I just finished reading an article “Centennial of Pyloromyotomy” in the Journal of Neonatal Surgery by Dr. V. Raveenthiran, a pediatric surgeon with SRM Medical College and Hospital in Chennai, India. Since 2012 was the year to celebrate the discovery by Dr. Conrad Ramstedt of the Ramstedt procedure, a surgical technique which saved my life as an infant, several articles have been published about the doctor and pyloric stenosis, Dr. Raveenthiran’s being one of them. In brief, his article discusses and evaluates some of the articles that report on the treatment of pyloric stenosis in the 100 years since Ramstedt’s discovery, including new diagnostic and surgical techniques.
A bit of background: Dr. Ramstedt discovered that he could best save babies suffering pyloric stenosis by cutting into the pylorus muscle of the stomach, in order to alleviate pressure and open the passage between the stomach and small intestine that had been blocked, and then by not stitching the incision on the pylorus muscle. (Previously, the pylorus muscle incision was stitched closed.) On Fred Vanderbom’s blog survivinginfantsurgery.Wordpress.com, he summarizes Dr. Raveenthiran’s article quite beautifully.
One point that Dr. Raveenthiran makes struck me most. He writes: “Colossal success of a curative procedure usually obviates the need for further scientific research by solving the underlying problem.” To paraphrase, Dr. Ramstedt’s surgical outcomes were so great, so successful, that the search for the origin of the often fatal condition in newborns, pyloric stenosis (PS), was no longer of immediate concern. Most of the article discusses the plethora of new techniques that have been developed over the years to reduce the scarring of the baby’s skin and to make the operation overall more efficient. What disturbs me though is the lack of energy being directed into discovering the etiology or cause of PS and working to preventthis condition in the first place. Pyloric stenosis has been known to humans for several hundred years, yet little is known about the cause.
I think it’s high time that medicine put a stop to PS altogether. Why? I’m coming from the baby’s point-of-view. Surgery sucks! The last thing a baby wants to go through shortly after he or she arrives in this world is hospitalization, separation from Mom and family, immobilization on a surgical table, and an invasive procedure or assault on the body. Years ago, the surgery was barbaric as anesthetic was often not used. An infant may have been brandied up (yes, given alcohol!), given a local anesthetic or given a paralytic, whereby she couldn’t move but was aware. Generally, from 1912 to the 1940s, no anesthesia was the norm. Then, the patient is left to cope with post-traumatic stress symptoms that can, and often do, persist well into adulthood. Over time anesthesia began to be used. (The history of the development of pediatric anesthesia and pain control for infants and neonates is a long and complicated one that varies significantly country to country.). Now more often in operating on babies with PS, anesthesia is administered, the recovery time is shorter, the baby is less isolated from family, and the incision is smaller. Yea! But wouldn’t you rather be cured so that a surgery wouldn’t be necessary?
Dr. Ian M. Rogers discusses his findings about using antacid therapy to change the pH balance in the stomach and stop the pylorus from becoming super spasmotic and ultimately blocking the os or opening into the small intestine. (Read “Pyloric Stenosis-The Real Cause” dated June 17, 2012 in myincision.) He encourages doctors to give an antacid, if appropriate, as soon as the baby is suspected of PS to see if gastric changes will prevent the need for surgery. Ah, prevention–a breath of fresh air!
The 21st century should no longer parrot the paradigm of the past. It’s time to work in new ways. Albert Einstein said: ”We cannot solve our problems with the same thinking we used when we created them.” So while I am deeply indebted to Dr. Conrad Ramstedt, it’s time to let go of the thinking of the past by taking some of the focus off of all the new iterations of the Ramstedt procedure and proceeding to a new era in treating pyloric stenosis, that is, early detection, treatment, and prevention. Babies, parents, families, and the practice of medicine itself deserve it. Let’s try what Dr. Rogers is offering. Let’s get other ideas on the table, for example, reducing stress on the pregnant mother. Let’s use Ramstedt’s technique when early treatment isn’t working or wouldn’t be advisable. Let’s work to make Ramstedt’s technique a strategy of the past.