0905 Laparoscopic vs open surgery for pyloric stenosis

The appropriate choice of operation for hypertrophic pyloric stenosis has been the subject of debate among paediatric surgeons since the early 1990’s. Analyses of data have included retrospective reviews, a couple of randomized controlled studies, a meta-analysis and, more recently another randomized, controlled study, this one involving 6 tertiary paediatric surgical centres in the UK, USA, Canada, Austria, and Finland. Questions that plagued surgeons were around shorter operative recovery times but possibly higher complication rates, and less postoperative analgesia but perhaps more in the way of incomplete pyloromyotomy after laparoscopy. The abovementioned multicentre study involved 180 infants(±⅔ older than 1 month and weighing more than 3.5 Kg). Primary outcomes were time to full enteral feeds and postoperative length of stay, while secondary outcomes included operation duration and operative and post-operative complications. Statistically significant advantages for the laparoscopic procedure were found: time to full enteral feeds 18.5 vs 23.9 hours (p=0.002), post-operative length of stay 33.6 vs 43.8 hours (p=0.027). Odds ratios for reductions with laparoscopy were 0.78 (95%CI 0.66-0.91) and 0.85 (0.73-0.98). The only secondary outcome difference was for operating time (30 vs 32 mins; p=0.008; odds ratio 0.88 (95%CI 0.80-0.97)), however if one isolates two important complications viz mucosal perforation and incomplete pyloromyotomy then 6/87 laparoscopic subects experienced these vs 1/93 in the open group. This difference approaches significance (2-tailed Fisher’s test 0.057) and should perhaps be flagged for future study. Total cost was not different for the procedures (2461±1344 GBP for open vs 2394±1527 GBP for laparoscopic). While data are not provided, the authors also comment on a significant reduction in post-operative analgesia requirements and the possibility of long-term cosmetic advantages of the laparoscopic repair. Overall, while statistically significant, in clinical terms the results do not speak overwhelmingly for the laparoscopic procedure, and the authors themselves state that the procedure should be reserved for units that have sufficient volumes and expertise.

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Lancet 2009; 373: 390-8)
Ann Surg 2004; 240: 774-8
Health Technol Assess 1997; 1: 1-149