Pyloric Stenosis

Fig. 4.1

Pyloric stenosis ultrasound transverse view

Fig. 4.2

Pyloric stenosis ultrasound longitudinal view

However, in a recent article published in the Permanente Journal, it was inferred that these parameters can be misleading as both the height and weight of infants can alter the pyloric thickness, although the thickness may be less than 3 mm for an infant of lower than average weight pyloric stenosis may still be present. This study clearly illustrates the importance of taking all factors into account when making a diagnosis, rather than relying solely on imaging techniques. A positive correlation can be seen between both age and weight of the infant with thickness of pyloric muscle [15].

Occasionally, a barium swallow is done, in which a characteristic ‘string sign’ is found, illustrating the narrowing of the pylorus allowing very limited barium to travel from the stomach to the duodenum. Other signs present on a barium swallow include the ‘shoulder sign’ which occurs when the hypertrophied pyloric muscle indents into the pyloric antrum and the ‘mushroom sign’ in which the hypertrophied pyloric muscle indents into the initial part of the duodenum.

Treatment

Preoperative Management

On suspicion of pyloric stenosis , the child should be kept nil by mouth. A nasogastric tube should be inserted and kept on free drainage. All fluid losses should be replaced using normal saline with 10 mmol/l potassium.

Fluid resuscitation usually using 5 % dextrose with 0.45 % saline should be used. The amount should be adjusted after assessing the amount of dehydration. Once urine output is established, 20 mmol/l of potassium should be added to IV fluid.

Surgical Treatment

Once the child is fully resuscitated, pyloromyotomy is the treatment of choice.

A pyloromyotomy is a simple procedure during which the hypertrophied pyloric muscle is cut longitudinally and then separated with the pyloric spreader. This releases the tension in the thick hypertrophied muscle and consequently allows the muscle to relax, relieving the stenosed muscle. This procedure is known as the Ramstedt’s pyloromyotomy, as he initiated this technique of just spreading the muscle rather than doing pyloromyotomy.

Surgical approaches could be either by right upper transverse abdominal incision or the transumbilical pyloromyotomy, which involves a supraumbilical skinfold incision. Laparoscopic approach is also increasingly utilised. A number of studies have been conducted to establish the differences, if any, between the two. Nonetheless, most studies have suggested that both are effective, with different studies giving contradicting evidence on what form of procedure is more superior. In one study, it was suggested, however, that laparoscopic surgery is slightly superior in that babies are able to have a full feed in a shorter duration of time compared to open pyloromyotomy (18.5 versus 23.9 h), as well as having a shorter duration of stay in hospital [16]. However, in a study by Lemoine et al. in 2011 [17], it has been suggested that a transumbilical pyloromyotomy is associated with increased postoperative pain compared to the laparoscopic approach.

Complications

Most common complications of surgery include inadvertent opening of the mucosa and incomplete myotomy. Other complications include wound infection and self-resolving vomiting.

Complications of surgery are minimal, and in most cases, a pyloromyotomy is said to be very effective. Hulka et al. [18] reviewed 901 pyloromyotomies to assess for both intra- and postoperative complications, with findings that only 4 % of individuals had complications during surgery. The main complication was duodenal perforation. Further, 6 % of individuals had postoperative complications, which most often included vomiting, resolving itself within 5 days. As with many surgeries, wound infection is a further possible complication. An incomplete pyloromyotomy can also be listed as a complication.

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