The use of small, laparoscopic equipment to correct pyloric stenosis in newborn children has advantages over open surgery - but the laparoscopic technique should only be performed in centres with the required level of expertise. These are the conclusions of an Article published Online First and in an upcoming edition of The Lancet, written by Dr Nigel Hall and Professor Agostino Pierro,Department of Paediatric Surgery, Institute of Child Health, University College London, UK and Great Ormond Street Children’s Hospital, London, UK, and colleagues.
Pyloric stenosis is a condition that causes severe vomiting in the first few months of life. There is narrowing (stenosis) of the opening from the stomach to the intestines, due to enlargement (hypertrophy) of the muscle surrounding this opening (the pylorus, meaning "gate"), which spasms when the stomach empties. Pyloromyotomy is a surgical procedure in which an incision is made in the longitudinal and circular muscles of the pylorus, to correct this spasming. Open pyloromyotomy has been available since the early 20th century. But in the 1990s, laparoscopic equipment was developed to allow enable much less invasive access in the abdomens of infants. The researchers did a randomised controlled trial to compare the two techniques - open (OP) and laparoscopic pyloromyotomy (LP) - for the treatment of pyloric stenosis.
This international study* looked at 190 children from six children’s surgery units, of which 93 were assigned to OP and 87 to LP. The primary outcomes of the study were the time to achieve full normal feeding and the duration of post-operative recovery. The study was double blinded - parents and doctors did not know which treatment was being received, and the children were bandaged post-operation so that it was still impossible to determine which type of operation they had undergone.
The researchers found that time to full normal feeding was lower in LP group (18.5 hours) versus the OP group (23.9 hours). Post-operative recovery time was also shorter in the LP group (33.6 hours) compared with the OP group (43.8 hours). Postoperative vomiting, and intra-operative and postoperative complications were similar between the two groups. The authors conclude: “In view of these results, we feel that most surgeons and parents would choose laparoscopy. Furthermore, the difference of more than 10 h in postoperative length of stay might mean an extra day in hospital after open pyloromyotomy, with logistical and cost implications... We think that our findings justify the continued use of laparoscopic pyloromyotomy for the treatment of pyloric stenosis, and recommend its use in centres with suitable laparoscopic experience.”
They add: “This was the first large multi-centre double-blind randomised controlled trial which supports the use of laparoscopy (key hole surgery)in children. The trial was stopped early due to benefit in one treatment arm (laparoscopy) and as such is the first randomised controlled trial in the field of paediatric surgery to report such strong findings. The results of this study represent a significant advance for the role of laparoscopy in children and will have an impact on the provision of surgery for children in the future.”
In an accompanying Comment, Dr Aydin Yagmurlu, Department of Paediatric Surgery, Faculty of Medicine, Ankara University, Turkey, says: “Surgeons who prefer the open approach and those surgeons with the skill and necessary experience in the laparoscopic approach can take comfort in knowing that both techniques have been validated by Hall and colleagues’ findings... I do not recommend surgeons with limited experience to try to instruct laparoscopic pyloromyotomy to their residents or registrars until they reach an accumulated institutional experience."
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