今日の臨床サポート

幽門狭窄症(小児科)

著者: 榊原裕史 地方独立行政法人東京都立病院機構 東京都立小児総合医療センター 総合診療科

監修: 渡辺博 帝京大学老人保健センター

著者校正/監修レビュー済:2022/08/17
患者向け説明資料

概要・推奨   

  1. 嘔吐で発症し、時間経過とともにその頻度は増加し、しばしば噴水様の非胆汁性嘔吐となる。
  1. 生後2週間から2カ月で発症し、男女比は4:1である。また第1子が3割を占める。
  1. 幽門筋の肥厚により生じる通過障害が原因である。
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尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
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(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
榊原裕史 : 特に申告事項無し[2022年]
監修:渡辺博 : 特に申告事項無し[2022年]

改訂のポイント:
  1. 粘膜外幽門筋切開術とアトロピン療法の奏効率に関する文献を追加した。
  1. 代謝性アルカローシスに伴う呼吸障害に関する文献を追加した。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 嘔吐で発症し、時間経過とともにその頻度は増加し、しばしば噴水様の非胆汁性嘔吐となる[1]
  1. 幽門筋の肥厚により生じる通過障害が原因である[1]
  1. 生後2週間から2カ月で発症し、男女比は4:1である。また第1子が3割を占める[1]
  1. 発症率は1,000人あたり2~3.5人であるが、地域差、人種差がみられる。白色人種で多く、アジア人では少ない。また近年、発症率低下の報告が散見される[1][2][3]
  1. 家族内の集積があり、発症率は一卵性双胎で約200倍、二卵性双胎、兄弟で約20倍と報告されている[4]
  1. 生後2週間までのエリスロマイシン投与との関連が指摘されている。またアジスロマイシンでも症例報告がみられる[5][6][7]
  1. 近年のメタアナリシスによれば、妊娠中・授乳中のマクロライド使用と肥厚性幽門狭窄症の発症には有意な関連はない[8]
  1. 遺伝的素因と環境要因により発症すると考えられており、関連する遺伝子座がいくつか報告されているが、正確な機序はいまだ明らかではない[9]
問診・診察のポイント  
  1. 生後2週間から2カ月の嘔吐を認める患児では、常に念頭に置く必要がある。

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文献 

Marta Hernanz-Schulman
Infantile hypertrophic pyloric stenosis.
Radiology. 2003 May;227(2):319-31. doi: 10.1148/radiol.2272011329. Epub 2003 Mar 13.
Abstract/Text Infantile hypertrophic pyloric stenosis is a common condition affecting young infants; despite its frequency, it has been recognized only for a little over a century, and its etiology remains unknown. Nevertheless, understanding of the condition and of effective treatment have undergone a remarkable evolution in the 20th century, reducing the mortality rate from over 50% to nearly 0%. The lesion is characterized by gastric outlet obstruction and multiple anatomic abnormalities of the pyloric antrum. The antropyloric muscle is abnormally thickened and innervated, and the intervening lumen is obstructed by crowded and redundant mucosa. Recognition of the obstructive role of the mucosa led to discovery of effective surgical treatment. Accurate clinical diagnosis in patients in whom a thickened antropyloric muscle is not readily palpable can be difficult, resulting in delayed diagnosis and can lead to emaciation and electrolyte imbalance, making the patient a suboptimal surgical candidate. Current imaging techniques, particularly sonography, are noninvasive and accurate for identification of infantile hypertrophic pyloric stenosis. Successful imaging requires understanding of anatomic changes that occur in patients with this condition and plays an integral role in patient care. Accurate, rapid, noninvasive imaging techniques facilitate rapid referral of vomiting infants and prompt surgical treatment of more suitable surgical candidates.

