Adequacy of Preoperative Resuscitation in Laparoscopic Pyloromyotomy and Anesthetic Emergence.

BACKGROUND: Pyloromyotomy is one of the most common surgical procedures performed on otherwise healthy infants. Pyloric stenosis results in a hypochloremic, hypokalemic metabolic alkalosis that is considered a medical emergency. This alkalotic state is believed to be associated with an increased incidence of apneic episodes. Because apnea tends to occur during anesthetic emergence, we sought to examine the association between the preoperative serum bicarbonate level and anesthetic emergence time after laparoscopic pyloromyotomy. METHODS: Data were collected from patients who underwent laparoscopic pyloromyotomies from April 2014 to October 2018. To estimate the correlation between preoperative bicarbonate level and emergence time while accounting for the positive skew of emergence time and potential confounding variables, a weighted quantile mixed regression was used. Due to a nonlinear association with emergence time, preoperative serum bicarbonate was split into 2 continuous intervals (<24 and ≥24 mEq/L) and the slope versus outcome was fit for each interval. RESULTS: A total of 529 patients who underwent laparoscopic pyloromyotomy were analyzed in this study. After controlling for confounders, the preoperative serum bicarbonate interval of ≥24 mEq/L was linearly associated with median emergence time (median increase of 0.81 minutes per 1 mEq/L increase of bicarbonate; 95% confidence interval [CI], 0.42-1.20; P < .001). Only 3 patients (0.6%) had apneic episodes after pyloromyotomy despite all having preoperative serum bicarbonate levels <29 mEq/L. CONCLUSIONS: Preoperative serum bicarbonate was positively associated with median anesthetic emergence time in a linear manner for values ≥24 mEq/L, although this correlation may not appear to be clinically substantial per 1 mEq/L unit. However, when preoperative serum bicarbonate levels were dichotomized at a commonly used presurgical threshold, the difference in median emergence time between ≥30 and <30 mEq/L was an estimated 5.4 minutes (95% CI, 3.1-7.8 minutes; P < .001).

Testosterone levels in umbilical-cord blood and risk of pyloric stenosis.

OBJECTIVE: The risk of infantile hypertrophk pylonc stenosis is ∼5 times more common in male than female infants. It has been hypothesized that the higher risk among male infants is associated with high levels of testosterone causing hypertrophy of the pylorus muscle. To test this hypothesis, we examined the association between the testosterone levels in the umbilical-cord blood and the risk of infantile hypertrophic pyloric stenosis. PATIENTS AND METHODS: We conducted a matched case-control study nested in the Danish National Birth Cohort using risk-set sampling. From a cohort of 101 042 pregnancies, we identified umbilical-cord blood samples from 46 case subjects (43 male and 3 female infants) who developed infantile hypertrophic pyloric stenosis in the first year of life and 150 gender- and gestational age-matched control subjects. The testosterone levels were measured by liquid chromatography-tandem mass spectrometry. Rate ratios were estimated by using conditional logistic regression. RESULTS: In male infants, the mean testosterone level at birth was 0.78 nmol/L in case subjects and 0.91 nmol/L in control subjects. The rate of infantile hypertrophic pyloric stenosis was inversely, albeit insignificantly, associated with the testosterone levels in male infants; there was a 29% (95% confidence interval: -46% to 65%; P = 35) lower rate per nmol/L. The association was not modified according to age, gestational age, or birth order. CONCLUSIONS: We found no support for the hypothesis that high testosterone levels in the umbilical-cord blood are strongly associated with a subsequently higher risk for infantile hypertrophic pyloric stenosis in male infants.

Predictors of emesis and time to goal intake after pyloromyotomy: analysis from a prospective trial.

BACKGROUND: Emesis after pyloromyotomy for pyloric stenosis is a common clinical phenomenon and the limiting factor in time to goal feeds. The amount of emesis that can be expected after myotomy is unknown. No data have been published that equip caregivers with the ability to understand which patients are more likely to have emesis and take longer to advance to goal feeds after pyloromyotomy. Therefore, we performed analysis of prospective data obtained from a randomized trial to determine if outcome can be predicted from preoperative or intraoperative variables. METHODS: The dataset was prospectively collected from a randomized trial comparing open to laparoscopic pyloromyotomy in 200 patients. All patients had serum electrolytes and sonographic pyloric measurement recorded upon presentation. The postoperative feeding schedule and criteria for stopping feeds was controlled by a standard computer entry order set. In this study, we used Pearson's correlation to evaluate the influence of patient variables, presenting electrolytes, and intraoperative variables against 2 outcome variables (postoperative emesis and time to goal feeds). Significance is defined as a P

Gastrin, somatostatin and infantile hypertrophic pyloric stenosis.

