Treatment Of Hypertrophic Pyloric Stenosis Research Articles

Hypertrophic Pyloric Stenosis Protocol: A Single Center Study.

Initial treatment of hypertrophic pyloric stenosis (HPS) is correction of electrolyte disturbances with fluid resuscitation. In 2015, our institution implemented a fluid resuscitation protocol based on previous data that focused on minimizing blood draws and allowing immediate ad libitum feeds postoperatively. Our aim was to describe the protocol and subsequent outcomes. We conducted a single-center retrospective review of patients diagnosed with HPS from 2016 to 2023. All patients were given ad libitum feeds postoperatively and discharged home after tolerating three consecutive feeds. The primary outcome was the postoperative hospital length of stay (LOS). Secondary outcomes included the number of preoperative labs drawn, time from arrival to surgery, time from surgery to initiation of feeds, time from surgery to full feeds, and re-admission rate. The study included 333 patients. A total of 142 patients (42.6%) had electrolytic disturbances that required fluid boluses in addition to 1.5x maintenance fluids. The median number of lab draws was 1 (IQR 1,2), with a median time from arrival to surgery of 19.5hours (IQR 15.3,24.9). The median time from surgery to first and full feed was 1.9hours (IQR 1.2,2.7) and 11.2hours (IQR 6.4,18.3), respectively. Patients had a median postoperative LOS of 21.8hours (IQR 9.7,28.9). Re-admission rate within the first 30 postoperative days was 3.6% (n = 12) with 2.7% of re-admissions occurring within 72hours of discharge. One patient required re-operation due to an incomplete pyloromyotomy. This protocol is a valuable tool for perioperative and postoperative management of patients with HPS while minimizing uncomfortable intervention.

The Safety and Effectiveness of Laparoscopic Pyloromyotomy Using 3-mm Electrocautery Hook versus Open Surgery for Treatment of Hypertrophic Pyloric Stenosis in Infants.

Background: The standard of treatment for infants with hypertrophic pyloric stenosis is still pyloromyotomy. Recently, in most of the pediatric surgery centers laparoscopic pyloromyotomy has become popular. The aim of the present study is to compare the outcomes of treatment in infants with hypertrophic pyloric stenosis between traditional open approach and laparoscopic pyloromyotomy using 3-mm electrocautery hook. Methods: A total of 125 infants, 104 (83.2%) males, with median age 33 (interquartile range, IQR 24, 40) days, who underwent pyloromyotomy because of hypertrophic pyloric stenosis, between 2005 and 2021, were included in the retrospective study. Of that number 61 (48.8%) infants were allocated to the open group and 64 (51.2%) to the laparoscopic group. The groups were compared in regards to time to oral intake, duration of surgery, the type and rate of complications, rate of reoperations, frequency of vomiting after surgery, and the length of hospital stay. Results: No differences were found with regards to baseline characteristics between two investigated groups. Laparoscopic approach was associated with significantly better outcomes compared to open approach: shorter duration of surgery (35 min (IQR 30, 45) vs. 45 min (40, 57.5); p = 0.00008), shorter time to oral intake (6 h (IQR 4, 8) vs. 22 h (13.5, 24); p < 0.00001), lower frequency of postoperative vomiting (n = 10 (15.6%) vs. n = 19 (31.1%)), and shorter length of postoperative hospital stay (3 days (IQR 2, 3) vs. 6 days (4.5, 8); p < 0.00001). In regards to complications and reoperation rates, both were lower in the laparoscopic pyloromyotomy group but the differences were not statistically significant (p = 0.157 and p = 0.113, respectively). The most common complication in both groups was mucosal perforation (open group, n = 3 (4.9%); laparoscopic group, n = 2 (3.1%)) followed by wound infection in open group, n = 3 (4.9%). No cases of wound infection were recorded in the laparoscopic group. Conclusion: Open and laparoscopic pyloromyotomy are equally safe and effective in treatment of hypertrophic pyloric stenosis. Laparoscopic technique is associated with faster recovery, shorter duration of surgery and shorter duration of hospital stay.

