Skip to main content
SpringerLink
Log in

Anesthesia for Hypertrophic Pyloric Stenosis

  • Chapter
  • First Online:
Anesthesiology

  • 3061 Accesses

Abstract

Hypertrophic pyloric stenosis (HPS) in an important differential diagnosis in the vomiting infant and remains the most common condition that requires surgical treatment in this age group.

Beyond the common issues that are faced by an anesthesia provider when delivering anesthesia to an infant, management of HPS requires an increased awareness of a number of potential pitfalls.

A review of the anatomy and physiology of the disease is presented, and the medical issues surrounding adequate correction of hydration status, and blood chemistry are discussed.

Safe anesthesia involves addressing aspiration risk at the start of the case and balancing reliable analgesia with the risk of apneas in the post-operative phase. The various benefits and drawbacks of the current induction strategies for general anesthesia, and the potential role for regional anesthesia are explored.

Pyloromyotomy has traditionally been done via the open Ramstedt procedure, but recently with the expansion of laparoscopic surgery, it is important to review the implications of pneumoperitoneum in the infant population.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 139.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 179.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 249.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. MacMahon B. The continuing enigma of pyloricstenosis of infancy: a review. Epidemiology. 2006;17:195–201.

    Article  PubMed  Google Scholar 

  2. de Laffolie J, Turial S, Heckmann M, Zimmer KP, Schier F. Decline in infantile hypertrophic pyloric stenosis in Germany in 2000–2008. Pediatrics. 2012;129:e901–6.

    Article  PubMed  Google Scholar 

  3. Aboagye J, Goldstein SD, Salazar JH, et al. Age at presentation of common pediatric surgical conditions: re-examining dogma. J Pediatr Surg. 2014;49:995–9.

    Article  PubMed  Google Scholar 

  4. Piroutek MJ, Brown L, Thorp AW. Bilious vomiting does not rule out infantile hypertrophic pyloric stenosis. Clin Pediatr (Phila). 2012;51(3):214–8. https://doi.org/10.1177/0009922811431159. Epub 2011 Dec 12.

    Article  Google Scholar 

  5. Glatsein M, Carbell G, Boddu SK. The changing clinical presentation of hypertrophic pyloric stenosis: the experience of a large, tertiary care pediatric hospital. Clin Pediatr. 2011;50:192–5.

    Article  Google Scholar 

  6. Dalton BG, Gonzalez KW, Boda S, Thomas PG, Sherman AK, St Peter SD. Optimizing fluid resuscitation in hypertrophic pyloric stenosis. J Pediatr Surg. 2016;51(8):1279–82. https://doi.org/10.1016/j.jpedsurg.2016.01.013. Epub 2016 Feb 3.

    Article  PubMed  Google Scholar 

  7. White MC, Langer JC, Don S, et al. Sensitivity and cost minimization analysis of radiology versus palpation for the diagnosis of hypertrophic pyloric stenosis. J Pediatr Surg. 1998;33:913–7.

    Article  PubMed  CAS  Google Scholar 

  8. Hernanz-Schulman M. Pyloric stenosis: role of imaging. Pediatr Radiol. 2009;39:S134–9.

    Article  PubMed  Google Scholar 

  9. Hirschsprung H. Falle von angeborener pyloric stenose. Jahrb Kinderhik. 1888;27:61.

    Google Scholar 

  10. Kusafuka T, Puri P. Altered messenger RNA expression of the neuronal nitric oxide synthase gene in infantile hypertrophic pyloric stenosis. Pediatr Surg Int. 1997;12:576–9.

    Article  PubMed  CAS  Google Scholar 

  11. Boybeyi O, Soyer T, Atasoy P, Gunal YD, Aslan MK. Investigation of the effects of enteral hormones on the pyloric muscle in newborn rats. J Pediatr Surg. 2015;50:408–12.

    Article  PubMed  Google Scholar 

  12. Serra A, Schuchardt K, Genuneit J, Leriche C, Fitze G. Genomic variants in the coding region of neuronal nitric oxide synthase (NOS1) in infantile hypertrophic pyloric stenosis. J Pediatr Surg. 2011;46:1903–8.

    Article  PubMed  Google Scholar 

  13. Aspelund G, Langer JC. Current management of hypertrophic pyloric stenosis. Semin Pediatr Surg. 2007;16:27–33.

    Article  PubMed  Google Scholar 

  14. Krogh C, Fischer TK, Skotte L, Biggar RJ, Øyen N, Skytthe A, et al. Familial aggregation and heritability of pyloric stenosis. JAMA. 2010;303(23):2393.

    Article  PubMed  CAS  Google Scholar 

  15. Gladstein K, Spence MA. A statistical analysis of birth-order effects with application to data on pyloric stenosis. Ann Hum Genet. 1978;42:213–7.

    Article  Google Scholar 

  16. Vermes GG, László D, Czeizel A, Acs N. Maternal factors in the origin of infantile hypertrophic pyloric stenosis—a population-based case-control study. Congenit Anom. 2016;56(2):65–72.

