Egg on my face!
After years of finding, digesting and archiving web-based reports on infant pyloric stenosis (“PS”) I have often commented on the virtual absence of any mention, let alone careful consideration, of the medical treatment alternative for PS. It is certainly so that based on what I have found, throughout the world the Ramstedt operation is now recommended and absolutely dominant.
However, in the two weeks since writing again about the medical therapy alternative, I have found several articles that do give at least some details more details of this alternative, although usually in passing and hardly positive.
This last week I discovered three more reports.
One was a 2006 report in French from Benin in West Africa about the value of the medical atropine treatment in developing countries where safe surgery is unlikely even if it’s available. It reported two successful cases of this. It also referred to supportive reports from India, Japan, Serbia and other countries which I have mentioned in previous posts.
Another article was in a 2010 journal for nurse practitioners (NPs) and doctors’ assistants (PAs): it comes with the promising title, Pyloric stenosis: exploring all the options. The article is modest (presumably due to its intended readers) but true to its title: it does cover the subject of PS in a comprehensive overview, including a survey of many of the possible ways of treating PS, including medical treatment with atropine sulfate.
This is how the writers deal with the hardly ever mentioned medical path of treating PS –
Despite poor outcomes without surgery,alternatives are necessary for patients who are not well enough to have surgery, who have limited access to surgery or whose family refuses surgery. One alternative is the use of atropine sulfate as an antispasmodic agent to prevent peristalsis in the stomach. It is administered intravenously at 0.01 mg/kg six times a day, 5 minutes before feeding, and the dose is increased daily until 150 mL/kg per day is achieved without emesis. When a patient’s vomiting has subsided and steady weight gain has been achieved, atropine can be decreased in three steps of 0.12, 0.06 and 0.03 mg/kg per day. Skilled nursing care is required to carry out these repeated injections.
Even with a longer hospital stay, no significant difference exists in medical cost between atropine and surgery. Disadvantages of IV atropine therapy include length of hospital stay and the necessity of continuing oral atropine after discharge. The long-term effects of atropine therapy on pyloric motility need to be investigated to clarify the value of medical treatment compared with surgical treatment.
For references to what is reported here, please use the link to read the full article.
I am grateful that this article does acknowledge that there is a place to consider atropine therapy. I have posted a survey of the possible long-term effects of treating PS both surgical and medically. Briefly here, many readers will feel that medical treatment should be the case in the light of –
1) the long-term physical effects of infant surgery which are rarely acknowledged although all-too-real for those affected; I have written about adhesions, GERD and IBS;
2) the various long-term emotional effects on many of the scarring from infant surgery;
3) the fact that medical treatment is non-invasive and cannot cause shock or trauma.
Here are the authors’ conclusions –
It is important for PAs and NPs seeing infant patients to know what to look for during examination and, for definitive cases, to educate the family about the therapeutic options. Surgical success rates approach 100%, and with the decreased length of hospital stay, decreased time to first feeding, lower surgical stress, potentially decreased surgical time and better long-term cosmesis, laparoscopic pyloromyotomy might be the best option. For patients in whom surgery is contraindicated or impractical, atropine sulfate therapy shows the greatest potential.
The final reference of interest here is a letter to a medical journal which has been in my files but which I had overlooked. This 1991 letter reports on 19 years of solid and positive experience with medical PS treatment in a British hospital. Two surgeons report on 62 PS babies, 7 of whom were successfully treated medically. They also affirm the work and writings of an earlier and well-known British pediatric surgeon, Dr Jacoby, who reported operating on 104 PS infants “with minimal morbidity and mortality [and] there were a further 101 who tended to present later, have less severe vomiting, showed less weight loss and dehydration, and who responded rapidly and successfully to atropine methonitrate (Eumydrin).”
This letter then states disturbingly, “In 1987 Eumydrin was taken off the market, having been in use for 60 years. Paediatricians were thus denied the opportunity of avoiding surgery with its 24-50% complication rate.” (Note that this very high complication rate was true of many UK hospitals at the time but has fallen since 1991; however, reading the posts of parents of today’s PS babies suggests that even now PS surgery comes with many more complications and ongoing problems than medical reports admit.) The entire letter is worth reading by those interested in this matter.
Note: To read the comments of pediatric surgery professor-emeritus Dr Ian M Rogers on the withdrawal of the drug Eumydrin, please see my post dated 5 September 2013.
Also very disturbing for me has been to find that The Lancet, a leading medical journal, is maintaining its unavailability to the public eye. Web searches show that this journal has included several articles on the “surgery or medical treatment for PS” issue going back to the earlier 20th century, but these are only available to subscribers or singly for an unreasonable sum of money (US$31.50 each!!!).
Withdrawing an effective drug… keeping the public from seeing articles on important matters, even after 60 or 70 years… sigh, it makes one wonder what some parts of the medical world want to hide from us?