UNLABELLED: Despite multiple and often contradictory research, no firm conclusions regarding the role of hypergastrinaemia in infantile hypertrophic pyloric stenosis (IHPS) have been established. Evaluation of somatostatin, the main physiological antagonist of gastrin, has not been assessed in previous studies. Long-term evaluation following pyloromyotomy suggests persistent abnormalities in gastrin and somatostatin in IHPS. The objective of this case-controlled study was to compare fasting serum gastrin and somatostatin levels in IHPS. Serum sample were collected from 39 children with IHPS at the time of pyloromyotomy and 20 age-matched controls with no evidence of gastrointestinal disease. Standard radioimmunoassay techniques were used to detect circulating levels of the hormones. A two-tailed t-test was used for statistical analysis. The levels of the two hormones (mean +/- SEM) revealed that there was no evidence of hypergastrinaemia in IHPS compared with controls (75.6 +/- 16.1 and 68.1 +/- 7.8 ng l(-1), respectively), but that the level of somatostatin was significantly elevated (38.9 +/- 6.4 and 30.5 +/- 5.8 ng l(-1), p = 0.016). An inverse trend in the gastrin/somatostatin levels could not be identified in IHPS. CONCLUSION: Somatostatin but not gastrin is raised in IHPS. Somatostatin is known to inhibit the actions of inhibitory neurotransmitters in the pylorus and may explain the development of pylorospasm, which is believed to be important in the development of pyloric tumours. These results do not agree with a previous long-term follow-up study, but reflect the hormonal imbalance at the time of pyloric hypertrophy.

Transient pseudohypoaldosteronism secondary to posterior urethral valves--a case report and review of the literature.

In transient pseudohypoaldosteronism (TPHA), renal tubular resistance to aldosterone is thought to be secondary to renal disease. We report a case of TPHA caused by posterior urethral valves associated with urinary tract infection and review 62 cases previously reported. The infant presented with unspecific signs of vomiting and dehydration, so that pyloric stenosis was first suspected. Laboratory data and retroperitoneal sonography led to the diagnosis TPHA. This case illustrates that urine culture and renal ultrasonography should be performed in any infant with electrolyte disturbances to exclude infection or obstructive uropathy.

Is acid base determination an accurate predictor of pyloric stenosis?

OBJECTIVE: To determine if acid base status predicts which vomiting patients have pyloric stenosis. DESIGN: Retrospective chart review. SETTING: Tertiary paediatric hospital. METHODOLOGY: We compared the clinical and biochemical parameters of 100 patients with a discharge diagnosis of pyloric stenosis and 84 patients of a similar age who presented to the emergency department with vomiting and who had an acid base determination. Patients were included from January 1995 to January 1997. Clinical correlates consisted of age, duration of vomiting, weight loss, gestation, and family history of pyloric stenosis. Biochemical correlates were pH, bicarbonate, base excess (BE), chloride, potassium, and sodium. RESULTS: Independent variables of significance were pH, BE, chloride, bicarbonate, potassium, weight loss (all of which had a P value < 0.0001), and sex (P = 0.006). Each variable was placed in a logistic regression equation with pyloric stenosis being the dominant variable. Variables of significance were pH (P = 0.0001), BE (P = 0.0001), and chloride (P = 0.009). A model for predicting pyloric stenosis using these variables was then created with pH > 7.45, chloride < 98, and BE > +3, with a positive predictive value of 88%. CONCLUSION: Acid base determination is a useful screening tool when considering pyloric stenosis. This model now needs to be validated on a prospective series of patients with vomiting.

[The characteristics of the morphofunctional state of the erythrocytes in peptic ulcer depending on the nature of the complications]. / Osoblyvosti morfofunktsional'noho stanu erytrotsytiv pry vyrazkovii khvorobi zalezhno vid kharakteru uskladnennia.

