1 00:00:00,000 --> 00:00:05,860 Hi everyone, I'm Kim Pribben. 2 00:00:05,860 --> 00:00:06,860 And I'm Em Gootee. 3 00:00:06,860 --> 00:00:10,240 We are research fellows at Cincinnati Children's Hospital. 4 00:00:10,240 --> 00:00:14,880 Today we will learn more about the diagnosis and management of pyloric stenosis with Dr. 5 00:00:14,880 --> 00:00:22,440 Alex Bondoc, a pediatric surgeon from Cincinnati Children's. 6 00:00:22,440 --> 00:00:27,200 Pyloric stenosis is a condition in infants where the pyloric muscle becomes thickened 7 00:00:27,200 --> 00:00:32,360 or hypertrophied, thus creating a much narrower passage between the stomach and the small 8 00:00:32,360 --> 00:00:33,640 intestine. 9 00:00:33,640 --> 00:00:38,620 This muscle thickening can block food from passing from the stomach into the small intestine 10 00:00:38,620 --> 00:00:40,400 and prohibits digestion. 11 00:00:40,400 --> 00:00:45,560 The classic symptom is projectile vomiting after feeding, followed by signs of hunger, 12 00:00:45,560 --> 00:00:49,120 which can lead to severe dehydration and weight loss. 13 00:00:49,120 --> 00:00:53,440 In today's podcast, we're going to review in detail to understand better how to diagnose 14 00:00:53,440 --> 00:00:56,640 and manage these patients both medically and surgically. 15 00:00:56,640 --> 00:00:59,640 Let's start with the case. 16 00:00:59,640 --> 00:01:05,000 Our patient is a seven weeks old male with no past medical history, whose parents reported 17 00:01:05,000 --> 00:01:06,700 five weeks of vomiting. 18 00:01:06,700 --> 00:01:11,440 He was initially breastfed, but due to persistent vomiting, the parent tried three different 19 00:01:11,440 --> 00:01:15,080 formulas without any improvement in the patient's symptoms. 20 00:01:15,080 --> 00:01:19,120 His vomiting would only occur after feedings and was described as large volume, projectile 21 00:01:19,120 --> 00:01:21,800 and not bloodier bilious in nature. 22 00:01:21,800 --> 00:01:26,800 His lab work would show a chloride level of 88 millimoles per liter and a bicarbonate 23 00:01:26,800 --> 00:01:29,040 level of 35 millimoles per liter. 24 00:01:29,040 --> 00:01:32,920 So what are the potential medical and anatomical conditions we would want to consider? 25 00:01:32,920 --> 00:01:38,080 In a child this age, what would be potentially the most common, most likely diagnosis of 26 00:01:38,080 --> 00:01:40,200 a baby that spits up? 27 00:01:40,200 --> 00:01:41,200 Reflux. 28 00:01:41,200 --> 00:01:46,480 G-E-R. Reflux, right? 29 00:01:46,480 --> 00:01:48,840 Reflux is really common in the first year of life. 30 00:01:48,840 --> 00:01:54,440 A few other things you may consider initially is a cow milk allergy, gastroenteritis, or 31 00:01:54,440 --> 00:01:56,440 maybe even a viral infection. 32 00:01:56,440 --> 00:02:01,360 Those are by far the most common things that you would see in an infant this age. 33 00:02:01,360 --> 00:02:05,960 You would then want to investigate less common anatomical causes like pyloric stenosis, proximal 34 00:02:05,960 --> 00:02:12,280 obstructions, or gut duplication, pylorespasm, duodenal webs, or pyloric atresia. 35 00:02:12,280 --> 00:02:17,320 One of the most important differential diagnosis assessments for this patient is to determine 36 00:02:17,320 --> 00:02:20,240 if the vomiting is bilious or non-bilious. 37 00:02:20,240 --> 00:02:23,040 In our patient, the vomiting was non-bilious. 38 00:02:23,040 --> 00:02:28,000 Don't forget that bilious vomiting should be considered as an emergency in an infant. 39 00:02:28,000 --> 00:02:30,400 So what would your initial diagnosis of this patient be? 40 00:02:30,400 --> 00:02:33,840 We'll say let's focus on pyloric stenosis now. 41 00:02:33,840 --> 00:02:36,800 What are the risk factors for pyloric stenosis? 