100 years of Pyloric Stenosis surgery – an academic’s review

In October 2012 I posted a tribute and three reflective articles on the centenary of the publication of the German Dr Conrad Ramstedt’s surgical technique to relieve pyloric stenosis (“PS”).

This operation saved my life less than two weeks after my birth in 1945, and it has become the most used treatment of this condition and the most common non-elective infant surgery.  However, debate continues on issues such as –

  • Can PS be more promptly diagnosed more often so that more treatment options are available?
  • Should medical (rather than surgical) treatment be tried on more PS babies, with surgery as a later option?
  • How important is it to choose a surgical technique that reduces scarring in later life?
  • Can the symptoms reported by PS surgery survivors (PTSD and a long list of immediately or later evident abdominal complaints) be linked with PS or its treatment, and perhaps avoided?
  • Do the medical journal articles on PS and pyloromyotomy (PLM) deal with great repetition on just a small number of the related issues and avoid other significant matters?

Last year I found only one or two medical journal articles prompted by the centenary of Ramstedt’s pyloromyotomy: these were available only upon what would be for many a costly subscription, and the Abstract (supplied by only one publisher) gave nothing significant away.

Raveenthiran Prof Dr V 2012.bmpHowever, I am very thankful that during the past week, the Indian Prof. Venkatachalam Raveenthiran published an online review of the past 100 years of PS surgery which he generously made available to anyone interested.  There is also a ‘pdf version available on the web.

So once again I’d like to report on a medical journal report:  to summarise it, highlight the main points, and where necessary “translate” it and sometimes comment on it for general reading.

I have found that some of Prof. Raveenthiran’s observations are of real interest to one who has learnt to be thankful for the discovery of this surgery – despite the many years of my struggle with some of its after-effects.

  • The discovery of a surgical technique that brought to an end the very high mortality rate of PS babies has not reduced the interest in the condition.  In fact, in recent years the number of research reports about PS and PLM published annually has increased, and several of the formerly accepted data have been contradicted or rejected.
    However, I (Fred) am not alone in having observed that much of this output is very repetitive and sometimes even trite (stating what is already established).
  • US measures PLM01-1Dr Raveenthiran observes and discusses the growing reliance on diagnosing PS by ultrasound (U/S) technology rather than by simply palpating “the olive” (feeling for the swollen pylorus).  Others and I have reported this also.  The Professor reviews some of the current rather rigid diagnostic criteria, their failings, and their nature which show the need for more research if U/S is to be a more reliable and effective tool.
  • Another current “discovery” is questioned and analysed by the doctor: the widely quoted Danish study that claimed that bottle-fed babies had 4.6 times as much risk of developing PS as breast-fed infants.  This research report also contradicts the “established belief” of earlier years, and Dr Raveenthiran asks some pertinent questions.
  • Plm Lap single port01During the last 20 years circumbilical (around the umbilicus or navel) and Minimal Access Surgery (MAS, also laparoscopic) techniques and equipment have been increasingly applied to infant surgery, including PLM.  In recent years, as this website page shows, MAS using miniaturised equipment (still leaving three but smaller scars) and single-incision laparoscopy (SILS) through the umbilicus have come into use, for both adult and infant patients, and most reports state that after a learning process is completed, the results with the new techniques show no major disadvantages plus the benefit of an improved cosmetic outcome.
    Prof. Raveenthiran expresses bemusement at this string of claimed improvements, questions the practicality of SILS, and mentions yet another new technique, endoscopic PLM (removing the blockage from inside the gastric canal) which has not yet been used on human subjects.
    At this point I (Fred again) recalled reading a recent report that found most pediatric surgeons who had graduated more than 20 years ago were still using open incisions for their PLMs.  As they say,  It’s hard to teach an ol’ dog a new trick.
    As one of the countless PS survivors whose main after-effect has been our struggle to come to terms with an eye-catching and ugly scar, I say (as strongly as I can):  Hey! Please! Yes!  All other considerations being equal, bring on more cosmetically-considered infant surgery!
    Note: See also Dr Raveenthiran’s comment below.
  • In his final paragraph, Prof. Raveenthiran castigates the common attitude that “PS doesn’t have any after effects”.  My comment on this: Hear! Hear!
    He mentions something else I and others have often pointed out: the almost total lack of long-term follow-up of PLM patients, and of research into the long-term effects of PS and PLM.  He touches on some of the problems that have been discovered (but largely ignored and unknown): significantly lower cognitive, receptive language and motor scores, irritable bowel syndrome, and chronic functional dyspepsia and functional abdominal pain at a later age.  He calls for much more long-term study of these problems.