In 64 patients with complicated peptic ulcer particular features were studied of morphofunctional status of erythrocytes depending on the type of the complication set in (acute gastrointestinal hemorrhage, penetration, perforation, stenosis). It has been found out that changes in peroxidated resistance of erythrocytes, in their power of being capable of deformation and aggregate formation, and in viscosity of the erythrocyte suspension were at their greatest in those patients presenting with peptic ulcer complicated by acute gastrointestinal hemorrhage.

Diagnostic aids in the differentiation of pyloric stenosis from severe gastroesophageal reflux during early infancy: the utility of serum bicarbonate and serum chloride.

This study evaluated whether serum bicarbonate levels, serum chloride levels, and other diagnostic criteria could be used to differentiate pyloric stenosis (PS) from severe gastroesophageal reflux (GER) during early infancy. The investigation was a retrospective, case-control study conducted in the emergency department of a large, academic children's hospital. Cases were 75 consecutive infants with PS confirmed in the operating room. Controls were 75 consecutive infants 12 weeks of age or younger with the diagnosis of GER whose serum electrolytes had been examined. Projectile vomiting was sensitive (0.93) but not specific (0.39) for PS. The mean serum bicarbonate level was 27.2 mmol/L for PS patients and 22.3 mmol/L for GER patients (P < .00001), and the mean serum chloride level was 95.7 mmol/L and 103.6 mmol/L for PS patients and GER patients, respectively (P < .00001). Serum bicarbonate levels of > or =29 mmol/L and serum chloride levels of < or =98 mmol/L had high positive predictive values (0.96 and 0.97, respectively) and were specific (0.99 for both) but not very sensitive (0.36 and 0.50, respectively) in identifying patients with PS. Only one patient would have been misclassified (false positive) as having PS using either of these cutoff values. These laboratory tests can also help discriminate between PS and GER when the history and physical examination fail to do so. For example, of the 20 patients with PS who did not have a pyloric mass palpated, 3 (15%) had serum bicarbonate levels of > or =29 mmol/L, and 6 (30%) had serum chloride levels of < or =98 mmol/L. In conclusion, the serum bicarbonate or serum chloride level offers a useful additional diagnostic tool in the evaluation of children presenting during early infancy with vomiting of uncertain etiology.

[Atypical infantile hypertrophic pyloric stenosis].

Infantile hypertrophic pyloric stenosis (IHPS) is the most common reason for nonbilious vomiting in infants. Its cause is unknown. Hypertrophy of pyloric muscle can progress after birth and reach complete gastric outlet obstruction. Usually symptoms start after the age of 3 weeks. In the past diagnosis was based on history of projectile, nonbilious vomiting and palpation of a pyloric mass. Greater awareness of IHPS and increased use of imaging modalities, mainly abdominal ultrasonography, have resulted in a change in the clinical condition at presentation. The length of illness before admission has decreased and weight loss, dehydration and metabolic abnormalities have become less common. We describe an atypical clinical manifestation of IHPS: bilious vomiting. This atypical presentation may be due to earlier diagnosis.

CEA, CA125 and CA19-9 levels in congenital gastrointestinal anomalies.

Preoperative and postoperative serum samples of 35 patients with different congenital gastrointestinal anomalies were analyzed for the markers CEA, CA 125 and 19-9 by immunoradiometric assay during a period of three years. The majority of the anomalies were aganglionic megacolon and hypertrophic pyloric stenosis. CA 125 and CA 19-9 were likely to indicate logistic model probabilities for babies with anomalies, while CEA was not (F=35.78, p<0.05 for CA CA 125 and F=4.36, p<0.05 for CA 19-9). Probability of no congenital anomaly for babies was: p (Normal)=e4.41-0.13CA125 - 0.05CA19-9/1+e4.41-0.13CA125- 0.05CA19-9 Using CA 125 as a marker, babies with congenital anomalies were determined with 83.3 percent probability (F= 11.33, p<0.05). On the other hand, it was not possible to predict the type of anomaly with these three markers. CEA, CA 125 and CA 19-9 seem to be prognostic variables associated with congenital anomalies. These biological markers provide information that can be incorporated into the diagnosis of anomalies but without doubt results of markers should be supported by clinical findings.

Pyloric stenosis in the age of ultrasonography: fading skills, better patients?

