I NFANTILE hypertrophic pyloric stenosis (IHPS) is at present one of the most common surgically treated diseases of the first months of life? 3 This entity, first ...
Infantile Hypertrophic Pyloric Stenosis: The Changing Trend in Treatment in a Danish County By Lars Rasmussen, Lars Peter Hansen, and Svend Arne Pedersen Odense, Denmark 9 From 1950 to 1984, 679 patients w e r e treated for infantile hypertrophic pyloric stenosis (IHPS) in the County of Funen, Denmark. Medical t r e a t m e n t was performed in 114 patients and p y l o r o m y o t o m y in 565. A pyloric t u m o r was palpated in 80% and a barium meal examination was performed in 24% of t h e patients. A shift t o w a r d intravenous fluid and general anesthesia is seen during t h e study period. Complications occurred in 17% of medically treated patients and in 8% of surgically t r e a t e d patients. Six deaths occurred among the medically treated and four among the surgically treated patients. During the study period, a shift toward centralization and surgical t r e a t m e n t took place. 9 1 9 8 7 b y Grune & Stratton, Inc. INDEX WORDS: Infantile pyloric stenosis.
hypertrophic pyloric stenosis (IHPS) I NFANTILE is at present one of the most common surgically
treated diseases of the first months of life? 3 This entity, first described by Hirschsprung in 1888, was treated medically in the beginning of this century, especially with spasmolytics.4 In 1911, surgical intervention by means of Fredet-Ramstedt's pyloromyotomy was introduced. 5 In the following years, mortality declined with either treatment. Improved treatment of the associated metabolic alkalosis and electrolyte disturbances with parenteral fluids 6 combined with better anesthesia has further reduced mortality, which is now < 1%?.7 We report our experience with all medically and surgically treated patients with IHPS hospitalized in the County of Funen, Denmark over a period of 35 years. MATERIALS A N D METHODS
During the period 1950 to 1984, 679 patients fulfilled the diagnostic criteria of IHPS and were included in the study. The male to female ratio was 4. I to 1.0. The patients were treated at the Pediatric Department of Odense University Hospital and in eight local hospitals, 114 medically and 565 with Ramstedt's pyloromyotomy. During the first 20 years, the nine hospitals had their own register of diseases and from 1971 a computerized registration of diseases was performed in the Health Center of the county. In both periods, IttPS was coded as "cogenital pyloric stenosis" or "pylorospasm." Twelve patients were registered as pylorospasm and eight of these were treated surgically. Case records of pylorospasm were not seen later than 1965. All hospitals were visited by the authors and all ease records were reviewed. The following data from each case record were registered: type and place of treatment, duration of hospital stay, palpable pyloric tumor, radiologlc examination, type of anesthesia, parenteral fluid and ammonia chloride administration, complications, and outcome. Data from the case records were registered twice by two independent key punch operators in order to diminish errors. Journal of PediatricSurgery, Vo122, No 10 (October), 1987: pp 953-955
RESULTS
Type and Place of Treatment The trend toward surgical treatment is shown in Table 1. During the study period, pyloromyotomy was performed in 83% of all patients and since 1978 medical treatment has not been used. Spasmolytics were attempted in 275 of the patients and were used before and after admission, and in some cases even after operation (Fig 1). Only few patients showed signs of drug poisoning. Five hundred twenty-seven (78%) of the patients were treated at the Pediatric Department, Odense University Hospital. The remaining patients were treated at the local hospitals; operations-were performed in only half of those. Between 1960 and 1964, six patients were referred for treatment outside the county at Rigshospitalet, Copenhagen. Since 1978, pyloromyotomy has been performed in only three hospitals. The shift toward centralization and surgical treatment is shown in Table 2.
Duration of Hospital Stay The median length of hospital stay of medically treated patients was 40.5 days (range 4 to 165 days, Table 3). The corresponding figure for operatively treated patients was 12.0 days (range 2 to 90 days). The duration of hospital stay after operation was 8.0 days (range 0 to 82 days), counting the day of operation as day 0.
Palpable Pyloric Tumor A palpable pyloric tumor was found in 57% of the medically treated and in 84% of the operated patients. Palpation rate was unchanged during the period, fluctuating around 80%.