    Article  Google Scholar 

  17. Krogh C, Biggar RJ, Fischer TK, Lindholm M, Wohlfahrt J, Melbye M. Bottle-feeding and the risk of pyloric stenosis. Pediatrics. 2012;130:e943–9.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Rammstedt C. Zur operation der angeborenen pylorus stenose. Med Klin. 1912;8:1702–5.

    Google Scholar 

  19. Perger L, Fuchs JR, Komidar L, Mooney DP. Impact of surgical approach on outcome in 622 consecutive pyloromyotomies at a paediatric teaching institution. J Pediatr Surg. 2009;44:2119–25.

    Article  PubMed  Google Scholar 

  20. Eltayeb AA, Othman MH. Supraumbilical pyloromyotomy: a comparative study between intracavitary and extracavitary techniques. J Surg Educ. 2011;68:134–7.

    Article  PubMed  Google Scholar 

  21. Pelizzo G, Bernardi L, Carlini V, et al. Laparoscopy in children and its impact on brain oxygenation during routine inguinal hernia repair. J Minim Access Surg. 2017;13(1):51–6. https://doi.org/10.4103/0972-9941.181800.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Gupta R, Singh S. Challenges in paediatric laparoscopic surgeries. Indian J Anaesth. 2009;53(5):560–6.

    PubMed  PubMed Central  Google Scholar 

  23. Tytgat SH, Stolwijk LJ, Keunen K, Milstein DM, Lemmers PM, van der Zee DC. Brain oxygenation during laparoscopic correction of hypertrophicpyloric stenosis. J Laparoendosc Adv Surg Tech A. 2015;25:352–7.

    Article  PubMed  Google Scholar 

  24. Hall NJ, Van Der Zee J, Tan L, Pierro A. Meta-analysis of laparoscopic versus open pyloromyotomy. Ann Surg. 2004;240:774–8.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Hall NJ, Eaton S, Seims A, et al. Risk of incomplete pyloromyotomy and mucosal perforation in open and laparoscopic pyloromyotomy. J Pediatr Surg. 2014;49:1083–6.

    Article  PubMed  Google Scholar 

  26. Ednie AC, Amram O, Creaser JC, Schuurman N, Leclerc S, Yanchar N. Hypertrophic pyloric stenosis in the maritimes: examining the waves of change over time. Can J Surg. 2016;59(6):383–90. https://doi.org/10.1503/cjs.002816.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Kawahara H, Takam Y, Yoshida H, et al. Medical treatment of hypertrophic pyloric stenosis: should we always slice the olive? J Pediatr Surg. 2005;40:1848–51.

    Article  PubMed  Google Scholar 

  28. Lukac M, Antunovic SS, Vujovic D, et al. Is abandonment of nonoperative management of hypertrophic pyloric stenosis warranted? Eur J Pediatr Surg. 2013;23:80–4.

    Article  PubMed  Google Scholar 

  29. Peters B, Oomen MW, Bakx R, Benninga MA. Advances in infantile hypertrophic pyloric stenosis. Expert Rev Gastroenterol Hepatol. 2014;8:533–41.

    Article  PubMed  CAS  Google Scholar 

  30. Kamata M, Cartabuke RS, Tobias JD. Perioperative care of infants with pyloric stenosis. Paediatr Anaesth. 2015;25:1193–206. https://doi.org/10.1111/pan.12792.

    Article  PubMed  Google Scholar 

  31. Nissen M, Cernaianu G, Thranhardt R, Vahad M, Barenberg K, et al. Does metabolic alkalosis influence cerebral oxygenation in infantile hypertrophic pyloric stenosis. J Surg Res. 212:229–37.

    Article  Google Scholar 

  32. Yanchar NL, Rangu S. Corrected to uncorrected? The metabolic conundrum of hypertrophic pyloric stenosis. J Pediatr Surg. 2017;52(5):734–8. https://doi.org/10.1016/j.jpedsurg.2017.01.024. Epub 2017 Jan 28.

    Article  PubMed  Google Scholar 

  33. Cook-Sather SD, Tulloch HV, Liacouras CA, et al. Gastric fluid volume in infants for pyloromyotomy. Can J Anaesth. 1997;44:278–83.

    Article  CAS  PubMed  Google Scholar 

  34. Fastle RK, Roback MG. Pediatric rapid sequence intubation: incidence of reflex bradycardia and effects of pretreatment with atropine. Pediatr Emerg Care. 2004;20(10):651–5.

    Article  PubMed  Google Scholar 

  35. Cook-Sather SD, Tulloch HV, Cnaan A, et al. A comparison of awake versus paralyzed tracheal intubation for infants with pyloric stenosis. Anesth Analg. 1998;86:945–51.

    Article  CAS  PubMed  Google Scholar 

  36. Algie CM, Mahar RK, Tan HB, et al. Effectiveness and risks of cricoid pressure during rapid sequence induction for endotracheal intubation. Cochrane Database Syst Rev. 2015;(11):CD011656. Published online 2015 Nov 18.

    Google Scholar 

  37. Neuhaus D, Schmitz A, Gerber A. Controlled rapid sequence induction and intubation—an analysis of 1001 children. Pediatr Anesth. 2013;23:734–40.

