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Surgery - Pyloric Stenosis
Introduction
pylorus hypertrophy in newborns, which obstructs the stomach's outflow.
Etiology
Uncertain, but maybe connected to anomalies in the smooth muscle, interstitial cells of Cajal, or pyloric innervation that cause the pyloric smooth muscle to enlarge and become hyperplasia.
linked to 2% of cases of jaundice because to a hepatic glucuronyl transferase activity deficiency that goes away following surgery.
Epidemiology
3 cases per 1000 annually; less common in Asian and African populations. The male to female ratio is 4:1; it usually manifests in the first two to twelve weeks of life, however premature babies may experience it later.
H HISTORY
The baby vomits milk violently, like a "projectile." This vomiting is not bilious, but if it persists, it could stain the baby's oesophagus with blood. The infant appears hungry and healthy at first, but over time, it becomes dehydrated and lethargic.
Examination
In addition to showing symptoms of dehydration (sunken fontanelles, dry mucous membranes, low skin turgor, and 5–15% body weight), the baby may appear healthy or underweight. Gastric peristaltic waves from the left to the right upper quadrant can be seen on an abdominal examination. A hard, olive-sized lump in the epigastrium is known as a pyloric "tumour" when the pylorus becomes hypertrophied.
Investigational studies
Blood: U&Es, capillary gases, and metabolic alkalosis with decreased K+ and Cl-—the latter indicating the degree of dehydration—are used to assess metabolic disturbance.
Imaging: An ultrasound shows that the pyloric canal has constricted (wall thickness > 4 mm, overall diameter > 10 mm, length > 18 mm) and the pylorus muscle has thickened.
Management
General: IV fluids are used to correct biochemical imbalances and rehydrate patients before to any operation; otherwise, there is a danger of apnea following anesthesia due to a loss of respiratory drive brought on by lower H+ from alkalosis and reduced CO2 from ventilation. To stop the stomach contents from aspirating, an NG tube is placed.
Operative: The final treatment, known as a Ramstedt's pyloromyotomy, is often performed in a specialized pediatric surgical department. can be carried out laparoscopically or through open incisions in the stomach or circumumbilical region. After identifying the pylorus and cutting the serosa with a knife or diathermy, the circular muscle splits along the anterior wall and descends to the mucosa. To make sure the mucosa has not been punctured, the stomach is next inflated with air; if this is the case, the defect needs to be sutured and an omental patch should be placed over the mucosa.
Complications
hunger, thirst, gastritis and oesophagitis, hypochloraemia, hypokalaemia, metabolic alkalosis, aspiration, and respiratory distress syndrome.
surgical site infections, incisional hernias, and mucosal perforations. 10% of patients experience chronic vomiting after surgery, however this normally goes away (may be linked to reflux illness).
Prognosis
Usually very good. In surgical patients, morbidity is less than 3% and mortality is less than 0.5%.
Introduction
pylorus hypertrophy in newborns, which obstructs the stomach's outflow.
Etiology
Uncertain, but maybe connected to anomalies in the smooth muscle, interstitial cells of Cajal, or pyloric innervation that cause the pyloric smooth muscle to enlarge and become hyperplasia.
linked to 2% of cases of jaundice because to a hepatic glucuronyl transferase activity deficiency that goes away following surgery.
Epidemiology
3 cases per 1000 annually; less common in Asian and African populations. The male to female ratio is 4:1; it usually manifests in the first two to twelve weeks of life, however premature babies may experience it later.
H HISTORY
The baby vomits milk violently, like a "projectile." This vomiting is not bilious, but if it persists, it could stain the baby's oesophagus with blood. The infant appears hungry and healthy at first, but over time, it becomes dehydrated and lethargic.
Examination
In addition to showing symptoms of dehydration (sunken fontanelles, dry mucous membranes, low skin turgor, and 5–15% body weight), the baby may appear healthy or underweight. Gastric peristaltic waves from the left to the right upper quadrant can be seen on an abdominal examination. A hard, olive-sized lump in the epigastrium is known as a pyloric "tumour" when the pylorus becomes hypertrophied.
Investigational studies
Blood: U&Es, capillary gases, and metabolic alkalosis with decreased K+ and Cl-—the latter indicating the degree of dehydration—are used to assess metabolic disturbance.
Imaging: An ultrasound shows that the pyloric canal has constricted (wall thickness > 4 mm, overall diameter > 10 mm, length > 18 mm) and the pylorus muscle has thickened.
Management
General: IV fluids are used to correct biochemical imbalances and rehydrate patients before to any operation; otherwise, there is a danger of apnea following anesthesia due to a loss of respiratory drive brought on by lower H+ from alkalosis and reduced CO2 from ventilation. To stop the stomach contents from aspirating, an NG tube is placed.
Operative: The final treatment, known as a Ramstedt's pyloromyotomy, is often performed in a specialized pediatric surgical department. can be carried out laparoscopically or through open incisions in the stomach or circumumbilical region. After identifying the pylorus and cutting the serosa with a knife or diathermy, the circular muscle splits along the anterior wall and descends to the mucosa. To make sure the mucosa has not been punctured, the stomach is next inflated with air; if this is the case, the defect needs to be sutured and an omental patch should be placed over the mucosa.
Complications
hunger, thirst, gastritis and oesophagitis, hypochloraemia, hypokalaemia, metabolic alkalosis, aspiration, and respiratory distress syndrome.
surgical site infections, incisional hernias, and mucosal perforations. 10% of patients experience chronic vomiting after surgery, however this normally goes away (may be linked to reflux illness).
Prognosis
Usually very good. In surgical patients, morbidity is less than 3% and mortality is less than 0.5%.
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