Management of Postoperative Complications Following Common Pediatric Operations.

This review discusses complications unique to pediatric surgical populations. Here the authors focus primarily on five of the most common procedures performed in children: appendectomy, central venous catheterization, pyloromyotomy, gastrostomy, and inguinal/umbilical hernia repair.

Guidelines of the Italian Society of Videosurgery (SIVI) in Infancy for the minimally invasive treatment of Hypertrophic Pyloric Stenosis in neonates and infants.

The most appropriate treatment for the infantile Hypertrophic Pyloric Stenosis (HPS) is still debated. The non-surgical conservative treatment with oral or intravenous administration of atropine does not enjoy a widespread appreciation for several factors (...).

Infantile hypertrophic pyloric stenosis: profile, management and outcome of patients admitted to a tertiary hospital in Bloemfontein, South Africa.

BACKGROUND: Infantile hypertrophic pyloric stenosis (IHPS) is the thickening of both muscle layers of the pylorus and is most commonly found in first-born males. It usually presents with projectile, non-bilious vomiting. Late presentation leads to severe dehydration and malnutrition with deranged serum-electrolytes and acid-base imbalance delaying treatment and prolonging hospital stay. This study aims to evaluate the profile, management and outcome of IHPS at a tertiary hospital in Bloemfontein, South Africa. METHOD: The study was a retrospective, descriptive record review including all patients with IHPS admitted to Universitas Hospital from January 2008 to February 2016. Of the 22 patients admitted, files for 19 patients were available for inclusion. RESULTS: Sixteen (84.2%) of the 19 patients were male. Of the 11 patients with available birth order, two were first-, two second-, six third- and one fourth-born. The patients' ages ranged from 27 to 194 days (median 51 days). The most common symptoms were projectile vomiting (78.9%) and poor weight gain (68.4%). Six patients had no ultrasound done, and 17 patients underwent a Ramstedt-pyloromyotomy. Eight patients received atropine as part of their initial management. The duration of symptoms ranged from 1 to 58 days (median 14 days). There was no reported mortality. The length of stay ranged from 2 to 60 days (median 7 days). CONCLUSION: The gender distribution and age at presentation were in keeping with the literature but not the birth order. The delay before surgery emphasises the poor general health and deranged biochemical state the patients present at the hospital.

Pyloric stenosis: an enigma more than a century after the first successful treatment.

Despite hypertrophic pyloric stenosis (HPS) being one of the most frequently treated pediatric surgical conditions, its etiology remains incompletely understood. We review the diagnosis and treatment of this condition with an emphasis on the evolution of surgical techniques that led to laparoscopic pyloromyotomy, the most frequently performed technique for HPS today. In addition, we review key developments in the understanding of HPS etiology and treatment, including the postulated etiology of work-induced hypertrophy of the pylorus, its association with prokinetic macrolide antibiotics, and the emerging role of atropine sulfate as a medical treatment for HPS or a rescue treatment for incomplete myotomy.

Corrected to uncorrected? The metabolic conundrum of hypertrophic pyloric stenosis.

OBJECTIVES: The purpose of this study was to evaluate factors associated with repeat blood testing after establishment of normal metabolic parameters and factors associated with reversal of metabolic correction back an uncorrected form in preoperative management of infants with Hypertrophic Pyloric Stenosis (HSP). METHODS: A retrospective review of infants with HSP undergoing repeat serum chemistries after already having normal labs were identified. Variables associated with repeating normal bloodwork and reversion of normal to abnormal labs were identified. Associations between reversion to abnormal and ordering of repeat labs were determined. RESULTS: 255 cases were studied with a median of 2 lab tests drawn per patient (range 1-9). Of 142 serum chemistry tests repeated after a normal test, 27% became abnormal, most commonly hyperkalemia. 61% of these went to surgery. No variables were associated with a normal test becoming abnormal. However, a time lapse of >12h was associated with the reordering of bloodwork despite it already being normal. CONCLUSIONS: There is little evidence to support need for repeat serum chemistry testing in cases of HPS once normality has been established. Development of clinical pathways to reduce the use of unnecessary serum testing may improve efficiency of patient care and limit unnecessary resource utilization. LEVEL OF EVIDENCE: Retrospective Case control: 3b.

A randomized trial to assess advancement of enteral feedings following surgery for hypertrophic pyloric stenosis.

