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Who should treat pyloric stenosis: The general or specialist pediatric surgeon?
Who Should Treat Pyloric Stenosis: The General or Specialist Pediatric Surgeon? By A.J.L. Brain and D.S. Roberts Norwich, England l Recent reports suggest that children under 3 years of age are best operated on by a specialist pediatric surgeon. In the United Kingdom, hypettrophic pyloric stenosis traditionally has been treated by adult general surgeons. Should this change7 In 1991, a retrospective review of 10 years’ experience with pyloric stenosis, managed by general surgeons in a large district general hospital, was published. In 1889, an accredited pediatric surgeon, who largely took over the management of pyloric stenosis, was appointed to the staff. His results with 70 children over a L-year period (series 2) were reviewed retrospectively and compared with the previously published general surgical series of 170 children (series 1). There was no significant difference in the gender, age, or weight distribution between the two series. There was a marked difference in the rates of wound infection (15.5% in series 1; 2.8% in series 2; P < .05), wound dehiscence (8.7% in series 1; 0% in series 2; P < .05), and breach of the duodenal mucosa (12.8% in series 1; g% in series 2; P < .Ol). The lower morbidity rate resulted in a shorter hospital stay, with emotional and financial savings. This supports the recommendation that children with this condition should be managed by a pediatric surgeon. Copyright o 1996 by W.B. Saunders Company INDEX
WORDS:
Hypertrophic
pyloric
stenosis,
infantile.
N THE UNITED KINGDOM, many children with congenital hypertrophic pyloric stenosis are treated by general surgeons. This is in contrast to other countries, such as the United States of America and Australia, where most children’s surgery is performed by specialist pediatric surge0ns.r Recently, this matter has been questioned. Several reports have suggested that surgery for children under 3 years should be carried out by surgeons with specialist training, with a sufficient workload to maintain their skills, and in a regional unit.l” This recommendation was based on the National Confidential Enquiry into Perioperative Deaths (NCEPOD)4 and on a review of the literature.5 The validity of this recommendation should be tested. There are many published series of the results of hypertrophic pyloric stenosis treated by general surgeons and by pediatric surgeons. These have been summarized by Jahangiri et al6 and by Atwell, who commented on their report. There has been no study within the same institution to compare the results of these two groups of surgeons. In 1989, a specialist pediatric surgeon was appointed to the staff of a large district general hospital, where children’s surgery had been carried out by
I
Journa/ofPed/atr~c
Surgery,
Vol31,
No 11 (November),
1996: pp 1535-1537
general surgeons. This provided an ideal opportunity to compare the results of treatment in a single institution, where the only difference was in the training of the surgeon. MATERIALS
AND METHODS
A retrospective review was used to compare the results of treatment by a pediatric surgeon (over a 60-month period, during 1989 and 1994) with those of general surgeons (lo-year series, 1978 to 1987.8 Data on gender, age, and weight at time of presentation were collected, as was information on the surgical technique and complications. In a separate study, the length of stay after surgery was compared for 78 consecutively treated children, admitted during a 36-month period, between 1988 and 1991. The technique was largely similar for the two groups. The surgeon was either a consultant or an experienced senior registrar. There was no routine use of prophylactic antibiotics. In the majority of cases, the incision was transverse right supraumbilical. Pyloromyotomy was performed in the standard Ramstedt fashion. Postoperative care was similar, managed by the pediatricians in the general surgical group and by the pediatric surgeon himself in the pediatric surgical group. In both groups, feeding was delayed for 24 hours, then started with small volumes of full-strength milk, aiming to achieve full feeding by 48 hours. The main difference was in the method of wound closure. Mass closure using polygalactin or polyglycolic acid sutures was performed in all pediatric surgical cases. For the general surgical operations, mass closure was carried out in only 16%; layered closure was performed for the remainder. Polygalactin or polyglycolic acid was used in 40%; a variety of sutures were used in the rest. RESULTS
In the lo-year general surgical series, data were available for only 164 of the 170 pyloromyotomies performed. These were compared with 70 pyloromyotomies in the pediatric surgical series. There were no significant differences with respect to gender, age, or weight distribution at the time of presentation (Table 1). There were marked differences in the incidence of a breach in the duodenal mucosa (Z’ < .Ol), the rate of wound infection (P < .05), and the rate of wound dehiscence (P < .05) (Table 2).