42 00:02:36,800 --> 00:02:39,920 There are several risk factors to consider when diagnosing an infant. 43 00:02:39,920 --> 00:02:44,840 For example, being a firstborn child or a male dramatically increases the infant's 44 00:02:44,840 --> 00:02:47,220 chances of developing pyloric stenosis. 45 00:02:47,220 --> 00:02:52,920 Other factors like family history, maternal diabetes, being bottle fed, prematurity, and 46 00:02:52,920 --> 00:02:58,320 even birth via c-section or exposure to certain antibiotics such as erythromycin can also 47 00:02:58,320 --> 00:02:59,480 play a role. 48 00:02:59,480 --> 00:03:04,280 It is also important to remember that pyloric stenosis usually affects babies between 2 49 00:03:04,280 --> 00:03:08,880 and 8 weeks of age, but can occur any time from birth to 6 months. 50 00:03:08,880 --> 00:03:15,680 So it's a relatively rare diagnosis, about 4 to 5 in a thousand live births, and the 51 00:03:15,680 --> 00:03:17,640 preponderance is heavily male. 52 00:03:17,640 --> 00:03:23,300 And then there have been lots of papers about other risk factors or epidemiologic findings 53 00:03:23,300 --> 00:03:27,940 related to pyloric stenosis, one of which is socioeconomic status. 54 00:03:27,940 --> 00:03:32,920 The Journal of Pediatric Surgery published a study in 2017 that took a retrospective 55 00:03:32,920 --> 00:03:37,640 approach, examining the data from 2007-2012. 56 00:03:37,640 --> 00:03:44,120 This study reviewed 584 patients with pyloric stenosis and found that African American infants 57 00:03:44,120 --> 00:03:48,400 presented with higher bicarbonate levels and lower chloride levels. 58 00:03:48,400 --> 00:03:52,480 That same study also suggested that babies that come from uninsured families also had 59 00:03:52,480 --> 00:03:57,880 lower chloride and higher bicarb levels upon presentation, and they often had longer times 60 00:03:57,880 --> 00:04:02,320 between the diagnosis and the operating room, though this delay may be due to the need to 61 00:04:02,320 --> 00:04:03,920 correct electrolytes. 62 00:04:03,920 --> 00:04:05,520 And is it a cause and effect relationship? 63 00:04:05,520 --> 00:04:07,660 Perhaps not, but we're talking adversity. 64 00:04:07,660 --> 00:04:10,100 This is a patient population you have to be aware of. 65 00:04:10,100 --> 00:04:14,360 Perhaps they're not seeking care as soon or they've been placed in the waiting room, 66 00:04:14,360 --> 00:04:16,080 they're not being seen as fast. 67 00:04:16,080 --> 00:04:17,080 Hard to say. 68 00:04:17,080 --> 00:04:20,960 When looking at other risk factors, a large-scale study out of Denmark and Holland found that 69 00:04:20,960 --> 00:04:24,480 pyloric stenosis is 87% heritable. 70 00:04:24,480 --> 00:04:28,440 This makes knowing the family's history crucial for diagnosis. 71 00:04:28,440 --> 00:04:34,080 It is particularly interesting that researchers were able to identify a molecular diagnostic 72 00:04:34,080 --> 00:04:35,080 marker. 73 00:04:35,080 --> 00:04:40,800 They can now trace specific genetic changes that may indicate the risk for pyloric stenosis. 74 00:04:40,800 --> 00:04:44,280 After reviewing a patient's history, the next step is a physical exam and ordering labs 75 00:04:44,280 --> 00:04:45,280 and imaging. 76 00:04:45,280 --> 00:04:49,880 A key physical exam finding is what is often called a palpable olive in the upper right 77 00:04:49,880 --> 00:04:53,680 quadrant, which is actually the palpable stenose muscle. 