MOJ ISSN: 2379-6162MOJS

Surgery
Editorial
Volume 3 Issue 2 - 2016
Endoscopic and Laparoscopic Treatment of Infantile Hypertrophic Pyloric Stenosis
Einar Arnbjörnsson*
Inflammatory Lung Disease Research Center of Guilan University of Medical Sciences, Iran
Received: June 10, 2016 | Published: June 15, 2016
*Corresponding author: Einar Arnbjörnsson, Associate Professor, Lund University and Department of Pediatric Surgery, Skåne University Hospital, Lund, Sweden, Email:
Citation: Arnbjörnsson E (2016) Endoscopic and Laparoscopic Treatment of Infantile Hypertrophic Pyloric Stenosis. MOJ Surg 3(2): 00042. DOI: 10.15406/mojs.2016.03.00042

Editorial

Infantile hypertrophic pyloric stenosis (IHPS) is a condition involving abnormal muscular hypertrophy at the pylorus. This causes vomiting and may call for surgical intervention [1]. Pyloromyotomy, introduced in both 1908 [2,3] and 1912 [4] and still first choice as treatment, is a definitive, curative surgical procedure for IHPS, whether open or minimally invasive. Complication rates are generally low, and mortalities are rare. However, Ramsted’s extramucosal pyloromyotomy [4] is not complication-free. In 5% of patients, complications are severe [5]. Thus, a search for alternatives is certainly in order.

Other treatment options are available for these patients. Reported outcomes of surgery versus nutritional therapy in this setting [6] indicate that nutritional intervention is a viable approach. Clinical results appear encouraging, regardless of a 25% failure rate. Although more prolonged, treatment is administered largely via supervised outpatient programs, with a substantial reduction in cost (less than one-third of surgical remedy) [6].

In terms of applicable medical agents, a past investigation of methyl scopolamine nitrate is on record (1955) [7], in addition to a more recent trial of intravenous atropine sulfate (1996) [8]. Furthermore, a meta-analysis assessing course and outcome of IHPS managed with atropine [9] supports the premise that either oral or intravenous atropine (1-2 months) is satisfactory as an alternative to pyloromyotomy, particularly if surgery is contraindicated. Nevertheless, this approach is not widely practiced, the current gold standard treatment for IHPS being surgery.

Data on nonsurgical pyloric dilatation in children is also sparse, given the limited success of balloon catheter dilatation as primary treatment of IHPS [10]. On the other hand, endoscopic pyloric balloon dilatation, done in young infants experiencing persistent emesis and gastric outlet obstruction >3 weeks post-pyloromyotomy for IPHS, has been promoted as an effective, safe, and less expensive method than repeat surgery [11]. An isolated success in fluoroscopic pyloric balloon dilatation has similarly prompted a call for further study as first-line remedy after such treatment failures [12].

In 2005, a new laparoscopic technique was described, entailing two incisions of pylorus along antimesenteric border, extending from antrum to duodenal bulb. The latter are made sufficiently deep to expose longitudinal muscle. An endoscope is then passed through pylorus to duodenum [13]. Initial results seem impressive, but long-term outcomes and multicenter experience are lacking [14]. Ostensibly, a combined strategy of balloon dilatation and laparoscopic release of serosa (atop hypertrophic pyloric muscle) may then constitute the optimal operative intervention in IHPS, aided by X-ray visualization to disclose of any subsequent pyloric leakage. Allowing serosa to remain intact could explain why intraluminal balloon dilatation as sole treatment is non-curative. Considering all therapeutic alternatives that exist, it does appear that rigid adherence to a single method of treating IHPS is simply unjustified.

References

  1. Huddy SP (1991) Investigation and diagnosis of hypertrophic pyloric stenosis. J R Coll Surg Edinb 36(2): 91-93.
  2. Dufour H, Fredet P (1908) La stenose hypertrophique du pylore chez le nourrisson et son traitement chirurgical. Rev Chir 37: 208-253.
  3. Fredet P, Lesne E (1908) Stenose du pylore chez Ie nourrisson. Resultat anatomique de la pyloroto- mie sur un cas traite et gueri depuis 3 mois. Bull Mem Soc Nat Chir 54: 1050.
  4. Ramstedt C (1912) Zur Operation der angeborenen Pylorusstenose. Med Klinik 8: 1702-1705.
  5. Perger L, Fuchs JR, Komidar L, Mooney DP (2009) Impact of surgical approach on outcome in 622 consecutive pyloromyotomies at a pediatric teaching institution. J Pediatr Surg 44(11): 2119-2125.
  6. Dessanti A, Migaleddu V, Castiglia P, Grandi N (2016) Infantile Hypertrophic Pyloric Stenosis Surgery versus Nutritional Therapy. J Pediatr Neonatal Care 4: 00143. DOI: 10.15406/jpnc.2016.04.00143.
  7. Corner BD (1955) Hypertrophic pyloric stenosis in infancy treated with methyl scopolamine nitrate. Arch Dis Child 30(152): 377-386.
  8. Nagita A, Yamaguchi J, Amemoto K, Yoden A, Yamazaki T, et al. (1996) Management and ultrasonographic appearance of infantile hypertrophic pyloric stenosis with intravenous atropine sulfate. J Pediatr Gastroenterol Nutr 23(2): 172-177.
  9. Wu SF, Lin HY, Huang FK, Chen AC, Su BH, et al. (2016) Efficacy of Medical Treatment for Infantile Hypertrophic Pyloric Stenosis: A Meta-analysis, Pediatrics and Neonatology.
  10. Hayashi AH, Giacomantonio JM, Lau HYC, Gillis DA (1990) Balloon catheter dilatation for hypertrophic pyloric stenosis. J Pediatr Surg 25(11): 1119-1121.
  11. Khoshoo V, Noel RA, LaGarde D, Buras F, Gilger MA (1996) Endoscopic balloon dilatation of failed pyloromyotomy in young infants. J Pediatr Gastroenterol Nutr 23(4): 447-451.
  12. Nasr A, Ein SH, Connolly B2 (2008) Recurrent pyloric stenosis: to dilate or operate? A preliminary report. J Pediatr Surg 43(2): 17-20.
  13. Ibarguen-Secchia E (2005) Endoscopic pyloromyotomy for congenital pyloric stenosis. Gastrointest Endosc 61(4): 598-600.
  14. Yang T, Li L, Zou Y (2015) Endoscopic pyloromyotomy for congenital pyloric stenosis. Gastrointest Endosc 82(4): 766.
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