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Neonatal surgical emergencies are challenging, often high‐risk procedures for the pediatric anesthesiologist. Though each emergency presents different anesthetic challenges, several error traps exist that are common to all procedures in this patient population. These error traps include errors in surgical timing, airway management, maintenance of normothermia and normoglycemia, and recognition of pharmacologic and physiologic differences. In this narrative review, we will discuss each error trap to aid the clinician in recognizing, planning for, and mitigating adverse events. [ABSTRACT FROM AUTHOR]

Background: MIRAGE syndrome is a rare multisystem disorder characterized by myelodysplasia, infection, growth restriction, adrenal hypoplasia, genital phenotypes, and enteropathy, resulting from mutations in the SAMD9 gene. This syndrome is notably rare, with fewer than 60 documented cases globally. We present a unique case of an 8-month-old boy with MIRAGE syndrome exhibiting a previously unreported clinical manifestation of pyloric stenosis, contributing to the expanding phenotypic spectrum of the disorder. Case presentation : An 8-month-old boy who was born full-term with a birth weight of 3.8 kg presented with multiple infections, including urinary tract infection, pneumonia, and viral illnesses, requiring hospital admissions. At three months, he was diagnosed with pyloric stenosis following recurrent vomiting. Further complications included respiratory failure, developmental delay, and failure to thrive. Genetic testing identified a heterozygous SAMD9 mutation (c.884del, p.(Pro295GlnfsTer104)) and an X-linked pathogenic duplication affecting 21 genes. These findings confirmed the diagnosis of MIRAGE syndrome. Conclusions: This case underscores the phenotypic diversity of MIRAGE syndrome, highlighting pyloric stenosis as a novel clinical feature. Early recognition and a comprehensive, multidisciplinary approach are crucial for managing the syndrome's severe and varied manifestations. More research needs to be undertaken to further understand the genotypes of MIRAGE syndrome and its phenotypical manifestations. [ABSTRACT FROM AUTHOR]

[Display omitted] • There is association between Recurrent Hypertrophic Pyloric Stenosis rate and neonatal age and pyloric canal length. • There are specific diagnostic criteria and various treatment options of recurrence. • Review of tertiary pediatric surgery center data and an available literature of recurrent pyloric stenosis. [ABSTRACT FROM AUTHOR]

Purpose: Delays in the diagnosis and treatment of infantile hypertrophic pyloric stenosis (IHPS) may lead to laboratory and clinical decompensation in infants. The aim of this study was to determine whether pyloric measurement parameters can be effectively used in the clinical prognosis of IHPS by evaluating the relationship between pyloric dimensions on ultrasonographic evaluation at the time of presentation and clinical and laboratory parameters in infants with pyloric stenosis. Methods: A retrospective observational study was conducted on 122 infants who were followed up with the diagnosis of IHPS in our neonatal clinic and operated on by a pediatric surgeon between January 2005 and December 2020. Results: The mean pyloric dimensions of the infants were pyloric length 20 mm (17–22), pyloric thickness 5 mm (4–5.8), and pyloric index 96.5 (72.2–124). Babies with preoperative laboratory values of hypokalemia, hypochloremia and metabolic alkalosis had statistically higher pyloric thickness >5 mm (4.1–6) and pyloric index >100 (86–130) parameters. Conclusion: Pyloric thickness and pyloric index parameters can predict clinical prognosis in babies diagnosed with IHPS in the perioperative period. [ABSTRACT FROM AUTHOR]

The article presents a case study of two male infants diagnosed with hypertrophic pyloric stenosis, highlighting their clinical presentation and management. Topics discussed include the genetic and environmental factors contributing to pyloric stenosis, the criteria for surgical intervention, and the increased incidence of the condition among twins.

