Advancing paediatric surgery through education and research

The Consequences and Cause of Pyloric Stenosis of Infancy

Ian Rogers and Frederick L Vanderborn 

A review by Mark Davenport

Pyloric stenosis has always been a fascinating and almost enigmatic disease – not so much on the treatment side perhaps although you can still spill ink on debating the role of the laparoscope but rather in its demographic background, natural history and above all aetiology. First born, male of the species, onset usually after 2-3 weeks of uninhibited feeding and its possible “resolution” with medical treatment of various sorts.

This unusual self-published booklet highlights this from two distinct viewpoints, a patient and a surgeon. The patient kicks off with his own story and that in itself is intriguing as he is now a retired Australian chaplain who was born in war-torn Holland in 1945. He reviews the subject in a semi-medical way with illustrations from the web and detours to the story of Conrad Ramstedt and his pyloromyotomy in 1912. He then spends more than a few pages on the scarring and with psychological trauma still evident almost 70 years after the event. This is self-diagnosed as post-traumatic stress disorder which is interesting given the generation he comes from. Furthermore I am not sure this resonates or chimes too much with today’s clientele who usually seem perfectly at ease with something they have little or no memory of how it came to be. Cosmetically, both the laparoscope and the Bianchi umbilical incision have also effectively minimised this aspect of surgery.

The second part is from the perspective of a retired general surgeon who graduated in the 1960s, researched in Glasgow of the 1970s and practiced in South Shields until 2004. Clearly this is his cause celebre and he has remained entangled with the subject ever since. It is strong on gastric acid, and indeed that is his central hypothesis that too much acid causes muscular hypertrophy of the pylorus. Whether this is driven by gastrin is reviewed and he quotes the 1970s studies of John Dodge who administered synthetic pentagastrin to late gestation dogs producing pyloric stenosis in 25% of the offspring. Other more recent observations on the innervation of the pylorus muscle, the relative lack of non-adrenergic, non-cholinergic nerves, the relationship with seasonality, formula feeding and the complex role of the genetic background are side-lined somewhat as not relevant to the thesis.

Much more contentiously he advocates anti-acid therapy (originally cimetidine, ranitidine and nowadays proton pump inhibitors) as the simple solution to the problem – almost to the exclusion of much else. There are some very dehydrated infants out there who really need a bit more than 10 mg/kg of cimetidine to cure their problems as all standard textbooks will tell you. There are indeed some papers on this, but only to reduce blood pH more rapidly to allow surgery, not actually to replace it, so real world evidence is tiny. Indeed medical treatment was discarded many, many years ago although it is true that there are relatively recent Japanese studies showing success from intravenous atropine administered six times a day for a period of up to 14 days with a success rate of about 90% and to the Reverend Vanderborn’s evident satisfaction no scar. But it’s a fairly strenuous investment in time and effort requiring a prolonged hospital stay to get there.

An interesting read certainly but to my mind I’d choose the knife any time.

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