Can pyloromyotomy for infantile hypertrophic pyloric stenosis be performed in any hospital?

Abstract

In order to document the incidence of perioperative complications in patients with infantile hypertrophic pyloric stenosis, a descriptive cohort study was performed in two teaching hospitals in the Netherlands. One hospital specialized in pediatric surgery and the other was a general surgery teaching hospital. All consecutive infants who underwent pyloromyotomy for the diagnosis hypertrophic pyloric stenosis in both hospitals between 1998 and 2002 were included. The children were diagnosed and treated according to a standard protocol. From all charts, complications durante- and post-operationem were recorded. A total of 256 pyloromyotomies were performed. Registered perioperative complications were duodenal mucosal perforation (n=6; 2%). Perioperatively unrecognized duodenal mucosal perforation occurred four times (1%). One re-operation was performed for an incomplete pyloromyotomy (0.3%). Persistent vomiting after the operation occurred in 18 children (7%). A large majority of postoperative complications were wound infections (n=16; 6%), 12 after right upper quadrant incision and 4 after umbilical incision; most of them were treated with antibiotics and/or incision for drainage of an abscess. An incisional hernia occurred four times. Prolonged vomiting was the only postoperative complication that differed significantly between the two teaching hospitals. The overall percentages of complications were equal to complication rates in literature, and since there were no extensive differences in major complications between the two teaching hospitals in this study, we can conclude that pyloromyotomy can be performed safely in specialized centers and in general centers provided with a multidisciplinary team.

The effect of surgical training and hospital characteristics on patient outcomes after pediatric surgery: a systematic review

“…It is not clear whether minimum annual caseloads should exist for specific conditions or whether minimum numbers of [29] OR, 6.7 (1.5-29.6) a van den Ende et al [24] OR operations on children is most important. The latter opinion could explain the results found by authors who showed that pediatric surgeons performing pancreaticoduodenectomies achieved good results despite very low numbers of operations [31].…”

“…One study showed that patients in specialist centers were more likely to be operated on laparoscopically [16]. The impact of different methods of Ramstedt pyloromyotomy [34], postoperative antibiotic regimes, and other aspects of care pathways [24] could, therefore, be explored. One recent article compared appendicitis outcomes between a teaching and a nonteaching hospital from a different perspective.…”

Non-laparoscopic minimal surgical approach to pyloromyotomy: An experience from a challenged resource setting

“…[2324] In our series mucosal perforation was seen in a total of four patients out of 316 patients (1.3%). However, some reported the incidence of perforation to be as high as 19% in the recent publications of open series.…”

Experience with a nonlaparoscopic, transumbilical, intracavitary pyloromyotomy

“…Among the complications of a pyloromyotomy (regardless of the approach), the most life-threatening is mucosal perforation, particularly if not recognized [15,38]. Although the incidence of perforation in most "open" series is low, numbers as high as 19% are still found in recent publications [35].…”

“…However, a substantial number of pyloromyotomies are performed by surgeons who only occasionally operate on children [33][34][35][36][37][38]. Therefore, these surgical colleagues should be taught an operation that is foremost safe, and reproducible.…”