From the Jenny Lind Children’s Depaltment, Norfolk and Norwich Hospital, Norwich, England. Address reprint requests to A.J.L. Brain, Addenbrooke’s Hospital, Ht1l.s Rd, Cambridge CB2 2QQ, England. Copyright o 1996 by W B. Saunders Company 0022-3468/96/3111-0015$03.00/0
1535
BRAIN
1536
Table
1. Patient
Characteristics
General
Surgical
% of males
Surgical
in
Series
GWV3d Surgical
Pediatric Surgical
(n=
(n = 70)
164)
78 5 (range, 1 to 17)
Mean age (wk) Mean weight
at the Time of Pyloromyotomy
and Pediatric
(kg) (range,
(range,
DISCUSSION
It might appear that the complication rate following pyloromyotomy performed by general surgeons was high. However, it was no higher than that of another published general surgical series.6 When comparing length of postoperative stay, it may be invalid to compare different periods. Postoperative discharge has tended to be earlier in recent years. Because of this, we looked at the 3-year transition period, starting 1 year before the appointment of the pediatric surgeon, when all pyloromyotomies were performed by general surgeons, and ending in the year when almost all the pyloromyotomies were carried out by the pediatric surgeon. Seventy-eight consecutive pyloromyotomies were studied (39 from each group). The present study may be limited by the fact that the two series were not concurrent. The general surgical children were operated on between 1978 and 1987, and the pediatric surgical patients during a later period, between 1989 and 1994. Although advances have been made in many fields (including the use of Table
2. Complications
Incurred Gl?lleral Surgeons (n = 164)
Duodenal mucosa breached Wound infection Wound dehiscence
12.8% 15.5% 6.7%
After
I--.-.-
4.0 2.4 to 5.5)
For the 78 consecutively treated patients, admitted between 1988 and 1991, the median length of stay after surgery was 3 days, and this did not differ for the two subgroups. However, 14 general surgical patients remained in the hospital for more than 3 days, the longest stay being 21 days. Only four pediatric surgical patients remained for more than 3 days, and all were discharged by the fifth day (Fig 1). One third (13 of 39) of the general surgical patients had complications after the pyloromyotomy. However, only one of the 39 pediatric surgical babies had a complication (a wound infection) (Fig 1).
Pyloromyotomy Pedlatnc Surgeons (n = 70)
P V&K?
0
1.01
2.8% 0
< .05 < .05
ROBERTS
25
68 5 (range, 2 to 13)
3.4 1.9 to 7.6)
AND
: : :o --+4 Post operative
0
No complication
A
Wound
infection
+
Wound
dehiscence
n
Feeding problem
: a.,*
,A
n
5
a
9
21
days in hospital
Fig 1. Length of hospital stay after pyloromyotomy for babies operated on consecutively (between 1988 and 1991).
the
78
antibiotics), during this time the management of pyloric stenosis has remained unchanged. Prophylactic antibiotics were not used routinely for either group. The complication rates for the separate series of consecutive pyloromyotomies (1988 to 1991), when the patients were being treated by either an adult or a pediatric surgeon, mirror the other results, lending credence to them. The pediatric surgical operations were performed by, or closely supervised by, one consultant. The general surgical pyloromyotomies were carried out by several consultants and experienced senior registrars. Kiely suggested that concentrating experience in the hands of fewer people would improve results.9,10 Perhaps this is why the pediatric surgical results were better. Whatever the reason, it is clear that it was beneficial for the surgery to be carried out by a specialist surgeon. The lower morbidity rates were significant, as were the reduced emotional and financial costs. If all pyloromyotomies in the United Kingdom were to be performed by specialists, many more pediatric surgeons would be needed. The savings from the reduction in complications would go a long way in financing this. These results should not be viewed as an attack on general surgeons. We do not advocate that every pyloromyotomy be performed by a pediatric surgeon. Rather, we advocate that pyloric stenosis be treated by those with motivation for good results and with sufficient experience to achieve these results. After all, one of the better series came from someone who was not a trained surgeon, but a medical pediatrician: Dr Jacobv.”
WHO
SHOULD
TREAT
PYLORIC
STENOSIS?
1537
REFERENCES 1. British Paediatric Association: The Transfer of Infants and Children for Surgery, 1993 2. Royal College of Surgeons of England and the British Association of Paediatric Surgeons: Report on Surgical Services for the Newborn, 1992 3. Anonymous: Report of the National Confidential Enquiry Into Postoperative Deaths. Lancet 335:1498-1500,199O 4. Campling EA, Devlin HB, Lunn JN: The Report of the National Confidential Enquiry Into Peri-operative Deaths 1989. London, England, NCEPOD, 1990 5. Atwell JD, Spargo PM: The provision of safe surgery for children. Arch Dis Child 67:345-349,1992 6. Jahangiri M, Bradley JWP, Osborne MJ, et al: Infantile
hypertrophic pyloric stenosis: Where should it be treated? Ann R Co11Surg Engl7.5:34-36,1993 7. Atwell JD: Invited comment. Ann R Co11Surg Engl75:36-37, 1993 8. Harvey MH, Humphrey G, Fieldman N, et al: Abdominal wall dehiscence following Ramstedt’s Operation: A review of 170 cases of infantile hypertropic pyloric stenosis. Br J Surg 78:81-82, 1991 9. Kiely EM: Commentary. Arch Dis Child 66:132-133, 1991 10. Eriksen CA, Anders CJ: Audit of results of operations for infantile pyloric stenosis in a district general hospital. Arch Dis Child 66:130-132,199l 11. Jacoby NM: Pyloric stenosis: Selective medical and surgical treatment. Asurveyofsixteenyears’expxience. Lancet 1:119-121,1%2
WORDS:
Hypertrophic
pyloric
stenosis,
infantile.