    Article  Google Scholar 

  38. Scrimgeour GE, Leather NW, Perry RS, et al. Gas induction for pyloromyotomy. Pediatr Anesth. 2015;25:677–80.

    Article  Google Scholar 

  39. Wang JT, Mancuso TJ. How to best induce anesthesia in infants with pyloric stenosis? Paediatr Anaesth. 2015;25(7):652–3. https://doi.org/10.1111/pan.12690.

    Article  PubMed  Google Scholar 

  40. Plaud B, Meretoja O, Hofmockel R, et al. Reversal of rocuronium-induced neuromuscular blockade with sugammadex in pediatric and adult surgical patients. Anesthesiology. 2009;110:284–94.

    PubMed  CAS  Google Scholar 

  41. Bouvet L, Albert ML, Augris C, Boselli E, et al. Real-time detection of gastric insufflation related to facemask pressure–controlled ventilation using ultrasonography of the antrum and epigastric auscultation in nonparalyzed patients: a prospective, randomized, double-blind study. Anesthesiology. 2014;120(2):326–34.

    Article  PubMed  Google Scholar 

  42. Saldien V, Vermeyen KM, Wuyts FL. Target-controlled infusion of rocuronium in infants, children, and adults: a comparison of the pharmacokinetic and pharmacodynamic relationship. Anesth Analg. 2003;97:44–9.

    Article  PubMed  CAS  Google Scholar 

  43. Westrin P. The induction dose of propofol in infants 1-6 months of age and in children 10-16 years of age. Anesthesiology. 1991;74:455–8.

    Article  PubMed  CAS  Google Scholar 

  44. Pani N, Panda CK. Anaesthetic consideration for neonatal surgical emergencies. Indian J Anaesth. 2012;56(5):463–9. https://doi.org/10.4103/0019-5049.103962.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Sale SM, Read JA, Stoddart PA, et al. Prospective comparison of sevoflurane and desflurane in formerly premature infants undergoing inguinal herniotomy. Br J Anaesth. 2006;96:774–8.

    Article  PubMed  CAS  Google Scholar 

  46. Haidon JL, Cunliffe M. Analgesia for neonates. Contin Educ Anaesth Crit Care Pain. 2010;10(4):123–7. https://doi.org/10.1093/bjaceaccp/mkq016.

    Article  Google Scholar 

  47. Willschke H, Machata AM, Rebhandl W, et al. Management of hypertrophic pylorus stenosis with ultrasound guided single shot epidural anaesthesia-a retrospective analysis of 20 cases. Pediatr Anesth. 2011;21:110–5.

    Article  Google Scholar 

  48. Somri M, Gaitini LA, Vaida SJ, et al. The effectiveness and safety of spinal anaesthesia in the pyloromyotomy procedure. Paediatr Anaesth. 2003;13:32–7.

    Article  PubMed  Google Scholar 

  49. Islam S, Larson SD, Kays DW, et al. Feasibility of laparoscopic pyloromyotomy under spinal anesthesia. J Pediatr Surg. 2014;49:1485–7.

    Article  PubMed  Google Scholar 

  50. Davidson AJ, Morton NS, Arnup SJ, et al. Apnea after awake-regional and general anesthesia in infants: the general anesthesia compared to spinal anesthesia (GAS) study: comparing apnea and neurodevelopmental outcomes, a randomized controlled trial. Anesthesiology. 2015;123(1):38–54.

    Article  PubMed  Google Scholar 

  51. Sun LS, Li G, DiMaggio CJ, et al. Feasibility and Pilot Study of the Pediatric Anesthesia NeuroDevelopment Assessment (PANDA) Project. J Neurosurg Anesthesiol. 2012;24(4):382–8.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Lady Cilento Children’s Hospital, South Brisbane, QLD, Australia

    Trung Du

Authors
  1. Trung Du
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Trung Du .

Editor information

Editors and Affiliations

  1. Hospital University Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA

    Basavana G. Goudra

  2. Department of Anesthesiology, Emory University, Atlanta, Georgia, USA

    Michael Duggan

  3. Department of Anesthesiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA

    Vidya Chidambaran

  4. University Hospitals Birmingham, Birmingham, United Kingdom

    Hari Prasad Krovvidi Venkata

  5. Emory University Hospital, Atlanta, Georgia, USA

    Elizabeth Duggan

  6. University of Alabama at Birmingham, Birmingham, Alabama, USA

    Mark Powell

  7. All India Institute of Medical Sciences (AIIMS), New Delhi, Delhi, India

    Preet Mohinder Singh

Rights and permissions

Reprints and permissions

Copyright information

© 2018 Springer International Publishing AG, part of Springer Nature

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Du, T. (2018). Anesthesia for Hypertrophic Pyloric Stenosis. In: Goudra, B., et al. Anesthesiology. Springer, Cham. https://doi.org/10.1007/978-3-319-74766-8_42

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-74766-8_42

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-74765-1

  • Online ISBN: 978-3-319-74766-8

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation