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Background/purpose: Ramstedt's pyloromyotomy for hypertrophic pyloric stenosis is elegant, effective, and time-honored. Although its basic principle has not changed over the last 95 years, considerable debate exists concerning the preferred access to the pylorus and the muscle-splitting technique. Reviewed here is the experience with an approach that combines the ease and safety of the "open" pyloromyotomy with the advantages of minimal invasiveness., Methods: This series encompasses 75 consecutive, prospectively recorded pyloromyotomies. A short, curved upper umbilical rim incision is made. The linea alba is transected transversally and the abdomen entered. The pylorus is grasped with a Babcock clamp and lifted to the incision, but not delivered. Two 3:0 guy sutures are placed in the hypertrophied musculature to lift and maintain the pylorus in place. A longitudinal serosal incision is made and deepened to 1 to 3 mm. Two double-pronged skin hooks are placed, one on each partially separated edge, and gentle upward and outward traction applied until complete splitting is achieved. The mucosa is not touched by an instrument., Results: The age of the 75 children ranged from 9 to 89 days (mean, 40; median, 36). Their weight ranged from 2.4 to 5.4 kg (mean, 3.7 kg; median, 3.6). Fifty-seven were boys. The mean operating time was 28 minutes. The pyloric muscle splitting was performed by general surgical residents in 66. There were no mucosal injuries. Seventy-two children were discharged within 24 hours, the remaining within 48 hours. Two superficial wound infections and one suture reaction occurred. There were no recurrences., Conclusion: Transumbilical intracavitary pyloromyotomy is a safe, reproducible procedure combining the advantages of the two most commonly employed approaches (traditional "open" and laparoscopic). Because the pylorus is not delivered, a smaller incision is used. The scar is virtually invisible. The safety of this procedure renders it well suited for the teaching setting.

Objective: To evaluate the effect of the treatment of congenital hypertrophic pyloric stenosis (CHPS) with endoscopic pyloromyotomy., Method: Nine consecutive infants (7 boys, 2 girls; age range 26 - 70 days; weight range 2.65 - 6.10 kg), with a diagnosis of CHPS according to typical clinical manifestations, transabdominal ultrasound (US), gastroenterography and gastroscope. All the cases had accompanying malnutrition, anaemia, metabolic alkalosis, and some were complicated with congenital heart disease. In gastroscope operating room, all the patients were given pentobarbital and midazolam intravenously. A gastroscope with an outer diameter of 5.9 mm was passed through mouth, stomach, pylorus to the descending segment of duodenum. Under gastroscopy, two incisions were made along the anterior and posterior wall of pylorus from the duodenal bulb to the antrum by using endoscopic electrosurgical needle knife and an arch sphincter sarcosome. Incisions were deepened by 2 to 3 procedures until the longitudinal muscle was exposed, about 2 to 4 mm according to transabdominal US performed before operation. The incision depth was 2 - 3 mm if pylorus wall was 4 - 6 mm in thickness; or 3 - 4 mm when the wall was thicker than 6 mm., Result: The endoscope was easily passed through the pylorus to the duodenum post-operation. The transabdominal US and gastroenterography showed that liquid easily flew through pylorus. All patients were able to have regular feeding about 2 to 10 hours after the operation. Vomiting in all patients was significantly decreased in frequency and amount, and in 8 infants vomiting stopped within 1 week, in one case it did not stop until 1 month after the treatment. Some cases showed slight adverse reaction, no perforation or massive haemorrhage in stomach or intestines occurred in any of the patients during and post-operation. Eight infants were doing well at follow-up (range 2 to 9 months). One girl had recurred vomiting at normal feeding after a period of 1 month postoperation without vomiting. This case was cured by second endoscopic pyloromyotomy., Conclusions: Endoscopic pyloromyotomy is effective, safe, simple, and offers several advantages: no need for open-abdomen surgery, feeding can be initiated rapidly.

Infantile hypertrophic pyloric stenosis is a common cause of upper gastrointestinal obstruction in infants and presents as projectile, nonbilious emesis in the first few weeks of life. In general, patients with infantile hypertrophic pyloric stenosis are diagnosed after a complete history and physical have been performed augmented by serum electrolyte evaluation, abdominal ultrasound, or upper gastrointestinal barium series. However, some patients can have equivocal radiographic testing and normal serum electrolytes. Two patients are presented in which esophagastroduodenoscopy was used to diagnose previously unsuspected infantile hypertrophic pyloric stenosis.

Background: Erythromycin treatment before 2 weeks of age has been shown to increase the risk of infantile hypertrophic pyloric stenosis (IHPS) up to 10 times. Erythromycin is a motilin agonist, a hormone that induces gastrointestinal contractions. The purpose of this study was to investigate if mutations in the motilin gene (MLN) cause IHPS or if the V15A polymorphism in MLN is associated with the disease., Methods: The MLN was screened for mutations, and the V15A polymorphism was determined in a total of 57 patients with IHPS using polymerase chain reaction and DNA sequencing. The polymorphism genotype and allele frequencies among the patients were compared with 184 controls., Results: We detected 3 different, not previously reported, MLN sequence variants in 4 patients. One of these variants results in an amino acid exchange in the motilin signal peptide (A25G). All 3 detected sequence variants were also found in controls or were not inherited with the disease. We found no significant association between the V15A polymorphism and the disease., Conclusions: We have excluded the MLN coding region as a major cause of IHPS. Future studies will evaluate the importance of this metabolic pathway in the pathogenesis of IHPS.