Copyright RSNA, 2003
PMID 12637675
T Sommerfield, J Chalmers, G Youngson, C Heeley, M Fleming, G Thomson
The changing epidemiology of infantile hypertrophic pyloric stenosis in Scotland.
Arch Dis Child. 2008 Dec;93(12):1007-11. doi: 10.1136/adc.2007.128090. Epub 2008 Feb 19.
Abstract/Text BACKGROUND: The aetiology of infantile hypertrophic pyloric stenosis (IHPS) has not been fully elucidated. Since the 1990s, a sharp decline in IHPS has been reported in various countries. Recent research from Sweden reported a correlation between falling rates of IHPS and of sudden infant death syndrome (SIDS). This was attributed to a reduction in the number of infants sleeping in the prone position following the "Back to Sleep" campaign.
OBJECTIVES: To describe the changing epidemiology of IHPS in Scotland, to examine the relationship between IHPS and SIDS rates and to examine trends in other factors that may explain the observed reduction in IHPS incidence.
DESIGN: Incidence rates of IHPS and SIDS were derived from routine data and their relationship analysed. Trends in mean maternal age, maternal smoking, mean birth weight and breastfeeding rates were also examined.
SETTING: The whole of Scotland between 1981 and 2004.
RESULTS: IHPS incidence fell from 4.4 to 1.4 per 1000 live births in Scotland between 1981 and 2004. Rates were consistently higher in males, although the overall incidence patterns in males and females were similar. Rates showed a positive relationship with deprivation. The fall in the incidence of IHPS preceded the fall in SIDS by 2 years and the incidence of SIDS displayed less variability than that of IHPS. Significant temporal trends were also observed in other maternal and infant characteristics.
CONCLUSION: There has been a marked reduction in Scotland's IHPS incidence, but this is unlikely to be a consequence of a change in infant sleeping position.

PMID 18285388
Jan de Laffolie, Salmai Turial, Matthias Heckmann, Klaus-Peter Zimmer, Felix Schier
Decline in infantile hypertrophic pyloric stenosis in Germany in 2000-2008.
Pediatrics. 2012 Apr;129(4):e901-6. doi: 10.1542/peds.2011-2845. Epub 2012 Mar 19.
Abstract/Text BACKGROUND AND OBJECTIVE: The incidence of infantile hypertrophic pyloric stenosis (IHPS) is highly variable over time and geographic regions. A decline in IHPS incidence was recently reported in Sweden, the United States, Denmark, and Scotland. In Sweden, the IHPS decline seemed to be concurrent with a declining incidence in sudden infant death syndrome (SIDS), which suggested a common cause; the latter was attributed to campaigns against the prone sleeping position. We investigated the time course of the IHPS incidence in all German federal states (N = 16) between 2000 and 2008. We examined correlations between the IHPS incidence and the SIDS incidence.
METHODS: Data were extracted from the public report of health (Gesundheitsberichterstattung des Bundes). We collected the numbers of IHPS (International Classification of Diseases, 10th Revision [ICD-10], code 40.0), SIDS (ICD-10, R95), and live births (LB; male/female) in each federal state for 2000-2008.
RESULTS: The IHPS incidence declined in Germany from 2000 (3.2086/1000 LB [range: 1.67-5.33]) to 2008 (2.0175/1000 LB [1.74-3.72]; P = .005). The recorded incidence was highly variable in different federal states and over time. The SIDS incidence also declined during the same time period (2000, median: 0.759/1000 LB [interquartile range: 0.54-1.029]; 2008, median: 0.416/1000 LB [interquartile range: 0.285-0.6485]; P = .0255). However, the SIDS regional distribution was different from that of IHPS.
CONCLUSIONS: The IHPS incidence declined by ∼38% nationwide. A parallel decline in SIDS displayed a different pattern in regional distribution; thus, a common cause was unlikely. The regional differences indicated that etiologic factors remained unresolved.

