What a difference a century makes! 100 years ago most babies with a medical problem such as pyloric stenosis died, as did many other little ones. Infections, disease, illnesses, poverty, accidents and tragedies claimed huge numbers of lives. Lack of effective birth control is not the only reason why so many people had (and in some countries still have) lots of babies.
A century ago this year a German Doctor, Conrad Ramstedt, published a report on his accidental discovery of what has been labelled since “the Ramstedt pyloromyotomy”, which revolutionised the treatment of infant pyloric stenosis (PS). Before 1912, medical treatment (with a drug) was the preferred treatment for PS, even though more or less than half the babies so treated died of starvation or dehydration anyway. The several surgical remedies then available were so severe and crude that they were regarded as a last resort. Read: “accompanied by an even higher risk of death – but you just might be lucky”.
In the previous post I included one of several photos published by a German university, showing the huge cosmetic improvement of PS surgery. In the two previous posts I mentioned and illustrated the two surgical techniques which were introduced some 20 years ago to give PS babies a future with minimal scarring from their life-saving operation: peri-umbilical and laparoscopic surgery.
Many of the medical journal articles of the past 10-20 years that deal with PS have dealt with one of two subjects: the pros and cons of umbilical and laparoscopic pyloromyotomy, and the advances of anesthetic drugs and technique.
Both peri-umbilical (“through the umbilicus”) and laparoscopic surgery are skills that require patient learning, special equipment and extra careful use. It is clear from the literature that whilst many small town general surgeons would perform the occasional PS operation on a baby (though all-too-often rather crudely), the new techniques required a specialist team and a well-equipped and funded hospital. No wonder so many pyloromyotomies today continue to be done “the old way”: the material on the web indicates that all the old incision favourites may still be found today, together with surgeons who still sew through a baby’s skin rather than burying their craft inside the wound or using adhesive glue or tape. Some of these little ones will grow up with a more disfiguring scar than mine from long-ago 1945!
However, in many countries the great majority of infant surgery is competently done from a technical point of view, and more often than not uses one of the two new and preferable techniques.
One 2004 article reported on a review of 8 medical articles comparing a total of 355 open (long incision) and 240 laparoscopic pyloromyotomies. It concluded that open surgery, apart from being more available results in slightly fewer complications from collateral damage, and thus had a greater immediate success rate – although the report remarked that this difference might only be due to a learning curve. Where available, the laparoscopic technique is comparable in terms of operating time, and better in terms of post-operative recovery time and hospital stay whilst giving a clear cosmetic benefit to the patient (and parents).
Another study comparing open and laparoscopic pyloromyotomy generally supported the previous report, and also found that the minimal access (laparoscopic) method results in the less pain and post-operative vomiting. Articles on the umbilical route reported that while potentially being the least scarring and having fairly similar benefits to the laparoscopic technique, it does run a higher risk of infection unless the site is very thoroughly cleansed and antibiotic treatment is given before the surgery.
Pediatric anesthesia is another subject that has attracted considerable attention during the past decade, and understandably for me, I was particularly interested in what I learnt about anesthetic technique for pyloromyotomy. Reading several of these articles has made me aware of the enormous complexity of this field: I am grateful that I could understand more than enough to benefit greatly from what I read, but I must also say that the material is too extensive and technically challenging for me to be able to pass much of it on. However, some general observations will be valuable.
- The effects of PS on a tiny baby affect many parts of its fragile little body, and anesthetic drugs have their own powerful effects: these two must be very well understood and then carefully matched and monitored during surgery.
- When I was operated on in 1945, some surgeons used ether, others local anesthetic around the incision, and some (from what I have been able to find, a fairly substantial minority) used alcohol and/or sugar to pacify the baby, or nothing at all, perhaps or of necessity together with a paralysing drug. As ether has so many side effects, I can understand why so many of the contemporary report writers (and I suspect my surgeon) used local anesthetic – and probably paralysed and sedated their little patient. (With what effects we have found out since.)
- Ether, so common, useful (and feared) in almost all surgery since the mid-1800s, was phased out in most “developed” countries in the 1980s.
- Today, local anesthesia is still used occasionally, for minor surgery, when other medical conditions make unconsciousness too hazardous, or when the parents refuse general anesthetic use.
- Despite critical information and policies laid down in the 1980s, there still seem to be surgeons today who don’t use pain relief for infant surgery. However, it is being increasingly recognised that pain does affect even newborn infants, and pediatric anesthesia is now an established field in medical knowledge and practice.
- There is an ongoing debate about the preferred way to intubate a baby (inserting a tube into a baby’s throat to deliver gases and prevent the breathing in of vomit and mucous). There seem to be arguments for doing this before general anesthesia is induced (with inevitable trauma to the baby) rather than after. It seems that most anesthetists today will intubate a baby after it has first been put to sleep with an intravenous sedative and its throat has been relaxed.
- A long inventory of anesthetic drugs is available today; each has its uses, benefits and drawbacks, and a PS surgery will normally involve the use and/or mixtures of several of these, as well as pain relieving drugs for the post-operative hours and days.
- Pediatric anesthesia only started to become a recognised specialty about 1940, just a few years before my surgery. Today the pediatric anesthetist is certainly a vital and skilled member of the PS surgery team. We have come a long way.