Background: Hypertrophic pyloric stenosis (HPS) is a common condition affecting infants before the first three months of life., Aim: Analysis of our results and comparison with literature to determine particularities of HPS in our country., Methods: We conducted a retrospective review of 142 patients presenting HPS, between 1990 and 2003., Results: In this study male sex was predominant, with a sex-ratio of 3.8/1. The classical symptom of projectile vomiting was always present, a pyloric tumor was palpated in 19.7% of the cases, metabolic disturbance was noted in 44.3% of patients. The diagnosis was confirmed by ultrasonography and sometimes contrast upper gastrointestinal study. All the infants were treated surgically unless three patients dying before operation, because of a late diagnosis. Postoperative courses were uneventful in 87.4% of cases. Three patients were dead after operation, because of medical complication., Conclusion: The cause of HPS is unknown. The diagnosis is suggested by clinic features and confirmed by imaging. Early diagnosis prevents from metabolic complications due to vomiting. Surgical treatment allows early feeding and is associated with a low complication rate and a good long-term outcome.

Introduction: Functional operations of the gastrointestinal tract are ideal indications for minimal-access surgery. The aim of this paper was to assess the safety and potential benefits of the laparoscopic Ramstedt pyloromyotomy using the experience of a single surgeon in a district general hospital., Methods: 90 consecutive infants underwent pyloromyotomy: 35 open procedures and 55 laparoscopic procedures. This is a retrospective study but the operative data of the laparoscopic group were collected prospectively., Results: There were no differences in demographic data between the groups. The open group had a shorter mean operating time, 22.14 min, than the laparoscopic group, 26.04 min (p = 0.022). There was no significant difference in the time to full feed between the two groups (p = 0.076). 62.9% of the infants in the open group vomited compared with only 43.4% in the laparoscopic group (p = 0.058). The laparoscopic group had shorter postoperative stay, 62.33 hours, compared to 91.89 hours (p = 0.001). There was one reoperation in each group: for complete wound dehiscence in the open group and for incomplete myotomy in the laparoscopic group., Conclusions: Laparoscopic pyloromyotomy (LPM) is as safe as the open procedure and has the potential benefits of shorter hospital stay and improved cosmesis.

We describe a technique of grasping the pylorus during laparoscopic pyloromyotomy using a percutaneously inserted vascular clamp. The use of the vascular clamp results in better visualization and stabilization during laparoscopic pyloromyotomy.

Introduction: The purpose of this study was to compare laparoscopic and open pyloromyotomy using data from multiple centers in the United States., Methods: Children's hospitals that have a predominant surgical approach to pyloromyotomy were identified in the Pediatric Health Information System database. Using 2005 data, institutions were stratified into open (OPEN) and laparoscopic (LAP) groups. Patients with significant comorbid conditions were excluded. Group differences were compared using t tests and Mann-Whitney nonparametric tests for continuous variables and exact tests for categorical variables., Results: A total of 3 hospitals were in the LAP group (n = 207), and 4 hospitals were in the OPEN group (n = 357). The LAP group had a longer mean length of stay (LAP = 2.5 +/- 1.7, OPEN = 2.1 +/- 1.4 days; P = .02). Mean total hospital charges were similar in both groups (LAP = $11307 +/- 9499, OPEN = $11245 +/- 4841; P = .93), but there was significant skewness of the distribution for the LAP group. Nonparametric analysis demonstrated a statistically significant difference in charges (LAP median = $9727, min = $5075, max = $94323, OPEN median = $10001, min = $1614, max = $46461; P = .004). Four patients in the LAP group had charges ranging from approximately $56000 to $94000, which may have resulted from surgical complications., Conclusion: Prolonged length of stay and skewed hospital charge data in patients undergoing laparoscopic pyloromyotomy may be the result of rare but serious complications associated with the laparoscopic approach.

Objective: The purposes of this study were to evaluate the accuracy of the ultrasonographic measurements used during diagnosis of hypertrophic pyloric stenosis (HPS), to examine the relationship between the palpability and the morphologic features of the pyloric mass, and to show the morphologic resolution of the pylorus after pyloromyotomy., Methods: One hundred three infants with the diagnosis of HPS by clinical findings and ultrasonographic measurements were treated surgically by Ramstedt pyloromyotomy. The measurement parameters were the muscle thickness, diameter, and channel length of the pylorus. The serial measurements were performed postoperatively for 1 year after surgery., Results: The preoperative ultrasonographic measurements of the pylorus were significantly correlated with the actual measurements obtained by surgery (P<.05). The diameter correlated most significantly with the palpability of the pylorus. In contrast to the prompt improvement of clinical symptoms, the muscle thickness did not reach the normal range (approximately 2 mm) until 8 months after surgery. The diameter had not decreased to its normal range (approximately 10 mm) by the end of the 1-year postoperative follow up period. The channel length decreased more rapidly than the other 2 parameters., Conclusions: The preoperative ultrasonographic measurements of the pylorus reliably evaluated the pyloric muscle thickness and diameter in HPS. The actual pyloric diameter correlated with the palpability of the pyloric mass. The morphologic resolution of the pylorus after surgery did not correlate with the prompt improvement of symptoms.