PMID 22430445
Camilla Krogh, Thea K Fischer, Line Skotte, Robert J Biggar, Nina Øyen, Axel Skytthe, Sanne Goertz, Kaare Christensen, Jan Wohlfahrt, Mads Melbye
Familial aggregation and heritability of pyloric stenosis.
JAMA. 2010 Jun 16;303(23):2393-9. doi: 10.1001/jama.2010.784.
Abstract/Text CONTEXT: Pyloric stenosis is the most common condition requiring surgery in the first months of life. Case reports have suggested familial aggregation, but to what extent this is caused by common environment or inheritance is unknown.
OBJECTIVES: To investigate familial aggregation of pyloric stenosis from monozygotic twins to fourth-generation relatives according to sex and maternal and paternal contributions and to estimate disease heritability.
DESIGN, SETTING, AND PATIENTS: Population-based cohort study of 1,999,738 children born in Denmark between 1977 and 2008 and followed up for the first year of life, during which 3362 children had surgery for pyloric stenosis.
MAIN OUTCOME MEASURE: Familial aggregation of pyloric stenosis, evaluated by rate ratios.
RESULTS: The incidence rate (per 1000 person-years) of pyloric stenosis in the first year of life was 1.8 for singletons and 3.1 for twins. The rate ratios of pyloric stenosis were 182 (95% confidence interval [CI], 70.7-467) for monozygotic twins, 29.4 (95% CI, 9.45-91.5) for dizygotic twins, 18.5 (95% CI, 13.7-25.1) for siblings, 4.99 (95% CI, 2.59-9.65) for half-siblings, 3.06 (95% CI, 2.10-4.44) for cousins, and 1.60 (95% CI, 0.51-4.99) for half-cousins. We found no difference in rate ratios for maternal and paternal relatives of children with pyloric stenosis and no difference according to sex of cohort member or sex of relative. The heritability of pyloric stenosis was 87%.
CONCLUSION: Pyloric stenosis in Danish children shows strong familial aggregation and heritability.

PMID 20551410
B E Mahon, M B Rosenman, M B Kleiman
Maternal and infant use of erythromycin and other macrolide antibiotics as risk factors for infantile hypertrophic pyloric stenosis.
J Pediatr. 2001 Sep;139(3):380-4. doi: 10.1067/mpd.2001.117577.
Abstract/Text OBJECTIVES: To evaluate the risk for infantile hypertrophic pyloric stenosis (IHPS) among infants prescribed systemic erythromycin, infants prescribed a course of erythromycin ophthalmic ointment, and infants whose mothers were prescribed a macrolide antibiotic during pregnancy.
STUDY DESIGN: Retrospective cohort study of infants born at an urban hospital from June 1993 through December 1999.
RESULTS: Of 14,876 eligible infants, 43 (0.29%) developed IHPS. Infants prescribed systemic erythromycin had increased risk of IHPS, with the highest risk in the first 2 weeks of age (relative risk = 10.51 for erythromycin in first 2 weeks, 95% CI 4.48, 24.66). Erythromycin ophthalmic ointment for conjunctivitis was not associated with increased risk of IHPS. Maternal macrolide antibiotics within 10 weeks of delivery may have been associated with higher risk of IHPS but the data were not conclusive.
CONCLUSIONS: This study confirms an association between systemic erythromycin in infants and subsequent IHPS, with the highest risk in the first 2 weeks of age. No association was found with erythromycin ophthalmic ointment. A possible association with maternal macrolide therapy in late pregnancy requires further study. Systemic erythromycin should be used with prudence in early infancy.

PMID 11562617
Wynne Morrison
Infantile hypertrophic pyloric stenosis in infants treated with azithromycin.
Pediatr Infect Dis J. 2007 Feb;26(2):186-8. doi: 10.1097/01.inf.0000253063.87338.60.
Abstract/Text Seven-week-old 32-week premature triplets were hospitalized because of rhinorrhea, cough with color change and posttussive emesis. One infant had a positive direct fluorescent antibody test for Bordetella pertussis, so all were treated with 5 days of azithromycin. Two of the infants were subsequently diagnosed with hypertrophic pyloric stenosis and underwent surgical pyloromyotomies 6 and 7 weeks, respectively, after the initial admission.