N THE UNITED KINGDOM, many children with congenital hypertrophic pyloric stenosis are treated by general surgeons. This is in contrast to other countries, such as the United States of America and Australia, where most children’s surgery is performed by specialist pediatric surge0ns.r Recently, this matter has been questioned. Several reports have suggested that surgery for children under 3 years should be carried out by surgeons with specialist training, with a sufficient workload to maintain their skills, and in a regional unit.l” This recommendation was based on the National Confidential Enquiry into Perioperative Deaths (NCEPOD)4 and on a review of the literature.5 The validity of this recommendation should be tested. There are many published series of the results of hypertrophic pyloric stenosis treated by general surgeons and by pediatric surgeons. These have been summarized by Jahangiri et al6 and by Atwell, who commented on their report. There has been no study within the same institution to compare the results of these two groups of surgeons. In 1989, a specialist pediatric surgeon was appointed to the staff of a large district general hospital, where children’s surgery had been carried out by
I
Journa/ofPed/atr~c
Surgery,
Vol31,
No 11 (November),
1996: pp 1535-1537
general surgeons. This provided an ideal opportunity to compare the results of treatment in a single institution, where the only difference was in the training of the surgeon. MATERIALS
AND METHODS
A retrospective review was used to compare the results of treatment by a pediatric surgeon (over a 60-month period, during 1989 and 1994) with those of general surgeons (lo-year series, 1978 to 1987.8 Data on gender, age, and weight at time of presentation were collected, as was information on the surgical technique and complications. In a separate study, the length of stay after surgery was compared for 78 consecutively treated children, admitted during a 36-month period, between 1988 and 1991. The technique was largely similar for the two groups. The surgeon was either a consultant or an experienced senior registrar. There was no routine use of prophylactic antibiotics. In the majority of cases, the incision was transverse right supraumbilical. Pyloromyotomy was performed in the standard Ramstedt fashion. Postoperative care was similar, managed by the pediatricians in the general surgical group and by the pediatric surgeon himself in the pediatric surgical group. In both groups, feeding was delayed for 24 hours, then started with small volumes of full-strength milk, aiming to achieve full feeding by 48 hours. The main difference was in the method of wound closure. Mass closure using polygalactin or polyglycolic acid sutures was performed in all pediatric surgical cases. For the general surgical operations, mass closure was carried out in only 16%; layered closure was performed for the remainder. Polygalactin or polyglycolic acid was used in 40%; a variety of sutures were used in the rest. RESULTS
In the lo-year general surgical series, data were available for only 164 of the 170 pyloromyotomies performed. These were compared with 70 pyloromyotomies in the pediatric surgical series. There were no significant differences with respect to gender, age, or weight distribution at the time of presentation (Table 1). There were marked differences in the incidence of a breach in the duodenal mucosa (Z’ < .Ol), the rate of wound infection (P < .05), and the rate of wound dehiscence (P < .05) (Table 2).