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.

Background: This study was conducted to evaluate the outcome of various approaches to pyloromyotomy: supraumbilical (SU), right upper quadrant (RUQ), and laparoscopic (LP)., Methods: Single-center retrospective review from 1998 to 2005 with institutional review board approval, evaluating 192 pyloromyotomies based on surgical approach: RUQ (119), SU (64), and LP (9). Patient demographics, acid-base/electrolyte status on presentation, mean operative time, postoperative length of stay, and complications were evaluated., Results: Patient demographics, acid-base/electrolyte status, and mean operative time were not significantly different. The median length of stay was 34, 29, and 24.5 hours for SU, RUQ, and LP, respectively (P = .479). The frequency of duodenal/gastric perforations in the SU, RUQ, and LP groups were 1, 4, and 1, respectively. The LP perforation was not recognized intraoperatively, resulting in sepsis and multiorgan failure. One patient in the SU group had a late adhesive bowel obstruction requiring laparotomy and bowel resection. Wound infection rates did not differ significantly between groups (SU, 4; RUQ, 2; LP, 1; P = .113)., Conclusion: Pyloromyotomy is associated with a low complication rate. Cosmetically, SU is superior to the RUQ approach. The added benefits of being able to examine the integrity of the duodenal mucosa intraoperatively and its short learning curve may make SU a safer alternative to LP for surgeons who are still practicing the RUQ approach.

Infantile hypertrophic pyloric stenosis (IHPS) is familiar to most pediatric and general practitioners, it is a pathology where the radiologist nowadays has a key role confirming the clinical suspicion based in ultrasound and upper-gastrointestinal barium examinations. There is hypertrophy and hyperplasia of the antropyloric portion of the stomach, which becomes abnormally thickened, it manifests as obstruction to gastric emptying. Infants with IHPS are clinically normal at birth, but they develop a nonbilious forceful vomiting during the first weeks of postnatal life, which is described as "projectile". Surgical treatment is curative. The clinical diagnosis hinges on palpation of the thickened pylorus. Imaging findings include the "string sign" (elongation of the pyloric canal) and the "double-track sign" (presence of linear tracts of contrast material separated by the intervening mucosa) on fluoroscopic observation. Sonographic examination demonstrates the thickened prepyloric antrum bridging the duodenal bulb and distended stomach. We present the case of a 26-days-old infant with IHPS; presenting this case we make a brief review of the clinical features and main imaging findings of IHPS.

Purpose: The best feeding regimen after pyloromyotomy for hypertrophic pyloric stenosis continues to be a topic of some debate. Postoperative emesis and length of hospital stay are principal concerns. We compared the outcome of infants after laparoscopic pyloromyotomy who were fed using a standardized feeding regimen or ad libitum., Materials and Methods: We reviewed the records of 227 infants who underwent laparoscopic pyloromyotomy within a 5-year period. We compared two sets of patients: those fed using a standardized feeding regimen and those fed ad libitum. The choice of feeding regimen was based solely on the attending surgeon's preference. Each group was examined for frequency of postoperative emesis, time to full feeds, and length of hospital stay., Results: Of the 227 patients in the study, 170 (74.9%) were fed using the standardized feeding regimen and 57 (25.1%) were fed ad libitum. The two groups were comparable with respect to age and sex distribution. Although children fed ad libitum had a significantly shorter time to full feeds that those fed a standardized feeding regimen (19.0 vs. 23.1 hours; P < 0.01), there was no significant difference in the frequency of postoperative emesis (1.8 vs. 1.9 times per patient; P = 0.68) or total length of hospital stay (49.0 vs. 50.3 hours; P = 0.73) when the ad libitum and standardized feed groups were compared. There were no complications in either group., Conclusion: A standardized feeding regimen offers no advantage over ad libitum feeds for infants who have undergone laparoscopic pyloromyotomy. Infants fed ad libitum are able to tolerate full feeds sooner and the frequency of postoperative emesis is not increased. Ad libitum feeding has become the standard postoperative feeding regimen for infants who have undergone pyloromyotomy at our hospital.

