Laparoscopic extramucosal pyloromyotomy versus open pyloromyotomy for infantile hypertrophic pyloric stenosis: Which is better?

Laparoscopic Pyloromyotomy By Takao Fujimoto,

Ba&ground/Purpose:The the advantages otomy compared otomy.

Extramucosal for Infantile Which Geoffrey

Pyloromyotomy Versus Open Hypertrophic Pyloric Stenosis: Is Better?

J. Lane, Osamu Segawa, Tokyo, Japan

aim of this study

or disadvantages with open

was to evaluate of laparoscopic pyloromytransumbilical fold pyloromy-

/VIethods:Thirty consecutive laparoscopic extramucosal pyloromyotomies (LP) performed from 1994 to 1997 were compared with 30 consecutive open pyloromyotomies (OP) performed during the same period with regard to age at operation, body weight, thickness of hypertrophied pyloric muscle, operating time, time of return to full feeding, frequency of postoperative emesis, surgical complications, and degree of surgical stress reflected by interleukin-6 (IL-6). LP was performed according to conventional techniques, and OP was performed using a transumbilical fold approach. Resuks: The groups were matched for age at operation, preoperative clinical and physical status, laboratory data, and size of the hypertrophied pylorus assessed by ultrasonography. There was a learning curve with LP; the average operating time required for the first 10 cases was significantly longer than the time required for OP, but later cases took just

I

NFANTILE HYPERTROPHIC pyloric stenosis (PS) is a common surgical condition encountered in early infancy. The incidence in Japan is approximately two to three per 1,000 live births.i Extramucosal pyloromyotomy is a standard procedure for this condition. With the development of laparoscopic surgery, laparoscopic pyloromyotomy (LP) for PS has been reported from France.z Since then there has been a number of reports on the experience with laparoscopic pyloromyotomy.3-s We introduced LP at Juntendo University in 1992.(j However, there has been serious criticism of LP, with opponents of it stating that pyloromyotomy could also be performed through a small skin incision with shorter operating time also using a transumbilical open pyloromyotomy (OP) rather than a small standard upper-abdominal incision. To From the Department of Pediatric Surgery, Juntendo University School of Medicine, Tokyo, Japan. Presented at the 45th Annual International Congress of the British Association of Paediatric Surgeons, Bristol, England, July 21-24, 1998. Address reprint requests to Takao Fujimoto, A4D, PhD, Associate Professon Department of Pediatric Surgery, Juntendo University School ofMedicine, 2-l-l Hongo, Bunkyo-ku, Tokyo 113.8421, Japan. Copyright 0 1999 by WE. Saunders Company 0022-3468/99/3402-0032$03.00/O 370

Saori Esaki, and Takeshi

Miyano

as long as OP cases. Time taken to full feeding was significantlyshorter in the LP group than the OP group (LP, 38 hours v OP, 64 hours). One case was converted from LP to OP because of mucosal perforation. The incidence of postoperative emesis was significantly higher in the OP group than in the LP group (OP, 25% v LP, 3%). The mean length of hospitalization was significantly shorter in LP (F’< .Ol). The intraoperative peak values of IL-6 in LP were significantly lower than those in the OP group (P < .Ol). Conc/usions: The advantages of LP are improved cosmesis, decreased surgical stress with earlier postoperative recovery, and shorter hospitalization. Because LP uses reusable devices, and the mean period of hospitalization is shorter, average operating costs could be reduced, representing a net saving in total hospital charges. J Pediatr Surg 34:370-372. Copyrighf 0 1999 by W.B. Saunders Company. INDEX WORDS: Infantile roscopic pyloromyotomy,

hypertrophic transumbilical

pyloric fold

stenosis, incision.

lapa-

evaluate the benefit of LP, we designed a prospective, randomized study to compare LP with OP performed using a transumbilical approach. MATERIALS

AND

METHODS

Sixty patients with PS treated between 1994 and 1997 were the subjects for this study, After obtaining written parental informed consent, patients were assigned alternatively to the OP or LP groups. At the end of the study period, there were 30 patients who had LP and 30 who had OP. These two groups were reviewed and compared with respect to age at operation, body weight at the time of admission, length and thickness of the hypertrophied pylorus, time taken to restart feeding postoperatively, time taken to achieve full feeding, incidence of postoperative emesis associated with feeding, and surgical complications. To assess the extent of surgical stress encountered during LP, chronological changes in interleukin-6 (IL-6) were compared between the LP and OP groups. Measurement of IL-6 was performed preoperatively, then at 1, 2, 4, 6, 24, and 48 hours after the commencement of surgery with an enzyme-linked immunosorbent assay kit. Statistical analysis was performed using the Student’s r test. A P value of less than .Ol was considered significant.