PURPOSE: The rate of feeding advancement following surgery for hypertrophic pyloric stenosis (HPS) affects length of stay. We hypothesized that: 1) a relaxed feeding regimen following pyloromyotomy would allow infants to achieve feeding goals more quickly without affecting postoperative emesis, and 2) preoperative metabolic derangements would impair the ability to advance feedings following pyloromyotomy. METHODS: A prospective, randomized trial compared two postoperative feeding methods. The primary outcome was length of time to tolerate two consecutive goal feeds (GFs). Infants were randomized into the Incremental-arm (N=74), in which infants were gradually advanced on enteral formula, or the Relaxed-arm (N=69), in which infants were allowed to consume up to GF immediately. Preoperative variables, time to GF, preoperative laboratory values, and postoperative emesis were recorded. A p-value less than 0.05 was significant. RESULTS: Patient demographics, pyloric ultrasound measurements, and episodes of postoperative emesis were similar between groups. Infants in the Relaxed-arm reached GF more quickly than those in the Incremental-arm and had a shorter length of stay (p<0.001). Infants with preoperative serum chloride less than 100mmol/L reached GF more slowly than those with normal labs (p<0.03). CONCLUSION: Following surgery for HPS, surgeons can safely utilize a relaxed, nonstructured feeding regimen, which may allow infants to reach feeding goals more quickly without untoward vomiting. LEVEL OF EVIDENCE: Level 1-therapeutic.

Health disparities in infants with hypertrophic pyloric stenosis.

BACKGROUND: This study investigates whether health disparities exist in infants with hypertrophic pyloric stenosis (HPS), to identify factors affecting definitive treatment, and if more morbidity occurs. METHODS: A 6-year retrospective analysis was performed on infants with HPS. Analysis of variance was used to evaluate the impact of socioeconomic factors on disease severity and hospitalization. General linear models were used to assess the impact of risk factors on the outcomes. RESULTS: There were a total of 584 infants. African-American's had lower serum chloride (P < .001), higher bicarbonate (P = .001), and sodium levels (P = .006), adding to longer hospitalization than whites (P = .03). Uninsured infants had lower sodium and chloride (P < .001) and higher bicarbonate (P < .001), resulting in a longer time to operation (P = .05) than privately insured infants. In multivariable analyses, African-American's were associated with chloride (P = .002) and higher bicarbonate (P = .009), and uninsured status remained significantly associated with all electrolyte abnormalities. CONCLUSIONS: African-American and poorly insured infants with HPS had greater risk of metabolic derangements. This required more time to correct dehydration and electrolytes, adding to longer hospitalizations.

Revisión de estenosis hipertrófica del píloro / Review of hypertrophic pyloro stenosis

La estenosis hipertrófica del píloro (EHP) es una patología quirúrgica común en la edad pediátrica. Apesar de ser una condición frecuente, su etiología aún no está claramente dilucidada. La presentación clínica corresponde a vómitos explosivos lácteos, no biliosos y en algunos casos oliva palpable en el abdomen u ondas peristálticas luego de ser alimentados. Si bien el manejo resolutivo de esta patología requiere la intervención del cirujano infantil, la sospecha inicial incluye al médico general y pediatra. Este artículo presenta una revisión de la literatura disponible sobre el tema.

Hypertrophic pyloric stenosis (EHP) is a common surgical pathology in children. Despite being a common condition, its etiology is not yet clearly known. The clinical presentation corresponds to milky, explosive and nonbilious threw up, and in some cases palpable olive in the abdomen or peristaltic waves after being fed. While surgical management of this condition requires the intervention of child surgeon, the initial suspicion includes the general physician and pediatrician. This article presents a review of the available literature on the subject.

Contemporary management of pyloric stenosis.

Hypertrophic pyloric stenosis is a common surgical cause of vomiting in infants. Following appropriate fluid resuscitation, the mainstay of treatment is pyloromyotomy. This article reviews the aetiology and pathophysiology of hypertrophic pyloric stenosis, its clinical presentation, the role of imaging, the preoperative and postoperative management, current surgical approaches and non-surgical treatment options. Contemporary postoperative feeding regimens, outcomes and complications are also discussed.

Acute Abdominal Pain in Children.

