Chris.Rishel: Typo

2022-09-03T22:45:28Z

Typo

← Older revision		Revision as of 15:45, 3 September 2022
Line 116:		Line 116:
	* Perforated mucosa		* Perforated mucosa
	* Wound infection		* Wound infection
	* ~~Facial~~ dehiscence		* Fascial dehiscence
	* Incisional hernia		* Incisional hernia
	* Postoperative bleeding		* Postoperative bleeding

Chris.Rishel: Created page with "{{Infobox surgical procedure | anesthesia_type =General | airway =ETT | lines_access =PIV | monitors =Standard 5-lead ECG | considerations_preoperative =Delay surgery to correct electrolyte abnormalities and hypovolemia | considerations_intraoperative =Decompress stomach prior to induction Modified RSI | considerations_postoperative =Resume feeding }}A '''pyloromyotomy''' is a surgical procedure performed to correct pyloric stenosis in infants. Pyloric stenosi..."

2022-09-02T17:31:53Z

Created page with "{{Infobox surgical procedure | anesthesia_type =General | airway =ETT | lines_access =PIV | monitors =Standard 5-lead ECG | considerations_preoperative =Delay surgery to correct electrolyte abnormalities and hypovolemia | considerations_intraoperative =Decompress stomach prior to induction Modified RSI | considerations_postoperative =Resume feeding }}A '''pyloromyotomy''' is a surgical procedure performed to correct pyloric stenosis in infants. Pyloric stenosi..."

New page

{{Infobox surgical procedure
| anesthesia_type =General
| airway =ETT
| lines_access =PIV
| monitors =Standard
5-lead ECG
| considerations_preoperative =Delay surgery to correct electrolyte abnormalities and hypovolemia
| considerations_intraoperative =Decompress stomach prior to induction
Modified RSI
| considerations_postoperative =Resume feeding
}}A '''pyloromyotomy''' is a surgical procedure performed to correct [[pyloric stenosis]] in infants. Pyloric stenosis typically presents during the first 3 months of life, classically with projectile vomiting, poor feeding, and dehydration, though some or all of these may not be present if diagnosed early.<ref>{{Cite journal|last=Taylor|first=Nicole D.|last2=Cass|first2=Daniel T.|last3=Holland|first3=Andrew J. A.|date=2013-01|title=Infantile hypertrophic pyloric stenosis: has anything changed?|url=https://pubmed.ncbi.nlm.nih.gov/23198903/|journal=Journal of Paediatrics and Child Health|volume=49|issue=1|pages=33–37|doi=10.1111/jpc.12027|issn=1440-1754|pmid=23198903}}</ref> Surgery is urgent but not emergent, and should be delayed to correct electrolyte abnormalities and provide intravenous fluid resuscitation.

==Overview==
===Indications===

* Pyloric stenosis

===Surgical procedure===
The procedure is most commonly performed laparoscopically, but can also be performed open through a small incision.<ref>{{Cite journal|last=Askew|first=Nathan|date=2010|title=An overview of infantile hypertrophic pyloric stenosis|url=https://pubmed.ncbi.nlm.nih.gov/21066945|journal=Paediatric Nursing|volume=22|issue=8|pages=27–30|doi=10.7748/paed.22.8.27.s27|issn=0962-9513|pmid=21066945}}</ref> After establishing access to the pylorus and identification of the hypertrophied pyloric muscle, the outer layers of tissue and muscle are cut to the mucosa. The two portions of the pylorus muscle are then tested for mobility and the mucosa is inspected for any unintentional damage prior to closure.

==Preoperative management==
===Patient evaluation===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
* Assess suitability for modified RSI vs. awake fiberoptic
|-
|Gastrointestinal
|
* Frequent projectile common, but not always present if diagnosed early<ref>{{Cite journal|last=Taylor|first=Nicole D.|last2=Cass|first2=Daniel T.|last3=Holland|first3=Andrew J. A.|date=2013|title=Infantile hypertrophic pyloric stenosis: has anything changed?|url=https://pubmed.ncbi.nlm.nih.gov/23198903/|journal=Journal of Paediatrics and Child Health|volume=49|issue=1|pages=33–37|doi=10.1111/jpc.12027|issn=1440-1754|pmid=23198903}}</ref>
* Palpable "olive-like" mass in right upper quadrant of abdomen<ref>{{Cite journal|last=Macdessi|first=J.|last2=Oates|first2=R. K.|date=1993-02-27|title=Clinical diagnosis of pyloric stenosis: a declining art|url=https://pubmed.ncbi.nlm.nih.gov/8461768/|journal=BMJ (Clinical research ed.)|volume=306|issue=6877|pages=553–555|doi=10.1136/bmj.306.6877.553|issn=0959-8138|pmc=1677170|pmid=8461768}}</ref>
|}