Diagnosis and treatment of primary hypertrophic pyloric stenosis (HPS) in older children

Hypertrophic pyloric stenosis (HPS) is the most important cause of non-bilious vomiting during infancy and it is usually idiopathic. It is very rare in older children and adolescents, in which gastric outlet obstruction (GOO) is more typically secondary to other conditions. Gastrointestinal malformation are frequently associated with Down syndrome and some of them (especially duodenal abnormalities) can be detected quite late. In infants the standard treatment of HPS is represented by a Ramstedt pyloromyotomy, while in adults a distal gastric resection is more indicated and it is usually associated to a Billroth I or II reconstruction. We present an unusual case of a 12-year-old girl with Down syndrome, diagnosed with late-onset HPS. She came to our attention with periodic non-bilious vomiting and growth delay. She underwent multiple imaging examinations, which highlighted the presence of an HPS. Based on patient's age and the thickness of the pyloric muscle, we decided to perform a partial gastrectomy with a Roux-en-y reconstruction. Patient was discharged on the X day. She is now on follow up, gains weight and presents good conditions. HPS is rare but possible during childhood and adolescence. Diagnosis is usually performed through ultrasounds (US) and upper gastrointestinal radiological series (UGI), but sometimes further examinations are required (abdominal MRI, esophagogastroduodenoscopy). In older children since less invasive techniques are not effective, we have to consider partial gastrectomy. Based on our experience, Roux-en-y reconstruction is a valid option, associated with poor complication and good quality of life.

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 (...).

Clinical Outcomes of Surgical Treatment of Hypertrophic Pyloric Stenosis &#x0D; with Application of Various Operational Access

Introduction. Treatment options of congenital hypertrophic pyloric stenosis (HPS) appear to be an acute issue nowadays due to the fact that this pathology is often detected in children of the first year of life - according to statistics, the incidence rate of congenital hypertrophic pyloric stenosis in children is 3:1000 live newborns. Since there are various treatment options of the given congenital pathology, there is no general consensus in the opinions of surgeons regarding the superiority of different treatment methods. Therefore, it is necessary to search for a single most relevant treatment technique for this pathology.The aim of the study was to analyze clinical outcomes for treatment of congenital hypertrophic pyloric stenosis in children with application of various surgical techniques: open pylorotomy (transverse, circumbilical incision) and laparoscopic pylorotomy.Materials and methods. The study included 67 patients, who received treatment in Kursk Regional Pediatric Hospital №2 in 2014-2018. Patients with congenital HPS were divided into 3 groups, depending on the performed surgical interventions. Group 1 included patients who underwent an open pylorotomy with transverse access, group 2 included patients who underwent an open pylorotomy with circumbilical access, and group 3 included patients who underwent laparoscopic pylorotomy. The following parameters were used to assess the efficiency of the treatment performed: the duration of the operative intervention, the duration of stay of a child in the ICU, the duration of stay of a child in the hospital, extubation time, initiation of enteral feeding, recovery rate of enteral feeding volume. The data were statistically performed using the Mann-Whitney test to determine the significance of differences between the mean values (p0.05).Results. The study results demonstrated that the shortest duration of operational intervention was observed in patients of group 3, it constituted 41,4 3,5 minutes. In addition, patients of this group spent the shortest average time in the ICU - 4,2 0,3 days - and in the hospital in general - 12,1 0,8 days; initiation of enteral feeding in patients of this group was registered in 10,8 1,2 hours and the recovery rate of enteral feeding volume was 4,8 0,5 days.Conclusions. Having analyzed clinical outcomes for treatment of pilorostenosis in the studied groups of children, it is possible to conclude that laparoscopic pyloromyotomy is preferred to open surgical interventions not only for reasons of cosmetic result, but also according to the criteria of the postoperative course of the disease in patients.