PMID 17259889
Matthew D Eberly, Matilda B Eide, Jennifer L Thompson, Cade M Nylund
Azithromycin in early infancy and pyloric stenosis.
Pediatrics. 2015 Mar;135(3):483-8. doi: 10.1542/peds.2014-2026.
Abstract/Text BACKGROUND AND OBJECTIVE: Use of oral erythromycin in infants is associated with infantile hypertrophic pyloric stenosis (IHPS). The risk with azithromycin remains unknown. We evaluated the association between exposure to oral azithromycin and erythromycin and subsequent development of IHPS.
METHODS: A retrospective cohort study of children born between 2001 and 2012 was performed utilizing the military health system database. Infants prescribed either oral erythromycin or azithromycin as outpatients in the first 90 days of life were evaluated for development of IHPS. Specific diagnostic and procedural codes were used to identify cases of IHPS.
RESULTS: A total of 2466 of 1 074 236 children in the study period developed IHPS. Azithromycin exposure in the first 14 days of life demonstrated an increased risk of IHPS (adjusted odds ratio [aOR], 8.26; 95% confidence interval [CI], 2.62-26.0); exposure between 15 and 42 days had an aOR of 2.98 (95% CI, 1.24-7.20). An association between erythromycin and IHPS was also confirmed. Exposure to erythromycin in the first 14 days of life had an aOR of 13.3 (95% CI, 6.80-25.9), and 15 to 42 days of life, aOR 4.10 (95% CI, 1.69-9.91). There was no association with either macrolide between 43 and 90 days of life.
CONCLUSIONS: Ingestion of oral azithromycin and erythromycin places young infants at increased risk of developing IHPS. This association is strongest if the exposure occurred in the first 2 weeks of life, but persists although to a lesser degree in children between 2 and 6 weeks of age.

published in the public domain by the American Academy of Pediatrics.
PMID 25687145
Mohammed Abdellatif, Sherief Ghozy, Mohamed Gomaa Kamel, Sameh Samir Elawady, Mohamed Mohy Eldeen Ghorab, Andrew Wassef Attia, Truong Thi Le Huyen, Diep Trong Vien Duy, Kenji Hirayama, Nguyen Tien Huy
Association between exposure to macrolides and the development of infantile hypertrophic pyloric stenosis: a systematic review and meta-analysis.
Eur J Pediatr. 2019 Mar;178(3):301-314. doi: 10.1007/s00431-018-3287-7. Epub 2018 Nov 23.
Abstract/Text Macrolides are bacteriostatic antibiotics with a broad spectrum of activity against Gram-positive bacteria. The aim of this study was to systematically review and meta-analyze the association between infantile hypertrophic pyloric stenosis (IHPS) and macrolides. Nine databases were searched systematically for studies with information on the association between macrolides and IHPS. We combined findings using random effects models. Our study revealed 18 articles investigating the association between macrolides and IHPS. There was a significant association between the development of IHPS and erythromycin (2.38, 1.06-5.39). The association was strong when erythromycin was used during the first 2 weeks of life (8.14, 4.29-15.45). During breastfeeding, use of macrolides showed no significant association with IHPS in infants (0.96, 0.61-1.53). IHPS was not associated with erythromycin (1.11, 0.9-1.36) or macrolides use during pregnancy (1.15, 0.98-1.36).Conclusions: There is an association between erythromycin use during infancy and developing IHPS in infants. However, no significant association was found between macrolides use during pregnancy or breastfeeding. Additional large studies are needed to further evaluate potential association with macrolide use. What is known? • Erythromycin intake in the first 2 weeks of life is associated with an increased risk of pyloric stenosis. What is New? • There is currently no evidence of significant association between macrolides use during pregnancy or breastfeeding and pyloric stenosis.

PMID 30470884
Eddie Chung
Infantile hypertrophic pyloric stenosis: genes and environment.
Arch Dis Child. 2008 Dec;93(12):1003-4. doi: 10.1136/adc.2008.141499.
Abstract/Text
PMID 19028966
Mary Jane Piroutek, Lance Brown, Andrea W Thorp
Bilious vomiting does not rule out infantile hypertrophic pyloric stenosis.
Clin Pediatr (Phila). 2012 Mar;51(3):214-8. doi: 10.1177/0009922811431159. Epub 2011 Dec 12.
Abstract/Text OBJECTIVE: To describe the incidence of bilious vomiting in infants with infantile hypertrophic pyloric stenosis that presented to a pediatric emergency department.
METHODS: A retrospective medical record review included all infants who presented to our level 1 pediatric emergency department from January 1, 2005, through December 31, 2009, who were diagnosed intraoperatively with infantile hypertrophic pyloric stenosis. Emesis was determined to be bilious if the vomit was described as "green," "containing bile," or "bilious."
RESULTS: The authors identified 354 infants with infantile hypertrophic pyloric stenosis. The median age was 4 weeks 6 days (range = 11 days to 13 weeks). Bilious emesis was encountered in 1.4% (5/354; 95% confidence interval = 0.5% to 3.2%). The pyloric thickness measurements on ultrasound were significantly smaller in those with bilious emesis compared with those without bilious emesis (z score = 2.64; P = .014).
CONCLUSION: Bilious emesis was the presenting symptom in a small proportion of infants with infantile hypertrophic pyloric stenosis.

