Peroral pyloromyotomy for the treatment of infantile hypertrophic pyloric stenosis.

Abstract

Infantile hypertrophic pyloric stenosis (IHPS) is the most common condition requiring surgical treatment in infants [1]. Traditionally, the standard treatments are laparoscopic or open pyloromyotomy [2]. Here, we report on the use of peroral pyloromyotomy (POP), also called gastric peroral endoscopic myotomy (G-POEM), which has shown promising results in the treatment of adult gastroparesis [3], for a novel application, the treatment of IHPS. A 35-day-old infant was admitted with a 1-week history of progressively forceful vomiting after feeding. An ultrasound scan showed a thickened pyloric muscle and extended pyloric channel length and an upper gastrointestinal series showed narrowing of the pylorus, which was filled with a thin strip of contrast agent (▶Fig. 1 a). The patient was therefore diagnosed as having IHPS. POP was proposed after a full multidisciplinary discussion. The procedure included four steps (▶Video 1): (i) a transversal mucosal incision was performed at the proximal antrum (▶Fig. 1b); (ii) a submucosal longitudinal tunnel was created across the pyloric ring (▶Fig. 1 c); (iii) full-thickness pyloromyotomy was performed, with a little extension at the antrum (▶Fig. 1d), after which an ultrathin gastroscope was used to inspect the mucosa and pyloric outlet; (iv) after careful hemostasis had been performed, the mucosal entry was closed by clips (▶Fig. 1 e). The postoperative upper gastrointestinal series showed a normal stream of the contrast without evidence of any leakage (▶Fig. 1 f). The patient recovered well without any perioperative complications. During 2months of follow-up, the patient took oral feeds well without vomiting and with an increase of 3 kg in body weight. Laparoscopic or open pyloromyotomy is the traditional standard treatment for IHPS [2]. However, because of severe dehydration, electrolyte disturbance, and malnutrition, these patients have a lower tolerance of surgery and recover more slowly than usual. In this video, we report the first application of POP in IHPS, which may indicate that POP is a minimally invasive, safe, and effective alternative for treating infants with IHPS.