Single-Site Umbilical Laparoscopic Pyloromyotomy Using a Pyloric Electrocoagulation Chisel Combined with a Left-Handed Main Operation for Congenital Hypertrophic Pyloric Stenosis.

Background: Laparoscopic pyloromyotomy has become a gold standard for the treatment of congenital hypertrophic pyloric stenosis (HPS). There have been recent reports on the use of transumbilical single-site laparoscopic surgery for congenital HPS; however, using transumbilical single-site laparoscopic surgery in pediatric cases is still controversial due to the difficulty with manipulation. In this study, some preliminary experience with the application of a novel transumbilical single-site laparoscopic approach in congenital HPS is described. Methods: A retrospective study was conducted involving 25 patients with congenital HPS treated in our hospital from August 2016 to August 2019. A pyloric electrocoagulation chisel combined with a left-handed main operation was completed in all of the patients and the operative times, postoperative length of stay, and operative complications were recorded. Results: The laparoscopic operation was completed in 25 patients with an average operative time of 21.9 ± 5.5 minutes, average postoperative length of stay of 2.5 ± 0.9 days, and no perforations of the pyloric mucosa, recurrent obstruction, surgical incision infections, and incision hernias. All of the patients had at least 3 months of follow-up, good growth and development, and the parents were satisfied with the postoperative scars. Conclusion: A pyloric electrocoagulation chisel combined with a left-handed main operation in the treatment of congenital HPS by a single-site umbilical laparoscopic pyloromyotomy is safe and effective, and can achieve a satisfactory cosmetic effect.

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.

Atropine: A Cure for Persistent Post Laparoscopic Pyloromyotomy Emesis?

Background: Atropine has been used as a successful primary medical treatment for hypertrophic pyloric stenosis. Several authors have reported a higher rate of incomplete pyloromyotomy with the laparoscopic approach compared to open. In this study, we evaluated the use of atropine as a medical treatment for infants with emesis persisting greater than 48 hours after a laparoscopic pyloromyotomy. Materials and Methods: We performed a retrospective chart review of infants receiving a laparoscopic pyloromyotomy between November 1998 and November 2012. Infants with emesis that persisted beyond 48 hours postoperatively were given 0.01mg/kg of oral atropine 10 minutes prior to feeding. Infants remained inpatient until they tolerated two consecutive feedings without emesis. Results: 965 patients underwent laparoscopic pyloromyotomy; 816 (84.6%) male and 149 (15.4%) female. Twenty-four (2.5%) received oral atropine. The mean length of stay for patients who received atropine was 5.6 ± 2.6 days, an average of 3 additional days. They were discharged home with a one-month supply of oral atropine. Follow up evaluation did not reveal any complications from receiving atropine. The median follow up was 21 days. None returned to the operating room for incomplete pyloromyotomy. There were 17 (1.8%) operative complications in our series; 9 mucosal perforations, 2 duodenal perforations, and 6 conversions to open for equipment failure or poor exposure. There were 4 (0.4%) post-operative complications: 2 episodes of apnea requiring reintubation and 2 incisional hernias that required a second operation. There were no deaths. Conclusion: Oral atropine is a viable treatment for persistent emesis after a pyloromyotomy and reduces the need for a second operation due to incomplete pyloromyotomy.

YU Pyloroplasty for the Correction of Chronic Hypertrophic Pyloric Gastropathy in Canines