Background: Several authors have reported on laparoscopic pyloromyotomy (LP) since the technique was originally described in 1990, but its benefits remain unproven. We performed a randomized controlled trial comparing LP to open circumumbilical pyloromyotomy (OP) for hypertrophic pyloric stenosis., Methods: In a prospective study, 102 infants with pyloric stenosis were randomly assigned to either LP (n = 50) or OP (n = 52). The primary outcome measure was the incidence of postoperative vomiting; the secondary parameters were the durations of surgery and anesthesia, surgical complications, and postoperative pain. All infants were managed according to standardized procedures regarding general anesthesia, surgical technique, postoperative analgesia, and feeding regimen. Parents, carers, and assessors responsible for the postoperative evaluation were blinded for the technique used., Results: There was no difference in the incidence of postoperative vomiting between the 2 groups. The overall incidence of complications was similar, but the durations of surgery and general anesthesia were significantly longer in the LP group than in the OP group (P = 10(-4) and P = .02, respectively). There were 3 cases of incomplete pyloromyotomy after laparoscopy, requiring a repeat procedure., Conclusions: Laparoscopic pyloromyotomy does not decrease the incidence of postoperative vomiting, has a similar complication rate compared with the open umbilical approach, but may expose patients to a risk of inadequate pyloromyotomy.

Background: Pyloromyotomy is commonly performed through a supraumbilical skinfold incision. Entry into the peritoneal cavity can be achieved via a vertical linea alba incision or a transverse muscle cutting approach. The aim of this study was to compare the morbidity associated with these 2 operative techniques., Methods: Case records of all babies undergoing umbilical pyloromyotomy between January 2000 and December 2004 were retrospectively compared for postoperative dehiscence, mucosal perforation, and wound infection (defined by the need for antibiotics or wound exploration). Data were analyzed with GraphPad Prism contingency tables and results were compared by Fisher exact test (P < .05)., Results: During the study period, 341 umbilical pyloromyotomies were performed at our institution. The surgeon was permitted choice of either operative approach (219 vertical linea alba, and 122 transverse muscle cutting). There were no significant differences between the 2 groups regarding age at presentation, sex, duration of symptoms, biochemical derangement, and operator seniority. No significant differences in morbidity were encountered with either of these 2 operative strategies., Conclusions: This study demonstrates that the vertical linea alba and transverse muscle cutting incisions have equivalent postoperative morbidity. These findings indicate that neither technique is demonstrably superior.

Hypertrophic pyloric stenosis (HPS) is a common condition affecting infants that presents with progressive projectile nonbilious vomiting. The pyloric portion of the stomach becomes abnormally thickened and manifests as gastric outlet obstruction. The cause is unknown. Pyloromyotomy remains the standard of treatment and outcome is excellent. This article reviews the diagnostic work up and imaging, preoperative resuscitation, the various surgical approaches used, and the effect of subspecialty training on outcomes after pyloromyotomy. Postoperative care and the variety of postoperative feeding regimens applied after pyloromyotomy are reviewed, as well as intra- and postoperative complications. Finally, medical management, in lieu of surgery, is discussed.

Seven-week-old 32-week premature triplets were hospitalized because of rhinorrhea, cough with color change and posttussive emesis. One infant had a positive direct fluorescent antibody test for Bordetella pertussis, so all were treated with 5 days of azithromycin. Two of the infants were subsequently diagnosed with hypertrophic pyloric stenosis and underwent surgical pyloromyotomies 6 and 7 weeks, respectively, after the initial admission.

Objective: We report a case of primary hypertrophic pyloric stenosis combined with a paraduodenal hernia in a 35-year-old woman., Clinical Presentation and Intervention: The patient presented with signs of obstructive ileus. CT of the abdomen revealed a marked dilatation of the stomach and the proximal jejunum as well as a circumferential thickening of the antral-pyloric region with characteristics indicating hypertrophic pyloric stenosis. Exploratory laparotomy revealed the presence of a paraduodenal hernia containing jejunal loops and marked thickening of the pyloric region. The jejunum was reduced to its normal place and the ostium of the paraduodenal hernia closed with a running suture. The hypertrophic pyloric stenosis was treated with pyloromyotomy. Since the patient had no predisposing factors for the development of secondary pyloric stenosis, we considered the pyloric stenosis as congenital in origin., Conclusion: To our knowledge this is the first reported case of congenital pyloric stenosis combined with the presence of a paraduodenal hernia in an adult., (Copyright 2007 S. Karger AG, Basel.)

Purpose: The semi-circumumbilical incision for treatment of infantile hypertrophic pyloric stenosis, described by Tan and Bianchi (Tan KC, Bianchi A. Circumumbilical incision for pyloromyotomy. Br J Surg 1986;73:399), does not allow a comfortable access to the pylorus in up to 30% of cases, resulting, not infrequently, in unexpected seromuscular lacerations. To get easier access to the pylorus we have performed the Ramstedt pyloromyotomy through a sliding umbilical window after full-circumumbilical incision in 13 initial consecutive cases., Patients and Methods: Skin was incised along the entire circumference of the umbilicus, and then was undermined, creating a circular subcutaneous space, 8 cm in diameter. The umbilical window, about 1.5 cm in diameter, was slid diagonally toward the right upper quadrant, by shifting a pair of muscle retractors, 3 to 4 cm from the umbilicus, with the umbilicus left in its original position under the slid skin. Through the sliding window at the right upper quadrant, the abdomen was entered, and the hypertrophied pylorus was identified within the center of the window. Then the pyloromyotomy was performed intracorporeally with ease., Results: In all 13 infants, an adequate pyloromyotomy was safely performed. The wound healed primarily in all cases, without leaving conspicuous scar, subcutaneous abscess formation, or incisional hernia. The postoperative course was quite uneventful in each., Conclusion: This new approach allows far easier access to and exposure of the pylorus, and facilitates a safe intracorporeal pyloromyotomy, and achieves an excellent cosmetic outcome.

