Redo Pyloromyotomy

Redo pyloromyotomy surgery

Redo pyloromyotomy is a secondary operation to pyloromyotomy (typically done to treat hypertrophic pyloric stenosis in newborns) which leaves the obstruction at the pylorus not fully resolved. This could be attributed to the unsuccessful division of the muscles, scarring or restenosis of the pyloric channel.

What is Redo Pyloromyotomy Surgery?

Redo pyloromyotomy surgery is an indication where the pyloric muscle (thickened muscle at the stomach exit) is properly divided by reopening or doing the pyloromyotomy surgery again. This allows food to pass normally through the stomach into the small bowel. It can be performed either by open or laparoscopic technique depending upon the condition of the patient and expertise of the surgeon.

Advantages of Redo Pyloromyotomy

• Less incisions and decreased pain after the surgery.
• Faster recovery
• Less risk of infection of the wound.
• Better cosmetic outcome

Redo pyloromyotomy surgery procedure

Re operative pyloromyotomy is the surgical correction of the primary pyloromyotomy [usually for infantile hypertrophic pyloric stenosis] which is either incomplete or unsuccessful leading to persistence of outlet obstruction of the stomach. The objective is to perform a total dissection of the hypertrophied pyloric muscle so that the food can be easily discharged from the stomach into the duodenum.

Preoperative Preparation

• Clinical examination

Imaging tests:

• Ultrasound - to identify uncomplete myotomy or thickened remained pyloric muscle.
• Upper GI study: to visualize the obstruction
• Laboratory tests

Preoperative management:

• IV replacement to treat dehydration.
• To clear stomach contents, nasogastric decomposition.
• Preoperative patient fasting (nil orally).

Anaesthesia

• General anaesthesia is applied.
• Intubation and continuous monitoring of vital signs are done on the patient.

Surgical Approaches

Redo pyloromyotomy may be performed in two methods:

Open Redo Pyloromyotomy

• Incision is made in small right upper quadrant/Upper midline.
• With the surgeon, the previous surgery scar tissue is dissected with great care to access the pylorus.
• The thickened pyloric muscle is distinguished.

Laparoscopic Redo Pyloromyotomy

• Complete hysterectomy performed with 3 small upper abdomen incisions (ports).
• The laparoscope (camera) is used to have a magnified view of the pyloric area.
• The new myotomy is carefully done by the use of specialized instruments which dissect the area of the skin.

Surgical Steps

Exposure of the Pylorus:

• Dissection of the pyloric mass is done by cutting through past adhesions or scar tissue.

Discovery of Old Myotomy Location:

• The surgeon identifies the previous site of incision in the pyloric muscle.
• Splitting not fully split through the eye or palpation.

Redo Myotomy (Splitting of Muscle):

• A longitudinal incision is carried out on the thickened pyloric muscle.
• The muscles are carefully divided until the mucosa (inner lining) sticks out making sure that the division is full.
• The mucosa should be left intact and any minor perforation should be sewn in with a fine suture.

Check of Complete Myotomy:

• The pyloric channel is examined in order to ensure that the separation is all the way to the gastric side to the duodenal end.
• Saline irrigation or air insufflation can be applied to make sure that there is no mucosal perforation or leak.

Closure:

• There are no sutures applied over the site of myotomy (to inhibit re-stenosis).
• Both the outer layers and skin incisions are closed in layers.
• Laparoscopic ports are excised and skin closures are made small.

Postoperative Care

• Feeding: Oral feeding is normally initiated within 12-24 hours following the surgery, and this will begin with small portions of clear fluids and then on solids, milk or formula.
• Pain management: Mild analgesics are employed.
• Monitoring: The patient is observed to vomit, mucosal breakdown, or to be infected.
• Hospitalization: 2-4 days usually based on recovery.

Recovery and Follow-Up

• Majority of the patients resume normal feeding in few days.
• The average length of full recovery is 1-2 weeks.
• Follow-up visit will provide adequate feeding tolerance and weight gain.

Indications for redo pyloromyotomy

Redo pyloromyotomy is recommended when the first pyloromyotomy is ineffective in the removal of the gastric outlet obstruction associated with hypertrophic pyloric stenosis (HPS). The condition usually presents itself in infants and even though primary pyloromyotomy is very effective, there is a little percentage of patients who might need to undergo another operation following the initial operation because of the persistence of the symptoms.

Continuous Vomiting following First Operative

• Most common indication.
• Persistent or projectile vomiting that occurs after 4872 hours after surgery is an indication of incomplete pyloromyotomy.
• Vomiting can be non-bilious and with feeds, as in the preoperative stage.

Partial Myotomy (Remaining Pyloric Muscle)

• In case the pyloric muscle has not completely been divided in the initial surgery, the gastric outlet is still partially blocked.
• On imaging (ultrasound or contrast study), a persistent narrowing of the pyloric canal is demonstrated.
• This is a technical etiology and the most common cause of re do surgery.

Pyloric Restenosis (Re-thickening or Scarring)

• In very rare instances fibrosis or scarring may result in a recurrence of narrowing of the pyloric channel after successful initial pyloromyotomy.
• May is several weeks or months after the initial surgery.

Chronic Gastric outlet obstruction on Imaging

• The radiological evidence of delayed gastric emptying or constricted pyloric passage despite a prior myotomy is evidence of the necessity of reoperation.
• The upper GI contrast studies present consistent, persistent string sign or obstruction.