Radiologic Examination Barium meal examination was performed in 24% of the patients. Most examinations were performed at the local hospitals, predominantly in infants without a From the Departments of Surgical Gastroenterologyand Pediatrics, Odense University Hospital Odense, Denmark. Address reprint requests to Lars Rasmussen, MD, Department of Surgical Gastroenterology, Odense University tlospitaL DK-5000 Odense, Denmark. 9 1987 by Grune & Stratton, Inc. 0022-3468/87/2210-0017503.00/0 953
954
RASMUSSEN, HANSEN, AND PEDERSEN
Table 1. Medically and Surgically Treated Patients With IHPS and Frequency of Pyloromyotomy in Funen County, Denmark 1950 1955 1960 to
to
to
1954 1959 1964 Medically treated (no.) SurgicaTlytreated (no.) Surgery (%)
28 36 56
46 71 61
22 75 77
1965
Table 2. Treatment at Odense Hospital and at Local Hospitals in Funen County, Denmark (Medical/Surgical)
1970 1975 1980
to
to
to
to
1 9 6 9 1974 1979 1984 10 98 91
7 103 94
1 96 99
0 86 100
palpable pyloric tumor. In the last years, ultrasound examination was used in a limited number of cases at Odense University Hospital.
Type of Anesthesia Anesthesia was performed in the 565 surgically treated patients, but in only 459 (81%) was the type registered. Local anesthesia was used in a total of 137 patients, particularly in the period until 1970. General anesthesia was performed in a total of 322 patients.
Complications and Outcome In 19 (17%) of 114 medically treated patients complications occurred, predominantly respiratory
No of patients
A
1960
1965
1970
tO
tO
tO
tO
1954
1959
1964
1969
1974
1975 1980 tO
tO
1979 1964
5/61 4/96 1/81 0 / 8 0 5/37 3/7 0/15 0/6 10/98 7/103 1/96 0/86
(Table 4). Forty-three (8%) of 565 surgically treated patients had complications. Complications with local anesthesia occurred in 12.4% and with general anesthesia in 7.5%. Two underwent a second operation because of insufficiency of the initial pyloromyotomy. Ten of 679 treated patients died; six were treated medically and death was due to atelectasis (3), congenital heart disease (2), and side effects of spasmolytics (1). Four were treated surgically and death was in these cases due to atelectasis (3) and sepsis (1). During the last 20 years, the mortality rate has been 0.
DISCUSSION
Parenteral fluids were used in 531 (78%) of the patients. Subcutaneous fluids were used in a total of 177 patients and intravenous fluids in 374 patients. Twenty patients received subcutaneous as well as intravenous fluids. Ammonia chloride was used for correction of metabolic alkalosis in 26% of the patients.
o-~
1955
tO
Odensehospital 14/30 27/63 10/56 LocalhospitaTs 14/6 19/8 12/19 Total 28/36 46/71 22/75
Parenteral Fluids and Ammonia Chloride Administration
60
1950
before admission
o--o after admission
40
In Scandinavia, it was common to treat patients with IHPS medically with spasmolytics up to the 1970s,8 whereas in America and Europe, a shifttoward surgery took place earlier.7'9 This shift is recognized during our 35-year study period, as all patients from the last period were surgically treated. Different treatments were observed in the nine hospitals of the county at various times. This was in agreement with findings in a large study from West Germany, where medical treatment was used in 10% to 74% in five pediatric clinics in the period from 1961 to 1974.19 In the county of Funen, the change toward surgery first occurred at our department and later at the local hospitals. At present treatment is centralized in few hospitals, in which surgery is the only treatment. During the study period, the duration of hospital stay was reduced for both medically and surgically treated patients. This reduction was probably caused by earlier admission to the hospital. In the last years, there has been a minor extension in hospital stay. This is probably explained by less pronounced and characTable 3. Median Length of Hospital Stay for 114 Medically and 565 Surgically Treated Patients in Funen County, Denmark
20-
Period (yr|
01950-
1960-
19"/0-
5/,
6/,
74
Fig 1.
Use of spasmolytics before end after admission.