Background: One of the causes of delay gastric emptying is the chronic hypertrophic pyloric gastropathy, unusual disease that can occur in acquired or congenital form. It is characterized by hypertrophy of the antral mucosa, by thickening of the muscular layer, or by hyperplasia of the pylorus. The animals are presented with a history of chronic intermittent vomiting. Treatment is based on surgical correction through techniques such as pyloromyotomy or transverse or Y-U pyloroplasty. Thus, the aim was report three cases of pyloric stenosis by hypertrophy in dogs of the breeds, Fila Brasileiro, English Bull Terrier and American Pitbull Terrier, emphasizing the diagnosis and therapy instituted.Cases: All animals in this study reached the Veterinary Hospital of the Federal University of Mato Grosso with a history of chronic intermittent vomiting. The findings of physical and laboratory examinations in all animals were unspecific, with those important to rule out other causes of vomiting. Contrast radiographic evaluation revealed marked stomach distension and delayed gastric emptying, indicated gastric outflow obstruction. In one case, a video endoscopy was performed. The images reveal hyperemia of the gastric mucosa with small areas of bleeding around the stomach. It was observed intense production of gastric juice and the presence of the same reflux. In the pyloric antrum, a thick fold reddish gastric mucosa, which partially obstructed the pyloric ostium. There was very little motility during the examination. As therapeutic approach for all cases, we opted for performing the surgical technique of pyloroplasty in Y-U, consisting of enlarging the diameter of the antral pyloric region in an attempt to create a broader pylorus, what make possible an emptying a gastric rapidly. All the pacients remained in hospital in the postoperative period receiving medications intravenously. Postoperative fluid based on Ringer’s lactate solution and administration of ondansetron (0.2 mg/kg every 8 h), sucralfate (30 mg/ kg every 12 h), sulfadoxine to trimethoprim (20 mg/kg every 12 h) and meloxicam (0.2 mg/kg every 24 h). Twelve h of fasting after the surgical procedure without vomiting, the dog received light past food. An average of three to four days post-surgical discharged with recommendations to keep antibiotic therapy for ten days and light diet. The fifteenth day of surgery, the patients returned for removal of skin spots, with good general condition and satisfactory healing. No cases of vomiting were reported. As the case one returned to perform the monitoring gastograma. The dog was anesthetized and giving the contrast. On radiographs, there was a slight delay in gastric emptying, which can be explained by the anesthesia used for contrast administration, as described in the literature. The images showed stomach and intestines in size, shape and normal position. The technique was satisfactory in reducing clinical signs in all these cases, confirmed by the absence of vomiting in the post-operative period.Discussion: The surgical technique used, pyloroplasty Y-U consists of traspor a part of the antral wall to the pyloric region in an attempt to create a broader pylorus, and possibly a time soon gastric emptying. It was possible to demonstrate with only three cases the pyloroplasty Y-U proved to be a simple and effective technique for the treatment of hypertrophic pyloric stenosis with a favorable prognosis in all cases. Thus, disease should be considered in the differential diagnosis in cases of gastric outflow obstruction, regardless of patients age.Keywords: dog, hypertrophy, pylorus.

Entrenamiento en pilorotomía endoscópica mediante el uso de modelos animales

IntroductionThe biological inanimate simulators (BIS) permit the development of skills in endoscopy. The extramucosal pyloromyotomy is the standard treatment for hypertrophic pyloric stenosis (HPS). The peroral endoscopic approaches severed hypertrophic circular muscular layer. This procedure has excellent results, however, for a non-expert endoscopist is difficult to identify the circular muscle and increases the risk of perforation. ObjectiveTo evaluate the feasibility of using BIS porcine for endoscopic training in endoscopic pyloromyotomy (EPM). MethodsExperimental design without group control in porcine BIS. Two endoscopists with previous experience in endoscopic submucosal dissection and esophagomyotomy used experimental design with no control group for the porcine SBI. We evaluated the different phases (technical success, complications and time) and calculated descriptive statistics. ResultsWe performed eight EPM, with an average time 28.4 ± 17.9minutes. The evaluation of the piece had a positive correlation with the endoscopic image. The site of PME approach was related to the procedure time, being greater on greater curvature of the antrum. There was variability in the time of the procedure being lower in anterior antral wall. There were no complications such as perforation and 6 PME were reported incomplete confirmed by pathology. ConclusionsThe SBI porcine allows training in complex endoscopic techniques with wide safety margin. The submucosal tunnel situation was directly related to the feasibility of the PME.

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.