Pyloromyotomy as described by Weber and Ramstedt has been the standard therapy for infantile hypertrophic pyloric stenosis since the 1960's and conservative therapy has been abandoned. The objective of this study was to test the effectiveness of systemic atropine applied intravenously for 7 days as a conservative therapeutic strategy and as an alternative to primary operation. Forty-two consecutive term infants with infantile hypertrophic pyloric stenosis were enrolled in the study over a period of 5 years. After confirmation of the diagnosis they all received intravenous atropine at a dose of 0.04 mg/(kg day) and increased by 0.01 mg/(kg day) up to 0.12 mg/(kg day), given as 6-8 single doses per/day. Nine pairs of parents requested that their child should be operated before completing the 7 days of medical therapy. Surgery was necessary in 8 of the remaining 33 infants (24,.2%) who did not improve after 7 days of conservative treatment. Successful treatment with i.v. atropine sulfate was achieved only in 25/33 term infants at an average maximal dose of 0.11 mg/(kg day), without any major side effects. Intravenous atropine sulfate has been considered as a potential alternative therapeutic strategy in the treatment of infantile hypertrophic pyloric stenosis. Clinical improvement however was often not seen before the 6th or 7th day of intravenous treatment. A success rate for the conservative approach of only 75% at day 7 in our study does not favour atropine therapy, in view of success rates above 95% with surgical repair.

Portal venous gas associated with hypertrophic pyloric stenosis is a rare finding. We describe an atypical radiologic finding discovered on abdominal ultrasound and computed tomographic scan in an infant with hypertrophic pyloric stenosis. Portal venous gas in the setting of hypertrophic pyloric stenosis constitutes a benign incidental finding for which surgical treatment should not be postponed.

Background/purpose: The popularity of the transumbilical approach for the treatment of infantile hypertrophic pyloric stenosis has increased over recent years mainly because of its superior cosmetic result. However, delivering a large pyloric tumor through a small incision can be technically demanding and is associated with significant complications. Described in this article is a novel yet simple technique to facilitate delivery of the pyloric tumor., Method: This is a prospective report of an 8-year experience of a single surgeon on consecutive patients with pyloric stenosis who underwent transumbilical pyloromyotomy assisted by the squeeze technique. Information on patient demographics, perioperative performance, and postoperative stay were recorded and analyzed. A standard surgical approach and postoperative feeding regimen were used in all cases., Results: Forty-six patients were operated on at a mean of 5.5 weeks and discharged 2.5 days postsurgery. There were no significant intra- or postoperative complications, and all patients were reviewed at 6 weeks postdischarge., Conclusion: The success of the squeeze technique in facilitating delivery of the pylorus strengthens the case for the continued use of the transumbilical over traditional and laparoscopic approaches for infantile hypertrophic pyloric stenosis.

Adult idiopathic hypertrophic pyloric stenosis (AIHPS) is a misleading anatomic and radio-clinical entity of unknown etiology. Only about 200 cases have been reported in the literature. It is a benign disease resulting from hypertrophy of the circular fibers of the pyloric canal. Despite the recent progress in radiography and endoscopy, it is very hard to define hypertrophic stenosis in adults. Differentiation of primary from secondary pyloric stenosis is frequently a task of the pathologist rather than the surgeon. The main therapy is surgical, although endoscopic dilatation has been tried. There remains controversy over the best surgical approach. A case is reported of a 48-year-old male patient with AIHPS who was subjected to distal gastrectomy. This paper discusses the possible causes of the disorder, the recommended diagnostic steps, and the different surgical approaches.

Background: The pathogenesis of infantile hypertrophic pyloric stenosis (IHPS) is not fully understood. Hypertrophy of the pyloric muscle is probably regulated by growth factors. Recent studies reported an increase in the local synthesis of insulin-like growth factor-1 (IGF-1). There are no reports concerning platelet-derived endothelial cell growth factor (PDEGF) playing an important role in the pathological angiogenesis. The aim of this study was to analyze the expressions of IGF-1 and PDEGF by immunohistochemistry (IHC) in the muscularis propria of the pyloric muscle in children with IHPS., Material/methods: Twenty-two muscle biopsies were obtained at the time of pyloromyotomy. The control group consisted of seven children. Specimens were evaluated by routine histopathological methods and by immunohistochemistry using monoclonal mouse anti-PDEGF or -IGF-1 antibodies. Cells showing positive reaction were counted in five random 200x high-power fields. Values were expressed as the mean +/-SD of the real expression area of the analyzed marker to the total analyzed area., Results: In children with IHPS the average area of PDEGF expression was 62+/-52.5, whereas in the control group it was 15+/-12.1. The average area of IGF-1 expression was 1037+/-491.9) in study group and 259+/-221.44 in the controls. Statistically significant differences were found., Conclusions: These results show a local increase in the expressions of IGF-1 and PDEGF in the muscularis propria of the pyloric muscle in children with IHPS, which may have implications to the pathogenesis of the disease.