Acute abdominal pain accounts for approximately 9% of childhood primary care office visits. Symptoms and signs that increase the likelihood of a surgical cause for pain include fever, bilious vomiting, bloody diarrhea, absent bowel sounds, voluntary guarding, rigidity, and rebound tenderness. The age of the child can help focus the differential diagnosis. In infants and toddlers, clinicians should consider congenital anomalies and other causes, including malrotation, hernias, Meckel diverticulum, or intussusception. In school-aged children, constipation and infectious causes of pain, such as gastroenteritis, colitis, respiratory infections, and urinary tract infections, are more common. In female adolescents, clinicians should consider pelvic inflammatory disease, pregnancy, ruptured ovarian cysts, or ovarian torsion. Initial laboratory tests include complete blood count, erythrocyte sedimentation rate or C-reactive protein, urinalysis, and a pregnancy test. Abdominal radiography can be used to diagnose constipation or obstruction. Ultrasonography is the initial choice in children for the diagnosis of cholecystitis, pancreatitis, ovarian cyst, ovarian or testicular torsion, pelvic inflammatory disease, pregnancy-related pathology, and appendicitis. Appendicitis is the most common cause of acute abdominal pain requiring surgery, with a peak incidence during adolescence. When the appendix is not clearly visible on ultrasonography, computed tomography or magnetic resonance imaging can be used to confirm the diagnosis.

Methicillin-Resistant Staphylococcus aureus Subhepatic Abscess Presenting as Pylorospasm in a Neonate.

Pylorospasm can present with sonographic findings similar to hypertrophic pyloric stenosis. We present a rare case of methicillin-resistant Staphylococcus aureus subhepatic abscess causing pylorospasm in a neonate.

Optimizing fluid resuscitation in hypertrophic pyloric stenosis.

BACKGROUND: Hypertrophic pyloric stenosis (HPS) is the most common diagnosis requiring surgery in infants. Electrolytes are used as a marker of resuscitation for these patients prior to general anesthesia induction. Often multiple fluid boluses and electrolyte panels are needed, delaying operative intervention. We have attempted to predict the amount of IV fluid boluses needed for electrolyte correction based on initial values. METHODS: A single center retrospective review of all patients diagnosed with HPS from 2008 through 2014 was performed. Abnormal electrolytes were defined as chloride <100mmol/L, bicarbonate ≥30mmol/L or potassium >5.2 or <3.1mmol/L. Patients with abnormal electrolytes were resuscitated with 20ml/kg saline boluses and continuous fluids at 1.5 times maintenance rate. RESULTS: During the study period 542 patients were identified with HPS. Of the 505 who were analyzed 202 patients had electrolyte abnormalities requiring IV fluid resuscitation above maintenance, and 303 patients had normal electrolytes at time of diagnosis. Weight on presentation was significantly lower in the patients with abnormal electrolytes (3.8 vs 4.1kg, p<0.01). Length of stay was significantly longer in the patients with electrolyte abnormalities, 2.6 vs 1.9days (p<0.01). Fluid given was higher over the entire hospital stay for patients with abnormal electrolytes (106 vs 91ml/kg/d, p<0.01). The number of electrolyte panels drawn was significantly higher in patients with initial electrolyte abnormalities, 2.8 vs 1.3 (p<0.01). Chloride was the most sensitive and specific indicator of the need for multiple saline boluses. Using an ROC curve, parameters of initial Cl(-)80mmol/L and the need for 3 or more boluses AUC was 0.71. Modifying the parameters to initial Cl(-) ≤97mmol/L and 2 boluses AUC was 0.65. A patient with an initial Cl(-)85 will need three 20ml/kg boluses 73% (95% CI 52-88%) of the time. A patient with an initial Cl(-) ≤97 will need two 20ml/kg boluses at a rate of 73% (95% CI 64-80%). CONCLUSION: Children with electrolyte abnormalities at time of diagnosis of HPS have a longer length of stay; require more fluid resuscitation and more lab draws. This study reveals high sensitivity and specificity of presenting chloride in determining the need for multiple boluses. We recommend the administration of two 20ml/kg saline boluses separated by an hour prior to rechecking labs in patients with initial Cl(-) value ≤97mmol/L. If the presenting Cl(-) <85 three boluses of 20ml/kg of saline separated by an hour are recommended. If implemented these modifications have potential to save time by not delaying care for extraneous lab results and money in the form of fewer lab draws.