78 00:04:53,680 --> 00:04:58,840 And now Dr. Bondoc will tell us what are some tips on how to find the stenosed area. 79 00:04:58,840 --> 00:05:02,960 As you're rolling the hypertrophied muscle over the retroperitoneum or even over the 80 00:05:02,960 --> 00:05:08,000 spine, so they tell you to warm up your hands, have mom or dad holding them tight so that 81 00:05:08,000 --> 00:05:09,480 they're not upset. 82 00:05:09,480 --> 00:05:13,280 And then maybe sometimes you can elicit it, especially if it's particularly large. 83 00:05:13,280 --> 00:05:14,280 All right. 84 00:05:14,280 --> 00:05:18,320 So once you're done with the physical assessment, the next step is reviewing the lab results. 85 00:05:18,320 --> 00:05:22,180 You really want to pay close attention to those electrolyte panels because signs of dehydration 86 00:05:22,180 --> 00:05:25,920 in those panels are very common and are part of the diagnostic criteria. 87 00:05:25,920 --> 00:05:32,480 Typically, you'll see issues like hyperboloidemia, hypokloremia, and elevated bicarb levels. 88 00:05:32,480 --> 00:05:37,240 Addressing these levels as soon as possible is really important as it can become life 89 00:05:37,240 --> 00:05:39,280 threatening very quickly. 90 00:05:39,280 --> 00:05:43,640 The cause of these abnormal labs are related to the chronic vomiting and poor nutritional 91 00:05:43,640 --> 00:05:44,640 intake. 92 00:05:44,640 --> 00:05:50,880 The loss of chloride and hydrogen ions can lead to hypokloremic metabolic alkalosis. 93 00:05:50,880 --> 00:05:55,720 Bicarbonate also becomes elevated and the excess is excreted in the urine, which obligates 94 00:05:55,720 --> 00:05:58,880 sodium loss to maintain electro-neutrality. 95 00:05:58,880 --> 00:06:03,800 As water loss follows sodium excretion, the patient becomes even more hemodynamically 96 00:06:03,800 --> 00:06:04,800 unstable. 97 00:06:04,800 --> 00:06:09,920 There is an association with Gilbert syndrome and pylorextinoosis as well. 98 00:06:09,920 --> 00:06:16,280 We've had some patients incidentally diagnosed with that disorder when they came in for pylorextinoosis, 99 00:06:16,280 --> 00:06:17,280 when they had their labs checked. 100 00:06:17,280 --> 00:06:20,200 Next, we would want to review the imaging on the patient. 101 00:06:20,200 --> 00:06:25,160 The common practice is to order a standard, non-invasive, non-ionizing ultrasound to help 102 00:06:25,160 --> 00:06:26,760 the diagnosis. 103 00:06:26,760 --> 00:06:30,440 When reviewing the ultrasound, the team would want to measure the pyloric channel and the 104 00:06:30,440 --> 00:06:31,520 muscle thickness. 105 00:06:31,520 --> 00:06:36,240 Any muscle thickness greater than 4 millimeters and a pyloric channel length greater than 15 106 00:06:36,240 --> 00:06:39,960 millimeters would suggest the patient has pylorextinoosis. 107 00:06:39,960 --> 00:06:45,480 Once we have a diagnosis, the next big step is fluid and electrolyte resuscitation, especially 108 00:06:45,480 --> 00:06:49,440 since these patients can have severe metabolic alkalosis. 109 00:06:49,440 --> 00:06:55,600 In a 2008 and subsequent 2016 follow-up study published in the Journal of Pediatric Surgery, 110 00:06:55,600 --> 00:07:00,200 they were able to really identify the specific fluid resuscitation care pathways needed to 111 00:07:00,200 --> 00:07:01,820 stabilize these patients. 112 00:07:01,820 --> 00:07:05,560 The treatment plan also reduced the number of blood draws and did not delay the time 113 00:07:05,560 --> 00:07:07,480 to surgery, which is pretty impressive. 114 00:07:07,480 --> 00:07:13,320 In this study, the researchers suggest administering a bolus of isotonic saline followed by maintenance 115 00:07:13,320 --> 00:07:14,320 IV fluids. 