23 - Infantile hypertrophic pyloric stenosis

Summary

Introduction

Although there were undoubtedly earlier descriptions, Hirschsprung gave the first accurate account of pyloric stenosis in 1887. The first reports of successful surgical treatment of pyloric stenosis appeared in the late nineteenth century. Various surgical techniques were described including gastroenterostomy and forcible dilatation of the pylorus (Loreta's operation). In 1902 Dent treated a baby with pyloric stenosis by performing a Heineke–Mickulicz pyloroplasty. Over the following decade various extramucosal pyloroplasties were reported until, in 1912, Ramstedt described the pyloromyotomy that has become the standard treatment today.

In the early years perioperative mortality was unacceptably high and medical therapy for pyloric stenosis was favored in many centers. This involved assiduous attention to feeding, anticholinergic drugs (of which atropine methylnitrate was most favored) and often long periods of time in hospital. Surgical treatment for pyloric stenosis became increasingly popular in North America and Britain after the Second World War, although a few pediatricians continued to report successful use of atropine into the 1950s. Medical treatment remained commonplace in Europe into the early 1970s before being superseded by surgery.

Ramstedt's procedure is now firmly established as the treatment of choice for pyloric stenosis. With appropriate preoperative rehydration and skilled anesthesia the perioperative mortality is negligible. Recent study has centered on the use of ultrasound for early diagnosis and the choice of incisions (transverse, circumumbilical or laparoscopic) for exposure of the pylorus.

Treatment

It is a testimonial to the success of Ramstedt's operation that it remains the procedure of choice for pyloric stenosis.