198084
1950 1955 1960 t965 1970 1975 1980
to to to to to to to
1954 1959 1964 1969 1974 1979 1984
Hospital Stay for Medically Treated (d)
HospitalStay for SurgicallyTreated (d)
Postoperative Stay (d)
50.0 47.0 35.0 34.5 15.0 --* --
28.5 15.0 15.0 14.0 8.0 6.0 7.0
16.5 10.0 9.0 9.0 5.0 3.0 3.0
*One patient stayed in the hospital for 30 days.
955
INFANTILE HYPERTROPHIC PYLORIC STENOSIS
Table4. Complications in 114 Medically and 565 Surglcally Treated P a t i e n t s W i t h IHPS Treatment Medically Wound infection Wound disruption Wound hernia Peritonitis
Surgically
-----
24 1 2 1
-14 7
2 8 10
Spasmolytic poisoning
1
0
Deaths (%)
6(5.3)
4(0.7)
Insufficient operation Respiratoric complications Other complications
teristic symptoms and signs in the patients at admission as well as time-consuming supplementary examinations in some cases. A pyloric tumor was palpable in 80% of our patients, which is in agreement with previous publications.7'9 Barium meal examinations were used more frequently in the local hospitals. In recent years, the noninvasive ultrasound examination is gradually replacing the barium meal and is claimed to be more specific. I1 At present, general anesthesia is preferred because of a lower complication rate compared with local anesthesia. 1"7s A low frequency of complications was found among our patients operated on under general anesthesia.
In the first 20 years of the study period, fluids were predominantly administered subcutaneously. The only complication was an abscess. Correction of metabolic alkalosis with ammonia chloride was introduced in 1960,6when intravenous access became more common. As patients are admitted earlier now with only slight metabolic alkalosis, ammonia chloride treatment is used less. 1~ In both groups, pulmonary complications were frequent. These were more frequent among the medically treated patients, probably because of longer duration of vomiting and associated metabolic alkalosis in these patients. Among the medically treated patients, one died of side effects of spasmolytics. Complications in surgically treated patients occurred in 7.6%, which is comparable with other studies? '2'7'I~ We found a higher mortality rate among the medically treated patients. The highest mortality rate was found during the first part of the study, probably caused by frequent dehydration and severe metabolic alkalosis. The surgically treated patients had the same low mortality rate, as reported in other large studies.7, to
At present, the accepted treatment of IHPS is correction of dehydration and metabolic aikalosis followed by Ramstedt's pyloromyot0my, which is associated with short hospitalization and low complication as well as mortality rate.
REFERENCES
1. Mustard WT, Ravitch MM, Snyder WH Jr, et al: Pediatric Surgery. Chicago, Year Book Medical, 1979 2. Behrman RE, Vaughan VC: Nelson Textbook of Pediatrics. Philadelphia, Saunders, 1983 3. Spider RD: Infantile hypertrophic pylorie stenosis: A review. Br J Surg 69:128-135, 1982 4. Svensgaard E: The medical treatment of congenital pylorie stenosis. Arch Dis Child 10:443-457, 1935 5. Ramstedt C: Zur operation der angeborenen pylorus-stenose. Med Klinik 8:1702-1705, 1912 6. Kildeberg P: Metabolic alkalosis in hypertrophic pyloric stenosis. Clinical significance and treatment. Aeta Pediatr 53:132-142, 1964 7. Eckstein HB, Agrawal M: Congenital hypertrophic pyloric stenosis. Z Kinderchir 36:50-52, 1982
8. BSggild-Madsen NB: Medicinsk behandling af kongenit pylorusstenose. Ugeskr Laeger 137:201-203, 1975 9. Benson CD, Lloyd JR: Infantile pyloric stenosis: A review of 1120 cases. Am J Surg 107:429-433, 1964 10. Sch~ifer KH, Bingel G: Konservative find chirurgische Therapie der spastischen, hypertrophisehen Pylorusstenose. Mschr Kinderheilk 123:503-508, 1975 11. Tunell WP, Wilson DA: Pyloric stenosis: Diagnosis by real time sonography, the pyloric muscle length method. J Pediatr Surg 19:795-799, 1984 12. Hansen LP, Rasmussen L: Early admission of patients with infantile hypertrophic pyloric stenosis. (submitted to J Pediatr Gastroent Nutr)