==== Electrolyte abnormalities and volume status ====
Patients may be hypovolemic and/or have electrolyte abnormalities from frequent vomiting, including:

* Metabolic alkalosis from acid loss
** Respiratory compensation leading to hypoventilation and increased arterial pCO<sub>2</sub>
* Secondary hyperaldosteronism from decreased blood volume
** Hypokalemia
** ± Hypernatremia
* Hypochloremia
* Hypoglycemia

<u>Surgery should be delayed to correct electrolyte abnormalities and provide fluid resuscitation.</u> Recommended preoperative thresholds include:<ref>{{Cite journal|last=van den Bunder|first=Fenne A. I. M.|last2=Hall|first2=Nigel J.|last3=van Heurn|first3=L. W. Ernest|last4=Derikx|first4=Joep P. M.|date=2020|title=A Delphi Analysis to Reach Consensus on Preoperative Care in Infants with Hypertrophic Pyloric Stenosis|url=https://pubmed.ncbi.nlm.nih.gov/31958865/|journal=European Journal of Pediatric Surgery: Official Journal of Austrian Association of Pediatric Surgery ... [et Al] = Zeitschrift Fur Kinderchirurgie|volume=30|issue=6|pages=497–504|doi=10.1055/s-0039-3401987|issn=1439-359X|pmid=31958865}}</ref>

* pH ≤7.45 (base excess ≤3.5)
* Bicarbonate <26 mmol/L
* Sodium ≥132 mmol/L
* Potassium ≥3.5 mmol/L
* Chloride ≥100 mmol/L
* Glucose ≥4.0 mmol/L (72 mg/dL)

===Labs and studies===

* Basic metabolic panel

===Operating room setup===
===Patient preparation and premedication===

* Fluid resuscitation, electrolyte correction, and stomach decompression

===Regional and neuraxial techniques===
Pyloromyotomy can be performed under spinal anesthesia with potential benefits of reduced operating room time and decreased risk of postoperative apnea. However, spinal anesthesia is often inadequate, requiring supplemental sedation and presenting aspiration risk without a secure airway.<ref>{{Cite journal|last=Ing|first=Caleb|last2=Sun|first2=Lena S.|last3=Friend|first3=Alexander F.|last4=Roh|first4=Arthur|last5=Lei|first5=Susan|last6=Andrews|first6=Howard|last7=Li|first7=Guohua|last8=Williams|first8=Robert K.|date=2016|title=Adverse Events and Resource Utilization After Spinal and General Anesthesia in Infants Undergoing Pyloromyotomy|url=https://pubmed.ncbi.nlm.nih.gov/27281725/|journal=Regional Anesthesia and Pain Medicine|volume=41|issue=4|pages=532–537|doi=10.1097/AAP.0000000000000421|issn=1532-8651|pmc=4912426|pmid=27281725}}</ref><ref>{{Cite journal|last=Sánchez-Conde|first=María Pilar|last2=Díaz-Alvarez|first2=Agustín|last3=Palomero Rodríguez|first3=Miguel Ángel|last4=Garrido Gallego|first4=María Isabel|last5=Martín Rollan|first5=Guillermo|last6=de Vicente Sánchez|first6=Jesús|last7=Laporta Báez|first7=Yolanda|last8=Vaquero Roncero|first8=Luis Mario|last9=Rodríguez López|first9=José María|date=2019|title=Spinal anesthesia compared with general anesthesia for neonates with hypertrophic pyloric stenosis. A retrospective study|url=https://pubmed.ncbi.nlm.nih.gov/31322795/|journal=Paediatric Anaesthesia|volume=29|issue=9|pages=938–944|doi=10.1111/pan.13710|issn=1460-9592|pmid=31322795}}</ref> Additionally, neuraxial anesthesia is not as well studied for laparoscopic pyloromyotomy which is currently the more common surgical approach.<ref>{{Cite journal|last=Islam|first=Saleem|last2=Larson|first2=Shawn D.|last3=Kays|first3=David W.|last4=Irwin|first4=Maria D.|last5=Carvallho|first5=Norman|date=2014-10|title=Feasibility of laparoscopic pyloromyotomy under spinal anesthesia|url=https://pubmed.ncbi.nlm.nih.gov/25280651/|journal=Journal of Pediatric Surgery|volume=49|issue=10|pages=1485–1487|doi=10.1016/j.jpedsurg.2014.02.083|issn=1531-5037|pmid=25280651}}</ref>

