Transcript Laparoscopic Pyloromyotomy - Children's Mercy Kansas City

Laparoscopic Pyloromyotomy
George W. Holcomb, III, M.D., MBA
Children’s Mercy Hospital
Kansas City, Missouri
Preoperative Evaluation
Pyloric Stenosis
•
•
•
•
•
•
Non-bilious emesis
2-8 wks of age
Male:Female
4:1
Dehydration/Metabolic Alkalosis
Jaundice 10%
Ultrasound length - > 14 mm
thickness - > 4 mm
Indications for Surgery
• Presence of pyloric stenosis
• Need to correct electrolyte abnormalities
and dehydration
Patient Positioning
• Baby placed across
operating table
• Table tilted toward surgeon
• Monitor in front of surgeon
• Assistant/camera holder to
right of surgeon
• Scrub nurse opposite
assistant
• Red rubber catheter in
stomach
Equipment
• 5 mm umbilical cannula
– 4 mm, 70o telescope
• Arthroscopy knife
(Linvatec)
• Pyloric spreader
• Atraumatic grasping
forcep
Tips and Tricks
• Set knife at 2 mm depth
• Incise serosa and muscle to 2 mm
• Sheath knife and use sheath to bluntly separate muscle
• Insert pyloric spreader –
Gently separate pyloric muscle fibers as you view the
submucosa
• Measure length – know length of stenosis on ultrasound
• Distend stomach with 45-60 cc air
• Place omentum over myotomy
Laparoscopic Pyloromyotomy
Alternative Approaches
• RUQ or upper midline incision
• Circumumbilical incision
Complications
• Incomplete myotomy
• Mucosal perforation
• Wound infection
Post-operative Management
• Advance diet per protocol
• Tylenol for pain
• Feed Like A Pyloric (FLAP)





NPO for 2 hours
Pedialyte 30cc PO Q 2h X 2,
Formula 30cc ½ str Q 2h X 2,
Formula 30cc full str Q 2h X 2,
Formula 45cc full str Q 3h ad lib
Recent Literature Reports
Retrospective Review – Laparoscopic,
Circumumbilical and RUQ Approaches
Intraoperative and Postoperative Data Comparison
Characteristic
RUQ
(n=190)
UMB
(n=49)
p Value
Operating room time 71 ± 13□
(min)
74 ± 14†
83 ± 15‡
<0.0001
Operative time (min)
25 ± 9□ ‡
32 ± 9†
42 ± 11
<0.0001
Postoperative length
of stay (d)
1.8 ± 1
1.6 ± 1
1.8 ± 1
0.26
Time to ad lib
feedings (h)
26 ± 22
22 ± 14
26 ± 19
0.07
Conversion rate (%)
LAP
(n=51)
2/51 (4)
JACS 201:66-70, 2005
Retrospective Review – Laparoscopic,
Circumumbilical and RUQ
Approaches
Intraoperative and Postoperative Data Comparison
Characteristic
LAP
(n=51)
RUQ
(n=190)
UMB
(n=49)
p Value
Complication rate (%)
4
10
14
0.23
Mucosal perforation
0
3
3
Wound infection
0
11
3
Wound dehiscence
1
1
1
Incisional hernia
0
2
0
Persistent emesis
1
2
0
JACS 201:66-70, 2005
An Effective Pyloromyotomy Length In
Infants Undergoing Laparoscopic
Pyloromyotomy
Daniel J. Ostlie, MD, Charles E. Woodall III, MD, Kerri R.
