Is Abandonment of Nonoperative Management of Hypertrophic Pyloric Stenosis Warranted?

Abstract

Aim Evaluation of the effectiveness of oral atropine versus surgical therapy for hypertrophic pyloric stenosis (HPS).

Methodology A total of 66 consecutive patients with HPS were treated at the University Children's Hospital between January 2006 and December 2011. The diagnosis was initially based on medical history and confirmed by ultrasonography (US). The patients were divided into two groups according to the treatment preferred by their parents. The conservatively treated group, consisting of 33 boys and 7 girls, mean age 22.25 days, was given water-soluble atropine sulfate therapy at an initial dose of 0.05 mg/kg/day divided into 8 single doses, and administered after stomach decompression, 20 minutes prior to feeding. If vomiting persisted, the daily dose was progressively increased up to 0.18 mg/kg. If vomiting did not stop and full oral feeding was not reestablished in a week, surgery was done. The second group of 26 patients, mean age 20.86 days, underwent an operative procedure, Ramstedt extramucosal pyloromyotomy after the initial resuscitation. US evaluation was performed on days 7, 14, and 21. The outcome of the treatment was tested by Yates modification of the χ2 test.

Results In the group of patients treated with atropine sulfate, 10 (25%) failed to respond to therapy, therefore, 8 boys and 2 girls underwent surgical treatment between the fifth and seventh day following institution of therapy. The remaining patients who received atropine sulfate (75%) were discharged when vomiting ceased, between the sixth and eighth day. They continued to take oral medication for 4 to 6 weeks, and were followed up by an ultrasound examination. The operated patients were discharged between the third and fifth day after surgery. There was a significant statistical difference between the groups regarding the outcome at a significance level of p < 0.05 (Yates χ2 = 5.839), with no complications regardless of the treatment option. However, at the significance level of p < 0.01 (Yates χ2 = 7.661), these methods demonstrate a difference in favor of surgical treatment.

Conclusion Further investigation of oral, intravenous or combined atropine sulfate treatment may clarify its position as an alternative to pyloromyotomy.

Keywords

hypertrophic pyloric stenosis - conservative treatment - atropine sulfate - pyloromyotomy

• References

• 1 Batcup G, Spitz L. A histopathological study of gastric mucosal biopsies in infantile hypertrophic pyloric stenosis. J Clin Pathol 1979; 32 (6) 625-628
• 2 Imura K, Kawahara H, Yagi M, Oue T, Okada A. Pyloric motor abnormality in patients with infantile hypertrophic pyloric stenosis. Pediatr Surg Int 1998; 14 (3) 178-181
• 3 Oue T, Puri P. Smooth muscle cell hypertrophy versus hyperplasia in infantile hypertrophic pyloric stenosis. Pediatr Res 1999; 45 (6) 853-857
• 4 Nagita A, Yamaguchi J, Amemoto K, Yoden A, Yamazaki T, Mino M. Management and ultrasonographic appearance of infantile hypertrophic pyloric stenosis with intravenous atropine sulfate. J Pediatr Gastroenterol Nutr 1996; 23 (2) 172-177
• 5 Nagita A, Yoshimoto Y. Medical treatment of hypertrophic pyloric stenosis with atropine sulfate. Jpn J Pediatr Surg 1998; 30: 837-840
• 6 Haller JO, Cohen HL. Hypertrophic pyloric stenosis: diagnosis using US. Radiology 1986; 161 (2) 335-339
• 7 Aspelund G, Langer JC. Current management of hypertrophic pyloric stenosis. Semin Pediatr Surg 2007; 16 (1) 27-33
• 8 Meissner PE, Engelmann G, Troeger J, Linderkamp O, Nuetzenadel W. Conservative treatment of infantile hypertrophic pyloric stenosis with intravenous atropine sulfate does not replace pyloromyotomy. Pediatr Surg Int 2006; 22 (12) 1021-1024
• 9 Hall NJ, Van Der Zee J, Tan HL, Pierro A. Meta-analysis of laparoscopic versus open pyloromyotomy. Ann Surg 2004; 240 (5) 774-778
• 10 Sretenović A, Smoljanić Z, Korać G, Sindjeć S, Lukac M, Krstić Z. [Conservative treatment of hypertrophic pyloric stenosis in children]. Srp Arh Celok Lek 2004; 132 (Suppl. 01) 93-96
• 11 Yamataka A, Tsukada K, Yokoyama-Laws Y , et al. Pyloromyotomy versus atropine sulfate for infantile hypertrophic pyloric stenosis. J Pediatr Surg 2000; 35 (2) 338-341, discussion 342
• 12 Kawahara H, Takama Y, Yoshida H , et al. Medical treatment of infantile hypertrophic pyloric stenosis: should we always slice the “olive”?. J Pediatr Surg 2005; 40 (12) 1848-1851
• 13 Kawahara H, Imura K, Nishikawa M, Yagi M, Kubota A. Intravenous atropine treatment in infantile hypertrophic pyloric stenosis. Arch Dis Child 2002; 87 (1) 71-74
• 14 van den Ende ED, Allema JH, Hazebroek FW, Breslau PJ. Can pyloromyotomy for infantile hypertrophic pyloric stenosis be performed in any hospital? Results from two teaching hospitals. Eur J Pediatr 2007; 166 (6) 553-557
• 15 Langer JC, To T. Does pediatric surgical specialty training affect outcome after Ramstedt pyloromyotomy? A population-based study. Pediatrics 2004; 113 (5) 1342-1347
• 16 Yagmurlu A, Barnhart DC, Vernon A, Georgeson KE, Harmon CM. Comparison of the incidence of complications in open and laparoscopic pyloromyotomy: a concurrent single institution series. J Pediatr Surg 2004; 39 (3) 292-296 , discussion 292–296
• 17 Kim SS, Lau ST, Lee SL , et al. Pyloromyotomy: a comparison of laparoscopic, circumumbilical, and right upper quadrant operative techniques. J Am Coll Surg 2005; 201 (1) 66-70
• 18 Safford SD, Pietrobon R, Safford KM, Martins H, Skinner MA, Rice HE. A study of 11,003 patients with hypertrophic pyloric stenosis and the association between surgeon and hospital volume and outcomes. J Pediatr Surg 2005; 40 (6) 967-972 , discussion 972–973