BJA Education, 18(6): 173e177 (2018)
doi: 10.1016/j.bjae.2018.03.001
Matrix codes: 1A01,
2D05, 3D00
Anaesthesia for pyloromyotomy
R. Craig* and A. Deeley
Alder Hey Children’s Hospital, Liverpool, UK
*Corresponding author: Richard.craig@alderhey.nhs.uk
Learning objectives
By reading this article you should be able to:

Describe the electrolyte and acid-base abnor-
malities associated with infantile hypertrophic
pyloric stenosis.

Explain why these electrolyte and acid-base ab-
normalities need to be corrected before surgery.

Describe the technique for ultrasound examina-
tion of the gastric antrum and qualitative
assessment of stomach contents before induction
of anaesthesia for pyloromyotomy.

Discuss the options for induction of anaesthesia
including choice of drugs and techniques.
Pyloric stenosis is the result of hypertrophy of the smooth
muscle of the pylorus, which forms the gastric outlet. Its
aetiology is uncertain, although a number of environmental
and hereditary contributory factors have been identified.
The reported incidence varies between 0.9 and 5.1 per 1000
live births.1 In England and Wales it is 1.5 per 1000 live births
and has remained static in recent years.2 The risk of the
disease is four to five times higher in boys than girls.3 There
is a decline in risk with increasing birth order with an odds
ratio of 1.9 for first-born children.3 The genetic element is
evidenced with higher rates of concordance in monozygotic
than dizygotic twins and a number of susceptibility loci have
been identified.
Babies with infantile hypertrophic pyloric stenosis present
most commonly in the 2nd and 3rd months of life.2 However,
a recent review of surgical outcomes for 9686 infants who
underwent pyloromyotomy in England over a 10-year period,
Richard Craig FRCA is a consultant paediatric anaesthetist at Alder
Hey Children’s Hospital.
Angela Deeley FRCA is a specialty trainee in anaesthesia in the
Health Education North West (Mersey) region.
Accepted: 5 March 2018
Crown Copyright © 2018 Published by Elsevier Ltd on behalf of British Journal of Anaesthesia. All rights reserved.
For Permissions, please email: permissions@elsevier.com
Advance Access Publication Date: 16 March 2018
Key points

Vomiting results in hypochloraemic, hypo-
kalaemic metabolic alkalosis and dehydration;
these must be corrected before general anaes-
thesia and surgery.

The stomach should be emptied using a naso-
gastric or orogastric tube before induction of
anaesthesia.

Ultrasound can be used to identify fluid in the
gastric antrum.

Ensuring adequate depth of anaesthesia with
complete neuromuscular block before laryngos-
copy minimises the risk of regurgitation and
pulmonary aspiration.