PMID 22166750
Chien-Yu Lin, Hsin Chi, Chyong-Hsin Hsu, Fu-Yuan Huang, Hung-Chang Lee, Nan-Chang Chiu
Peristaltic waves in infantile hypertrophic pyloric stenosis.
J Pediatr. 2014 Feb;164(2):423.e1. doi: 10.1016/j.jpeds.2013.08.052. Epub 2013 Oct 8.
Abstract/Text
PMID 24112865
J S Janik, E R Wayne, J P Janik
Pyloric stenosis in premature infants.
Arch Pediatr Adolesc Med. 1996 Feb;150(2):223-4.
Abstract/Text
PMID 8556133
W K Rohrschneider, H Mittnacht, K Darge, J Tröger
Pyloric muscle in asymptomatic infants: sonographic evaluation and discrimination from idiopathic hypertrophic pyloric stenosis.
Pediatr Radiol. 1998 Jun;28(6):429-34.
Abstract/Text OBJECTIVE: To compare the morphological and functional US appearance of the pylorus in healthy infants with those suffering from idiopathic hypertrophic pyloric stenosis (IHPS) in order to determine the pathological limits and to find out the most discriminating morphometric parameter.
MATERIALS AND METHODS: The pylorus of 84 asymptomatic infants was prospectively evaluated with respect to morphology (pyloric length, pyloric diameter, muscle thickness and pyloric volume) and function (gastric peristalsis and emptying, pyloric opening and the fluid passage). Results were compared with 85 patients with proven IHPS.
RESULTS: In every normal infant we observed frequent pyloric opening with passage of gastric contents and quick gastric emptying. All infants with proven IHPS presented with a permanently closed pylorus and exaggerated, retrograde gastric peristalsis. For each of the four parameters, highly significant differences (P < 0.0001) were found between the control and IHPS groups. Pathological limits were 3 mm for muscle thickness (accuracy 100 %), 15 mm for pyloric length (accuracy 94 %), 11 mm for pyloric diameter (accuracy 92 %) and 12 ml for pyloric volume (accuracy 96 %).
CONCLUSIONS: Evaluation of pyloric function plays an important role in the diagnosis of IHPS. The morphometric parameters are highly accurate in differentiating IHPS from a normal pylorus, muscle thickness being the most discriminating parameter.

PMID 9634457
Corey W Iqbal, Douglas C Rivard, Vincent E Mortellaro, Susan W Sharp, Shawn D St Peter
Evaluation of ultrasonographic parameters in the diagnosis of pyloric stenosis relative to patient age and size.
J Pediatr Surg. 2012 Aug;47(8):1542-7. doi: 10.1016/j.jpedsurg.2012.03.068.
Abstract/Text INTRODUCTION: Pyloric thickness of 3 mm or higher and length of 15 mm or higher by ultrasonography (US) is widely accepted as diagnostic criteria for pyloric stenosis (PS). However, infants presenting at earlier ages are held to this same criteria, which may not be applicable.
METHODS: Retrospective review was conducted on patients evaluated with pyloric US to rule out PS from May 2010 through December 2010. Pearson correlation was used to detect an association between weight and age with pyloric thickness and length. Sensitivity and specificity for US parameters were determined.
RESULTS: Three hundred four patients underwent 318 ultrasounds, of which 67 had PS. Of those with PS, age and weight had a positive correlation with thickness (P < .007), and age positively correlated with length (P < .001). In patients with and without PS, there was a negative correlation for both age and weight with thickness (P < .02). Those who did not have PS held a stronger negative correlation between age and thickness (P = .002). Overall, US had a 100% sensitivity and specificity for PS. Thickness of 3 mm or higher was 100% sensitive and 99% specific, and pyloric length of 15 mm or higher was 100% sensitive and 97% specific.
CONCLUSIONS: Although significant associations between age and weight with pyloric thickness and length may exist, our data indicate that this does not have an impact on the diagnostic criteria for PS.

