Can pyloric stenosis surgery be avoided?

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.

A “Skinnerbox” used in children’s hospitals in the 1940s to protect babies from infectiion.

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.

  • Atropine sulphate by injection and medication relaxes muscles and can be used to treat infant pyloric stenosis

    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.

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6 thoughts on “Can pyloric stenosis surgery be avoided?

  1. Wendy

    What great information! The more people that know about this, the better. If people know this information before becoming parents, they can make decisions that work best for them.

    Reply
  2. Fred Vanderbom Post author

    Thank you for your encouragement. I do hope that many parents who have to become parrt of the decisions and care related to surgery for their child will read and be helped by the research, advocacy and personal experience of adult “survivors” like you and me.

    Reply
  3. Rahul Dev Ghosh

    My father was 84 years old, is diagnosed with pyloric stenosis Can he be treated with Atropine? Please help me

    Reply
    1. Fred Vanderbom Post author

      I am not a doctor so don’t have the broad general education doctors have. However, I have had many contacts and done much reading. From these I can say –
      1. There are similarities and differences between infant and adult PS.
      2. Atropine sulphate had some possible bad side effects, so is little used now. But Ranitine is a safer form of the same drug and widely used for both kinds of PS.
      3. With adult PS, this and other drugs (incl. Botox) are used to help the muscle to relax and open. But stretching (by balloon dilation) is also used, often several times. Surgery is only done as a last resort as the technique to manage adult PS is more radical than the operation used for babies.
      4. If your father can handle the operation, fine. Otherwise he may need to stay with the gentler (but sometimes inadequate) repairs. Please note that the operation also has some side effects.
      Best wishes for a good outcome!

      Reply
  4. Annette

    I am a female, born in 1951, Irish background, possibly 2-3 weeks early. My mother said i used to projectile vomit, age 6 months. Coincidentally she also reported that I did not put on weight (the clinic nurse’s solution was to feed my mother more) and was small for my age growing up. I suspect PS but was never treated. Do you think there are many cases who are undetected as they resolve without surgery?

    Reply
    1. Fred Vanderbom Post author

      Thank you for your question, Annette. You pose an intriguing puzzle…
      It is hard to give a definite answer, especially without your mother adding to your story.
      If your projectile vomitting did in fact not start until you were 6 months, it’s not likely to have been PS, although some very few PS cases do show up after the normal “under 4 months” rule-of-thumb. Another contra-indication is your mention of your mother being told to feed herself better! A PS baby will not normally respond to a mother eating more – perhaps unless some of the breastmild is getting through, which could underline that this may not be PS (see below).
      Another uncertainty is about your projectile vomitting: all babies (as you’d probably have experienced) vomit, sometimes quite forcefully. And not all PS babies are super-projectile-vomitters: I’ve read stories on the web about the vomit going “across the room” or “3-4 meters”, but the several videos I’ve seen never show it going beyond 1 meter (although quite often arching): awful enough but not necessarily (to my mind) “projectile”. So what did you do?
      The other unknown for me is whether your problem was diagnosed at the time. Many doctors are wary of doing much to diagnose PS unless the parents put on pressure and their baby is clearly losing weight and condition (hunger, dehydration). Doctors are inclined to take a wait-and-see attitude until some of the ducks line up. I understand you were not even given the medical treatment for PS: if that is so, it could still mean you were a very mild and late PS case – and these babies usually survive without any intervention and grow out of their pylorus enlargement and vomitting. Or it could mean that the suspicion was that there were feeding problems or you had another condition, such as pylorospasm (when the muscle is not swollen to block food but has a form of hiccups) or reflux or an allergy.
      If you don’t mind responding here or emailing me via the Contact page, I’d be interested to know more about why you suspect you had PS. Many people with your story have continuing gastric problems, and some of these have a Pyloroplasty or other operation later to relieve PS-related problems.
      Regarding your last question, I read between the lines there that what troubled you has resolved itself? If so, I’m pleased for you!
      Sadly, PS is not a condition that attracts much statistical research, and I’ve not seen any reports on the matter you ask about. This would suggest that continuing problems after PS (whether diagnosed and treated or not) are relatively rare: it’s not a high profile issue. On the other hand, I have on file the stories of 36 people who posted on Facebook’s largest PS Group about their troubled experience of PS in later life, often because they escaped surgery in their infancy.
      Best wishes!

      Reply

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