Laparoscopic extramucosal pyloromyotomy versus open pyloromyotomy for infantile hypertrophic pyloric stenosis: Which is better?

doi:10.1016/S0022-3468(99)90212-9

Journal of Pediatric Surgery

Volume 34, Issue 2, February 1999, Pages 370-372

https://doi.org/10.1016/S0022-3468(99)90212-9 Get rights and content

Abstract

Background/Purpose: The aim of this study was to evaluate the advantages or disadvantages of laparoscopic pyloromyotomy compared with open transumbilical fold pyloromyotomy.

Methods: Thirty consecutive laparoscopic extramucosal pyloromyotomies (LP) performed from 1994 to 1997 were compared with 30 consecutive open pyloromyotomies (OP) performed during the same period with regard to age at operation, body weight, thickness of hypertrophied pyloric muscle, operating time, time of return to full feeding, frequency of postoperative emesis, surgical complications, and degree of surgical stress reflected by interleukin-6 (IL-6). LP was performed according to conventional techniques, and OP was performed using a transumbilical fold approach.

Results: The groups were matched for age at operation, preoperative clinical and physical status, laboratory data, and size of the hypertrophied pylorus assessed by ultrasonography. There was a learning curve with LP; the average operating time required for the first 10 cases was significantly longer than the time required for OP, but later cases took just as long as OP cases. Time taken to full feeding was significantly shorter in the LP group than the OP group (LP, 38 hours v OP, 64 hours). One case was converted from LP to OP because of mucosal perforation. The incidence of postoperative emesis was significantly higher in the OP group than in the LP group (OP, 25% v LP, 3%). The mean length of hospitalization was significantly shorter in LP (P < .01). The intraoperative peak values of IL-6 in LP were significantly lower than those in the OP group (P < .01).

Conclusions: The advantages of LP are improved cosmesis, decreased surgical stress with earlier postoperative recovery, and shorter hospitalization. Because LP uses reusable devices, and the mean period of hospitalization is shorter, average operating costs could be reduced, representing a net saving in total hospital charges.

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Cited by (121)