Options for analgesia include rectus sheath block,
transversus abdominis plane block, or local
anaesthetic wound infiltration.
found that 30% of patients were aged 7e28 days at the time of
surgery.2 The classic presentation is projectile vomiting of
non-bilious stomach contents, loss of weight or failure to gain
weight (crossing centiles on the growth chart), and dehydra-
tion. Abdominal examination may reveal a palpable ‘olive’;
however, modern developments mean that the majority of
patients are being diagnosed earlier with ultrasound and this
physical finding is becoming less common.
Pathophysiology and electrolyte changes
Vomiting is the principal symptom of pyloric stenosis, classi-
cally described as being projectile in nature. The vomitus in
pyloric stenosis consists of gastric secretions. These secretions
are high in hydrogen and chloride ions with some sodium and
potassium, all of which are lost along with water. The elec-
trolyte losses result in a hypokalaemic, hypochloraemic
metabolic alkalosis. The water loss causes dehydration and a
reduction in plasma volume; this results in the secretion of
aldosterone. Aldosterone causes sodium and water retention
173
Anaesthesia for pyloromyotomy
by the kidneys in an attempt to restore blood volume. It has
effects on the Naþ/Kþ exchange mechanism causing further
potassium loss in the urine, in addition to that lost in gastric
secretions, worsening the hypokalaemia.
Initially, bicarbonate is excreted in the urine to compen-
sate for the alkalosis caused by hydrogen ion loss from the
stomach; this produces alkaline urine. Eventually mainte-
nance of plasma volume becomes the priority and the kidneys
excrete hydrogen ions in exchange for sodium and water,
resulting in the paradoxical production of acidic urine despite
the metabolic alkalosis.
Medullary chemoreceptors in the brain stem respond to
changes in the hydrogen ion (Hþ) concentration in the cere-
brospinal fluid (CSF), with an increase in the Hþ ion con-
centration stimulating ventilation. An increase in the arterial
partial pressure of carbon dioxide results in an increased CSF
Hþ concentration as the carbon dioxide readily penetrates
the CSF where it is promptly hydrated to form carbonic acid.
Conversely, metabolic alkalosis can cause respiratory
depression and apnoea. This will be aggravated by the CNS
depressant effect of general anaesthesia. Preterm infants of
<60 weeks postmenstrual age are known to be at risk of
postoperative apnoea. This complication has also been re-
ported in term infants after pyloromyotomy.4 Therefore, to
minimise the risk of postoperative apnoea, the alkalosis must
be corrected before surgery. Furthermore, equilibration of
CSF pH with plasma pH takes several hours.1 It is possible
that plasma pH may have returned to normal whilst the CSF
pH remains increased, thereby exerting a respiratory
depressant effect; hence all infants should be monitored for
apnoea after pyloromyotomy.
The degree of dehydration must be calculated and cor-
rected slowly unless there is cardiovascular instability with
hypovolaemic shock; in this case the child should receive an
initial bolus of isotonic crystalloid 20 ml kg1 followed by
frequent reassessment and further fluid resuscitation if
required. The patient is kept nil by mouth and maintenance
fluid in the form of 0.45% saline with glucose 5% and 10 mmol
potassium chloride per 500 ml bag is given at a rate of
150 ml kg1 day1; this will correct the deficiencies in sodium,
potassium, and chloride.5 Once the alkalosis has been cor-
rected, the fluid input is reduced to 100 ml kg1 day1.
Biochemical findings once the alkalosis has been corrected
should be within the following range: pH 7.3e7.45; Cle
95e112 mmol litre1; base excess e4 to 2.5 mmol litre1; Kþ
3.5e5.5 mmol litre1.
Pyloric stenosis is a medical, not a surgical, emergency.
Patients can safely wait for surgery while they are rehydrated
and their electrolyte abnormalities and alkalosis are corrected.
Surgery
Ramstedt described a surgical approach to the management