Background: Infantile hypertrophic pyloric stenosis (IHPS) is a condition whose etiology is not clear, but it is characterized by progressive hypertrophy of the circular muscles of the pylorus with consequent obstruction of the gastric outflow, mostly in neonates and infants under the age of one year. Objectives: To assess the treatment outcome and associated factors of infantile pyloric sphincter stenosis among paediatric patients admitted to HFCSUH and JUSHYRH. Methodology: A retrospective patient record review with 78 participants was studied consecutively using a structured questionnaire. The data was processed and analyzed using Epi Info 7 and SPSS version 24. Descriptive analysis was done, and then associated factors to the outcome were assessed using logistic regression analysis. The association's significance was determined using an odds ratio with a 95% confidence interval and a P-value less than 0.05. The study period was from November 1st to 30th, 2022. Results: The magnitude of unfavorable IHPS was 17.1% with a 95% confidence interval of 16.7–23.9%. Hypokalemia (AOR = 2.3, CI = 3.015–19.54), severe dehydration (AOR = 30.9, CI = 2.89–31.75), and delayed presentation (AOR = 7.37, CI = 2.761–12.08) were independent predictors. Conclusions: The study found a highly unfavorable treatment outcome with delayed presentation; dehydration and electrolyte disturbance were the main predictors of poor outcome. It is recommended to increase community awareness about non-bilious vomiting in infants and ensure high suspicion among healthcare providers. Moreover, following guidelines to correct fluid and electrolyte disturbances and managing these patients in the pediatric ICU postoperatively. [ABSTRACT FROM AUTHOR]

Aim Most cases of oesophageal strictures can be treated effectively with elective outpatient endoscopic dilation in a specialized centre. With this case series review, we aim to evaluate our patient cohort from June 2020 to January 2022. Methods: We retrospectively analyzed 185 consecutive patients submitted to oesophageal and pyloric dilation procedures in day surgery settings from June 2020 to January 2022. Results: In our retrospective case series, we analyzed 185 patients submitted to oesophageal dilation (89%) or pyloric dilation (11%). Analysis of the type of anaesthesia correlated to the primary diagnosis showed that 52% of achalasia patients had deep sedation via native airway, and caustic stricture was corrected in almost all cases during general anaesthesia (89%). It is worth noting that in our study, only 1.6% of patients experienced complications that prevented same-day discharge, such as fever or arrhythmia. Severe complications, including significant bleeding or perforation, were entirely absent. Conclusions: We can conclude that oesophageal dilations were performed with safety and efficiency in our centre, with very few unplanned recoveries and a negligible rate of complications. The standardization of outpatient care pathways has further bolstered our efficiency, ensuring the best possible outcomes for our patients. [ABSTRACT FROM AUTHOR]

Acute gastric dilatation leading to compromised vascular visceral vascular flow is an exceptionally rare complication typically described in patients with bulimia or anorexia following binge episodes. We present a fatal case involving a non-bulimic patient who experienced an acute gastric dilatation secondary to pyloric stenosis. Despite intensive treatment, the patient succumbed to complications arising from acute reperfusion syndrome. Managing such patients is highly challenging, and the prognosis is often poor, as supported by the limited reports available in the literature.

Persistent vomiting in a small infant can be due to delayed gastric emptying which is a significant cause of distress and morbidity. After ruling out common medical causes, evaluation for a surgical cause such as pyloric stenosis is imperative. The diagnosis of pylorospasm is often missed between the medical and surgical realms. We describe a six-week-old infant with persistent nonbilious vomiting who was referred with a suspicion of pyloric stenosis. However, on evaluation clinical findings and imaging were not suggestive of pyloric stenosis. A diagnosis of pylorospasm was made and the patient was managed with anticholinergics without any surgery. The patient had an unremarkable recovery. The diagnosis of pylorospasm needs to be kept in mind in an infant with persistent nonbilious vomiting. It responds satisfactorily with pharmacotherapy and avoids the need for surgery.