Pyloromyotomy: randomized control trial of laparoscopic vs open technique

Purpose Open pyloromyotomy remains as the criterion standard treatment for hypertrophic pyloric stenosis with the laparoscopic approach rapidly gaining adoption. We present a prospective, randomized trial between the 2 approaches. Methods After institutional review board approval, 98 patients with hypertrophic pyloric stenosis were consecutively randomized to either open or laparoscopic pyloromyotomy. Postoperative and hospital course were evaluated by review of the hospital records and long-term follow-up with scripted telephone survey using Likert scales. The length of operating room time, surgical procedure, postoperative stay, time to refeeding, and complications were evaluated. Secondary outcomes of cosmetic results and parental satisfaction were determined. Results Ninety-eight patients were enrolled during a 4-year period. There were no significant differences between 2 groups on all primary outcomes. There were 3 complications in the open group—a wound dehiscence, a surgical site infection, and a gastric serosal tear—and 2 complications in the laparoscopic group—mucosal perforation and a suture granuloma. In long-term follow-up on 72 patients (56 months), parents described significant cosmetic results with laparoscopic approach. Conclusions There was no difference in operating time, hospital stay, or refeeding patterns between open and laparoscopic pyloromyotomy. The complication rates were similar between the 2 methods. However, long-term cosmetic results were significantly superior in the laparoscopic group.

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.

Hypertrophic Pyloric Stenosis

Hypertrophic pyloric stenosis (HPS) is a gastric outlet obstruction related to the thickening of the pyloric muscle. It typically affects first-born males between the ages of 6 to 8 weeks. Sonography is the modality of choice for diagnosing HPS. This review discusses the etiology, signs and symptoms, sonographic findings, and treatment for hypertrophic pyloric stenosis.

Learning curves for pediatric laparoscopy: how many operations are enough? The Amsterdam experience with laparoscopic pyloromyotomy

BackgroundFew studies on the surgical outcomes of open (OP) versus laparoscopic pyloromyotomy (LP) in the treatment of hypertrophic pyloric stenosis have been published. The question arises as to how many laparoscopic procedures are required for a surgeon to pass the learning curve and which technique is best in terms of postoperative complications. This study aimed to evaluate and quantify the learning curve for the laparoscopic technique at the authors’ center. A second goal of this study was to evaluate the pre- and postoperative data of OP versus LP for infantile hypertrophic pyloric stenosis.MethodsA retrospective analysis was performed for 229 patients with infantile hypertrophic pyloric stenosis. Between January 2002 and September 2008, 158 infants underwent OP and 71 infants had LP.ResultsThe median operating time between the OP (33 min) and LP (40 min) groups was significantly different. The median hospital stay after surgery was 3 days for the OP patients and 2 days for the LP patients (p = 0.002). The postoperative complication rates were not significantly different between the OP (21.5%) and LP (21.1%) groups (p = 0.947). Complications were experienced by 31.5% of the first 35 LP patients. This rate decreased to 11.4% during the next 35 LP procedures (p = 0.041). Two perforations and three conversions occurred in the first LP group, compared with one perforation in the second LP group.ConclusionThe number of complications decreased significantly between the first and second groups of the LP patients, with the second group of LP patients quantifying the learning curve. Not only was the complication rate lower in the second LP group, but severe complications also were decreased. This indicates that the learning curve for LP in the current series involved 35 procedures.

Single-incision laparoscopic pyloromyotomy: initial experience

Laparoscopic pyloromyotomy has become the standard treatment for hypertrophic pyloric stenosis. Single-incision laparoscopic surgery is an emerging operative approach that utilizes the umbilical scar to hide the surgical incision. To describe our initial experience with single-incision laparoscopic pyloromyotomy in 15 infants. Laparoscopic pyloromyotomy was performed through a single skin incision in the umbilicus, using a 4-mm 30 degrees endoscope and a 5-mm trocar. The 3-mm working instruments were inserted directly into the abdomen via separate lateral fascial stab incisions. All patients were prospectively evaluated. The procedure was performed in 15 infants (13 male) with mean age of 45 +/- 16 days and mean weight of 4.04 +/- 0.5 kg. All procedures were completed laparoscopically, and one case was converted to a conventional triangulated laparoscopic work configuration after a mucosal perforation was noted. The perforation was repaired laparoscopically. On average, operating time was 29.8 +/- 13.6 min, and postoperative length of stay was 1.5 +/- 0.8 days. All patients were discharged home on full feeds. Follow-up was scheduled 2-3 weeks after discharge, and no postoperative complications were noted in any of the patients. Single-incision laparoscopic pyloromyotomy is a safe and feasible procedure with good postoperative results and excellent cosmesis. The main challenge is the spatial orientation of the instruments and endoscope in a small working space. This can be overcome by a more longitudinally oriented working axis than used in the conventional angulated laparoscopic configuration.

