The 1970s medical journal articles about infant pyloric stenosis (PS) that interested me most I have kept for this post.
But first an observation: during the 1970s it became clear that countries other than those in Europe and North America had started making greater contributions. Whilst the majority of the 21 articles about treating infant PS I have drawn on for the previous and this blog come from the “old world”, almost half come from Denmark, Hong Kong, Iran, Israel, Singapore, South Africa and Sweden.
In 1981 Iranian pediatric surgeons wrote an interesting and telling history and comparison of PS treatments… in the German language. They tracked and explained the change from the medical to the surgical treatment of PS over 23 years and 244 cases in Tehran’s hospitals between 1958 and 1980.
During this period, 127 cases were treated with atropine and similar drugs that relax the baby’s pylorus and stomach (and other muscles). More often than not this medical treatment, extended over a month or more, will allow enough food to pass to keep the infant alive long enough for the enlarged pyloric muscle to do what it does usually: at the age of 4-6 months it starts to return to normal sufficiently for the baby to survive without surgery or further medication.
It has been found that the pylorus that is not cut at surgery will often return to normal in later life; however, in other cases it continues to interfere with feeding, sometimes enough to warrant surgery later in childhood, adolescence, or even adulthood.
Between 1958 and 1965, Tehran’s pediatricians were divided on the preferred treatment of PS, and as a result 78% of 138 cases during those years were treated with medication. During the latter years of the trial (1966-80), surgery was advised and practised for 83% of PS cases. A marked change: why did it occur?
The report points out that early in the 20th century, surgery for PS was wanted only by the most desperate parents and done only by risk-taking surgeons, as the deathrate from surgery (between 25 and 90%) was much higher than that from atropine and other medical remedies. But during the 23 years’ review, the pediatric community in Tehran became convinced that it should now advise surgery more readily. This reflects the shift that I reported happening in earlier decades in the English-speaking world, though not in every other country.
The Iranian surgeons worked through a transverse incision (as had become common in the USA), and general anesthesia was the rule, with local pain control used in certain cases (as elsewhere). Complications and morbidity (continuing health problems) were tracked and found to be more frequent among medical cases. As I have mentioned in earlier posts, the reduction in hospital stays which surgery made possible was a major advantage, and x-ray exposure also fell dramatically as babies no longer had to be monitored over a lengthy period.
It is interesting that this article was written in German, reflecting substantial links with a country which also took its time to move from medical to surgical treatment for PS.
The second article of special interest to me came from the pediatric surgeons at the Sacramento Medical Center in California. They reviewed 50 cases between 1963 and 1970; it is noteworthy that only 38 were Caucasian, only 8 of 39 were first-born males, and only 4 of 11 first-born girls. Whether or not PS is more common among first-borns is still far from clear.
Some of the information given is enough to give a non-professional but interested PS student some idea of the many considerations that surround PS treatment.
> 8 of the 50 cases were found to be “severely alkalotic”: they had a low CO2 level which is a warning about an infant’s ability to withstand a general anesthetic.
> Of the 50 babies, 46 went to surgery, of whom 44 had a general anesthetic and 2 local.
> Four patients were treated with intravenous fluid and electrolyte infusion, as well as lavage (stomach washes) and graded feedings. There was one death in this group: a baby who arrived in a very poor condition after 3 weeks of vomiting and died two days later. The other three stayed in hospital between 12 and 16 days, followed by further medical therapy at home. These 3were followed for a minimum of two years, and each had intermittent signs of gastric dysfunction, poor feeding habits, intermittent episodes of nausea and vomiting, and retarded growth and development.
> The babies who had surgery had a 26% complication rate (pneumonia, wound infections, and an incomplete pyloromyotomy).
> In addition to this, a terrible 39% needed repair to the duodenum during surgery (a high risk with this operation) and two cases suffered liver damage, it seems as a result of too many enthusiastic physical examinations searching for “the pyloric olive”!
> This report also includes an interesting discussion of the several incisions used for PS surgery, and comments that each seems to have its supporters. Historically, the various abdominal incisions used to treat PS were developed to minimize wound rupture, something that brought with it high mortality in small, starved and weak infants. The incisions used in the 1970s included those mentioned in the post on the 1960s. This report from Sacramento details the method linked with each incision and adds transverse (horizontal) skin incisions situated to the right and above the umbilicus.
> It is remarked that the actual abdominal incision used is essentially a matter of cosmetic consideration only. In fact it often seems to depend on the personal preference of the surgeon. It seems to me that in actual fact the cosmetic result depends little on the incision used and a lot on the skill of the surgeon and the later development of the patient’s belly.
Right paramedian (vertical) incisions were used in 18 of the 46 surgery cases in this series, subcostal (under the ribs) in 9, and transverse in 19. All three wound infections occurred in the last group. There were no wound ruptures in this review.
The final article that interested me especially was a careful study of abdominal wound rupture reported in a 1972 Bulletin of the Hong Kong Medical Association.
During 1967-71, 5749 abdominal operations in a Hong Kong hospital were studied to assess the incidence and causes of wound dehiscence (or rupture along the incision line) after the surgery. 593 of these operations were done on pediatric patients (under 12 years), with a dehiscence rate of 3%; among the adults (57% of whom were aged between 51 and 86) the rate was much lower, 0.89%. The overall rate of wound rupture was 1.1% which it is claimed compares favourably with other studies.
Of the children 79 had tranverse incisions, with 10% of the wounds rupturing. 86 of the children had vertical incisions (mid or para-midline) with 12% dehiscing. I note that both this and the previous report I have outlined seriously doubt the advantages of the now popular transverse incisions!
Among the children, biliary atresia, intussusception and congenital hypertrophic stenosis were the three conditions which were associated with very high incidence of wound disruption. Although only 8 of these procedures involved babies with PS and this is a small number on which to base conclusions, the report found it that these babies had the highest dehiscence rate, at 25%.
PS is often diagnosed late after prolonged starvation with vitamin C and protein deficiency. Biliary atresia brings with it poor general health, malnutrition, and abdominal distension. Good wound healing is much hampered as a result.
Transverse incisions have long been strongly favoured, especially in the US, because according to reports like that of Campbell and Swenson in 1972, transverse incisions in infants have a dehiscence rate around 0.2% compared with 3.37% of vertical incisions rupturing.
However, the two Hong Kong surgeons found there was little difference between the rates of wound dehiscence after transverse and vertical incisions among the paediatric age group.
And they comment that In spite of the vast amount of work that has been carried out in the last three decades on wound healing, there is still no reliable method of improving and accelerating the healing of wounds. Abdominal wounds continue to dehisce occasionally.