Background: Gastric adenomyoma is a rare benign tumor composed of glandular structures and smooth muscle fibers. While some classify gastric adenomyoma as a hamartoma, others view it as an abortive form of heterotopic pancreas. Despite its benign nature, there is a risk of malignant transformation. Predominantly found in the antrum, gastric adenomyoma affects all ages but is most common in adults aged 40–60 years. Symptoms are nonspecific, and its similarity to other lesions complicates diagnosis. This paper aims to provide a review of medical literature on gastric adenomyoma and its diagnosis and treatment methods, along with presenting an additional case report on the same topic. Case presentation: We present the case of a 55-year-old Syrian man who experienced vomiting, weight loss, and chronic partial constipation. An obstructing mass in the pylorus was detected, and then an open surgery was performed to excise the lesion. A biopsy of the resected mass was obtained for histopathological examination. The final diagnosis of the lesion was pyloric-region adenomyoma with severe pyloric stenosis. After the successful surgery, the patient recovered without any recurrence or complications. Conclusions: Several diagnostic approaches are available, including radiological studies, endoscopic examination, and fine needle aspiration guided by endoscopic ultrasonography. Treatment options involve endoscopic submucosal dissection and complete laparotomy resection. Further studies and thorough reviews are recommended to better understand the best clinical practices. Practitioners should consider gastric adenomyoma when encountering a mural gastric lesion. [ABSTRACT FROM AUTHOR]

Infantile hypertrophic pyloric stenosis (IHPS) is one of the most commonly encountered paediatric surgical conditions. It is estimated to affect between 1 and 4 infants per 1,000 births, representing the most common cause of surgical intervention in the first 6 months of life. The exact aetiology remains unclear. It is known to be more common in males (4:1), especially those that are first-born. Abdominal examination can sometimes detect visible stomach peristalsis in the left upper quadrant and the pathognomic sign of an "olive shaped" epigastric mass may be present. In cases of diagnostic uncertainty or where a definitive mass is not felt, ultrasound is the investigation of choice for confirming IHPS, with high sensitivity and specificity. Following appropriate pre-operative optimisation and surgical correction is undertaken. The Ramstedt's pyloromyotomy con be performed via a right upper quadrant, peri-umbilical, or laparoscopic approach. The vast majority of cases recover quickly with no concerns, with the infant almost invariably discharged soon after treatment. Perforation requiring mucosal repair and incomplete pyloromyotomy requiring re-do surgery as the specific complications. [ABSTRACT FROM AUTHOR]

Objective: Unusual clinical course. Background: Pyloric obstruction after dichlorvos poisoning causes repeated vomiting and inability to eat. Choledocholithiasis and cholelithiasis are the common digestive diseases, with high morbidity and relapse in elderly patients. However, the complex situation of these diseases' coexistence is a clinically intractable problem, and literature on selecting optimal surgical planning is scarce. Case Report: A thin 79-year-old woman took dichlorvos due to family conflicts. She improved after being urgently sent to local hospital for gastric lavage and detoxification. Over the next 3 months, she presented with intermittent nausea, vomiting, epigastric pain, and mental apathy, and was readmitted. Gastroscopy showed extensive scarring in the antrum, pyloric obstruction, and gastric retention. Magnetic resonance cholangiopancreatography revealed gallstones and choledocholithiasis. Also, she presented with gastric retention, hypertension, moderate anemia, hypoproteinemia, and electrolyte disturbances. After hospitalization, conservative treatment was performed, without improving vomiting, followed by surgical treatment. Gastrojejunostomy, Braun anastomosis, and nasojejunal feeding tube placement were performed for pyloric stenosis; cholecystectomy for cholelithiasis; and choledochotomy, intraoperative choledochoscopy examination, basket stone extraction, and primary suture of common bile duct without indwelling T tube for choledocholithiasis. Patient recovered and was discharged 9 days after surgery. She was recovered well, without vomiting, at 2-month follow-up. Conclusions: Gastrojejunostomy plus Braun anastomosis is effective treatment of elderly patients with pyloric obstruction formed after pesticide-induced corrosion. Careful selection of choledocholithotomy with primary suture without indwelling T tube reduced postoperative pain and accelerated recovery. This complex case of pyloric obstruction with gallbladder and bile duct stones provides useful considerations for clinical treatment. [ABSTRACT FROM AUTHOR]