of pyloric stenosis in 1912. This involved a horizontal inci-
sion through the abdominal wall in the right upper quadrant,
and a longitudinal incision through the muscle of the pylo-
rus, through to, but not perforating, the mucosa. Surgical
advances have altered the skin incision for better cosmetic
appearance. A curved circum-umbilical skin incision is now
commonplace. However, the incision of the pylorus remains
much the same. A laparoscopic approach was described by
Alain and colleagues in 1991.6 In England, 23.7% of pylo-
romyotomies were performed laparoscopically in 2011.2 In
174 BJA Education - Volume 18, Number 6, 2018
the USA, the proportion of pyloromyotomies performed
laparoscopically in 2015 was 65.5%.7 A review of 9686 infants
who underwent pyloromyotomy in England between 2002
and 2011 found that laparoscopic pyloromyotomy may be
associated with an increased risk of inadequate myotomy
requiring reoperation (odds ratio 2.28; 95% confidence in-
terval 1.14e4.57).2 However, a review of 4847 infants who
underwent pyloromyotomy in the USA between 2013 and
2015 found no difference between open and laparoscopic
pyloromyotomy re-operation rates.7 The English report
found no difference between laparoscopic and open pylo-
romyotomy in postoperative length of stay, whilst the US
report described a reduced length of stay after laparoscopic
pyloromyotomy (1.5 days vs 1.9 days).2,7 Laparoscopic pylo-
romyotomy may be associated with less postoperative pain
and a slightly shorter time to full feeds.1,8 The duration of
surgery and anaesthesia is similar for laparoscopic and open
pyloromyotomy.7
Anaesthesia
The gastric outlet obstruction associated with pyloric stenosis
prevents stomach emptying and poses a risk of pulmonary
aspiration of gastric secretions under general anaesthesia.
The stomach may contain significant volumes of acidic
gastric secretions; these need to be removed before induction
of anaesthesia and consequent suppression of the protective
airway reflexes. Previously, nasogastric (NG) tubes were
inserted routinely as part of the medical management some
time before arrival in the operating room. It has been pro-
posed that constant drainage of gastric secretions worsens the
electrolyte imbalance and, in the absence of milk feeds, is
unnecessary in the preoperative period.9 Consequently,
depending on institutional practice, a patient may arrive in
the operating room without an NG tube; these patients still
require insertion of a NG or orogastric tube to empty the
stomach before induction of anaesthesia. In a small pro-
spective randomised trial of the effects of preoperative NG
tubes on emesis rates, patients were randomised to receive a
gastric tube at diagnosis or only immediately before anaes-
thesia.10 None of the 25 patients who had an NG tube inserted
early vomited on induction. Two of the 25 patients in whom
an NG tube was inserted in theatre, vomited on induction of
anaesthesia, risking aspiration of acidic stomach contents.
For those patients who arrive in theatre with an NG tube in
place, maintain an index of suspicion that the NG tube may be
blocked or malpositioned. Check the depth of insertion: it
should be >20 cm. Check the fluid balance chart: a fluid balance
chart documenting regular aspirates suggests a well-placed NG
tube. If suctioning the NG tube yields absolutely no gastric
fluid, consider that it may be blocked. Insufflate a small
amount of air to exclude a blocked NG tube. If in doubt, remove
the NG tube and replace it with a 14 French orogastric tube.
Emptying the stomach may be performed by rotating the
infant from the supine, to left lateral decubitus, to prone, to
right lateral decubitusdaspirating the NG tube in each
position.
Ultrasound assessment of gastric contents has been stud-
ied in infants with pyloric stenosis demonstrating that a
qualitative assessment of stomach contents can be made
quickly and easily before induction of anaesthesia (Table 1;
Fig. 1).11 This non-invasive bedside test may be a way of
confirming an empty stomach.
 Anaesthesia for pyloromyotomy