==Intraoperative management==
===Monitoring and access===

* Standard monitors
* Preoperative IV recommended

===Induction and airway management===

* Decompress stomach via OG or NG in 3 positions immediately prior to induction<ref>{{Cite journal|last=Cook-Sather|first=S. D.|last2=Liacouras|first2=C. A.|last3=Previte|first3=J. P.|last4=Markakis|first4=D. A.|last5=Schreiner|first5=M. S.|date=1997|title=Gastric fluid measurement by blind aspiration in paediatric patients: a gastroscopic evaluation|url=https://pubmed.ncbi.nlm.nih.gov/9043730|journal=Canadian Journal of Anaesthesia = Journal Canadien D'anesthesie|volume=44|issue=2|pages=168–172|doi=10.1007/BF03013006|issn=0832-610X|pmid=9043730}}</ref>
** Supine
** Left lateral decubitus
** Right lateral decubitus
* Modified rapid sequence induction recommended
** Traditional RSI with cricoid pressure shown to increase incidence of hypoxemia without additional reduction in aspiration<ref>{{Cite journal|last=Park|first=Raymond S.|last2=Rattana-Arpa|first2=Sirirat|last3=Peyton|first3=James M.|last4=Huang|first4=Jia|last5=Kordun|first5=Anna|last6=Cravero|first6=Joseph P.|last7=Zurakowski|first7=David|last8=Kovatsis|first8=Pete G.|date=2021-02-01|title=Risk of Hypoxemia by Induction Technique Among Infants and Neonates Undergoing Pyloromyotomy|url=https://pubmed.ncbi.nlm.nih.gov/31361669/|journal=Anesthesia and Analgesia|volume=132|issue=2|pages=367–373|doi=10.1213/ANE.0000000000004344|issn=1526-7598|pmid=31361669}}</ref>
** IV typically already in place for fluid resuscitation and electrolyte correction
* Awake intubation has fallen out of favor
** Associated with more attempts and longer intubation time compared to RSI<ref>{{Cite journal|last=Cook-Sather|first=S. D.|last2=Tulloch|first2=H. V.|last3=Cnaan|first3=A.|last4=Nicolson|first4=S. C.|last5=Cubina|first5=M. L.|last6=Gallagher|first6=P. R.|last7=Schreiner|first7=M. S.|date=1998|title=A comparison of awake versus paralyzed tracheal intubation for infants with pyloric stenosis|url=https://pubmed.ncbi.nlm.nih.gov/9585274/|journal=Anesthesia and Analgesia|volume=86|issue=5|pages=945–951|doi=10.1097/00000539-199805000-00006|issn=0003-2999|pmid=9585274}}</ref>
* Inhalation induction possible
** Some evidence to suggest no increased risk of aspiration or hypoxemia<ref>{{Cite journal|last=Scrimgeour|first=Gemma E.|last2=Leather|first2=Nicholas W. F.|last3=Perry|first3=Rachel S.|last4=Pappachan|first4=John V.|last5=Baldock|first5=Andrew J.|date=2015|title=Gas induction for pyloromyotomy|url=https://pubmed.ncbi.nlm.nih.gov/25704405/|journal=Paediatric Anaesthesia|volume=25|issue=7|pages=677–680|doi=10.1111/pan.12633|issn=1460-9592|pmid=25704405}}</ref>
** Unclear benefit if IV is present preoperatively

===Positioning===

===Maintenance and surgical considerations===

* Consider risk of postoperative apnea if using opioids

===Emergence===

* Extubate awake

==Postoperative management==
===Disposition===

* PACU
* Resume feeding within hours
** Moderate regurgitation is common and should not delay resuming feeds

===Pain management===

* Acetaminophen
* Careful use of opioids given risk of postoperative apnea

===Potential complications<ref>{{Cite journal|last=van den Bunder|first=Fenne A. I. M.|last2=van Heurn|first2=Ernest|last3=Derikx|first3=Joep P. M.|date=2020-01-15|title=Comparison of laparoscopic and open pyloromyotomy: Concerns for omental herniation at port sites after the laparoscopic approach|url=https://pubmed.ncbi.nlm.nih.gov/31941898|journal=Scientific Reports|volume=10|issue=1|pages=363|doi=10.1038/s41598-019-57031-4|issn=2045-2322|pmc=6962153|pmid=31941898}}</ref><ref>{{Cite book|url=https://www.worldcat.org/oclc/689994897|title=Current Procedures: Surgery|date=2010|publisher=McGraw-Hill Medical|others=Rebecca M. Minter, Gerard M. Doherty|isbn=0-07-145316-4|location=New York|chapter=Chapter 46. Operative Management of Pyloric Stenosis: Pyloromyotomy|oclc=689994897}}</ref>===

* Incomplete pyloromyotomy
* Perforated mucosa
* Wound infection
* Facial dehiscence
* Incisional hernia
* Postoperative bleeding

==Procedure variants==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Laparoscopic pyloromyotomy
!Open pyloromyotomy
|-
|Unique considerations
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|
|-
|Indications
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|
|-
|Position
|
|
|-
|Surgical time
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|-
|EBL
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|-
|Postoperative disposition
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|-
|Pain management
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|-
|Potential complications
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|}

==References==
<references />
[[Category:Surgical procedures]]

Pyloromyotomy - Revision history

Chris.Rishel: Typo