Background/purpose: Laparoscopic pyloromyotomy has recently gained wide acceptance as the optimum treatment of infantile hypertrophic pyloric stenosis (IHPS). However, medical treatment may be superior to laparoscopic surgery in invasiveness. The efficacy of our regimen of intravenous atropine therapy for IHPS was assessed in comparison with surgical treatment., Methods: Medical treatment was initially chosen for 52 (61%) of 85 infants with IHPS at our institute between 1996 and 2004. Atropine was given intravenously at 0.01 mg/kg 6 times a day before feeding. When vomiting ceased and the infants were able to ingest 150 mL/kg per day of formula after stepwise increases in the feeding volume, they were given 0.02 mg/kg atropine 6 times a day orally, and the dose was decreased stepwise., Results: Of the 52 patients, 45 (87%) ceased projectile vomiting with treatment using intravenous (median, 7 days) and subsequent oral (median, 44 days) atropine administration. The median hospital stay was 13 days (6-36), and no significant complications were encountered during atropine therapy. The remaining 7 patients required surgery. Of 40 who underwent surgery, 4 had wound infections and 1 with hemophilia had postoperative hemorrhagic shock. The patients who underwent successful atropine therapy had body weights comparable with those who underwent surgery at the age of 1 year., Conclusions: The high success rate of intravenous atropine therapy for IHPS suggests that this therapy is an effective alternative to pyloromyotomy if the length of the hospital stay and the necessity of continuing oral atropine medication are accepted.

Objective: Hypertrophic pyloric stenosis is a common pediatric surgical condition. A Ramstedt pyloromyotomy is performed either via laparotomy or laparoscopy. We report our first 25 cases of laparoscopic pyloromyotomy at an academic children's hospital., Methods: From January 2002 through February 2003, we retrospectively reviewed our first 25 laparoscopic pyloromyotomies. All patients had documented hypertrophic pyloric stenosis by ultrasound criteria. Three incisions were made, one 5-mm umbilical port, one 3-mm right upper quadrant port, and a third left upper quadrant working stab incision. A 4-mm, 30 degrees scope was used in all cases. A longitudinal pyloromyotomy was performed using an arthrotomy scalpel. The pylorus was further separated with a laparoscopic Benson spreader. At the completion of the pyloromyotomy, the stomach was insufflated with air to identify any mucosal injury., Results: Age range was 2.3 weeks to 8.4 weeks. Operating time has decreased from 70 minutes to 15 minutes. Two conversions to an open procedure were necessary, both during the first 10 cases. No mucosal perforations or incomplete pyloromyotomies have occurred. Feeds were started within 4 hours and advanced to goal. Time to discharge ranged from 12 hours to 30 hours. One patient developed umbilical cellulitis that was successfully treated with antibiotics., Conclusions: Laparoscopic pyloromyotomy is a safe, effective procedure for hypertrophic pyloric stenosis in a resident teaching environment. Laparoscopy permits excellent visualization, has comparable postoperative recovery, and superior cosmesis.

Background: Laparoscopic pyloromyotomy (LPM) for the treatment of infantile hypertrophic pyloric stenosis (HPS) has gained popularity in recent years. This study examines the learning curve associated with LPM., Methods: We performed a retrospective analysis of patients undergoing LPM at a children's hospital between January 1, 1997 and June 30, 2003. Data including age, weight, complications, operative time, time to feeding, and length of postoperative stay were analyzed using the Student's ttest., Results: A total of 51 patients underwent LPM during the study period. Patient characteristics were similar throughout the study period. Operative time ranged from 12 to 55 minutes (mean, 25 minutes). Mean operative time decreased significantly from 31+/-11 minutes for the first 15 patients, to 25+/-6 minutes for the second 15 patients, to 20+/-7 minutes for the last 15 patients (P<0.05). Operative times were erratic for the early cases but became more consistent over time, especially after 30 cases. Conversion to an open procedure was required in two patients. Complications included an umbilical port site wound dehiscence and readmission for persistent vomiting. There were no mucosal perforations. Time to ad lib feeding and postoperative length of stay did not change over time., Conclusion: LPM has a steep learning curve, especially for the first 15 patients. Operative time decreases and becomes more consistent after about 30 cases. Despite the learning curve, LPM can be performed safely and effectively without an increase in complications.

The aetiology of infantile hypertrophic pyloric stenosis (IHPS) remains obscure. Cases in twins, usually monozygotic, have been sporadically reported as evidence for the genetic origin of the disease. We present a case of IHPS in a pair of dizygotic male twins together with a review of the literature, focusing on the question of whether the twin cases actually support a genetic or an acquired nature of IHPS.