BACKGROUND: Jodhpur disease is an entity described for the first time in 1997 by Sharma, in Jodhpur, India. This author modified the classification of gastric obstructions to include gastric outlet obstruction once any identifiable restriction at the pyloric level had been ruled out. CLINICAL CASE: We present 4 cases that presented with recurrent non-biliary vomiting without secondary obstruction of the pyloric lumen treated with Heineke-Mikulicz pyloroplasty, obtaining remission of the clinical picture. We searched different sources of medical information for cases grouped as "Jodhpur disease" or clinically coincident, collecting more than 50, which we compared with our series. CONCLUSION: With the information obtained, we conclude that this entity is more frequent in male preschoolers, characterized by vomiting of non-biliary gastric contents from a few days to 4 years of evolution, frequently associated with abdominal distension or epigastric mass. We suggest the gastroduodenal esophagus series as an initial approach study that demonstrates obstruction to the gastric outlet tract, confirmed by endoscopy, ruling out associated secondary causes. Therapeutic management, once the hydration and nutritional status of the patient has been corrected, could be the Heineke-Mikulicz pyloroplasty, used in most reported cases with successful results. [ABSTRACT FROM AUTHOR]

Introduction: Infantile hypertrophic pyloric stenosis (IHPS) is a common cause of infant vomiting. Emergency department (ED) diagnosis is usually made by pyloric ultrasound and treated by pyloromyotomy.Case Report: An eight-week-old boy with a history of IHPS about six weeks status post pyloromyotomy presented to the ED with vomiting and failure to thrive, and a critically narrowed pylorus was identified by ultrasound. An upper gastrointestinal series confirmed recurrent pyloric stenosis, necessitating another pyloromyotomy.Conclusion: Prolonged vomiting after pyloromyotomy should be concerning for recurrent IHPS. Upper gastrointestinal series should augment ultrasound to diagnose recurrent IHPS and determine whether a second pyloromyotomy is warranted.

Objectives: This study aims to share our experience of laparoscopic exploration for infantile hypertrophic pyloric stenosis. Material and methods: This retrospective study was conducted in the Department of Pediatric Surgery, Khyber Teaching Hospital, Peshawar from June 2017 to July 2020. This study includes all patients whose diagnosis of infantile hypertrophic pyloric stenosis (IHPS) was confirmed through ultrasound parameters and laparoscopic pyloromyotomy was performed. Data was retrieved from the laparoscopic surgery record. Retrieved data was tabulated and fed in SPSS 25 for analysis. Results: This study included 42 patients with a mean age of 50.28 ±18.5days and a mean weight of 3.35±0.76 kg. Male patients were 57 % while females were 43 %. The mean time to resuscitate the patient pre-operatively was 34.6±15.4 hours while the mean postoperative hospital stay was 45±12.47 hours. The mean operative time was 31.6±10.4 min. Operative time decreased with time depicting improvement in our learning curve (p=0.004). The method of working instrument placement had no impact on operative time (p=0.337). Meantime to full oral feed was 9.7±5.1 hours. We did not encounter mucosal perforation or incomplete myotomy. No surgery was converted to open. Conclusion: Laparoscopic pyloromyotomy is a safe and effective method of treatment for infantile hypertrophic pyloric stenosis. [ABSTRACT FROM AUTHOR]

