20
Infantile Hypertrophic Pyloric Stenosis DR. SANJAY KHOPE. MS, M Ch., FACS, FISPU CONSULTANT PEDIATRIC SURGEON

Infantile hypertrophic pyloric stenosis

Embed Size (px)

Citation preview

Infantile Hypertrophic Pyloric Stenosis

Infantile Hypertrophic Pyloric StenosisDr. Sanjay Khope. MS, M Ch., FACS, FISPUCONSULTANT PEDIATRIC SURGEON

Historical Aspects1888 Hirschsprung ( angeborener pylorusstenose)1908 Dufour and Fredet surgical correction accomplished by cutting muscle up to mucosa and closing muscle transversely1912 Ramstedt Closure of muscle was not required and modern standard operation evolved.1992 Laparoscopic pyloromyotomy

sairajsk123 (s) - in 1888 Hirschsprung gave the first complete discription of HPS and labeled it as angeborener pylorusstenose(congenital pyloric stenosis and thought it tobe due to failure of involution of fetal pylorus.Etiological factorsPrevalence 1.5 to 4 per 1000 live births in white populationsBoys : Girls ratio 2:1 to 5:1 clear male preponderanceIncreased risk for first born infants with positive family history more if father had IHPSIHPS thought to be caused by factors other than developmental issuesEnvironmental factors: Erythromycin or Azithromycin exposure, transpyloric feeding of premature babies

Emerging new theoriesGI Hormones-gastrin, Substance P, epidermal growth factor,Substance P could produce chronic Pylorospasm and stenosisNitric Oxide can induce smooth muscle relaxation in stomach. Deficiency of NO in pyloric muscle can induce muscle spasm (NADPH Nicotinamide Adenine dinucleotide phosphate diaphorase /nitric oxide synthetase activity not seen in circular muscle biopsy specimen)No definitive cause of IHPS-process occurs weeks after birth and whatever may be triggering mechanism -end result is circular muscle hypertrophy.

InvestigationsBiochemical investigations: Serum Electrolytes, Serum bilirubinAbdominal USGPlain X-ray abdomenDye Study

Biochemical ChangesHypochloremic, Hypokalemic AlkalosisParadoxical AciduriaHyperbilirubinemia due to glucoronyl transferase deficiencyDehydrationMalnutrition

Clinical featuresProjectile VomitingCoffee-ground appearance of vomitusInfants hungry after vomiting and do not look ill initiallyLate dehydration.JaundiceConstipation/ hunger diarrhoea

Radiological signsDelayed gastric emptyingElongated pyloric canal String signRat tail signRail road track signCervical pyloric sign on USGDetection of pyloric tumor 3.5-4 mm thickness and pyloric channel length of 16 mm or more

DiagnosisBIOCHEMICAL EVALUATIONABG ANALYSISDYE STUDYULTRASONOGRAPHYVisible gastric peristalsis Golf Ball waves .CLINICAL EVALUATION IS SUFFICIENT-Palpable tumour. (forgotten Skill)

PathognomonicSign- Olive shaped tumour

RAT TAIL SIGN

CERVICAL PYLORIC SIGN

Preoperative preparationBenson & Alpern stages of severity based on HCO3 levelsI slight 35 mEq/lA majority of patients can tolerate their gastric secretions therefore do not have complete obstructions. No nasogastric tube

Preoperative preparationIv fluids0.45 glucose saline.Correction of electrolyte imbalanceAvoid NG tube

Ramstedts Operation

Post operative ManagementResumption of oral fluids 4-6 hrs after surgeryGraded increase in oral fluids till feeds are accepted without emesisVisible gastric peristalsis as well as the size of pyloric tumour take time to disappear. Dye study may not be of use to diagnose incomplete myotomy.Antibiotic Prophylaxis not requiredReflux may persist for a week

ComplicationsMinimal in experienced handsVomiting in the early post operative period-GER, GASTRIC ATONYBEYOND 3-4 days suspect Incomplete myotomy.Torgersons muscle Incise medial canalis loopUnsuspected Duodenal perforationmay go undetected especially in laparoscopic Ramstedts.Wound infection & Dehiscence.Evidence based studyComparison with laparoscopic Surgery- not much differences in complication rates.

THANK YOU