Table 1 Gastric ultrasound before induction of anaesthesia for pyloromyotomy

Gastric ultrasound

1. This should take place in the operating theatre, before induction of anaesthesia with the infant being actively warmed.
2. Place the infant in the right lateral decubitus position (right side down). Assessment in the supine position usually reveals nothing but
air artefact from air in the fundus and body of the stomach.
3. Place a high frequency linear array probe (25 mm footprint) over the xiphisternum in the sagittal plane. The image depth should be set
to 4 cm.
4. Identify the liver and the antrum of the stomach under the liver edge (Fig. 1). Move the probe parasagittal both left and right of the mid
line to get a good view of the antrum. Scanning too far to the left will usually reveal air in the body and fundus.
5. Evaluate the antrum; this is a qualitative assessment to decide if the antrum contains fluid or is relatively empty. It may be possible to
see the NG tube (Fig. 1, image 2).
6. The empty antrum will appear flat with thick muscular walls. The full antrum will be round and distended with thin walls.
7. In the infant, gastric contents will have a ‘starry night’ appearance. Successful aspiration via the NG tube will cause this to disappear
and the thick walled, collapsed antrum to appear. This may require manipulation of the NG tube (advancement or withdrawal).
www.gastricultrasound.org

To reduce the risk of pulmonary aspiration of gastric con-
tents, smooth induction of anaesthesia, avoidance of hypo-
xaemia, and airway instrumentation with complete
neuromuscular block are paramount.12 The risk of vomiting or
regurgitation is highest during laryngoscopy when airway
stimulation is at its greatest.12 Ensure an adequate depth of
anaesthesia and complete neuromuscular block before
laryngoscopy to prevent the patient coughing and gagging.
Classic rapid-sequence induction and intubation, as per-
formed in adult patients, with pre-oxygenation, cricoid pres-
sure and no bag-mask ventilation, should not be applied
without modification when anaesthetising neonates and in-
fants.12 The infant airway is compressible and easily
deformed by external pressure. The application of cricoid
pressure may make intubation difficult; if not impossible.13
Identification of the cricoid ring is also more difficult than in
adults. Cricoid pressure is, therefore, best avoided. Functional
residual capacity is reduced in infants compared with older
children and adults as a result of increased chest wall elas-
ticity and splinting of the diaphragm by their comparatively
large abdomens. They also have a much greater oxygen con-
sumption, which makes the onset of hypoxaemia much more
rapid in infants than adults. This means that gentle bag-mask
ventilation is required after induction of anaesthesia and
before tracheal intubation to prevent hypoxaemia and
bradycardia.
Choice of anaesthetic induction technique remains
controversial. In the authors’ institution, 17 out of 25 consul-
tant paediatric anaesthetists choose to perform an inhalation
induction whilst the remaining eight choose an i.v. induction.
The use of inhalation induction for pyloromyotomy has
been described in a retrospective case series of 269 cases
including 252 inhalation inductions.14 None of the patients in
this case series suffered pulmonary aspiration of gastric
contents. All but one patient had a working peripheral i.v.
cannula in place before induction. The following description
of the technique represents local practice in the authors’
institution. Induction takes place in the operating room, after
evacuation of gastric contents and gastric ultrasound exam-
ination, with active warming and standard monitoring
established. The i.v. cannula is flushed with 0.9% saline to
check that it is working. Sevoflurane (4e6%) in oxygen at
6 litre min1 is administered via face-mask with a Jackson
Rees T-piece Intersurgical Mapleson F infant T-piece
breathing system, Intersurgical Ltd. Wokingham, Berkshire,
UK. Gentle continuous positive airway pressure is applied by
partially occluding the reservoir bag of the breathing system.
A good face-mask seal and a patent upper airway are
confirmed by movement of the reservoir bag as the infant
breathes spontaneously. Attention to patient positioning,
avoiding excessive neck flexion caused by the relatively large
occiput, and skill in holding the face-mask, are required to
avoid inadvertently occluding the airway. Once the infant
has lost consciousness, atracurium 0.5 mg kg1 is adminis-
tered. As the baby becomes apnoeic, gentle bag-mask venti-
lation replaces spontaneous ventilation. Care is taken to
avoid vigorous bag-mask ventilation and bag-mask ventila-
tion with an occluded upper airway; both are likely to inflate
the stomach and increase the risk of aspiration. Time is
allowed for neuromuscular block to take effect before
laryngoscopy. The onset time [injection to 95% depression of
the first twitch of the train-of-four represented as the mean
and standard error of the mean (SEM)] of atracurium
0.5 mg kg1 in neonates and infants is 0.9 (0.1) min.15
Laryngoscopy is performed and the infant’s trachea is intu-
bated with a size 3.0 Microcuff endotracheal tube (Halyard
Health Inc. Alpharetta. Georgia. USA).
I.V. induction of anaesthesia can be performed with either
propofol 3 mg kg1 or ketamine 2 mg kg1.1 Neuromuscular
block can be achieved with succinylcholine 2 mg kg1, atra-
curium 0.5 mg kg1, or rocuronium 0.3e0.7 mg kg1. Recovery
after atracurium 0.5 mg kg1 is more rapid in neonates than
infants or older children. The time from injection until the
first twitch of the train-of-four has recovered to 25% of the
control twitch height, represented as the mean (SEM), is 28.7
(1.9) min in neonates compared with 33.7 (1.2) min in older
children.15 Recovery from atracurium does not rely on hepatic
microsomal enzyme systems, which are immature in neo-
nates and infants. The mean [standard deviation (SD)] onset
time of rocuronium 0.3 mg kg1 was reported as 47 (12) s in
children aged <6 months, producing 100% block in 18 out of 19
children.16 The time for recovery of the first twitch of the
train-of-four to 25% of the control twitch height after
rocuronium 0.3 mg kg1 in this age group is 26.1 (SD 11.1) min,
compared with 41.9 (3.2) min in infants aged 2e11 months
who received rocuronium 0.6 mg kg1.16,17 The effect of
rocuronium is prolonged in neonates compared with other
age groups.1
Historically, awake intubation was a popular airway
management strategy for infants undergoing pylo-
romyotomy. The perceived advantage was the preservation of
protective airway reflexes and avoidance of hypoxaemia after