Copyright © 2012 Elsevier Inc. All rights reserved.
PMID 22901914
Hisayoshi Kawahara, Yuichi Takama, Hideki Yoshida, Hiroshi Nakai, Hiroomi Okuyama, Akio Kubota, Norikazu Yoshimura, Shinobu Ida, Akira Okada
Medical treatment of infantile hypertrophic pyloric stenosis: should we always slice the "olive"?
J Pediatr Surg. 2005 Dec;40(12):1848-51. doi: 10.1016/j.jpedsurg.2005.08.025.
Abstract/Text BACKGROUND/PURPOSE: Laparoscopic pyloromyotomy has recently gained wide acceptance as the optimum treatment of infantile hypertrophic pyloric stenosis (IHPS). However, medical treatment may be superior to laparoscopic surgery in invasiveness. The efficacy of our regimen of intravenous atropine therapy for IHPS was assessed in comparison with surgical treatment.
METHODS: Medical treatment was initially chosen for 52 (61%) of 85 infants with IHPS at our institute between 1996 and 2004. Atropine was given intravenously at 0.01 mg/kg 6 times a day before feeding. When vomiting ceased and the infants were able to ingest 150 mL/kg per day of formula after stepwise increases in the feeding volume, they were given 0.02 mg/kg atropine 6 times a day orally, and the dose was decreased stepwise.
RESULTS: Of the 52 patients, 45 (87%) ceased projectile vomiting with treatment using intravenous (median, 7 days) and subsequent oral (median, 44 days) atropine administration. The median hospital stay was 13 days (6-36), and no significant complications were encountered during atropine therapy. The remaining 7 patients required surgery. Of 40 who underwent surgery, 4 had wound infections and 1 with hemophilia had postoperative hemorrhagic shock. The patients who underwent successful atropine therapy had body weights comparable with those who underwent surgery at the age of 1 year.
CONCLUSIONS: The high success rate of intravenous atropine therapy for IHPS suggests that this therapy is an effective alternative to pyloromyotomy if the length of the hospital stay and the necessity of continuing oral atropine medication are accepted.

PMID 16338303
Anita Erika Mercer, Robert Phillips
Question 2: can a conservative approach to the treatment of hypertrophic pyloric stenosis with atropine be considered a real alternative to surgical pyloromyotomy?
Arch Dis Child. 2013 Jun;98(6):474-7. doi: 10.1136/archdischild-2013-303655.
Abstract/Text
PMID 23661669
Giuseppe Lauriti, Valentina Cascini, Pierluigi Lelli Chiesa, Agostino Pierro, Augusto Zani
Atropine Treatment for Hypertrophic Pyloric Stenosis: A Systematic Review and Meta-Analysis.
Eur J Pediatr Surg. 2018 Oct;28(5):393-399. doi: 10.1055/s-0037-1604116. Epub 2017 Jul 12.
Abstract/Text INTRODUCTION:  Several authors have reported the use of atropine as an alternative treatment to pyloromyotomy in infants with hypertrophic pyloric stenosis (HPS). Our aims were to review the efficacy of atropine in treating HPS and to compare atropine therapy versus pyloromyotomy.
MATERIALS AND METHODS:  Using a defined search strategy (PubMed, MEDLINE, OVID, Embase, Cochrane databases), two investigators independently identified studies reporting the use of atropine for HPS. Case reports and opinion articles were excluded. Outcome measures included success rate, side effects, and length of hospital stay. Maneuvers were compared using Fisher's exact test, and meta-analysis was conducted using RevMan 5.3. Data are expressed as mean ± standard deviation.
RESULTS:  Systematic review: of 2,524 abstracts screened, 51 full-text articles were analyzed. There were no prospective or randomized studies. Twelve articles (508 infants) reported HPS resolution using atropine in 402 (79.1%) patients. Atropine side effects were documented in 38/251 (15.1%) infants and included tachycardia, increased transaminases, and flushed skin. Meta-analysis: five studies compared atropine treatment (293 infants) with pyloromyotomy (537 infants). Pyloromyotomy had higher success rate (100%) than atropine (80.8%; p < 0.01) and shorter hospital stay (5.6 ± 2.3 vs. 10.3 ± 3.8 days, respectively; p < 0.0001).
CONCLUSION:  Comparative but nonrandomized studies indicate that atropine is less effective than pyloromyotomy to treat infants with HPS. Currently, there is no evidence-based literature to support atropine treatment in these infants. To our knowledge, atropine should be reserved for patients unfit for general anesthesia or surgery.