116 00:07:14,320 --> 00:07:20,440 This can be a dextrose 5% and half normal saline, but they wanted you to add 20 mEq 117 00:07:20,440 --> 00:07:21,920 per liter of potassium chloride. 118 00:07:21,920 --> 00:07:26,400 It is also important to avoid nasogastric compression because you really want to avoid 119 00:07:26,400 --> 00:07:29,840 exacerbation of the metabolic alkalosis. 120 00:07:29,840 --> 00:07:33,600 So after fluid resuscitation, let's say that the baby isn't stable enough to go to the 121 00:07:33,600 --> 00:07:34,800 operating room. 122 00:07:34,800 --> 00:07:37,340 How can you medically manage pylorextinoosis? 123 00:07:37,340 --> 00:07:40,080 You could aggressively observe the patient. 124 00:07:40,080 --> 00:07:42,820 But atropine is a traditional medical management. 125 00:07:42,820 --> 00:07:48,800 And it's essentially fallen out of favor because how good pediatric anesthetists are and there 126 00:07:48,800 --> 00:07:54,880 isn't necessarily a high importance rate between congenital anomalies that would make a patient, 127 00:07:54,880 --> 00:07:57,240 a baby, a high anesthetic risk. 128 00:07:57,240 --> 00:08:02,400 When considering all of this and the fact that it is a 45 minute curative operation 129 00:08:02,400 --> 00:08:07,040 that can be done safely and quickly, you are likely choosing that option. 130 00:08:07,040 --> 00:08:10,720 In this case, our patient was stabilized and was able to go to the OR. 131 00:08:10,720 --> 00:08:15,520 Now let's talk a little bit about the surgical management of pylorextinoosis. 132 00:08:15,520 --> 00:08:19,640 First question would be, do you order pre-op antibiotics? 133 00:08:19,640 --> 00:08:24,240 According to a 2023 study from Journal of Pediatric Surgery, antibiotic prophylaxis 134 00:08:24,240 --> 00:08:29,760 may be unnecessary for a pyloromyotomy and may carry unnecessary long-term side effects. 135 00:08:29,760 --> 00:08:34,920 Next, you'll want to decide if your pyloromyotomy will be done laparoscopically or as an open 136 00:08:34,920 --> 00:08:35,920 procedure. 137 00:08:35,920 --> 00:08:39,880 But before we review the surgical setup and technique, Dr. Bondak has an interesting piece 138 00:08:39,880 --> 00:08:43,480 of history about the pyloromyotomy procedure. 139 00:08:43,480 --> 00:08:48,000 The first pyloromyotomy was done actually the year before by someone else, but Ramstedt 140 00:08:48,000 --> 00:08:51,880 was the one who popularized it and a spreader bears his name. 141 00:08:51,880 --> 00:08:56,520 He used a coffee spoon and he actually intended to do a pyloroplasty but ended up doing a 142 00:08:56,520 --> 00:09:02,880 myotomy only because the baby got unstable or they could do it appropriately, so he only 143 00:09:02,880 --> 00:09:04,160 did the myotomy. 144 00:09:04,160 --> 00:09:06,800 So that's how we figured out the myotomy would be curative. 145 00:09:06,800 --> 00:09:08,760 That's a pretty interesting use of a coffee spoon. 146 00:09:08,760 --> 00:09:12,680 Now let's talk more about the pre-op and the surgical procedure. 147 00:09:12,680 --> 00:09:17,040 Once we choose our approach and get the baby into the OR, the next step is to ensure that 148 00:09:17,040 --> 00:09:20,120 there is gastric suction in prior to induction. 149 00:09:20,120 --> 00:09:23,880 We didn't put an NG in, so we were paying the price for that, but what we typically 150 00:09:23,880 --> 00:09:27,640 will do or what some of the old-school anesthetists and I would assume that they've taught the 151 00:09:27,640 --> 00:09:33,720 fellows and their junior partners is you will suction the baby while awake in three different 152 00:09:33,720 --> 00:09:34,720 positions. 