Recent trend in management of Congenital Hypertrophic Pyloric Stenosis

Abstract

Infantile Hypertrophic Pyloric Stenosis (IHPS) is a common cause of gastric outlet obstruction in infants This condition is caused by diffuse hypertrophy and hyperplasia of the smooth muscle of the antrum of the stomach and pylorus. It usually occurs in infants aged 2-8 weeks. No definitive cause for hypertrophic pyloric stenosis has been found. However, various environmental and hereditary factors have been implicated. Typical presentation is onset of projectile vomiting, slight haematemesis, persistent hunger, weight loss, dehydration, lethargy, and infrequent or absent bowel movements may be seen. Stomach wall peristalsis may be visible. Enlarged pylorus classically described as an 'olive', can usually be palpated in the right upper quadrant or epigastrium of the abdomen. The infant is best examined from the right, with mild pressure applied using the first 3 fingers of the right hand in a cephalad direction. Careful examination reveals an oblong, smooth, hard mass that is 1-2 cm in length. This mass is the hypertrophied pylorus and is commonly referred to as an olive. Patients with nonbilious vomiting typically have IHPS or reflux. Other conditions that can manifest with nonbilious vomiting include pylorospasm, hiatal hernia, and preampullary duodenal stenosis. Ultrasound examination confirms the diagnosis in the majority of cases, allowing an earlier diagnosis in infants with suspected disease but no pyloric mass on physical examination. Criteria for diagnosis include pyloric thickness greater than 3mm or an overall pyloric length greater than 14mm. Ultrasonography has a sensitivity of approximately 95%. Nuclear medicine scanning is not routinely used for hypertrophic pyloric stenosis; however, possible findings include delayed gastric emptying. Endoscopy has been advocated by some investigators as a successful tool in the diagnosis of IHPS.Demonstration of the cauliflower- or nipplelike projection of the mucosa is characteristic in patients with IHPS. Fredt-Ramstedt pyloromyotomy performed through a right upper quadrant transverse incision is the gold standard in treatment of infantile hypertrophic pyloric Stenosis (IHPS) allover the past century. In the recent 25 years, laparoscopic and circum-umbilical approaches have been introduced as alternatives to improve the cosmetic results. The 3 approaches had comparable favorable outcomes. Remarkable differences were in the learning curve of the technique evidenced by the operative time. The other main difference was thefinal cosmetic appearance. Therefore, the RUQ approach is the standard and easiest-to-master approach while LPM and UMB offered thepotential of a better cosmetic outcome. Conclusion: Fredt-Ramstedt pyloromyotomy performed through a right upper quadrant (RUQ) transverse incision is the gold standard in treatment of infantile hypertrophic pyloric Stenosis (IHPS) allover the past century. It is also the easiest-to-master approach among all other options while LPM and UMB approaches offered the potential of a better cosmetic outcome.