reply to letter to the editor
TRANSCRIPT
children may prove to be a difficult conversation withparents. This conversation must balance the perceivedbenefits of laparoscopic repair with the potential, but as yetunproven, risk of neurotoxicity from general anesthesia.
Robert WilliamsIan Black
Kennith SartorelliCollege of Medicine
University of VermontBurlington, VT, USA
E-mail address: [email protected]
doi:10.1016/j.jpedsurg.2011.02.055
References
[1] Walker K, Halliday R, Holland A, et al. Early developmental outcomeof infants with infantile hypertrophic stenosis. J Pediatr Surg 2010;45:2369-72.
[2] Williams R, Adams D, Eladjem E, et al. The safety and efficacy ofspinal anesthesia for surgery in infants: the Vermont Infant SpinalRegistry. Anesth Analg 2006;102:67-71.
[3] Lachko L, Simhi E, Freud E, et al. Impact of spinal anesthesia for openpyloromyotomy on operating room time. J Pediatr Surg 2009;44:1942-6.
[4] Somri M, Gaitini L, Vaida S, et al. The effectiveness and safety of spinalanesthesia in the pyloromyotomy procedure. Pediatr Anesth 2003;13:32-7.
Reply to Letter to the Editor
To the Editor,Thank you for the opportunity to respond to the insightful
comments from Dr Williams et al. They raise severalimportant points that are worthy of further discussion. First,although our study revealed evidence of neurodevelopmentaldelay in infants after pyloromyotomy under generalanesthesia (GA), this does not necessarily imply causation[1]. Although it remains possible that the delays we observedwere solely the result of GA in these infants, it would seemperhaps more likely that they reflect a combination of factorsthat might include a link between those genes predisposing toinfantile hypertrophic pyloric stenosis (IHPS), any residualelectrolyte imbalances, mild starvation, and GA [1].Certainly, as part of our continuing study, we propose toreevaluate these children at 3 years to assess for any long-term developmental delay. Rather than to engender panic,however, we agree that these data should stimulatecolleagues to reflect upon their own practice and considerthe need for a well-supported and properly fundedrandomized, controlled trial.
In our own institution, the largest of 3 pediatric teachinghospitals in New South Wales, Australia, pyloromyotomyhas generally been performed under GA. Although, in thepast, this mode of anesthesia may have simply reflected atraditional attitude, during the last 3 years, many of ourcolleagues, after a careful review of the surgical literature,have moved to a laparoscopic approach to the operativetreatment of IHPS [2]. A double-blind, randomizedmulticenter trial published in 2009 identified severaladvantages with this technique, including a shorterrecovery, early time to full feeds, and reduced analgesicrequirements [3]. We suspect that many pediatric surgeonswould now be reluctant to revert to an open technique thatthe switch to spinal anesthesia would require withoutcompelling evidence.
Finally, although Dr Williams et al correctly identifymany of the advantages associated with spinal anesthesia,such a technique requires considerable skill and is not itselfwithout risk, including an inadequate block, respiratoryinsufficiency, and rarely, sepsis [4,5].
Karen WalkerRobert HallidayNadia Badawi
Grace Centre for Newborn CareThe Children's Hospital at Westmead
The University of SydneyNew South Wales, Australia
E-mail address: [email protected]
Andrew J.A. HollandDepartment of Surgery
The Children's Hospital at WestmeadThe University of Sydney
New South Wales, Australia
doi:10.1016/j.jpedsurg.2011.02.058
References
[1] Walker K, Halliday R, Holland AJA, et al. Early developmentaloutcome of infants with infantile hypertrophic pyloric stenosis. J PediatrSurg 2010;45:2639-72.
[2] Aspelund G, Langer JC. Current management of hypertrophic pyloricstenosis. Sem Pediatr Surg 2007;16:27-33.
[3] Hall NJ, Pacilli M, Eaton S, et al. Recovery after open versuslaparoscopic pyloromyotomy for pyloric stenosis: a double-blindmulticentre randomised controlled trial. Lancet 2009;373:390-8.
[4] Luz G, Buchele H, Innerhofer P, et al. Spinal anaesthesia and meningitisin former preterm infants: cause-effect? Paediatr Anaesthesia 1999;9:262-4.
[5] Tobias JD. Spinal anaesthesia in infants and children. PaediatrAnaesthesia 2000;10:5-16.
1299Correspondence