Laparoscopic Pyloromyotomy The LP performed was a modified version of the procedure originally described by HL Tan7 Under general anesthesia, a 5-mm diameter trocar was introduced through the umbilicus using an open technique for visualization and insufflation with carbon dioxide. Intraabdominal Jotuna/

of fediatric

Surgery,

Vol34,

No 2 (February),

1999: pp 370-372

LAPAROSCOPIC

VERSUS

OPEN

PYLOROMYOTOMY

371

pressure was maintained at 8 mm Hg, and insufflation speed was set at 0.5 L/min. We normally make two stab wounds in the upper abdomen in the midclavicular line just below the costal margin bilaterally and introduce a 4-mm trocar under direct vision. The duodenum just distal to the pyloric vein is grasped using an atraumatic laparoscopic grasper (3.5 mm diameter), and a seromuscular incision is made over the hypertrophied pylons with a sheathed knife (Karl Storz Inc. Tuttlingen, Germany) commencing along the 1 to 2 mm proximal to the pyloric ring extending to the gastric antrum. Then, a pyloric spreader (Karl Storz Inc) is inserted via the left trocar, and the myotomy is commenced vigorously in the standard fashion until the muscle is separated, relieving the obstmction. To test for mucosal injury, the stomach was inflated through a nasogastric tube, and passage of air through the pyloric lesion to the duodenum was confirmed. Bulging of the mucosal layer with no evidence of defect was confirmed.

Open Pyloromyotomy This technique involves a 2.5-cm crescent-shaped fold incision and a vefiical fascial incision along the hypertrophied pylorus was delivered gently through the wound, and pylormnyotomy was performed in the usual

supraumbilical linea alba. The supraumbilical manner.

Postoperative Feeding Protocol In all cases, postoperative feeding was commenced according to our standard postoperative feeding protocol for pyloromyotomy, which involves recommencing feedin g 3 hours after completion of the operation. The first feed was 5 mL/kg of an electrolyte solution followed by 5 mL/kg of ordinary formula. The interval between feedings was 3 hours, and the first three feedings were given via a nasogastric tube. If more than 75% of the previous feeding was still present in the stomach, before the next scheduled feeding, the feeding was postponed; if 50% to 75% of the previous feeding was still present, the same volume of feed was given. If less than 50% of the previous feeding was present, the volume was increased as follows: 10 mL/kg for three feedings, 15 mL/kg for three feedings, then 20 mL/kg thereafter. Thus, if a patient’s postoperative recovev was unremarkable, they could be feeding at a vohmle of 160 mUkg/d (ie, 20 mL/kg per feeding) 22 hours after surgery. We regard this volume as full feeding. The volume of feed was reduced or the feeding postponed if vomiting occurred.

RESULTS

Preoperative status such as age at operation, body weight, duration of preoperative emesis, electrolyte levels, and the size of the hypertrophied pylons are shown (Tables 1 and 2). The preoperative status of the LP and OP groups was similar. Laparoscopic surgery was performed by the same senior registrar under the supervision of the attending surgeon, as was the open pyloromyotomy. The open transumbilical fold pyloromyotomy also was performed by the same senior registrar under the supervision of the Table 1. Preoperative

Status

Weight Serum

at admission Na (mEq/dL)

Serum

Cl (mEq/dL)

(kg)

2 15.74

43.63

2 18.85

.96

? 13.12

12.19

? 8.57

.05

4061

2 604

3805

2 5611

.76

97 2 11.9

Length Thickness

(mm)

139 2 2.0

.I9

101 2 7.3

.21

(n = 301

25 x 13

23x12

4.9 k 1.2

(mm)

4.8 k 1.8

same attending surgeon. The results for these two groups are shown (Table 3). Operating time for LP was 27.38 Z? 10.4 minutes and for OP was 3 1.87 2 8.01 minutes. The transumbilical approach took a little longer than a conventional OP because of the time involved in exposing the pylor~~sthrough the umbilical wound. Feeding could be recommended successfully 3 hours after pyloromyotomy and incrementally increased in LP, but feeding in OP patients was delayed because of poor tolerance. The time taken to achieve full feeding was markedly different between the two groups (LP, 34.97 ? 5.6 hours v OP, 61.23 2 5.1 hours; P < .Ol), and postoperative emesis occurred in 0.3% (1 of 313 feedings) of the LP group but in 25% (157 of 63 1 feedings) of the OP group. This difference was statistically significant (P = .Ol). The extent of surgical stress during and after pyloromyotomy was assessedby measuring IL-6. Whereas the IL-6 response in both groups was lower compared with other types of major surgery, the peak intraoperative levels of IL-6 in the LP group were lower than those in the OP group (Fig 1). However, the patterns of IL-6 response were slightly different from those we obtained in our preliminary study, which we have reported.6 One infant had mucosal perforation in the LP group, which was treated by converting the LP to an OI? The mucosal defect was approximated and covered with omentum using fibrin glue. Three serosal lacerations (10%) and two wound infections (7%) occurred in the OP group. DISCUSSION