Georg Thieme Verlag KG Stuttgart · New York.
PMID 28701002
Fenne A I M van den Bunder, Job B M van Woensel, Markus F Stevens, Tim van de Brug, L W Ernest van Heurn, Joep P M Derikx
Respiratory problems owing to severe metabolic alkalosis in infants presenting with hypertrophic pyloric stenosis.
J Pediatr Surg. 2020 Dec;55(12):2772-2776. doi: 10.1016/j.jpedsurg.2020.05.041. Epub 2020 Jun 6.
Abstract/Text OBJECTIVE: Uncorrected metabolic alkalosis in infantile hypertrophic pyloric stenosis (IHPS) could lead to perioperative apnea. However, the precise incidence of preoperative respiratory problems and the association with metabolic alkalosis are unknown. Therefore, we aimed to determine the incidence of preoperative respiratory problems in IHPS and to assess the association with metabolic alkalosis.
METHODS: We retrospectively reviewed all patients diagnosed with IHPS during 2007-2017. Respiratory problems were classified as present or absent. With multivariate logistic regression we analyzed the association between bicarbonate and respiratory problems, corrected for gestational age and birth weight.
RESULTS: We included 459 infants, of whom 23 developed preoperative respiratory problems (5.0%). Infants with preoperative respiratory problems were more often female (43.5% vs. 13.3% p = 0.001) and had significantly higher median serum levels of bicarbonate (32.0 mmol/L vs. 30.0 mmol/L), base excess (6.5 mmol/L vs. 5.3 mmol/L) and pCO2 (6.4 kPa vs. 5.9 kPa), compared to infants without respiratory problems. Multivariate analysis of serum bicarbonate and presence of respiratory problems showed an OR of 2.18 per 10 mmol/L (95% CI 1.21-4.71) (p = 0.009). The optimal bicarbonate cutoff point was 25.7 mmol/L (sensitivity 100%, specificity 13.4%).
CONCLUSION: IHPS with metabolic alkalosis potentially results in preoperative respiratory problems. A lower bicarbonate target before surgery might be recommended and respiratory monitoring should be considered.
LEVEL OF EVIDENCE: Level IV.

Copyright © 2020 Elsevier Inc. All rights reserved.
PMID 32641249
Sabina Siddiqui, R Eric Heidel, Carlos A Angel, Alfred P Kennedy
Pyloromyotomy: randomized control trial of laparoscopic vs open technique.
J Pediatr Surg. 2012 Jan;47(1):93-8. doi: 10.1016/j.jpedsurg.2011.10.026.
Abstract/Text PURPOSE: Open pyloromyotomy remains as the criterion standard treatment for hypertrophic pyloric stenosis with the laparoscopic approach rapidly gaining adoption. We present a prospective, randomized trial between the 2 approaches.
METHODS: After institutional review board approval, 98 patients with hypertrophic pyloric stenosis were consecutively randomized to either open or laparoscopic pyloromyotomy. Postoperative and hospital course were evaluated by review of the hospital records and long-term follow-up with scripted telephone survey using Likert scales. The length of operating room time, surgical procedure, postoperative stay, time to refeeding, and complications were evaluated. Secondary outcomes of cosmetic results and parental satisfaction were determined.
RESULTS: Ninety-eight patients were enrolled during a 4-year period. There were no significant differences between 2 groups on all primary outcomes. There were 3 complications in the open group-a wound dehiscence, a surgical site infection, and a gastric serosal tear-and 2 complications in the laparoscopic group-mucosal perforation and a suture granuloma. In long-term follow-up on 72 patients (56 months), parents described significant cosmetic results with laparoscopic approach.
CONCLUSIONS: There was no difference in operating time, hospital stay, or refeeding patterns between open and laparoscopic pyloromyotomy. The complication rates were similar between the 2 methods. However, long-term cosmetic results were significantly superior in the laparoscopic group.

Copyright © 2012 Elsevier Inc. All rights reserved.
PMID 22244399

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