153 00:09:34,720 --> 00:09:38,280 Head down, turn to the right, turn to the left to make sure you've sucked out that 154 00:09:38,280 --> 00:09:39,880 big atonic bag. 155 00:09:39,880 --> 00:09:41,780 Why is this step so important? 156 00:09:41,780 --> 00:09:46,840 Because again, you relax the baby, you have no NG, the baby vomits and aspirates. 157 00:09:46,840 --> 00:09:52,240 So it's very specific to paroxysmosis because of what's happened metabolically, physiologically 158 00:09:52,240 --> 00:09:53,240 with the stomach. 159 00:09:53,240 --> 00:09:57,560 In this patient, Dr. Bondock chose to proceed with a laparoscopic procedure. 160 00:09:57,560 --> 00:10:01,000 Let's walk through some important surgical techniques and tips. 161 00:10:01,000 --> 00:10:04,840 Positioning wise, you would want to actually turn the baby perpendicular to the long axis 162 00:10:04,840 --> 00:10:07,840 of the bed and plan to operate from the baby's feet. 163 00:10:07,840 --> 00:10:12,240 The surgeon would start by making three incisions, one in the umbilicus, one in the right upper 164 00:10:12,240 --> 00:10:15,600 quadrant and the other in the upper left quadrant. 165 00:10:15,600 --> 00:10:19,840 You have the scope at the belly, at the umbilicus and then two stab incisions, right? 166 00:10:19,840 --> 00:10:21,800 So what size instruments are we using? 167 00:10:21,800 --> 00:10:22,800 Three millimeter instruments. 168 00:10:22,800 --> 00:10:27,600 So again, just think about all these things that if someone opens the five millimeter 169 00:10:27,600 --> 00:10:30,500 instruments that means you got to make a big incision. 170 00:10:30,500 --> 00:10:34,640 It is important that the full extent of the bovey tip is in the patient and the surgeon 171 00:10:34,640 --> 00:10:37,400 is able to turn the bovey while moving it. 172 00:10:37,400 --> 00:10:42,840 You will want to identify the theoretical anatomic demarcation of the pylorus and duodenum 173 00:10:42,840 --> 00:10:47,680 by identifying the pyloric sphincter and the duodenar jejunal junction. 174 00:10:47,680 --> 00:10:52,040 You will also generally see one well-defined vein with the rest around it looking like 175 00:10:52,040 --> 00:10:54,840 regular gastroepiploic vessels. 176 00:10:54,840 --> 00:10:58,480 If you see where it bows, you can usually see the bulging of the muscle. 177 00:10:58,480 --> 00:11:00,740 So how do you know how long to make your myotomy? 178 00:11:00,740 --> 00:11:07,240 This is why you should know how long the channel is because if it's 15, 18 millimeters, that 179 00:11:07,240 --> 00:11:12,720 three millimeter Maryland grasp or when you open it completely is 13 millimeters. 180 00:11:12,720 --> 00:11:18,920 If you only make a 13 millimeter myotomy on a 15 or an 18 millimeter channel, you're 181 00:11:18,920 --> 00:11:21,240 going to have an incomplete myotomy. 182 00:11:21,240 --> 00:11:26,840 Now that the stenosis has been found intraoperatively, what techniques are used to address it? 183 00:11:26,840 --> 00:11:30,080 One of the most common, that's the way I was taught to do it, is you take both ends 184 00:11:30,080 --> 00:11:36,200 of the grasp or the slit, score the pylorus, the cirrhosis surface of the pylorus, find 185 00:11:36,200 --> 00:11:40,600 one way in with the bovey blade, twist it so you crack the muscle and then you can get 186 00:11:40,600 --> 00:11:41,600 this spreader. 187 00:11:41,600 --> 00:11:46,200 And it's got that serrated, gentle jaw on both sides because then it grips the muscle 188 00:11:46,200 --> 00:11:47,320 and spreads it apart. 189 00:11:47,320 --> 00:11:51,720 And then you grab both ends of the separated muscle and it's supposed to move independently 190 00:11:51,720 --> 00:11:52,960 of each other. 