Background: Ramstedt pyloromyotomy through a right upper quadrant (RUQ) transverse incision has been the traditional treatment for hypertrophic pyloric stenosis. Recently, laparoscopic (LAP) and circumumbilical (UMB) approaches have been introduced as alternative methods to improve cosmesis, but concerns about greater operative times, costs, and complications remain. This study compares the three operative techniques and examines their advantages and complication rates., Study Design: We performed a retrospective review of patients undergoing pyloromyotomy at a children's hospital between January 1997 and June 2003., Results: Two hundred ninety patients underwent pyloromyotomy by LAP (n = 51), RUQ (n = 190), or UMB (n = 49). Complication rate, time to ad libitum feeding, incidence of emesis, and postoperative length of stay did not differ considerably among groups. Two LAP patients were converted to RUQ. Mucosal perforation occurred in three patients each in the RUQ and UMB groups, but none in the LAP group. Operative times were considerably less for LAP (25 +/- 9 minutes) than for RUQ (32 +/- 9 minutes) and UMB (42 +/- 12 minutes) (p < 0.05, ANOVA, Bonferroni). Charges related to operations and anesthesia were considerably greater for UMB (operation: US 1,574 dollars +/- US 433 dollars; anesthesia: US 731 dollars +/- US 190 dollars) compared with the other two groups (p < 0.05, ANOVA, Bonferroni), but did not differ between LAP (operation: US 1,299 dollars +/- US 311 dollars; anesthesia: US 586 dollars +/- US 137 dollars) and RUQ (operation: US 1,237 dollars +/- US 411 dollars; anesthesia: US 578 dollars +/- US 167 dollars). Data are presented as mean +/- SD., Conclusions: Advantages of LAP include a shorter mean operative time without higher complications or costs. UMB is associated with the greatest mean operative time and costs. Laparoscopic pyloromyotomy is a safe and effective approach to the treatment of hypertrophic pyloric stenosis.

Background: The umbilical fold incision for infantile hypertrophic pyloric stenosis provides a convenient exposure and cosmetically appealing scar. This study investigates the possible difference in infection rates between traditional and supraumbilical approaches for pyloromyotomy., Methods: All patients who underwent pyloromyotomy for infantile hypertrophic pyloric stenosis at a tertiary pediatric hospital were reviewed. Baseline wound infection rate was determined through review of patients with right upper quadrant incisions (group 1). A nonrandomized comparison was performed between patients with a supraumbilical approach (group 2) and those undergoing supraumbilical incisions after prophylactic antibiotic administration (group 3)., Results: Complete records were reviewed on 384 patients over a 6-year period. Demographics and preoperative factors were similar among groups. The rate of infection in group 1 (n = 258) was 2.3%. With introduction of the supraumbilical approach, there was a statistically significant increase in wound infection rate to 7.0% (chi 2 ; group 1 vs group 2, P < .05). The use of prophylactic antibiotics with a supraumbilical approach reduced this rate of infection back to 2.3% (chi 2 ; group 1 vs group 3, P < 1.0 and group 2 [n = 85] vs group 3 [n = 42], P < .3)., Conclusions: The risk of wound infection by classic pyloromyotomy of 2.3% is significantly increased with an open supraumbilical approach. The use of prophylactic antibiotics reduces this risk of wound infection.

Aim: The availability of large clinical databases allows for careful evaluation of surgical practices, indicators of quality improvement, and cost. We used a large clinical database to compare the effect of surgeon and hospital volume for the care of children with hypertrophic pyloric stenosis (HPS)., Methods: Patients with International Classification of Diseases-9 codes for HPS and pyloromyotomy were selected from the 1994 to 2000 National Inpatient Samples database. Multiple and logistic regression models were used to evaluate the risk-adjusted association between provider volume and outcomes., Results: Postoperative complications occurred in 2.71% of patients. Patients operated on by low- and intermediate-volume surgeons were more likely to have complications compared with those operated on by high-volume surgeons (95% confidence interval [CI], 1.25-3.78 and 95% CI, 1.25-2.69, respectively). Patients operated at low-volume hospitals were 1.6 times more likely to have complications compared with those operated at intermediate- or high-volume hospitals (95% CI, 1.19-2.20). Procedures performed at high-volume hospitals were less expensive than those at intermediate-volume hospitals by a margin of 910 dollars (95% CI, 443-1377 dollars)., Conclusions: These data represent the largest study to date on the epidemiology, complication rate, and cost for care for HPS. Patients treated by both high-volume surgeons and at high-volume hospitals have improved outcomes at less cost.

