Abstract
Abstract
Background:
Different approaches of dealing with mucosal injury during pyloromyotomy for hypertrophic pyloric stenosis have been described. There is, however, no consensus on the best technique to use. We conducted a survey among International Pediatric Endosurgery Group (IPEG) members on their experience of mucosal injuries during pyloromyotomy, the way in which these were handled, any modification in subsequent postoperative care, and impact on outcome.
Materials and Methods:
A confidential survey was sent to IPEG members querying demographic data, number of pyloromyotomies performed, operative approach, incidence of mucosal injury, intraoperative management, and postoperative consequences. Statistical analysis was performed to determine factors associated with complications and outcome.
Results:
In total, 231 mucosa injuries were included in the study. Of these, 93% were noticed intraoperatively. Cases were nearly equally distributed between laparoscopic (49%) and open (51%) procedures, and the risk of mucosal injuries was no different between the two. Most surgeons addressed mucosal perforation with primary mucosal repair (70%), whereas a minority (27%) performed full-thickness closure, rotation, and repyloromyotomy in a different quadrant. Common alterations in management included delay in feeding (84%), longer hospital stay (30%), and contrast study before feeding (12%). The vast majority of patients had no adverse sequelae after a mucosal injury (96%), but three patients underwent re-operation. No correlations were found between repair method and complications.
Conclusions:
Mucosal injuries that are noticed and addressed intraoperatively resulted in few complications, regardless of the repair method. Among the queried surgeons, primary mucosal repair is the current standard of care. Primary mucosal repair is equivalent to full-thickness closure in terms of complications and outcome.
Introduction
S
Several different approaches of dealing with mucosal injury have been described. Traditional teaching calls for full-thickness closure (FTC) of the pyloromyotomy, rotation of the pylorus, and repyloromyotomy in a different quadrant. As far back as 1981, simple primary mucosal repair (PMR) has been proposed. 5 To date, there is no consensus on the best technique to use.
The goal of this study was to determine the most prevalent ways in which pediatric surgeons deal with mucosal injures during pyloromyotomy and to evaluate any difference in consequences among methods.
Most pediatric surgeons vividly remember their complications and therefore should be able to recall events surrounding past occurrences when things did not go as planned. Based on this premise, we conducted an anonymous, confidential survey among members of the International Pediatric Endosurgery Group (IPEG) on their experience of mucosal injuries during pyloromyotomy, intraoperative management, any modification in subsequent postoperative care, and the impact on patient outcome.
Materials and Methods
Data collection
An anonymous, confidential online survey was sent to 650 IPEG members around the world between October and November 2014. The survey included data on certification status, experience in terms of practicing years and number of pyloromyotomies performed, operative approach (open or laparoscopic), number of mucosal injuries encountered, the way in which mucosal injuries were managed, and any modifications in subsequent postoperative care, as well as postoperative complications and outcome. Two participation requests (an initial invitation and a reminder four weeks later) were sent to the IPEG membership by electronic mail.
Statistics
Descriptive statistics were computed using SPSS software (version 20.0; SPSS Inc., Chicago, IL). The fall-out rate for each operation was taken into account by calculating the response as a percentage. A binomial multivariate logistic regression was used to calculate the probabilities of repair technique on patient outcome. Proportions of the repair methods in relation to demographic data and the occurrence of complications were compared using Fisher's exact test. Significance was defined as P ≤ .05.
Results
Demographics
A total of 207 individuals completed the online survey (recall of 32%). Of these, 202 described themselves as pediatric surgeons, and the remainder were general surgeons or others. One-fourth (25%) of the participants had more than 20 years of experience, and 30% had between 10 and 20 years of experience. Nearly 74% of the participants had performed over 50 pyloromyotomies. Only 2.6% of participants were still in surgical training.
Operative data
Operations were equally distributed between an open (51%) and laparoscopic (49%) approach. Pyloromyotomies were performed using electrocautery in 28%, an arthrotomy knife in 32%, and other instruments in 40% (scalpel, grasper, special laparoscopic blade, or pyloromyotomy spreader). In total, 231 mucosal injuries were accrued by 67% of the participants. The majority of the injuries (93%) were noticed intraoperatively. One-third of respondents reported no mucosa injury and were therefore excluded from further analysis.
Postoperative management
After the incidence of a mucosa injury most surgeons initiated a delay in feeding (84%), and 30% prolonged the hospital stay of the patient. In 13% of the cases, additional imaging was ordered before feeding (upper gastrointestinal contrast studies [n = 30], ultrasound [n = 1], or plain radiography [n = 1]).
Most of the reported cases had a normal postoperative course (96%). The overall complications rate totaled 1.7%. Two patients suffered from an intraabdominal infection, and two patients sustained postoperative sepsis. Three patients were re-operated on for complications associated with the mucosal injury. There was no reported fatalities.