From the Jenny Lind Children’s Depaltment, Norfolk and Norwich Hospital, Norwich, England. Address reprint requests to A.J.L. Brain, Addenbrooke’s Hospital, Ht1l.s Rd, Cambridge CB2 2QQ, England. Copyright o 1996 by W B. Saunders Company 0022-3468/96/3111-0015$03.00/0
1535
BRAIN
1536
Table
1. Patient
Characteristics
General
Surgical
% of males
Surgical
in
Series
GWV3d Surgical
Pediatric Surgical
(n=
(n = 70)
164)
78 5 (range, 1 to 17)
Mean age (wk) Mean weight
at the Time of Pyloromyotomy
and Pediatric
(kg) (range,
(range,
DISCUSSION
It might appear that the complication rate following pyloromyotomy performed by general surgeons was high. However, it was no higher than that of another published general surgical series.6 When comparing length of postoperative stay, it may be invalid to compare different periods. Postoperative discharge has tended to be earlier in recent years. Because of this, we looked at the 3-year transition period, starting 1 year before the appointment of the pediatric surgeon, when all pyloromyotomies were performed by general surgeons, and ending in the year when almost all the pyloromyotomies were carried out by the pediatric surgeon. Seventy-eight consecutive pyloromyotomies were studied (39 from each group). The present study may be limited by the fact that the two series were not concurrent. The general surgical children were operated on between 1978 and 1987, and the pediatric surgical patients during a later period, between 1989 and 1994. Although advances have been made in many fields (including the use of Table
2. Complications
Incurred Gl?lleral Surgeons (n = 164)
Duodenal mucosa breached Wound infection Wound dehiscence
12.8% 15.5% 6.7%
After
I--.-.-
4.0 2.4 to 5.5)
For the 78 consecutively treated patients, admitted between 1988 and 1991, the median length of stay after surgery was 3 days, and this did not differ for the two subgroups. However, 14 general surgical patients remained in the hospital for more than 3 days, the longest stay being 21 days. Only four pediatric surgical patients remained for more than 3 days, and all were discharged by the fifth day (Fig 1). One third (13 of 39) of the general surgical patients had complications after the pyloromyotomy. However, only one of the 39 pediatric surgical babies had a complication (a wound infection) (Fig 1).
Pyloromyotomy Pedlatnc Surgeons (n = 70)
P V&K?
0
1.01
2.8% 0
< .05 < .05
ROBERTS
25
68 5 (range, 2 to 13)
3.4 1.9 to 7.6)
AND
: : :o --+4 Post operative
0
No complication
A
Wound
infection
+
Wound
dehiscence
n
Feeding problem
: a.,*
,A
n
5
a
9
21
days in hospital
Fig 1. Length of hospital stay after pyloromyotomy for babies operated on consecutively (between 1988 and 1991).
the
78
antibiotics), during this time the management of pyloric stenosis has remained unchanged. Prophylactic antibiotics were not used routinely for either group. The complication rates for the separate series of consecutive pyloromyotomies (1988 to 1991), when the patients were being treated by either an adult or a pediatric surgeon, mirror the other results, lending credence to them. The pediatric surgical operations were performed by, or closely supervised by, one consultant. The general surgical pyloromyotomies were carried out by several consultants and experienced senior registrars. Kiely suggested that concentrating experience in the hands of fewer people would improve results.9,10 Perhaps this is why the pediatric surgical results were better. Whatever the reason, it is clear that it was beneficial for the surgery to be carried out by a specialist surgeon. The lower morbidity rates were significant, as were the reduced emotional and financial costs. If all pyloromyotomies in the United Kingdom were to be performed by specialists, many more pediatric surgeons would be needed. The savings from the reduction in complications would go a long way in financing this. These results should not be viewed as an attack on general surgeons. We do not advocate that every pyloromyotomy be performed by a pediatric surgeon. Rather, we advocate that pyloric stenosis be treated by those with motivation for good results and with sufficient experience to achieve these results. After all, one of the better series came from someone who was not a trained surgeon, but a medical pediatrician: Dr Jacobv.”
WHO
SHOULD
TREAT
PYLORIC
STENOSIS?
1537
REFERENCES 1. British Paediatric Association: The Transfer of Infants and Children for Surgery, 1993 2. Royal College of Surgeons of England and the British Association of Paediatric Surgeons: Report on Surgical Services for the Newborn, 1992 3. Anonymous: Report of the National Confidential Enquiry Into Postoperative Deaths. Lancet 335:1498-1500,199O 4. Campling EA, Devlin HB, Lunn JN: The Report of the National Confidential Enquiry Into Peri-operative Deaths 1989. London, England, NCEPOD, 1990 5. Atwell JD, Spargo PM: The provision of safe surgery for children. Arch Dis Child 67:345-349,1992 6. Jahangiri M, Bradley JWP, Osborne MJ, et al: Infantile
hypertrophic pyloric stenosis: Where should it be treated? Ann R Co11Surg Engl7.5:34-36,1993 7. Atwell JD: Invited comment. Ann R Co11Surg Engl75:36-37, 1993 8. Harvey MH, Humphrey G, Fieldman N, et al: Abdominal wall dehiscence following Ramstedt’s Operation: A review of 170 cases of infantile hypertropic pyloric stenosis. Br J Surg 78:81-82, 1991 9. Kiely EM: Commentary. Arch Dis Child 66:132-133, 1991 10. Eriksen CA, Anders CJ: Audit of results of operations for infantile pyloric stenosis in a district general hospital. Arch Dis Child 66:130-132,199l 11. Jacoby NM: Pyloric stenosis: Selective medical and surgical treatment. Asurveyofsixteenyears’expxience. Lancet 1:119-121,1%2