Since the first successful LP was reported by Alain et al* in 1991, many institutions have now introduced Ll?3-6 Criticism of LP has included the following: (1) an OP could be performed using a small incision to give the cosmesis equivalent to that of laparoscopic surgery; (2) open procedures are less expensive because special equipment is not required; (3) length of hospital stay and Table 3. Operative

20.91

Pylorus

open

bl = 30)

P VCl1Ll.S

44.23

138 2 3.8

Evaluation of the l-fypertrophied in Both Groups Laparoscopic

of the Patients open hl = 301

Age at admission (dl Duration of emesis cd)

Table 2. Uitrasonographic

and Postoperative Lapamscopic h = 29)

Operating

time (min) (h) Time to restartfeeding Time to full feeding (h) Postoperative emesis (vomit per feeding)

Data Op-37 (II = 30)

P Vallle

27.38

2 10.4

31.87

2 8.01

.Ol

3.61

2 0.88

13.57

!I 6.43

<.OOOl

34.79

2 5.6

61.23

2 5.1

<.OOOl

l/313

(0.3%)

160/631

(25%)

FUJIMOTO

Fig I. IL-6 response during laparoscopic peak value of IL-6 is lower in the laparoscopic than in the open pyloromyotomy group.

pyloromyotomy. pyloromyotomy

The group

cost of hospitalization are the same; (4) open procedures are quicker; and (5) there is a lack of randomized studies between OP and LP procedures. Most pediatric surgeons have not chosen laparoscopy for performing pyloromyotomy. Previous reports on LP have tended to concentrate only on describing and discussing surgical technique and wound cosmesis.3-5Recently, Greason et al8 reported that the advantages of LP include excellent cosmesis, decreased morbidity, and decreased incidence of postoperative ileus. We also believe that the most significant advantage of LP is that it is a less traumatic operation than an open procedure. In an open procedure, especially the transumbilical fold approach, manipulation of and tension on the pylorus to deliver it through the umbilical wound can induce edema in the muscle layer, mucosal swelling, and, occasionally, serosal laceration. Our patients returned to full feeding earlier and had a lower postoperative emesis rate in the LP group compared with the OP group supporting the hypothesis that LP is less invasive. Turnock and Rangecroft reported that the use of a delayed feeding regimen reduced postpyloromyotomy

ET AL

vomiting and recommended delaying the introduction of feedings until 18 hours after pyloromyotomy. The tolerance of an early feeding regimen in the LP group confirms that there is lack of trauma to the pylorus during LP. We feel that this is the most considerable benefit of LP. To improve cosmesis, we recently have started to use a 3.3-mm laparoscope instead of a 5-mm laparoscope. This allows us to further improve the cosmesis that we are able to achieve using conventional LP instruments. No wound infection was encountered in the LP group in contrast to a 7% wound infection rate in the OP group. The complication rate in the OP group was the same as the published rate in the literature.l”J1 IL-6 responses during pyloromyotomy in both the LP and OP groups were much lower than the levels seen in other major pediatric operations.r2 However, the peak level in the LP group was lower than that of the OP group. We encountered one mucosal perforation during LP, which we were able to convert successfully to an open procedure. The cause of the perforation was that the pyloromyotomy knife had lost its edge and was blunt, meaning that the surgeon had to make several attempts to incise the pylorus. No perforation has been encountered since, because we ensure that the pyloromyotomy knife is sharp. In adults, laparoscopic cholecystectomy provides a good opportunity for training, but this procedure is not commonly performed in children, and training is limited in many centers to appendectomy. LP, however, provides a good opportunity for young surgeons and residents to study the basics of laparoscopic surgery. Thus, LP has the additional advantage of providing an opportunity for training younger staff. Our data confirm that LP is associated with excellent cosmesis, less pain, minimal surgical stress, and lower morbidity. These results encourage us to continue to apply laparoscopy to newborn and young infants, and we recommend its use for the management of infantile hypertrophic pyloric stenosis.

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7. Scorpio RJ, Tan HL, Hutson scopic and open surgical techniques,

JM: Comparison between laparoJ Laparoen Surg 5:81-84,1995

8. Greason KL, Allhouse MJ, Tompson WMR, et al: A prospective, randomized evaluation of laparoscopic versus open pyloromyotomy in the treatment of infantile hypertrophic pyloric stenosis. Pediatr Endosurg Innovative Tech 1:175-179, 1997 9. Tumock RR, Rangecroft L: Comparison of postpyloromyotomy feeding regimen in infantile hypertrophic pyloric stenosis. JR Co11 Surg Edinb 36:164-165, 1991 10. Zeidan B, Wyatt J, Mackersie of infantile hypertrophic pyloric 1064, 1988 11. Fitzgerald pyloromyotomy.

A, et al: Recent results of treatment stenosis. Arch Dis Child 63:1060-

P, Lau G, Langer J, et al: Umbilical J Pediatr Surg 25:1117-1118, 1990

12. Tsang T, Tam PKH: Cytokine Pediatr Surg 29:794-797, 1994

response

fold incision

of neonatal

surgery.

for J