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4 cases of hypertrophic stenosis of the pylorus, an infrequent benign disease often associated with gastro-duodenal lesions and characterized by narrowing and lengthening of the channel owing to hypertrophy-hyperplasia of the circular muscular fibres, are reported. Aetiopathogenesis, diagnosis and therapy, namely always gastric resection, are discussed.
The results of surgical treatment of pyloroduodenal stenosis of ulcer etiology at the stage of decompensation in 123 patients are analysed. Choice of a method of operation with regard for the degree of the impairement in motor and secretory gastric functions, intraoperative conditions and severity of the state of a patient is substantiated.
Results of treatment of congenital pylorostenosis in children during last 15 years were studied. There was established, that degree of hypotrophy increases proportionally to duration of vomitive period. Changes of clinical signs of illness due to depression of immune defence, observation by divisional pediatrician with administration of spasmolytic preparation constitute the causes of late hospitalization to unit of pediatric surgery. Late results of treatment witness, that timely performance of operation constitutes an effective method.
Two regimens of postoperative fluid management are currently used following pyloromyotomy. Both early or delayed feeding have their advocates. The present study reviews 127 infants managed by the early feeding regimen. Although vomiting was common (79%) early discharge (75% within 72 h) was followed by no adverse effects. Weight gain at 7 days was unaffected by postoperative vomiting. Early feeding and early discharge can be achieved without increase in morbidity and may be the preferred method of postoperative management.
A large body of data on segregating families is used to generate specific recurrence risks conditional on sex and birth order for the best-fitting model of polygenes plus maternal effect. The method is general for diseases of complex inheritance, and lies within the competence of any serious genetic clinic. The question of whether consultees demand as much specificity should be subordinate to the question of whether counsellors are justified in providing less.
The late-term results of treatment of pyloroduodenal ulcerous stenosis by means of selective proximal vagotomy (SPV) in combination with transverse gastroduodenoanastomosis (GDA) were studied in 110 patients. The results are compared with those of SPV combined with longitudinal GDA after Jaboulay. Clinical, radiological, endoscopic, biochemical, and morphological examination showed the advantages of transverse GDA over longitudinal GDA. It is concluded that combination of SPV with transverse GDA is the operation of choice.
Gastric outlet obstruction is a well-recognized sequela of corrosive ingestion. Such patients are traditionally treated surgically. We have treated three such patients with intralesional steroid injections combined with through-the-scope balloon dilation. All three patients responded well and are asymptomatic after 12 months, 14 months and 3 years and 3 months of follow-up, respectively. Endoscopic balloon dilation combined with intralesional steroid may be an effective alternative to surgery in such patients.
Twenty-five patients with proven gastric outlet obstruction secondary to peptic ulcer disease were treated by endoscopic balloon dilatation using 'through the scope' balloons. The stricture could not be negotiated in one patient. Two patients continued to have gastric outlet obstruction despite the dilatation and required surgery. Two patients have returned up to 11 weeks after treatment with signs of recurrent gastric outlet obstruction. Twenty patients (80 per cent) remained asymptomatic (follow-up: median 9 months, range 2-24 months).
One hundred infants undergoing pyloromyotomy were studied prospectively to ascertain the optimum time at which to reintroduce feeds after operation. The babies were randomized to be fed after 4 or 18 h and were then assessed by monitoring the frequency of postoperative vomiting and the number of days taken to achieve full oral feeding. There was significantly more postoperative vomiting in the early group, while both groups required the same number of days to achieve full oral feeding. The conclusion reached was that a delay in the reintroduction of feeds until 18 h after pyloromyotomy is to be recommended.
In 1983-1988, in the city of Minsk 196 patients with congenital hypertrophic pylorostenosis (CHRS) were under treatment. The mean CHPS incidence is 1.06 per 1,000 neonates. X-ray examination was performed in 170 cases. CHPS was excluded by error only in one case (0.5%) on day 3 of the disease. In 8 cases, compensated pylorostenosis was diagnosed. It was characterized by proper evacuation from the stomach and positive dynamics of the body weight at the moment of examination. It is suggested that CHPS develops in response to the enhancement of hydrochloric acid secretion. The study points to the high efficacy, simplicity and safety of the method proposed.
Bezoars are concretions made up of a variety of partially digested materials seen in several portions of the gastrointestinal tract; they may result in gastrointestinal obstruction. Bezoar types described in the scientific literature include bezoars resulting from drugs. Their development is usually associated with some predisposing risk factor. The case of a patient is described, who was admitted to the hospitaĺs Emergency Department because of a clinical event suggesting a gastrointestinal bleeding episode. After admission, endoscopy demonstrated the presence of a bezoar whose components included a great number of Adalat Oros tablets. A review of the drugs that induced bezoar formation is made, and associated risk factors, formation mechanisms, bezoar appearance, and treatments used are all described.