Mucosa injury: laparoscopic versus open approach
Over time, 13% of respondents who reported more than one mucosal injury changed from an open to a laparoscopic approach in the course of their reported experience. Fisher's exact test showed no difference in the frequency of mucosal injuries between laparoscopic and open procedures (P > .05).
Seventeen percent of cases in which mucosal injuries were noted during a laparoscopy procedure were converted to open surgery for the repair.
Mucosal injury repair
Only 27% of the reported mucosal injuries were addressed using an FTC with rotation and pyloromyotomy in another quadrant. The majority (70%) of the cases in this series were treated with PMR. An omental patch was additionally used in 27% of the cases, and 3% of respondents reported the use of some type of other method, including a special “muscle-mucosa-muscle U-stitch.”
There is no difference in the proportions of the surgical approach and the mucosal injury repair method (Fisher's exact test, P≤.05). There is a positive correlation between PMR and surgical experience over 20 years (P = .01). A delay of feeding was recorded after PMR in 91% and after FTC in 77%, which was not statistically significant (P = .084). Similarly, the repair method had no effect on the length of hospital stay (P = .208). There was no correlation between repair method and outcome or complications by Fisher's exact test. One of the three re-operations occurred after PMR, another one after FTC, and one after the use of another unspecified method.
Surgeons who reported more than one injury tended to be loyal to their particular type of repair over time. Among those who switched methods (n = 7), all changed from FTC to PMR. When asked how they would repair a mucosal injury if it happened to them in the future, all respondents to the question said they would do a PMR, whereas none would use a mucosal patch, and only one respondent would definitively convert from a laparoscopic to an open procedure.
Discussion
There is no consensus on the best repair method of a mucosal injury during pyloromyotomy. Although PMR was described more than three decades ago, 5 most of our work colleagues considered the board exam answer to be FTC with rotation of the pylorus and another pyloromyotomy in a different quadrant.
In a study from 1995, Royal et al. 6 retrospectively described 15 mucosal injuries occurring during open surgery over a 21-year period, of which 4 were repaired by the traditional FTC, whereas 11 were addressed by PMR. No differences were found in terms of complications or outcome. The authors concluded that “mucosal perforation can be repaired with equal efficacy and safety using the traditional pyloric rotation approach or primary mucosal closure.” To our knowledge, there are no further or larger reports on the topic in the medical literature to date.
Contradictory to popular conception, this study shows that the overwhelming majority of pediatric surgeons chose to use PMR when confronted with a mucosal injury that was noticed during pyloromyotomy. Furthermore, when asked what their preferred method would be in the future, the tendency points toward PMR as well.
Adverse sequelae resulting from mucosal injuries that are noted and addressed intraoperatively are rare. This means that surgeons should take every effort to identify mucosal lesions early on and treat them by their method of choice. Although most surgeons delay feeding and discharge, this study provides no evidence whether such action is helpful or warranted. We were surprised to find that only 13% of surgeons performed further imaging after a mucosal injury. Apparently, good outcome is attainable without any further imaging studies in most cases.
Corroborating other reports,7–9 there seems to be no significant difference in mucosal injury rate between the laparoscopic and open approach. As shown in our survey, most pediatric laparoscopic surgeons are currently comfortable repairing a mucosal injury by laparoscopic means. Conversion to open surgery is rare and not automatic.
Interestingly, and against our expectations, more experienced surgeons were even more likely to perform PMR than their younger counterparts. This may be an effect of training, in which younger surgeons are taught to strictly adhere to the traditionally accepted principles and guidelines. Older surgeons may find it easier to lay dogma aside.
Our study has several limitations. For one, surveys in general are susceptible to recall bias, particularly when the response rate is less than one-third. Several reports in the literature have documented deaths after missed mucosal injuries.5,10 The fact that none was reported by our respondents may be due to either a low mortality rate of this condition in the current era of pediatric surgery or deliberate underreporting despite the confidential and anonymous nature of our survey. Also, the IPEG membership may be more avid to do laparoscopy in general and more likely to perform a relatively innovative procedure such as PMR. We were actually surprised to find that close to half of all included pyloromyotomies were performed by traditional open surgery in this select group. A prospective study or some type of multicenter registry on mucosal repair during pyloromyotomy would overcome some of the pitfalls of our retrospective survey.
In conclusion, most mucosal injuries during pyloromyotomy in our study were managed by PMR, regardless of whether an open or laparoscopic approach was used. As long as the injury is noticed and addressed intraoperative by either method, postoperative complications are infrequent, and patients rarely require re-operation. Therefore, PMR is equally safe and effective compared with FTC and should therefore be considered the standard procedure for mucosal injury recognized during pyloromyotomy.
Footnotes
Disclosure Statement
No competing financial interests exist.