Mucosal Herniation or Obstruction of adhesion

• Mechanical obstruction can be due either to hernia of the mucosa through the site of myotomy or external adhesions.
• Such conditions might require redo pyloromyotomy surgery or revision surgery to correct the defect.

Poor or Failure to Thrive

• Infants who still lose weight or do not gain enough weight despite already having pyloromyotomy and are able to eat normal weight may need to be looked at as obstruction being still not relieved.

Diagnostic Uncertainty / Misdiagnosis

• On rare occasions, when the initial signs are still present because of other causes of the outlet of the gastric and the primary surgery is not sufficient enough, redo pyloromyotomy can be done after ensuring that the pyloric muscle has not atrophied.

Redo pyloromyotomy complications

Redo pyloromyotomy is considered to be a safe and effective corrective procedure in incomplete or failed initial pyloromyotomy. Nonetheless, because it will be the operation of an already operated area with scar tissue, it will have slightly greater risk of complications than the initial operation.

The following are the most important intraoperative and postoperative complications with redo pyloromyotomy:

Mucosal Perforation

• Majority of surgical complication.
• Activates when the mucosa (the inner layer) of the stomach or duodenum is accidentally punctured in the course of the muscle division.
• The cases of redo are associated with the increased risk because of the scarring and distorted anatomy.
• Treatment: Emergency repair, using fine absorbable sutures.
• Prognosis: Generally good following immediate repair.

Bleeding

• May cause by the injury of small blood vessels during the dissection of scar tissue.
• Small, usually minor and managed intraoperative.
• Prevention: Careful and gentle dissections, particularly in cases of redo surgery when the vascular planes are not very clear.

Infection

• Post-operative wound or port-site infections can be received.
• Prevailing in open over laparoscopic operations.
• Prevention: Asepsis and postoperative wound treatment.

Adhesion Formation

• Internal scar tissue (adhesions) may develop as a result of recurrent surgery and may lead to obstruction of the bowel in the future.
• Reduced through proper handling of tissues and laparoscopic approach where feasible.

Persistent Vomiting

• May takes 2-3 days after surgery because of pyloric edema, gastric dysmotility or reflux.
• In general heals in 48-72 hours.
• Continued vomiting after this time could indicate some other underlying condition and needs to be re-examined.

Incomplete Redo Myotomy

• Uncommon, but may arise should the pyloric muscle not be full-divided once more.
• Results in persistent effects of obstruction and could necessitate additional assessment or amendment.

Mucosal Herniation

• This inner lining (mucosa) can protrude out through the muscle laceration in case the myotomy is excessively deep or uneven.
• May lead to mechanical obstruction or retarded gastric emptying.
• May need surgical repair in case of symptomatic.

Gastric Outlet Obstruction Postoperative

• Seldom caused by edema, hematoma or scarring at the sites of myotomy.
• In most cases temporary but sometimes needs treatment.

Anaesthetic Complications

• Associated with general anaesthesia 
• Avoided because of preoperative starvation and correct anaesthesia.

Repetition of Obstruction (Very Rare)

• Appears when scarring or fibrosis grows up again at the pyloric site after surgery.
• Rarely occurs with a redo surgery that has been performed well.

Success rate of redo pyloromyotomy

Redo pyloromyotomy- It is an operation done when the first pyloromyotomy is not effective enough to resolve gastric outlet obstruction completely and in such a case, it is carried out by more experienced pediatric surgeons.

Overall Success Rate

• Clinical studies and pediatric surgical case reports show that the success rate of redo pyloromyotomy is about 95 98%.
• After the redo procedure most of the infants have full resolution of vomiting, normal feeding and consistent weight gain.

Best hospital for redo pyloromyotomy India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Conclusion

Redo pyloromyotomy is a very efficient and competent surgical practice to rectify the unsuccessful gastric outlet obstruction after an incomplete or failed initial pyloromyotomy. It has very good results despite the technical difficulty of having scar tissue and changed anatomy and can have good results when done by qualified pediatric surgeons. Having a success rate of 95-98, a majority of the patients report having all the symptoms healed, normal feeding and healthy weight gain within a few recovery days. The laparoscopic procedures which are being used in modern times are more accurate, less painful and have better cosmetic outcomes. The diagnosis should be as early as possible, the surgeon should be very careful and the postoperative monitoring should be as close as possible in order to achieve the best results. Comprehensively, redo pyloromyotomy is the conclusive treatment of unresolved hypertrophic pyloric stenosis and offers good long-term outcomes to the infants with the condition.

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FAQ

1. Is laparoscopic surgery applicable on redo pyloromyotomy?

• Yes. Laparoscopic approach is now gaining popularity in cases in which the operation has been previously done as it offers more visualization, scarring, and recovery time than open surgery.

2. What is the long-term prognosis following pyloromyotomy redo?

• The long-term outcomes are good. Majority of infants are normally digested, grow, and develop without a reoccurrence of later in life symptoms, or complications.

3. Which tests prove the necessity of redo surgery?

• Ultrasound- residual thickness of the pyloric muscle
• Upper GI contrast examination - reveals slowed gastric emptying or continuing obstruction.
• These are imaging tests useful to verify incomplete pyloromyotomy prior to re operation.