Carbon dioxide embolism in a 3-week-old neonate during laparoscopic pyloromyotomy: a case report

Laparoscopic pyloromyotomy has gained popularity in the treatment of hypertrophic pyloric stenosis. This is the first case report of carbon dioxide embolism during laparoscopic pyloromyotomy. We describe a case of carbon dioxide embolism in a 3-week-old neonate during laparoscopic pyloromyotomy by injection of carbon dioxide into a patent umbilical vein. The diagnosis of carbon dioxide embolism was made on the basis of the abrupt decrease in end-tidal CO 2, sudden decreased Sp o 2, hypotension, and cyanosis. Portable x-ray with the clinical presentation was sufficient for a diagnosis of carbon dioxide embolism. Treatment included termination of CO 2 insufflation, placing the patient in Durant's position, and adequate resuscitation as necessary. Despite the fact that the insufflation pressure was in the recommended range, a carbon dioxide embolism was thought to be caused by injection of carbon dioxide into a patent umbilical vein. Although laparoscopic pyloromyotomy has demonstrated to be a safe and effective procedure, this is a serious and rare complication causing prolonged length of stay and skewed hospital charges.

Laparoscopic Treatment of Simultaneously Occurring Pyloric Stenosis and Malrotation

Hypertrophic pyloric stenosis (HPS) is a common cause of nonbilious vomiting in the neonatal period with an incidence of approximately 1 to 3 per 1000 live births. The Ramstedt pyloromyotomy has been the standard treatment since 1912. In 1991, Alain et al. reported a novel approach to HPS using laparoscopy. Since this original description, the laparoscopic pyloromyotomy has become progressively more popular and, in many institutions, has replaced the open approach. Similarly, malrotation is a condition affecting the neonatal population, resulting from incomplete intestinal rotation about the superior mesenteric artery during weeks 10 through 11 of development. If left untreated, it can lead to abnormal mesenteric attachments and a narrowed mesenteric base, placing the patient at risk for midgut volvulus. The standard surgical treatment has been the open Ladd procedure first described in 1932. In 1996, Gross described a minimally invasive procedure to address malrotation. The association of concurrent pyloric stenosis and malrotation has rarely been reported in the pediatric literature. This is the first published report of a laparoscopic treatment of HPS and malrotation simultaneously.

Intravenous Atropine Treatment in Hypertrophic Pyloric Stenosis: Evaluation by Clinical Course and Imaging

Hypertrophic pyloric stenosis (HPS) is the principal disease to consider in neonates presenting with frequent projectile vomiting and poor weight gain. Ramstedt pyloromyotomy is commonly used for the surgical treatment of HPS. The present study investigated the efficacy of nonsurgical medical treatment using intravenous administration of atropine and the examined the clinical course and results of ultrasonography and a contrast upper gastrointestinal series. A 34-day-old girl was admitted with chief complaints of projectile vomiting and poor weight gain. HPS was diagnosed on the basis of the clinical course and results of imaging studies. After intravenous administration of atropine, projectile vomiting resolved and weight increased without complications. On imaging studies, barium introduced into the stomach by tube rapidly entered the duodenum after atropine administration. Ultrasonography initially showed no reductions in hypertrophic muscle in the pyloric region, but gradual reductions were identified in subsequent months.