This is a world-wide disease, more common in Caucasians and probably on the increase. The aetiology remains very poorly understood. Presentation is between 2 and 8 weeks with vomiting, classically projectile, in an otherwise well hungry child. The diagnosis can confidently be made in most cases by a careful test feed; ultrasound and barium meal examinations are only required for difficult cases. Intravenous fluid replacement is essential prior to surgery and 24 h or longer may be required to correct acid base disturbances and enable safe general anaesthesia. Pyloromyotomy (Ramstedt's operation) remains the only satisfactory treatment, our mortality rate for this is 0.4%. Occasional vomits occur postoperatively in over half of patients but we are sceptical of the value of graded postoperative feeding regimens. There are no known long-term sequelae to surgery and this remains a most rewarding paediatric surgical condition to treat.
The Bouveret's syndrome is a rare complication of a bilio-digestive fistula, where a big stone occludes the pyloro-duodenal region. The clinical symptomatology is atypical, symptoms of the disease are acute and only in fifty per cent of cases it is possible to have a positive anamnesis for biliary lithiasis. The evolution of the occlusion is generally rapid. The clinical case we are in possession of, shows a particularly chronic evolution with a 15 month sub-occlusive symptomatology that caused a massive gastric dilatation. The diagnosis of Bouveret syndrome was set forth during operation, as generally happens in about 50% of cases. The surgical treatment is still the only one capable to solve the obstruction of the alimentary canal and the bilio-digestive fistula at the same time.
INTRODUCTION: Debate exists as to whether IHPS can be treated in district general hospitals as effectively as in specialist paediatric surgical units. AIM: To review the surgical treatment of IHPS in babies admitted to a district general hospital under the care of two consultant general surgeons with a paediatric surgical interest. PATIENTS AND METHODS: The case notes of 66 babies operated on for IHPS over a 42 month period between April 1995 and September 1998 were retrospectively reviewed. Demographics, operative details, hospital stay, and overall complications were all documented. RESULTS: Peri-operative complications occurred in 2 patients, both requiring omental patches for duodenal perforation. Nine patients had 1 or 2 episodes of postoperative vomiting; 4 had either a wound or urinary tract infection; and 1 baby developed an incisional hernia. There was no mortality. DISCUSSION: The complication rate seen in this series is comparable to that of specialist centres, and supports current guidelines suggesting that IHPS can be managed by general surgeons with a paediatric surgical interest in a district general hospital.
Pylorostenosis is still the most frequently encountered type of congenital intestinal obstruction. A severe course of the disease with a fatal outcome is observed today. Successful treatment is linked in many respects with adequate feeding of the patient. The authors examined and performed operations on 90 children. According to the type of feeding they were divided into 3 groups. Group 1 consisted of patients given the generally accepted oral diet in portions, group 2 was made up of infants fed according to a "forced" schedule (the physiological requirements were supplied by the natural way by the 3rd-4th postoperative day), and group 3 received enteral feeding through a tube. The tube was introduced by means of an endoscope before or during the operation. It was found that in feeding through a tube children with pylorostenosis could be given 2-3 times more milk before the operation and in the first days after it. Regurgitation and the phenomena of esophagitis and jaundice are arrested in this case. The gain in weight is 3 times that in children of group 1. The authors consider this type of feeding to be justified in gravely ill patients. The "forced" schedule is used in an uncomplicated course of the disease. Feeding of infants with pylorostenosis by the generally accepted method was found to be unsatisfactory and the authors rejected it.
Pyloric biopsies obtained at pyloromyotomy from 46 infants were studied by light and electron microscopy and compared to 8 autopsy control cases without any evidence of infantile hypertrophic pyloric stenosis (IHPS). A positive family history of this disorder was recorded in 8 cases (2 girls and 6 boys). The most frequent changes in the myenteric plexus comprised axonal alterations. In glial cells, cytoplasmic vacuolisation or an increase of intermediate filaments occurred. In ganglion cells, vacuolisation of perikaryal cytoplasm or dense bodies were observed. No obvious differences were seen between sporadic and hereditary cases. In addition to these fine structural alterations, immunohistochemistry in 6 IHPS cases and 4 controls revealed differences in the distribution of substance P, bombesin, calcitonin gene related peptide and enkephalin-like immunoreactivity within the myenteric plexus between IHPS and control cases. The immunoreactivity, however, was unevenly distributed from case to case and even within individual cases. The reduction of immunoreactivity corresponded, at least in part, to an increase of neurofilaments or abnormal organelles within axons. Increased immunoreactivity was apparently related to focal accumulation of dense cored vesicles noted in the preceding study. It is suggested that these and other changes reported interfere with the normal gastrointestinal reflex mechanisms leading to intestinal obstruction.
Thirty-two patients underwent a pyloromyotomy via an umbilical incision; in 11 a modified umbilical approach was used to facilitate delivery of the pyloric mass. Incisions are made in the skin fold of the upper half of the umbilicus and at the midline, joining the two at the top. The skin incision is closed by upper umbilical translocation with a very good cosmetic result. This incision allows easy access to the pylorus and provides more convenient exposure. The absence of traction on the retractors avoids tissue ischemia, which leads to wound abscess development.
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