Tag Archives: century

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!