191 00:11:52,960 --> 00:11:57,880 One thing to note is if the myotomy is incomplete, you might feel resistance as you grip the 192 00:11:57,880 --> 00:12:00,840 muscle or they may still move as if they're connected. 193 00:12:00,840 --> 00:12:06,040 It also might be a little bloody because it's all done bluntly and oftentimes you'll actually 194 00:12:06,040 --> 00:12:08,800 see the mucosa bulging through the hole. 195 00:12:08,800 --> 00:12:13,840 The other thing sometimes we can do is when there's blood or serous fluid, I'll have 196 00:12:13,840 --> 00:12:21,520 the anesthetist put air down a suction catheter and theoretically looking for bubbles of air 197 00:12:21,520 --> 00:12:23,400 if you've violated the mucosa. 198 00:12:23,400 --> 00:12:25,880 I also lay a piece of omentum on top of there. 199 00:12:25,880 --> 00:12:28,460 Oh right, what about an open pylotomy? 200 00:12:28,460 --> 00:12:30,560 What technique does Dr. Bondoc prefer? 201 00:12:30,560 --> 00:12:35,080 So the way I was taught was to do it through a peri-umbilical incision and then you tunnel 202 00:12:35,080 --> 00:12:38,760 up because remember again, another nice thing about working on babies is you can make a 203 00:12:38,760 --> 00:12:43,240 small incision but you can stretch their skin and move it around so that you can get all 204 00:12:43,240 --> 00:12:46,640 the way up to the right upper quadrant through a peri-umbilical incision. 205 00:12:46,640 --> 00:12:50,240 It is also common practice to use a transverse incision. 206 00:12:50,240 --> 00:12:54,080 Alright, so what complications and risks would you tell the family about when you get consent 207 00:12:54,080 --> 00:12:55,760 for either of these procedures? 208 00:12:55,760 --> 00:13:00,160 When talking with the families, it is important to share that while the outcomes are generally 209 00:13:00,160 --> 00:13:06,400 really good, some of the risks of the procedure would be an incomplete myotomy, mucosal perforation, 210 00:13:06,400 --> 00:13:08,840 aspiration and maybe wound infection. 211 00:13:08,840 --> 00:13:13,560 Other weird things about this operation are incisional hernias actually because you've 212 00:13:13,560 --> 00:13:18,960 made a stab and typically they don't close the fascia on those stab incisions in the 213 00:13:18,960 --> 00:13:19,960 left and right upper quadrant. 214 00:13:19,960 --> 00:13:25,320 I've seen two omental hernias so I always try to close it with at least one little micro-stitch. 215 00:13:25,320 --> 00:13:27,000 And what about the complication rates? 216 00:13:27,000 --> 00:13:29,240 The rates of complication after pylormyotomy. 217 00:13:29,240 --> 00:13:35,840 They're either equivalent or better actually with open because I think to me, lap pylormyotomy 218 00:13:35,840 --> 00:13:41,480 is an experience and a feel operation because like we said, there's no magical way to 219 00:13:41,480 --> 00:13:47,040 know exactly how complete your myotomy is because I definitely lose my nerve going towards 220 00:13:47,040 --> 00:13:50,480 the duodenum and sometimes people will stop short. 221 00:13:50,480 --> 00:13:52,600 But overall, the risks are rare. 222 00:13:52,600 --> 00:13:56,640 So what are some post-op care instructions we can tell the families and the nurses after 223 00:13:56,640 --> 00:13:57,640 surgery? 224 00:13:57,640 --> 00:14:03,060 I tell them that it is very common for babies to vomit afterwards and it doesn't necessarily 225 00:14:03,060 --> 00:14:05,600 mean that the operation didn't work. 226 00:14:05,600 --> 00:14:06,960 And why does this happen? 