Background: The advent of sophisticated endoscopic devices allows for a variety of procedures heretofore performed surgically. This study describes the results of endoscopic pyloromyotomy for congenital hypertrophic pyloric stenosis (CHPS)., Methods: Ten consecutive infants (7 boys, 3 girls; age range 3-7 weeks), with a diagnosis of CHPS, underwent endoscopic pyloromyotomy while under conscious sedation by using an endoscopic electrosurgical needle knife or a sphincterotome. Incisions were made from the antral to the duodenal side of the pylorus. All procedures except one were performed on an outpatient basis., Results: No complication was encountered in any patient. All patients began regular feedings as soon as they recovered from the effects of the sedative medication and were discharged on the same day. At follow-up (range 6 months to 2 years), all patients were doing well., Conclusions: Surgery for CHPS has undergone little change in recent decades except for the advent of the laparoscopic approach. Surgical pyloromyotomy is considered simple, inexpensive, and safe. Endoscopic pyloromyotomy is equally simple, probably less expensive, and it can be performed as an outpatient procedure.

Unlabelled: A recent alternative feeding regimen at the progressive feeding (PF) after a pyloromyotomy for hypertrophic pyloric stenosis (HPS) is the so-called ad libitum feeding (AL). The aim of this study was to determine if this new feeding regimen has modified the follow-up of postoperative course in HPS., Population and Methods: From January 1998 to December 2003, 97 consecutive neonates have been operated on for HPS in our hospital. This retrospective study was based on the comparison between two groups of patients with different postoperative feeding regimens: group one of 30 neonates with PF regimen and group two of 60 neonates with AL regimen. Seven remaining neonates had had a mucosal perforation and were not included in this comparative study but in a separate group (MP). The clinical, ultrasonographic, operative and postoperative data were compared., Results: There was no difference between the PF and AL groups for sex ratio M/F=4/1, preoperative weight loss ratio, ultrasonographic data and intra-operative difficulties rate. A small difference was found - which was not significative - between the PF and the AL groups for median age at diagnosis (44,6 v 36,7 days, respectively). A statistically significative difference between the PF and the AL groups was observed for time to establish feeding (69 vs 35.6 hours, respectively) (P<0,001), postoperative stay (4.16 vs 2.98 days, respectively) (P<0,001) and total hospital charges. We didn't found any difference in the incidence and severity of postoperative emesis whether slow (PF) or rapid (AL) feeding regimens were used. Furthermore, intra-operative mucosal tear didn't influence postoperative course and the duration of hospital stay., Conclusion: We recommend AL regimen for routine feeding in simple cases after pyloromyotomy for HPS. It has a positive impact on length of hospital stay, and decreases hospital charges. Most neonates with MP can be managed with a rapid feeding regimen.

Introduction: The pyloric "olive" (PO) is the result of the anomalous growth of the pyloric muscle among patients with pyloric stenosis (PS). It frequently is unexpectedly large, or some other times surprisingly small, and those variations in size have been difficult to explain., Materials and Methods: We measured the PO in 145 consecutive patients with PS during the operation, and then we classified them as small if their length was less than 20 mm, medium if 20 to 30 mm, or large if more than 30 mm; several variables were analyzed by mean of the chi square or Spearman rho tests., Results: Six cases were excluded due to an unclear total length record of the PO. The PO size was classified as small in 19 (13.7%), medium in 71 (51%) and large in 49 (35.3%). The PO size did not associate with gender, way of birth, the presence of jaundice, constipation or any specific blood group or Rh factor, and it did not correlate with birth weight or month and gestational order either. Medium and large PO were more frequently palpated than smaller (94-100% vs. 83%, p = 0.009); PO size correlated with the duration of the history of vomiting (CQ 0.267, p = 0.002), child's age (CQ 0.243, p = 0.005) and weight at operation (CQ 0.190, p = 0.048). A daily weight loss surpassing 5 g was more commonly found among small PO (p = 0.038)., Conclusions: In more than a third of the PS patients, PO is unexpectedly large, and in one of every seven it is surprisingly small. The bigger PO size associates with a longer disease, and with older and heavier patients, which probably is explained by a slighter clinical course. A small PO is more difficult to palpate during clinical evaluation.

Background: Besides laparoscopic pyloromyotomy, the operation for pyloric stenosis has been performed using 2 standard open surgical exposures: the right upper quadrant (RUQ) incision and the semi-circumumbilical (UMB) incision. The aim of this study was to compare the morbidity and cosmetic results of both open exposures., Methods: Between 1990 and 1995, we performed 104 pyloromyotomies through a RUQ incision. These operations were retrospectively compared with 133 UMB incisions performed between 1995 and 1999., Results: There were no significant differences between the 2 groups regarding age at presentation, sex, and preoperative status. Only a significantly higher percentage of patients with a metabolic alkalosis before surgery was found in the UMB group, but this did not affect morbidity rate. The groups did not differ significantly with respect to mucosal perforations (P =.95), wound infections (P =.53), inadequate pyloromyotomies (P =.42), or other complications. The mean operating time was slightly longer in the UMB group (P <.025). The UMB approach produced a better cosmetic result, with an almost invisible scar., Conclusions: This study has shown that the UMB approach has equal intra- and postoperative complication rates as compared with the RUQ approach. The main advantage of the UMB approach is that it produces an excellent long-term cosmetic result.