n = 24) or general (n = 36) anesthesia at a tertiary pediatric medical center were derived from the computerized database. Primary outcome measures were total operating room time, procedure duration, anesthesia release time, wake-up time, and anesthesia control time (anesthesia release plus wake-up). Nonparametric Mann-Whitney test was used for statistical analysis, and Levene's test was used to assess the equality of variances in samples; P ≤ .05 was considered significant. Results Mean total operating room time was 50.9 (12.1) minutes in the spinal anesthesia group and 69.5 (26.8) minutes in the general anesthesia group ( P = .001). Corresponding values for mean wake-up time were 3.6 (2.9) and 17.2 (25.3) minutes ( P < .001), and for mean anesthesia control time, 13.2 (6.7) and 28.5 (24.6) minutes ( P < .001). There were no between-group differences in procedure duration or anesthesia release time. On Levene's test, between-group differences were significant for total operating time and wake-up time ( P = .01 for both). Conclusions The use of spinal anesthesia for open pyloromyotomy in infants with HPS shortens the operating room time by reducing the wake-up time.

A rare presentation in a case of gastric duplication cyst communicating to the pancreatic duct: coincidental detection during pyloromyotomy for hypertrophic pyloric stenosis

A rare case of gastric duplication of childhood is reported. A 1-month-old boy underwent pyloromyotomy for infantile hypertrophic pyloric stenosis. At laparotomy, a protruding lesion was identified in the anterior wall of the pylorus. The pylorus was hypertrophic as indicated preoperatively, and a normal pyloromyotomy was performed. Wedge biopsy of the protruding lesion revealed an intestinal structure, and gastric duplication was diagnosed. The child remained asymptomatic thereafter, but considering the risk of the duplication becoming symptomatic, a second laparotomy was performed at 1 year of age. The duplication cyst shared part of the wall with the pylorus, and the cyst was removed by cystectomy, leaving the pyloric muscle intact. The cyst was found to be communicating with the pancreatic duct. The child is doing well without any symptoms as of 18 months after second laparotomy. To the best of our knowledge, this is the youngest case of gastroduodenal duplication with pancreatic duct communication yet reported.