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Background: Non-hypertrophic gastric outlet obstruction (GOO) in children is rare and usually presents beyond infancy. Aetiology is variable, and management is not well established due to its rarity. Methods: We aimed to conduct a descriptive study of these cases within our geographic area. It is a retrospective chart review of all children with non-hypertrophic gastric outlet obstruction presenting to three hospitals in northwest Syria during the period 2019–2023. Demographics, presentation, and management data were extracted. Results: Twelve cases were identified, eight males, with age range 1–12 years and follow-up range 3–42 months. Eight patients had a history drinking battery acid and one with ingestion of high-dose ibuprofen. The other three had no clear aetiology. Five patients improved by endoscopic balloon dilatations (EBD), and seven needed surgeries. All those who had successful EBD were treated within 3 weeks of ingestion. Conclusion: Non-hypertrophic GOO in children is rare and mostly related to caustic material ingestion. Treatment by endoscopic balloon dilatation is likely to be successful if done within 3 weeks from caustic ingestion. After that period, often surgery is needed. [ABSTRACT FROM AUTHOR]

Background: Initial treatment of hypertrophic pyloric stenosis (HPS) is correction of electrolyte disturbances with fluid resuscitation. In 2015, our institution implemented a fluid resuscitation protocol based on previous data that focused on minimizing blood draws and allowing immediate ad libitum feeds postoperatively. Our aim was to describe the protocol and subsequent outcomes. Methods: We conducted a single-center retrospective review of patients diagnosed with HPS from 2016 to 2023. All patients were given ad libitum feeds postoperatively and discharged home after tolerating three consecutive feeds. The primary outcome was the postoperative hospital length of stay (LOS). Secondary outcomes included the number of preoperative labs drawn, time from arrival to surgery, time from surgery to initiation of feeds, time from surgery to full feeds, and re-admission rate. Results: The study included 333 patients. A total of 142 patients (42.6%) had electrolytic disturbances that required fluid boluses in addition to 1.5x maintenance fluids. The median number of lab draws was 1 (IQR 1,2), with a median time from arrival to surgery of 19.5 hours (IQR 15.3,24.9). The median time from surgery to first and full feed was 1.9 hours (IQR 1.2,2.7) and 11.2 hours (IQR 6.4,18.3), respectively. Patients had a median postoperative LOS of 21.8 hours (IQR 9.7, 28.9). Re-admission rate within the first 30 postoperative days was 3.6% (n = 12) with 2.7% of re-admissions occurring within 72 hours of discharge. One patient required re-operation due to an incomplete pyloromyotomy. Discussion: This protocol is a valuable tool for perioperative and postoperative management of patients with HPS while minimizing uncomfortable intervention. [ABSTRACT FROM AUTHOR]

The aim of the present study was to determine the correlation between obesity, serum levels of leptin and proximal gastric cancer. Sixty-four gastric cancer patients operated on with curative intent were included in the study. We determined the correlation between the preoperative serum levels of leptin and the tumor's location. Serum leptin levels were correlated significantly with the proximal third location (p=0.04), gastric outlet obstructing tumors (p<0.0001), CRP levels (p=0.03) and BMI (p<0.0001). Patients with high serum levels of leptin had significantly more intestinal types of gastric cancer (p=0.033) and better differentiation (p=0.009). The linear regression model determined the proximal tumor location (beta: 0.467; p=0.045), BMI (beta: 0.657; p=0.001), high preoperative serum albumin (beta: 0.563; p=0.016) and the presence of pyloric stenosis (beta: 0.525; p=0.006) as related significantly to serum leptin levels. The Cox proportional hazard model identified age (HR: 0.003; 95 % CI: 0–0.794; p=0.041), preoperative serum levels of leptin (HR: 0.125; 95 % CI: 0.018–0.887; p=0.037) and the number of extracted LNs (HR: 0.001; 95 % CI: 0–0.677; p=0.038) as independent prognostic factors. Serum levels of leptin were significantly elevated in patients with proximal gastric cancer, suggesting that the leptin's effect might be due to its systemic secretion. This might explain the higher incidence of proximal gastric cancer in obese patients. Elevated serum leptin levels were an independent prognostic factor. [ABSTRACT FROM AUTHOR]