It is always enormously troubling for parents when their worst fears are confirmed and they hear that their infant can only be saved by having surgery. Then will follow a day or more of additional upsets as their little one is prepared so that it can live to tell the tale of its surgery.
Pyloric stenosis (PS) is by far the most common condition of early infancy that is mostly treated in the operating room. But before a PS baby can go to surgery, its dehydration and blood chemistry must be corrected, so for a day or so the family will be seeing their recently received pride-and-joy in a hospital cot with an intravenous (IV) line attached to its little body, sometimes inserted into the head, sometimes into a splinted arm. They may even witness the medical staff toiling and needing more expert help to find a vein that has not “collapsed” or shrunk from the dehydration. They will witness their newborn child’s plaintive crying at not receiving nourishment. Sometimes the baby is not even allowed to be held and hugged.
No wonder my parents could never answer my questions about my p s surgery. I can only speculate but knowing them, I very strongly suspect they were too traumatised to return to that terrible time, let alone open themselves to my innocent and childly questions.
Is surgery the only way of avoiding the death of a baby with an abdominal blockage? Unfortunately, many of the more complex conditions of infancy such as gastroschesis, Hirschsprung’s disease, protruding bowels and diaphragmatic hernias can only be dealt with surgically. But infant pyloric stenosis cases vary greatly in their severity and the more slowly developing and milder cases can be (and in many countries are) corrected with a course of medication.
In my previous post I mentioned that PS is much more likely to be treated surgically in English-speaking countries than elsewhere. The facts are interesting and tell the overall story quite well. There are several reports available on the web; please contact me if you need help.
A Danish study followed 679 patients in one of its counties between 1950 and 1984. 114 cases were treated by medication, resulting in a complication rate of 17% and 6 deaths. 565 babies were given surgery with 8% having complications and 4 dying. During this 25 year period there was a marked trend towards surgery, intravenous preparation, and the use of general anesthesia.
- The have been several much more encouraging and recent studies in Japan.
A 1996 Japanese study reported the successful treatment of 21 of 23 infants (91%) with pyloric stenosis using intravenous atropine, administered until vomiting ceased, followed by oral atropine for 2 weeks.
- A small Japanese study between 1996 and 1998 followed 14 medical and 20 surgical ps cases. All the surgeries were successful although 2 had wound infections. The medical cases were treated with atropine sulphate which relaxes the muscles and must be carefully monitored during the course (typically 3 weeks) and especially at the beginning. 11 babies were treated orally, 2 intravenously, one had to be terminated because of side effects and 2 had to go to surgery. None of the cases resulted in death or had recurrences, the shrinkage of the pyloric swelling was similar in all babies, but the cost of the medical treatment was lower.
- Another Japanese study has reported a success rate of 87% in 52 patients treated with intravenous and oral atropine in 2005. Hospital stays ranged from 6-36 days (averaging 13 days), but despite the longer hospital stay, the costs for the medical group were similar to those for the surgical group, without the risks of general anesthesia and surgery. The medical patients showed no difference in weight from the norm at age one year.
- A small Taiwanese study reported in 2004 followed 5 patients, all of whom were successfully treated in the graduated way reported above over a period of between 27 and 45 days.
- A Serbian study reported on the careful and successful medical treatment of PS without any of the side-effects which have mentioned in many other reports.
- Four fairly recent Indian studies of which I have read Abstracts (summary reports) are even more encouraging. One found a 96% success rate from 52 cases. It’s not hard to understand that in an emerging country such as India a simpler, more readily available and cheaper treatment will be more attractive than in that part of the world driven by quick and technological success. One of the India researchers summed up: We conclude that oral atropine proved to be a simple, effective, safe, very cheap and acceptable treatment option for IHPS.
- The research reports I have had access to add up to this:
although surgery is preferable in the majority of cases, medical treatment for pyloric stenosis could prove useful to patients who –
have been diagnosed but are not yet at a critical stage of the condition,
don’t have easy access to surgical care,
have other complicating conditions making surgery too risky,
or whose parents refuse surgery.
- A comparison of the early Danish study with the Asian reports makes it clear that the medical treatment of ps can be as successful as the surgical, provided qualified, committed and vigilant management is available over a fairly lengthy period.
It must be remembered that most doctors in English-speaking countries have been trained as scientists and to work for the best outcome from a narrowly scientific viewpoint. Treatment options other than the “established standard” of the paediatrician are often regarded with scepticism or dismissed with a list of factors which upset parents will be hard-pressed to question. Often the “established standard” (that is, surgery) is indeed the best way forward, but sometimes (at least) it will not be. From the considerable body of reports and other literature I have read, many cases of pyloric stenosis can be treated without surgery, provided a few provisos are in place.