On a personal level, I was once again gratified and reassured as I found that almost everything Prof. Raveenthiran chose to mention and highlight in his essay was a matter that I have also raised, discussed and advocated for in these blogs – albeit without the benefit of medical training and without supposed academic status.  Isn’t it wonderful that the web allows any and all of us to dig out information for our own and others’ help and healing?

Another new year has dawned… Here’s to the victory of truth!

Advertisements

7 thoughts on “100 years of Pyloric Stenosis surgery – an academic’s review

  1. Fred Vanderbom Post author

    Prof Raveenthiran kindly made this Comment after I sent him a link to this post:
    I wish to clarify one aspect of it – that is regarding scars. It is not the open surgery that is to blamed for a bad scar. Rather it is the technique of skin closure that matters. It is well known that plastic surgeons make surgical scars in the face that are invisible. If all other surgeons follow the plastic principle while closing their surgical wounds, the scar will be invisible irrespective of its long length. Laparoscopy or other techniques that are described to avoid scars are a medical myth. Sometimes I have seen Laparoscopy scars that are unsightly albeit small.
    I herewith enclose a copy of my satire on so called minimal invasive surgery which I hope you will enjoy reading.
    Fred’s Comment: I value and endorse this Comment. While discussing scars in past blogs I have noted that the scars from laparoscopic surgery can be as unsightly as many of those from open surgery.

    Reply
  2. Wendy

    Fascinating! I am so grateful to hear about Dr. Reveenthiran’s ideas and to have access to the PDF (read it once over breakfast but realized it required more concentration (sans meal) so will read again. Incredible that little to no PLM follow-up has been made. Irresponsible! And to know that my raggedy scar, rather like the stitching on a football, was avoidable! Steam is coming out of my ears! Thank you for the accessible summary of the doctor’s article. Given the repetitive nature of PS articles in general, his words are fresh air.

    Reply
  3. Fred Vanderbom Post author

    Your remarks have my full agreement, Wendy. I am very thankful for the morsels of clarifying information that some of our medical correspondents have given us in the past year: may this grow!
    While I can understand that not every surgeon will command the specialized skills and commitment of a plastic surgeon, I do wonder why pediatric surgeons and general surgeons working on infants have not been trained and personally committed to giving much, much more attention to the long-term consequences and cosmetics of their work.
    Several of the issues of infant surgery show, I’m afraid, that some of the future needs of babies and children have far too often been written off as of little or no concern – and this was (and perhaps still is) justified with some arrogance in terms of, “Surely, saving life is all that really matters?”

    Reply
  4. Meg

    I stumbled across this website while researching surgical options for the removal/reduction of my own unsightly PS scar. While I am grateful for the life-saving surgery I received 29 years ago, my vanity has never been able to come to terms with my mutilated abdomen. I am grateful for the access to Prof. Venkatachalam Raveenthiran’s research and observations regarding the long-term effects of PS surgery on infant patients. Thank you for this article!

    Reply
  5. Fred Vanderbom Post author

    Thank you Meg for your endorsement.
    The many readers here would be very interested to know how you go with your hopes (or plans?) for scar revision surgery. Many us would love it, but few seem to sign up for it and the reports on its outcomes are very rare indeed!
    I hope it will become better cared about by those surgeons who operate on infants that so many of us, as you say, value the gift of our lives but wish our scars were not as disfiguring.
    One surgeon has written to me privately that the problem is at least in part due to the fact that most general and pediatric surgeons care little about the quality of their wound closure; he remarked that if all surgeons used the techniques of plastic surgeons, people like us would have far less angst.
    Best wishes for your journey!

    Reply
    1. Meg

      Thank you, Fred! I will be sure to come back and share my experiences going forward. It’s tough to know where to begin! My scar resulted in adhesions, which have caused me discomfort from an early age. It pulses and itches whenever I exercise. After a general practitioner told me there would be no point in having it removed, I did my best to accept it. At a pool party in the 2nd grade I told my friends that I gave birth to an alien baby. (The scar appeared violent and jagged enough to convince them.) But now that I am financially stable I am looking into the best options for scar revision. Informational resources regarding this particular area are scarce. Blogs like yours give me valuable insight, and much comfort in knowing I’m not alone. Thanks again!

      Reply
  6. Wendy

    Hi Meg, I want to encourage you to share your experience on SIS if you go ahead with scar revision. I’ve got what I call a TV antennae scar. Raggedy, for sure. But I would never have surgery to fix it. I try to avoid surgery at all costs after the rough PS beginnings. Good luck to you!

    Reply

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s