Open Versus Laparoscopic Pyloromyotomy for Pyloric Stenosis—A Systematic Review and Meta-Analysis
2022, Journal of Surgical Research
Citation Excerpt :
Of 410 abstracts, seven RCTs (eight reports) were used for final analyses9,19,26-30 (Fig. 1). Randomization was constrained in four trials26,28-30 and unrestricted in two trials,9,19 and minimization was used in one RCT.27 No RCT applied blinding for both participants and assessors, whereas in two RCTs, blinding of outcome assessment was applied.19,27
Infantile hypertrophic pyloric stenosis is treated by either open pyloromyotomy (OP) or laparoscopic pyloromyotomy (LP). The aim of this meta-analysis was to compare the open versus laparoscopic technique.
A literature search was conducted from 1990 to February 2021 using the electronic databases MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. Primary outcomes were mucosal perforation and incomplete pyloromyotomy. Secondary outcomes consisted of length of hospital stay, time to full feeds, operating time, postoperative wound infection/abscess, incisional hernia, hematoma/seroma formation, and death.
Seven randomized controlled trials including 720 patients (357 with OP and 363 with LP) were included. Mucosal perforation rate was not different between groups (relative risk [RR] LP versus OP 1.60 [0.49-5.26]). LP was associated with nonsignificant higher risk of incomplete pyloromyotomy (RR 7.37 [0.92-59.11]). There was no difference in neither postoperative wound infections after LP compared with OP (RR 0.59 [0.24-1.45]) nor in postoperative seroma/hematoma formation (RR 3.44 [0.39-30.43]) or occurrence of incisional hernias (RR 1.01 [0.11-9.53]). Length of hospital stay (−3.01 h for LP [−8.39 to 2.37 h]) and time to full feeds (−5.86 h for LP [−15.95 to 4.24 h]) were nonsignificantly shorter after LP. Operation time was almost identical between groups (+0.53 min for LP [−3.53 to 4.59 min]).
On a meta-level, there is no precise effect estimate indicating that LP carries a higher risk for mucosal perforation or incomplete pyloromyotomies compared with the open equivalent. Because of very low certainty of evidence, we do not know about the effect of the laparoscopic approach on postoperative wound infections, postoperative hematoma or seroma formation, incisional hernia occurrence, length of postoperative stay, time to full feeds, or operating time.
Congenital Anomalies and Surgical Disorders of the Stomach
2020, Pediatric Gastrointestinal and Liver Disease, Sixth Edition
Hypertrophic pyloric stenosis presents with projectile vomiting in neonates. After correction of the dehydration and metabolic alkalosis, pyloromyotomy provides permanent relief. Congenital gastric outlet obstructions can be caused by distal gastric webs, atresias, or duplications. Treatment involves excision of the obstruction or surgical bypass maneuvers. Focal foveolar hyperplasia is a rare cause of gastric outlet obstruction. Treatment is surgical or endoscopic. Gastric volvulus is a twisting of the stomach with risk of ischemia and necrosis of the stomach. Immediate surgical correction with detorsion is paramount. Congenital microgastria is characterized by a hypoplastic stomach and megaesophagus. Surgical feeding access may be necessary. Gastric augmentation is the last resort for treatment. Gastric perforation may occur as a result of trauma, hypoxic/ischemic, duodenal or jejunal obstruction, medications, esophageal atresia, or spontaneously. Intestinal duplications can occur anywhere from the mouth to the anus. Accumulation of mucosal secretions can produce a mass effect, leading to obstruction. Presentation is dependent on location and size. Whenever possible, treatment is complete excision. Gastric polyps are uncommon in children. Most polyps can be removed endoscopically. Patients with familial adenomatous polyposis, Peutz-Jeghers syndrome, and juvenile polyposis require lifelong care due to increased risk of malignancy. Gastric tumors of all types are rare and include lymphomas, leiomyomas, leiomyosarcomas, teratomas, carcinomas, gastrointestinal stromal tumors, carcinoid tumors, and inflammatory pseudotumors. Most isolated gastrointestinal tumors are treated by radical complete surgical resection. Foreign body ingestion is a common pediatric problem. In cases of witnessed ingestion or sonographic or radiologic evidence, button batteries, multiple magnets, and sharp objects should be removed immediately. Endoscopy has a high success rate.
Outcomes of laparoscopic resection of Meckel's diverticulum are equivalent to open laparotomy
2019, Journal of Pediatric Surgery
Meckel's diverticulum (MD) is a common congenital anomaly caused by failure of involution of the omphalomesenteric duct. Enthusiasm for minimally invasive surgery (MIS) in children has burgeoned as technologies have advanced, but the outcomes of laparoscopic resection in comparison to open laparotomy for MD remain poorly defined. We queried a large national database to compare current practice patterns and clinical outcomes between surgical approaches for MD in the pediatric population.
The National Surgical Quality Improvement Program-Pediatric (NSQIP-Ped) database was queried for patients undergoing surgical intervention for MD (2011–2014). Patients were stratified by surgical approach. Baseline characteristics, intraoperative variables, and perioperative complications were compared by univariate analysis using Pearson's χ² test for categorical variables and Kruskall-Wallis test for continuous variables. Primary outcomes of interest were length of stay (LOS), rate of readmission, and 30-day mortality. Secondary outcomes included operative time, anesthesia time, postoperative complications, and rates of reoperation.
