What is the treatment for pyloric stenosis?

Treatment of Pyloric Stenosis

Surgical pyloromyotomy is the definitive and curative treatment for infantile hypertrophic pyloric stenosis, but preoperative medical resuscitation to correct fluid and electrolyte abnormalities must always precede surgery—this is never an emergency operation. 1, 2

Preoperative Medical Management (Always First)

Correct metabolic derangements before any surgical intervention:

• Fluid resuscitation is mandatory to correct intravascular volume depletion from persistent vomiting 1
• Electrolyte correction must address the characteristic hypochloremic, hypokalemic metabolic alkalosis before proceeding to surgery 1, 2
• Surgery should be delayed until metabolic abnormalities are fully corrected—emergent surgery is contraindicated and increases morbidity 1, 2

Definitive Surgical Treatment

Pyloromyotomy (either open or laparoscopic) is curative in 100% of cases:

• Laparoscopic pyloromyotomy is equally safe and effective as open surgery, with average surgical time of 25.4 minutes, time to full feedings of 19 hours, and superior cosmetic results 3
• Open pyloromyotomy remains the gold standard with comparable efficacy (average surgical time 26.1 minutes, time to full feedings 23.2 hours) 3
• Both techniques achieve cure in all patients when performed correctly 4
• Ultrasound has 96% sensitivity for diagnosis and should be used routinely 2, 4

Medical Treatment Alternative (Non-Standard)

Intravenous atropine therapy can be considered if prolonged hospitalization is acceptable, but surgery remains standard of care:

• Atropine 0.01 mg/kg IV 6 times daily before feeding achieves cessation of vomiting in 87% of cases 5
• Median hospital stay is 13 days (range 6-36 days) with median 7 days IV atropine followed by 44 days oral atropine 5
• The 13% failure rate requires subsequent surgery 5
• This approach avoids surgical complications (wound infection in 10% of surgical cases) but requires extended hospitalization and prolonged medication 5, 4

Perioperative Complications to Monitor

Surgical complications are uncommon but include:

• Mucosal perforation occurs in approximately 1.4% (2/140 patients), requires postoperative suturing 4
• Wound infection occurs in 5% (7/140 patients) 4
• Postoperative vomiting typically resolves within 24 hours; persistent vomiting beyond this warrants evaluation for incomplete myotomy 1
• Overall complication rate is 16%, with serious complications (Clavien-Dindo grade IIIb/IVa) in 2.9% without long-term sequelae 4

Critical Pitfalls to Avoid

• Never rush to surgery—pyloric stenosis is not a surgical emergency; inadequate preoperative resuscitation increases morbidity and mortality 1, 2
• Never proceed with surgery until electrolytes are normalized—the metabolic alkalosis must be corrected first 1, 2
• Do not confuse with gastroparesis treatments—balloon dilatation, G-POEM, and gastrojejunostomy are not treatments for pyloric stenosis 6