Hypertrophic pyloric stenosis can be diagnosed accurately by physical examination alone. However, ultrasonographic confirmation is obtained in the majority of cases, often before clinical evaluation by the surgeon. The present study examines whether the easy access to ultrasonography by the primary physician has affected the care of infants with pyloric stenosis. During a 24-month period, 100 infants were treated for pyloric stenosis at the authors' institution. There were 78 boys and 22 girls; the age range was 9 to 90 days (median, 30.0 days). The children were referred for surgical evaluation, but abdominal ultrasonography was ordered concomitantly (or within 1 hour of surgical consultation) in all cases. The median age at the onset of the first symptoms was 24.0 days. The time between onset and hospital admission was less than 7 days for 72 patients, and more than 2 weeks for seven. Metabolic alkalosis or acidosis, hypokalemia, hypochloremia, and dehydration were noted in 10%, 5%, 3% and 9%, respectively. Six infants had prolonged pre- and postoperative courses, because of prematurity (4) or associated conditions (2). For the remaining patients, total hospitalization period and postoperative stay were 3.8 +/- 0.9 days and 2.8 +/- 0.6 days, respectively. Although the diminished importance of clinical skills in the diagnosis of pyloric stenosis may be regrettable, the availability to the primary care physician of this easy, safe, inexpensive, and reliable imaging modality may contribute to prompter treatment. The patients were hospitalized, with a correct diagnosis, within days of the appearance of the initial symptoms. Because so little time had elapsed, water and electrolyte imbalances were not present, and the patients could be operated on within hours of admission.

In vivo experimental models on the evaluation of haemoperfusion.

We described some experimental models that were performed in rabbits and in swine in order to evaluate the efficacy of haemoperfusion treatment in hypochloremic alkalosis, uraemia and cytotoxic drug poisoning. In all the models, an extracorporeal circuit was used constituted mainly by a hematic sampling line and a cartridge, containing an anion exchange resin. Access to the blood stream was achieved by isolation and catheterization of the vessels either of the neck or of the leg, or both. The experimental model for the evaluation of haemoperfusion in hypochloremic alkalosis was carried out in rabbits by a pyloric stenosis because its size and weight are similar to new-born humans and its stomach is a simple monogastric one. The hypochloremia and alkalosis were achieved in only 4 hours. The other two experimental models were carried out in pigs because, in these cases, it was better to choose a large size animal with a nutritional similarity to humans, and with the capability to produce a stable chronic renal failure. The pigs were submitted to a bilateral ureter ligature to create a chronic renal failure or to a bilateral renal vessel ligature to avoid the physiologic precipitation of some drugs in renal tubules.

[The effect of the autotransfusion of UV-irradiated blood on liver function in patients with ulcerative pyloric stenosis]. / Vliianie AUFOK na funktsional'noe sostoianie pecheni u bol'nykh s iazvennym stenozom privratnika.

The parameters of proteinogram were studied in 182 patients. It was shown that autotransfusions of UV-irradiated blood was an effective measure for the correction of the disturbed protein metabolism.

Changes in gastric hormones associated with gastric outlet obstruction. An experimental study in rats.

To determine the effect of persistent narrowing of the gastric outlet on peptic ulcer disease, changes in gastric hormones induced by pyloric stenosis were studied in an experimental model in the rat. Pyloric stenosis was created by constricting the pylorus to a 4-mm channel. Changes in serum gastrin and plasma somatostatin concentrations, in the length of the lesser curvature, in the size of the fundic and pyloric regions, and in the G-cell and D-cell counts were determined after 4 and 8 weeks (PS4W and PS8W) and compared with those of control groups. The size of the stomach, the serum gastrin concentration, and the corrected G-cell count (indexed to stomach size) were greater in PS8W than in PS4W rats, and both were greater than in respective controls (p < 0.005). Serum somatostatin concentrations were not different, but the total D-cell count and the corrected D-cell count were higher in PS4W and PS8W rats than in controls. Moreover, the total D-cell count and the corrected D-cell count were greater in PS8W than in PS4W (p < 0.05, p < 0.005).

Hemoperfusion with a new anion exchange resin corrects the metabolic alkalosis in pyloric stenosis: an experimental demonstration.

