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The umbilical fold approach to pyloromyotomy: is it a safe alternative to the right upper-quadrant approach?
M J Leinwand1, D B Shaul, K D Anderson
1Department of Surgery, Childrens Hospital, Los Angeles, CA 90027, USA.
Insights
The circumumbilical (UMB) pyloromyotomy offers a better cosmetic scar but has higher complication rates than the right upper quadrant (RUQ) approach. Prophylactic antibiotics reduce wound infections in both methods.
Area of Science:
- Pediatric Surgery
- Surgical Outcomes
- Minimally Invasive Surgery
Background:
- Hypertrophic pyloric stenosis (HPS) management involves surgical pyloromyotomy.
- Standard surgical approaches include the circumumbilical (UMB) and right upper quadrant (RUQ) incisions.
- The UMB approach offers cosmetic advantages but has been linked to increased complications.
Purpose of the Study:
- To compare the technical and wound complication rates between UMB and RUQ pyloromyotomy.
- To evaluate the impact of prophylactic antibiotics on wound infection rates in HPS surgery.
Main Methods:
- Retrospective analysis of 344 patients undergoing pyloromyotomy for HPS.
- Comparison of complication rates (intraoperative, mucosal perforation, serosal tear, postoperative, wound infection) between UMB and RUQ groups.
- Assessment of the effect of prophylactic antibiotic use on wound infection rates.
Main Results:
- The UMB approach showed significantly higher intraoperative (13.3% vs 2.8%) and postoperative (14.4% vs 2.8%) complication rates.
- Mucosal perforation rates were higher with the UMB approach (8.9% vs 1.6%), increasing hospitalization length.
- Prophylactic antibiotics reduced wound infection rates in both groups, diminishing the statistical difference between UMB (4.5%) and RUQ (0%).
Conclusions:
- The UMB pyloromyotomy provides superior cosmetic results but is associated with increased complication rates compared to the RUQ approach.
- Technical complications were manageable, and overall hospital stay was not significantly affected by the surgical approach.
- Prophylactic antibiotics effectively decrease wound infection rates, making them a valuable adjunct in HPS surgery.
Background:
Hypertrophic pyloric stenosis has been approached using two standard incisions for pyloromyotomy: the circumumbilical (UMB) and the right upper quadrant (RUQ). The UMB approach produces an almost undetectable scar but has been associated with more complications.
Study Design:
A 5-year retrospective analysis was performed on 344 patients (90 UMB and 254 RUQ) to compare technical and wound complications. The effect of prophylactic antibiotics on wound infection was also evaluated.
Results:
The intraoperative complication rate was 5.5% (13.3% UMB versus 2.8% RUQ; p = 0.001). The mucosal perforation rate was 3.5% (8.9% UMB versus 1.6% RUQ; p = 0.003). Mucosal perforations increased the mean +/- SD length of hospitalization in UMB patients (3.9 +/- 0.8 versus 2.4 +/- 1.1 days; p < 0.001). The serosal tear rate was 2.0% (4.4% UMB versus 1.2% RUQ; p=0.08). The postoperative complication rate was 5.8% (14.4% UMB versus 2.8% RUQ; p < 0.001), and the wound infection rate was 2.6% (6.7% UMB versus 1.2% RUQ; p = 0.01). Antibiotic prophylaxis decreased the rate of wound infection to 1.8% and eliminated the statistical difference between the groups (4.5% UMB versus 0% RUQ; p=0.16). The rate of other postoperative complications was 3.2% (7.8% UMB versus 1.6% RUQ; p = 0.009). Duration of hospital stay did not differ between the groups overall (2.6+/-1.12 days for UMB versus 2.7+/-1.5 days for RUQ; p = 0.35).
Conclusions:
The UMB approach to pyloromyotomy was cosmetically superior but increased complication rates. Technical complications were easily corrected and length of stay was not affected. Wound infections were decreased in both groups by the use of prophylactic antibiotics.