A total of 148 cases of MD were identified, of which 73 (49.3%) were initially managed with a laparoscopic approach and 75 (50.7%) were managed with an open approach. We found a high rate of conversion from laparoscopy to an open approach (20/73 or 27.4%). The median age of the laparoscopic group was higher than the open group (8.3 vs. 2.5 years, p < 0.001). Operative and anesthesia time, LOS, 30-day mortality, post-operative complications, and rates of reoperation and readmission were similar between groups (all p > 0.05).
Nearly half of all resections for MD in children are now approached laparoscopically. This approach has equivalent outcomes to traditional open laparotomy. More widespread use of a hybrid approach with laparoscopy and exteriorization of the small bowel through an extended port site may facilitate avoiding open laparotomy. Routine conversion to open for palpation of the MD or segmental small bowel resection should be avoided in the absence of compelling intra-operative findings or operative complications.
Level III (retrospective comparative study).
Postoperative outcomes of open versus laparoscopic pyloromyotomy for hypertrophic pyloric stenosis
2018, Journal of Surgical Research
Hypertrophic pyloric stenosis (HPS) is one of the most common indications for non-elective surgery in the neonatal population. Multiple small prospective trials have shown that postoperative outcomes for laparoscopic versus open pyloromyotomy are equivalent or slightly better with the minimally invasive approach. This study uses a prospective national database to compare postoperative complications and length of stay for infants undergoing laparoscopic versus open pyloromyotomy.
Infants undergoing either open or laparoscopic pyloromyotomy for HPS were identified from the 2013 National Surgical Quality Improvement Project-Pediatric Participant Use File. Post-operative complication rates for an open versus laparoscopic approach were compared using chi square or Fisher’s exact test as appropriate. Operative time and post-operative length of stay were compared using the Wilcoxon two-sample test.
A total of 3256 infants were identified from the 2013 and 2014 American College of Surgeons National Surgical Quality Improvement Project-Pediatric Participant Use File who underwent pyloromyotomy for HPS. Of these, 1182 were open and 2074 were laparoscopic. Postoperative outcomes are depicted in Table 2. Laparoscopic pyloromyotomy was associated with statistically significant decrease in overall morbidity (2.4% versus 1.2%, P = 0.007).
We have demonstrated that post-operative outcomes after laparoscopic pyloromyotomy are equivalent or superior to an open approach. The minimally invasive approach to pyloromyotomy is a safe and feasible option in the treatment of HPS in infants.
Should general surgery residents be taught laparoscopic pyloromyotomies? An ethical perspective
2014, Journal of Surgical Education
The authors examine the ethical implications of teaching general surgery residents laparoscopic pyloromyotomy.
Using the authors’ previously presented ethical framework, and examining survey data of pediatric surgeons in the United States and Canada, a rigorous ethical argument is constructed to examine the question: should general surgery residents be taught laparoscopic pyloromyotomies?
A survey was constructed that contained 24 multiple-choice questions. The survey included questions pertaining to surgeon demographics, if pyloromyotomy was taught to general surgery and pediatric surgery residents, and management of complications encountered during pyloromyotomy. A total of 889 members of the American Pediatric Surgical Association and Canadian Association of Paediatric Surgeons were asked to participate. The response rate was 45% (401/889). The data were analyzed within the ethical model to address the question of whether general surgery residents should be taught laparoscopic pyloromyotomies.
From an ethical perspective, appealing to the ethical model of a physician as a fiduciary, the answer is no.
We previously proposed an ethical model based on 2 fundamental ethical principles: the ethical concept of the physician as a fiduciary and the contractarian model of ethics.
- •
  The fiduciary physician practices medicine competently with the patient’s best interests in mind. The role of a fiduciary professional imposes ethical standards on all physicians, at the core of which is the virtue of integrity, which requires the physician to practice medicine to standards of intellectual and moral excellence. The American College of Surgeons recognizes the need for current and future surgeons to understand professionalism, which is one of the 6 core competencies specified by the Accreditation Council for Graduate Medical Education.
- •
  Contracts are models of negotiation and ethically permissible compromise. Negotiated assent or consent is the core concept of contractarian bioethics.
- •
  Nonnegotiable goods are goals for residency training that should never be sacrificed or negotiated away. Fiduciary responsibility to the patient, regardless of level of training, should never be compromised, because doing so violates the professional virtue of integrity. The education of the resident is paramount to afford him or her the opportunity to provide competent care without supervision to future patients. Such professional competence is the intellectual and clinical foundation of fiduciary responsibility, making achievement of educational goals during residency training another nonnegotiable good.
Hypertrophic Pyloric Stenosis
2012, Pediatric Surgery, 2-Volume Set: Expert Consult - Online and Print

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^☆: Presented at the 45th Annual International Congress of the British Association of Paediatric Surgeons, Bristol, England, July 21–24, 1998.

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Laparoscopic extramucosal pyloromyotomy versus open pyloromyotomy for infantile hypertrophic pyloric stenosis: Which is better?☆

Abstract

J Pediatr Surg

J Pediatr Surg

J Pediatric Surg

J Pediatr Surg

J Pediatr Surg

Pyloric Stenosis