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Complications of pyloromyotomy for infantile hypertrophic pyloric stenosis
F Hulka1, M W Harrison, T J Campbell
1Department of Surgery, School of Medicine, Oregon Health Sciences University, Emanuel Hospital and Health Center, Portland 97201, USA.
Insights
Pyloromyotomy (PM) for infantile hypertrophic pyloric stenosis (IHPS) has low complication rates, with duodenal perforation being rare. Most postoperative vomiting can be managed nonoperatively, but persistent symptoms warrant evaluation.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Neonatal Care
Background:
- Limited contemporary data exists on complications following pyloromyotomy (PM) for infantile hypertrophic pyloric stenosis (IHPS).
- A review was conducted to assess the frequency and outcomes of IHPS patients experiencing complications after PM.
Purpose of the Study:
- To determine the incidence and nature of intraoperative and postoperative complications associated with pyloromyotomy (PM) in infantile hypertrophic pyloric stenosis (IHPS).
- To evaluate the management and outcomes of these complications.
Main Methods:
- A 25-year retrospective review of infants undergoing PM for IHPS at two pediatric surgery centers.
- Inclusion of infants referred for PM complications from other institutions.
Main Results:
- 901 PMs performed; 4% intraoperative complications (39 duodenal perforations, 1 difficult intubation).
- 6% postoperative complications; wound infection <1%, postoperative vomiting in 3%.
- Mortality rate 0.1%; 11 referred patients managed with conservative or surgical interventions.
Conclusions:
- Pyloromyotomy (PM) is generally safe, but complications like duodenal perforation, though infrequent, require prompt recognition and treatment.
- Persistent postoperative vomiting beyond 5 days necessitates radiologic evaluation.
- Incomplete PM is rare and requires reoperation; a standardized approach to PM for IHPS is recommended.
Background:
Few references exist regarding contemporary complications of pyloromyotomy (PM) for infantile hypertrophic pyloric stenosis (IHPS). Therefore, we reviewed the frequency and outcome of patients with IHPS who developed complications from PM.
Method:
A 25-year retrospective review was performed in two populations. The first group included all infants who had a PM for IHPS at two pediatric surgery centers. The second group included all infants referred from other institutions who developed complications following PM for IHPS.
Results:
Between 1969 and 1994, 901 PMs were performed. Intraoperative complications occurred in 40 patients (4%), including 39 duodenal perforations and 1 difficult intubation requiring prolonged ventilation. No unrecognized duodenal perforations or incomplete PMs were found. Postoperative complications developed in 52 patients (6%). The wound infection rate was less than 1%. Postoperative vomiting occurred in 31 infants (3%). The mortality rate was 0.1%, with 1 death due to sepsis from delayed diagnosis of Hirschsprung's disease. During the same study period, 11 patients were referred from other hospitals for postoperative complications. Five had persistent vomiting treated successfully with expectant management. Six infants needed reoperation: 3 for persistent IHPS, 1 for gastric outlet obstruction, and 1 for small bowel obstruction secondary to adhesions; 1 required wound abscess drainage.
Conclusion:
Pyloromyotomy is not without complications. Duodenal perforation should be infrequent, but when it occurs, it can usually be readily recognized and treated with minimal morbidity. Postoperative vomiting can be managed nonoperatively, but if it persists longer than 5 days, radiologic evaluation should be performed. Incomplete PM is uncommon and should not occur. A second myotomy is needed when the diagnosis of incomplete myotomy is established. A single standard of care should be expected of all surgeons who perform PM for IHPS.