In my previous post I wrote about the introduction during the early 1990s of umbilical pyloromyotomy, the surgical treatment of infant pyloric stenosis (PS) in a way that results in minimal scarring. Growing up and venturing into the adult world with an obvious but mystery scar has been a significant hurdle for many PS survivors.
I know this from personal experience. Many of us who escaped a very early death would be even more grateful for the gift of our life if early surgery had not left us with challenges including sometimes PTSD, a prominent scar and / or parents from a past age which expected children to be seen but not heard, even if it concerned their troubling personal questions.
A second new treatment option was introduced for PS babies in the 1990’s. Minimal access (MAS) or laparoscopic surgery became available from 1991 for a growing if short list of infant “procedures”. Medical journal articles trace the growing refinement and availability of MAS for PS through the 1990s and the decade since.
At first MAS for PS came with frequent complications (or “a high morbidity rate” to use medical jargon). The frequency of mistakes and after-effects associated with PS surgery had been steadily reduced during the 20th century, but now increased again as surgeons had to work without direct sight of their “target area”.
- Perforation of the mucosa (the inner lining of the pylorus) or the duodenum is the result of a too deep or lengthy cutting of the pyloric muscle: it is life threatening if not immediately recognised and repaired.
- Incomplete pyloromyotomy results from insufficient splitting of the swollen pylorus and does not become clear until it is found that the baby continues to vomit several days after its operation.
- Bleeding is not normally a hazard in pyloromyotomy, but when it occurs it also must be managed promptly.
- Infection of the umbilicus can occur from both umbilical and MAS pyloromyotomy because of the difficulty of sterilising the folds inside the umbilical stump.
It was found that pediatric surgeons needed some 25 operations to become MAS-pyloromyotomy-skilled, and that this surgery should therefore only be considered in hospitals with sufficiently skilled teams of surgeons and anesthetists.
Which new surgical technique is to be preferred?
During my years of work on this subject it has become clear to me that if one of my grandchildren had needed PS surgery (which I am grateful has not occurred) I would advise that provided there was a choice and that provided the operation could be done by a skilled and careful surgeon, the parents choose surgery via the umbilicus rather than MAS.
The scar from a carefully done umbilical pyloromyotomy can be almost invisible, as the photos with the previous post make clear.
However, MAS pyloromyotomy is normally done through three small stab wounds of about 3 cm each and including one through the umbilicus. These wounds often heal very well and become almost invisible after a year or so, much to the relief of the anxious parents. But the scars will grow with the child, eventually tripling in size and usually becoming quite indented. I have noticed that these PSers even before teenage look seem to have three belly buttons, not something I would have found easier to deal with than the centipede scar on my belly! The development of these obvious pits is impossible to avoid although good plastic surgery in later life could release them from the underlying tissue and reduce the indentation.
The development of anesthesia continued during the 1990s and many reports and other articles help tell this story. The use of the various forms of ether had died out in most operating rooms due to its undesirable effects. The trauma that resulted from the giving of ether and other early anesthetics disappeared as quick acting sedative drugs like sodium pentothal came to be injected prior to the induction of deep anesthesia. Paralysing drugs and endo-tracheal tubing to support breathing and avoid the inhalation of vomit and secretions were now only introduced after the patient was unconscious.
Lay persons like me will be utterly horrified that during the 1990s some pediatric anesthetists and surgeons continued to insist on the claimed benefits of intubating the patient while awake, and/or to maintain that infants are not affected by lack of general or local pain control and by being paralysed during awake surgery. Whilst I can understand that every choice of technique will more than likely have both drawbacks and benefits, the fact that these issues continued to be debated during the 1990s tells me something about human nature and some of the problems of the medical profession.
Finally what I find a somewhat sad note. A 1991 letter by two British paediatricians tells us that Eumydrin, a muscle relaxing drug long used to treat most mild PS cases with medicine rather than the knife, was taken off the market in 1987. These men also commented that this move was not unconnected with a growing lack of training and experience among doctors in the non-surgical treatment of PS. This meant that surgery for PS was becoming the only available treatment for PS, at least in the English-speaking world.