An experimental model of hypertrophic pyloric stenosis was made by suture of the pyloric wall and gastrostomy in 10 rabbits under general anesthesia. Blood sampling indicated severe alkalosis and hypochloremia 3h 30 min after surgery. To correct the derangement, we tested an ion exchange resin (Dowex SAR), coated with a methacrylic hydrogel. A cartridge containing 18 g of this resin was inserted in an extracorporeal circuit. This chloride charged resin achieved uptake of HCO3- ions, and elution of Cl- ions. The electrolytic balance was fully restored after 10 min of treatment.

Serum electrolytes and capillary blood gases in the management of hypertrophic pyloric stenosis.

The purpose of this study was to assess whether the concentration of serum chloride and other variables, namely serum sodium, potassium and bicarbonate, can be used to predict metabolic acid-base status in infants with hypertrophic pyloric stenosis (HPS) and to assess whether such a prediction is influenced by the state of hydration. One hundred and sixty-three infants with HPS who had at least one set of serum electrolyte and capillary blood gas estimations performed after admission were studied retrospectively. A further 25 infants who had their electrolyte and blood gases measured after at least 12 h of rehydration and correction of the serum sodium and chloride abnormalities were studied prospectively. Stepwise multiple regression analysis, using standard bicarbonate as the dependent variable, revealed serum chloride concentration to be the most powerful independent predictor of standard bicarbonate level (r = -0.69, P less than 0.0001). Other variables did not improve the correlation significantly. In the retrospective study of untreated patients, the calculation of a 90 per cent prediction interval for the model indicated that if the serum chloride level is less than 96 mmol/l, one could be 95 per cent confident (one tail) that the patient was alkalaemic. To be 95 per cent confident that the patient was not alkalaemic, the serum chloride level would have to be greater than 121 mmol/l. The prospective study found that following rehydration a serum chloride level greater than or equal to 106 mmol/l more accurately predicted absence of alkalaemia. We conclude that predictability of acid-base status from measurement of serum chloride depends on the state of hydration of the patient.

[The effect of the surgical trauma on the postoperative course in duodenal ulcer patients]. / Vliianie operatsionnoi travmy na posleoperatsionnoe techenie u bol'nykh iazvoi dvenadtsatiperstnoi kishki.

The effect of various types of operative interventions on the course of the early postoperative period was studied in 419 patients with duodenal ulcer. The blood biochemical values and hemodynamic parameters were studied. The indications for operation were absolute in 128 and relative in 291 patients. It was established that under conditions of a specialized medical institution the negative aspects of surgical treatment of duodenal ulcer may be brought to minimum both in patients with absolute and in those with relative indications for operation.

Alterations in serum electrolytes in congenital hypertrophic pyloric stenosis: a study in Nigerian children.

This is a retrospective analysis of serum electrolyte values recorded at presentation in 20 infants who had pyloromyotomy for congenital hypertrophic pyloric stenosis (CHPS) during a 5-year period at Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. All patients showed disturbance of the normal serum electrolyte pattern which, with one exception, was characterized by metabolic alkalosis associated with normal potassium levels in cases presenting early and metabolic alkalosis with hypokalaemia in cases presenting 3 weeks or later from the onset of symptoms. Late presentation of CHPS occurred much more frequently in this series than is reported from Europe and America.

Plasma chloride and alkalaemia in pyloric stenosis.

Fifty infants with infantile hypertrophic pyloric stenosis were studied prospectively to evaluate the reliability of plasma chloride estimation in the assessment of the acid-base status on admission and during correction of alkalaemia. Four cases were subsequently excluded because of a breach of the study protocol, leaving 46 cases in the study. Seventeen (37 per cent) were normoacidaemic on admission; 13 had plasma chloride concentrations of greater than or equal to 106 mmol/l and four had chloride concentrations of 100-105 mmol/l on admission. Twenty-nine (63 per cent) were alkalaemic on admission; six cases had chloride concentrations of 100-105 mmol/l and 23 cases had concentrations of less than 100 mmol/l. Of those 29 cases requiring correction of alkalaemia, normoacidaemia was achieved at a plasma chloride concentration of greater than or equal to 106 mmol/l in 21 cases (72 per cent) and at a concentration of 100-105 mmol/l in eight cases (28 per cent). Plasma chloride is a reliable parameter in the assessment and correction of alkalaemia in infantile hypertrophic pyloric stenosis provided that a concentration of at least 106 mmol/l is the goal.