Wade, RN, Charles L. Snyder, MD, George K. Gittes, MD,
Ronald J. Sharp, MD, Walter S. Andrews, MD, J. Patrick
Murphy, MD, George W. Holcomb III, MD, MBA
Children’s Mercy Hospitals and Clinics
Kansas City, Missouri
Surgery 136:827-32, 2004
Purpose
To evaluate whether there is an
effective pyloromyotomy length that
can prevent the development of an
inadequate myotomy
Results
October 1999 – October 2003
• 171 infants
• Mean age – 5.2 wks (± 2.8)
• Ultrasound
▲
Mean length– 19.52 ± 2.8 mm
▲
Mean thickness– 4.29 ± 0.7 mm
Surgery 136:827-32, 2004
Results
• Operative time
•
23.5 (± 8.3) min
• Length of myotomy
•
1.94 (± 0.21) cm
• Standardized feeding protocol
– 33 pts (19%) experienced at
least one feeding setback
• Hospitalization
•
Postoperative–32.6 (±27.7) hrs
•
Total – 53.2 (± 38.7) hrs
Surgery 136:827-32, 2004
Results
171 Infants
• No mucosal
perforations
• No gastric or
duodenal injuries
• No inadequate
pyloromyotomies
Surgery 136:827-32, 2004
Conclusions
• Laparoscopic approach for
pyloromyotomy is safe and
effective
• The length of the myotomy
can be measured effectively
• A pyloromyotomy length of
approximately 2 cm is
effective in relieving the
pyloric obstruction
Surgery 136:827-32, 2004
Prospective Randomized Trial of
Laparoscopic vs Open
Fundoplication
Open Versus Laparoscopic Pyloromyotomy
For Pyloric Stenosis: A Prospective
Randomized Trial
Shawn D. St. Peter
George W. Holcomb III
Casey M. Calkins
Walter S. Andrews
J. Patrick Murphy
Charles L. Snyder
Ronald J. Sharp
George K. Gittes
Daniel J. Ostlie
The Center for Prospective
Clinical Trials
Children’s Mercy Hospital
Kansas City, MO
Introduction
We conducted the first large prospective
randomized controlled trial investigating the
role of laparoscopy in treating pyloric stenosis
Ann Surg 244:363-370, 2006
Methods
Sample Size
• Mean operative times were utilized from
retrospective data within our institution
• Power = 0.80 and α = 0.05
• 60 patients in each arm
• Potentially significant complications occur
infrequently
• Therefore, a recruitment goal of 100 patients in
each arm was established
Assignment
• Individual unit randomization sequence
• Non-stratified
• Blocks of 10
• Allotment obtained from randomization
sequence after permission form signed
Interventions
• Operations were performed by 7
pediatric surgeons at a single institution
• The surgical resident (fellow) or on-call
surgeon performed the operation
• Allotment had no influence on which
surgeon performed the operation
Interventions
Open Pyloromyotomy
• 2-3 cm incision, transverse right upper
quadrant or upper midline
• Pylorus exteriorized through incision
• Incision in pylorus with #15 blade
• Muscle spreader used to complete myotomy
Interventions
Laparoscopic Pyloromyotomy
• 5 mm port in umbilicus
• 2 stab incisions
• right and left upper quadrants
• 3 mm instruments
• Grasper in surgeon’s left hand
• Blade followed by spreader in surgeon’s right
hand
Management
Diet Orders
• Standard diet order sets for both groups
• 2 feedings of Pedialyte®
• 2 feedings of ½ strength formula/breast milk
• 2 feedings of full strength formula/breast
milk
• Resume home regimen
• Criteria for stopping feeds outlined in order set
• Discharged when home diet tolerated
Management
Pain Control
• Acetaminophen (10mg/kg) PO/PR
every 4 hours as needed for pain
• No patients received narcotics
Data Collection
•
•
•
•
•
•
•
•
•
•
Age
Weight
Electrolytes on presentation
Ultrasound measurements of the pylorus
Operating time
Time to complete advancement of diet
Number of episodes of post-operative emesis
Number of doses of tylenol (10mg/kg)
Length of post-operative hospitalization
Complications
Statistics
• Continuous variables were compared using
an independent sample, 2-tailed Student’s ttest
• Discrete variables were analyzed with
Fisher’s exact test
• Significance was defined as P value < of 0.05
• All measures evaluated on intention-to-treat
basis
Results
Upon Presentation
OPEN (n = 100) LAP (n = 100) P Value
(Mean +/- S.E.) (Mean +/- S.E.)
Age (weeks)
5.24 +/- 0.25
5.33 +/- 0.22
0.77
Thickness (mm)
4.17 +/- 0.08
4.16 +/- 0.09
0.88
Length (mm)
19.51 +/- 0.27
19.38 +/- 0.27
0.74
Cl - (mmol/L)
99.36 +/- 0.78
99.76 +/- 0.79
0.72
HCO3 -(mmol/L) 28.18 +/- 0.51
27.86 +/- 0.49
0.65
Results
Outcomes
OPEN (n = 100) LAP (n = 100) P Value
(Mean +/- S.E.)
(Mean +/- S.E.)
OR time (mins) 19:28 +/- 0.60
19:34 +/- 0.78
0.93
Emesis (#)
1.84 +/- 0.23
0.05
Full Feeds (hrs) 21:01 +/- 2.16
19:30 +/- 1.46
0.43
LOS (hrs)
33:10 +/- 1.63
29:38 +/- 1.69
0.12
Tylenol (doses)
2.23 +/- 0.18
1.59 +/- 0.16
0.01
2.61 +/- 0.27
Results
Complications
• 1 mucosal perforation in the open group
• 1 incisional hernia in the open group
• 1 laparoscopic case was converted to open
• 4 wound infections in the open group
compared to 2 wound infections in the
laparoscopic group (P = 0.68)
Results
Cosmetic Outcome
OPEN
LAP
Conclusions
• Operative approach for pyloromyotomy has
no significant influence on operating time or
length of recovery
• Laparoscopic pyloromyotomy results in
significantly less post-operative discomfort
•
Fewer episodes of emesis and doses of
tylenol
• Laparoscopic pyloromyotomy results in
obvious cosmetic benefits
Conclusions
• All surgeons confirmed they will
perform the pyloromyotomy with the
laparoscopic approach
? ? ?