227 00:14:06,960 --> 00:14:09,720 My theory is that the stomach is still atonic, right? 228 00:14:09,720 --> 00:14:12,720 It's not going to remodel itself immediately. 229 00:14:12,720 --> 00:14:16,680 Sometimes if you're challenging the baby, they still will vomit and that's okay. 230 00:14:16,680 --> 00:14:22,480 Now once you get into days and complete intolerance of feats, then you have to worry about something 231 00:14:22,480 --> 00:14:23,880 like an incomplete myotomy. 232 00:14:23,880 --> 00:14:28,320 Yes, that makes perfect sense because the stomach is getting back on track. 233 00:14:28,320 --> 00:14:32,240 We would want the patient to take in nothing by mouth initially and then introduce feats 234 00:14:32,240 --> 00:14:33,680 very slowly. 235 00:14:33,680 --> 00:14:38,280 And some researchers have demonstrated that following a more flexible protocol, such as 236 00:14:38,280 --> 00:14:44,200 reducing formula or volume if a baby vomit six times but continuing to feed smaller amounts 237 00:14:44,200 --> 00:14:49,120 and then increasing as tolerated allows for greater flexibility and decreases the length 238 00:14:49,120 --> 00:14:50,120 of hospital stay. 239 00:14:50,120 --> 00:14:53,960 I think it's really important to educate not only the family but also the pediatric 240 00:14:53,960 --> 00:14:59,920 care team on the hospital floors that some vomiting is expected and is actually acceptable. 241 00:14:59,920 --> 00:15:03,860 Just follow the protocol and keep trying smaller amounts of feeds and monitor closely. 242 00:15:03,860 --> 00:15:07,720 It is also important to monitor the patient for apnea and signs of pain. 243 00:15:07,720 --> 00:15:11,520 Overall, this procedure is a very well tolerated operation. 244 00:15:11,520 --> 00:15:15,840 Finally, looking at the studies on adults who had a pyloric myotomy as kids, it's 245 00:15:15,840 --> 00:15:19,760 pretty clear that they don't tend to have major issues like nausea, vomiting, reflux 246 00:15:19,760 --> 00:15:22,160 or other gastrointestinal problems later in life. 247 00:15:22,160 --> 00:15:26,960 This suggests that long-term follow-ups are usually not necessary, which is really reassuring 248 00:15:26,960 --> 00:15:32,200 for both patients and the doctors. 249 00:15:32,200 --> 00:15:36,320 In this episode, we discussed how to diagnose and manage the care of children with pylorectal 250 00:15:36,320 --> 00:15:37,320 stenosis. 251 00:15:37,320 --> 00:15:38,960 Here are a few things to consider. 252 00:15:38,960 --> 00:15:43,960 During the initial patient presentation, it is really important to get a good family history, 253 00:15:43,960 --> 00:15:47,200 review electrolyte panels and ultrasound results. 254 00:15:47,200 --> 00:15:50,900 When determining the next steps in the patient's care, try to get the patient's fluids and 255 00:15:50,900 --> 00:15:51,900 electrolytes balanced. 256 00:15:51,900 --> 00:15:57,420 It is really important for avoiding morbidity or mortality by stabilizing them for surgery. 257 00:15:57,420 --> 00:16:02,640 Surgery can be done either laparoscopically or as an open procedure with similar outcomes. 258 00:16:02,640 --> 00:16:06,440 And lastly, make sure that the care teams and families understand post-op care. 259 00:16:06,440 --> 00:16:09,960 Remember, the patients may vomit and it might be expected. 260 00:16:09,960 --> 00:16:14,400 Adjusting the amount and frequency of feedings will help speed up the recovery. 261 00:16:14,400 --> 00:16:17,080 Thank you for listening this episode. 262 00:16:17,080 --> 00:16:22,440 We will cast MD along with Cincinnati Children's Hospital, sharing knowledge to improve child 263 00:16:22,440 --> 00:16:47,640 health around the globe.