BJA Education - Volume 18, Number 6, 2018 175

Anaesthesia for pyloromyotomy
Fig 1 Ultrasound images of the gastric antrum. Full gastric antrum, showing the starry night appearance, at the top. Empty antrum at the bottom after evacuation of the
gastric contents by aspiration of the NG tube.
induction of anaesthesia. In 1998, Cook-Sather and col-
leagues18 showed that the successful first attempt intubation
rate is greater, and time to intubation shorter, in patients
receiving general anaesthesia and a neuromuscular blocking
agent than patients having awake intubation, with no differ-
ence in complication rates. Awake intubation is no longer
recommended.
The use of a Microcuff tracheal tube may be advantageous.
They are currently available for children weighing >3 kg and
reduce the time to isolation of the lower respiratory tract by
reducing the need for tracheal tube changes to establish the
best fit.
Anaesthesia is maintained with sevoflurane or desflurane
in a mixture of oxygen and air. Nitrous oxide is usually avoi-
ded because it causes expansion of bowel gas. Isoflurane is
associated with more episodes of postoperative apnoea and
longer recovery times when compared with desflurane in in-
fants undergoing pyloromyotomy.19
Analgesia may be provided by ultrasound guided rectus
sheath block, transversus abdominis plane (TAP) block, or
local anaesthetic infiltration by the surgeon. Rectus sheath
block is an appropriate choice for open pyloromyotomy with a
circum-umbilical skin incision. TAP block may be useful for
open or laparoscopic pyloromyotomy. There is no evidence
that a regional technique is more effective than local infil-
tration but it has been suggested that bilateral rectus
sheath blocks reduce the intraoperative end-tidal vapour
concentration required to maintain adequate anaesthesia
during open pyloromyotomy.20
Paracetamol is the only systemic analgesic required. I.V.
paracetamol is licensed for use in neonates of >32 weeks
postmenstrual age but great care must be taken to ensure the
correct dose is given. Suitable doses for small babies are:
176 BJA Education - Volume 18, Number 6, 2018
7.5 mg kg1 every 8 h for preterm infants between 32 and 36
weeks postmenstrual age; 7.5 mg kg1 every 6 h for infants
between 36 and 44 weeks postmenstrual age; 15 mg kg1 every
6 h from 44 weeks postmenstrual age (7.5 mg kg1 in a 3 kg
child is 22.5 mg or 2.25 ml of the standard 10 mg ml1 i.v.
preparation). The rectal paracetamol 40 mg kg1 is an alter-
native. There is rarely any need for opioid analgesics. Regular
paracetamol is usually sufficient for postoperative analgesia.
During a laparoscopic approach, be especially vigilant
during abdominal insufflation. The procedure is usually well
tolerated but intra-abdominal pressure should be kept less
than or equal to 10 mmHg.1 Ventilator adjustments are likely
to be required to maintain an adequate minute ventilation
and the absorption of CO2 across the peritoneum may lead to
hypercapnia.
Towards the end of the operation the surgeon may ask the
anaesthetist to insufflate a volume of air into the stomach
through the NG tube. The absence of air escaping through the
mucosa suggests that it has remained intact. Visualisation of
air passing into the duodenum suggests that the division of
the pylorus has been satisfactory. Great care must be taken to
ensure that air is introduced into the NG tube and not an i.v.
line. However, the introduction of NG tubes with connections
that are not compatible with i.v. Luer syringes and purple
coloured enteral syringes should mitigate this risk. The NG
tube should be aspirated again and can then be removed. The
infant is extubated in the left lateral position once fully awake.
There should be adequate spontaneous ventilation and the
child should be obviously awake and moving vigorously.
The patient should be recovered in a postoperative recov-
ery area until fully awake, then nursed with continuous pulse
oximetry and apnoea monitoring for 12 h. If there have been
no apnoeas, apnoea monitoring may be discontinued after

12 h. If there have been episodes of apnoea, then monitoring
should continue for a further 12 h after the apnoea. Post-
operative feeding regimes vary between centres; some sur-
geons advocate a 2 h nil by mouth period, but there is a trend
toward early feeding on demand. The first feed is usually
water or dioralyte followed by increasing volumes of milk
feeds on demand.
Declaration of interest
None declared.
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Education.
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