An update on common gastrointestinal emergencies.

The evaluation of the child with acute abdominal pain often poses as a diagnostic challenge due to the wide range of diagnoses. Surgical emergencies need to be rapidly identified and managed appropriately to minimize morbidity and mortality. Presenting symptoms, clinical examination, and laboratory findings can guide selection of diagnostic imaging. This article reviews common surgical causes of abdominal pain in children.

Pyloromyotomy versus i.v. atropine therapy for the treatment of infantile pyloric stenosis: nationwide hospital discharge database analysis.

BACKGROUND: Several studies have suggested that i.v. atropine has a potential role in treating infantile hypertrophic pyloric stenosis (IHPS). It remains unclear, however, whether surgery can be replaced by i.v. therapy. METHODS: Data were extracted on infants with IHPS who were treated with atropine and/or surgery, from a nationwide administrative database through 2006-2008. Patient demographic data, treatment effects and length of hospital stay were analyzed in each treatment group. RESULTS: A total of 585 infants met the criteria for IHPS; 188 patients (32%) were initially treated with atropine (i.v. form, n = 180; oral form, n = 8), while 397 were treated with surgery as a first-line therapy. Of the 180 infants receiving i.v. atropine, 38 were withdrawn from medical management and subsequently underwent surgery. Thus, the overall success rate of i.v. atropine was 78.9% (142/180). Surgery had a success rate of 100%, and postoperative complications were found in 2.8% of patients (12/435). Medical management required longer hospital stay than surgery (mean, 13.5 days vs 8.0 days; P < 0.001). CONCLUSION: Surgery remains the suitable standard management option for IHPS, with its high success rate, minimal complications and shorter hospital stay compared with i.v. atropine therapy.

Hypertrophic pyloric stenosis in the third world.

The relative rarity of hypertrophic pyloric stenosis (HPS) in the developing world makes its diagnosis a challenge to many physicians. This study audits the management of HPS at a tertiary hospital in South Africa, with a view to defining its regional pattern. This is a retrospective review of records of all patients (n = 63) managed for HPS over an eight-year period (2002-2010). The mean age at presentation was 6.2 weeks and the male/female ratio was 6:1. The majority of patients presented with non-bilious vomiting. Abdominal ultrasound had a sensitivity of 65% and 81.3% when the criteria of pyloric muscle thickness >4 mm and pyloric channel length >16 mm were used, respectively. The overall complication rate was 14.3% and the mortality rate was 0%. Despite the rarity of HPS in the Third World, the outcome of its management is favourable. However, the sensitivity of abdominal ultrasound for diagnosing HPS is low.

Hypertrophic pyloric stenosis: predicting the resolution of biochemical abnormalities.

PURPOSE: Hypertrophic pyloric stenosis (HPS) is a common condition of infancy, often presenting with marked biochemical derangement, requiring correction. Previous studies have looked at the relationship between serum electrolytes and acid-base balance in HPS but not at the relationship between the degree of biochemical derangement and time taken to resolve the biochemical abnormality. METHODS: Retrospective analysis was performed on all 151 infants undergoing pyloromyotomy over a 3 year period. Of these, 105 met the inclusion criteria of: compliance with the unit HPS fluid protocol, and the documentation of at least three serial biochemical investigations. The rate of correction for each biochemical marker (sodium, potassium, chloride, urea, pCO2, hydrogen ion concentration, bicarbonate and the base excess) was plotted against the degree of disturbance and then against time. RESULTS: A significant relationship (P < 0.01) was found between the rate of correction of an abnormal chloride, urea or base excess and the degree of initial derangement. This enables the prediction of the time taken for the required correction of biochemical abnormalities prior to theatre. CONCLUSION: This method of analysis may be of value in comparing the effectiveness of different fluid regimes in use for the correction of biochemical abnormalities in infants with IHPS.

An overview of infantile hypertrophic pyloric stenosis.

In paediatric general surgery hypertrophic pyloric stenosis (HPS) is well-researched and documented (Dudgeon 2005, Panteli 2009). Significant medical advances have improved its diagnosis, treatment and prognosis, and there is now almost a 100 per cent success rate (Panteli 2009). However, the cause of this disease process remains poorly understood (Dudgeon 2005, Panteli 2009). This article reviews the literature on the cause and management of HPS.