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CJS, Vol. 41, No. 2, April 1998 151

Original ArticleArticle original

BALLOON PYLOROPLASTY IN CHILDREN WITH DELAYEDGASTRIC EMPTYING

Peter L. Skarsgard, MD;*† Geoffrey K. Blair, MD;* Gordon Culham, MD‡

From the *Department of Surgery and ‡Department of Radiology, British Columbia’s Children’s Hospital, Vancouver, BC

Presented at the 27th annual meeting of the Canadian Association of Pediatric Surgeons, Magog, Que., Sept. 3, 1995

†Resident in General Surgery, University of British Columbia

Accepted for publication June 27, 1997

Correspondence to: Dr. Peter Skarsgard, Ste. 17, 1570 West 15th Ave., Vancouver BC V6J 2K6

© 1998 Canadian Medical Association (text and abstract/résumé)

OBJECTIVE: To evaluate initial experience with balloon pyloroplasty for delayed gastric emptying in children.DESIGN: A retrospective review.SETTING: A tertiary care pediatric hospital.PATIENTS: Seven children with scintiscan-proven delayed gastric emptying that was refractory to maximalmedical therapy.INTERVENTIONS: Balloon pyloroplasty under fluoroscopic guidance, mostly on an outpatient basis. For 1child, the procedure was endoscopically monitored also.OUTCOME MEASURES: Postoperative symptoms and physical findings, gastric emptying and complications.RESULTS: Of the 7 children who underwent balloon pyloroplasty, 3 were rendered asymptomatic and 2more were symptomatically improved. Four of the original 7 patients underwent postdilation scintigraphy,and all 4 showed normalization of the gastric emptying time. There were no complications.CONCLUSIONS: Initial experience with fluoroscopically-guided balloon pyloroplasty indicates that it is a safeand easily tolerated procedure, worthy of further study.

OBJECTIF : Évaluer les premières expériences de pyloroplastie par ballonnet dans les cas de retard de la vi-dange gastrique chez les enfants.CONCEPTION : Étude rétrospective.CONTEXTE : Hôpital pédiatrique de soins tertiaires.PATIENTS : Sept enfants présentant un retard de la vidange gastrique démontré par scintigraphie et réfrac-taire à la thérapie médicale maximale.INTERVENTIONS : Pyloroplastie par ballonnet guidée par fluoroscopie, surtout en service externe. Dans uncas, on a surveillé l’intervention par endoscopie aussi.MESURES DE RÉSULTATS : Symptômes postopératoires et résultats physiques, vidange gastrique et complications.RÉSULTATS : Sur les sept enfants qui ont subi une pyloroplastie par ballonnet, les symptômes sont disparusdans trois cas et se sont atténués dans deux autres. Quatre des sept patients du début ont subi une scinti-graphie après la dilatation et la durée de la vidange gastrique s’est normalisée chez les quatre patients encause. Il n’y a eu aucune complication.CONCLUSIONS : Les premières expériences de la pyloroplastie par ballonnet guidée par fluoroscopie indiquentque l’intervention est sans danger et facilement tolérée, et qu’il vaut la peine de l’étudier plus à fond.

Delayed gastric emptying(DGE) is being increasinglyidentified in infants and chil-

dren, especially those with gastro -

esophageal reflux.1 Although the pre-cise pathophysiology of DGE remainsunknown, there is almost certainly aneurologic component, as most chil-

dren with DGE (and indeed gastro -esophageal reflux) have neurologicdamage. Cisapride therapy can improvethe rate of gastric emptying in some

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SKARSGARD, BLAIR, CULHAM

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152 JCC, Vol. 41, No 2, avril 1998

adults with DGE,2,3 but it is less effec-tive in children.4 Surgical pyloroplastyhas been shown to be effective in ame-liorating the symptoms of DGE;5 how-ever, most children with DGE are at in-creased risk of surgical treatmentbecause of associated medical and neu-rologic illness. Balloon dilation of thepylorus has been described for severaladult and pediatric conditions.6–9 Thepurpose of this study was to evaluateradiologic balloon dilation (balloon py-loroplasty) of the pylorus as a less inva-sive therapy for DGE.

METHODS

Between May 1991 and February1994, 7 children between the ages of2.5 and 16 years who had scintiscan-proven DGE were referred for surgicalmanagement. Each child had sympto-matic DGE, with postprandial vomit-

ing being the most common and trou-blesome complaint (Table I). In 1child who failed to thrive, serial weightmeasurements showed a levelling ofthe growth curve, and 3 others hadpoor weight gain. Duration of symp-toms ranged from 6 months to 4 years.All 7 children had undergone medicalmanagement of varying duration, buteach child had at least 2 months oftreatment at maximal doses of cis-apride. No child showed significantimprovement with medical therapy.Four children had chronic neuro-

logic conditions, placing them athigher risk for surgical treatment.Three children had cerebral palsy andmental retardation; 1 child had con-genital lactic acidosis due to nicoti-namide adenine dinucleotide cy-tochrome C-reductase deficiency, withdevelopmental delay and hypotonia; 1child had coexistent gastroesophageal

reflux documented by upper gastroin-testinal contrast radiography.The 7 children underwent gastric

emptying scintiscanning to objectivelydocument DGE. At our institution,emptying is considered delayed if thet1/2 (time till half of the isotope re-mains in the stomach) is 90 minutesor longer. Six children had a t1/2longer than 160 minutes, and 1 childhad a t1/2 of 90 minutes.Five children underwent an upper

gastrointestinal contrast radiography.One child showed gross esophagealreflux without hiatus hernia, and 1had a small hiatus hernia. The otherstudies were unremarkable. Four chil-dren had an upper endoscopy. Thisshowed esophageal erosions in 1 childand a hiatus hernia in another. Theother 2 studies gave normal results.All balloon dilations were done by a

radiologist under fluoroscopic guid-

Table I

90

> 160

> 160

> 160

> 160

> 160

> 160

Clinical Presentations of Seven Children With Delayed Gastric Emptying Who Underwent Balloon Pyloroplasty

Gastric emptyinghalf-time, min*Patient no.

1

2

3

4

5 11

9

6

3

2.5

Age, yr

Cerebral palsy. Vomiting for8 mo approx. 3 h afterfeeding. Poor weight gain

Vomiting since 5 yr of age

Vomiting, 4–5 times daily.Abdominal pain, heartburn.Poor weight gain

Cerebral palsy. Postprandialvomiting

Congenital lactic acidosis.Vomiting since birth, 4–5times daily, during and afterfeeding. Failure to thrive

Presenting condition

UGI: normalEndoscopy: normalAbdominalultrasonography: normal

UGI: normalEndoscopy: hiatus herniaManometry: normal

UGI/SBFT: 2 minorepisodes of reflux

Endoscopy normal

UGI: esophageal reflux,no hiatus hernia

Investigations

6 12 Cerebral palsy, scoliosis.Vomiting for 6 mo. Poorweight gain

UGI: small hiatus hernia

7 16 Vomiting for 2 yr. Otherwisehealthy

Endoscopy: esophagealerosions

UGI = upper gastrointestinal contrast study, SBFT = soft bowel follow-through*Normal < 90 min

ance. A guide wire was passed downthe esophagus to lie across the pylorus,with the tip well into the duodenum.A balloon catheter of appropriate size(Table II) was then advanced over theguide wire to the level of the pylorus.The balloon, after being appropriatelypositioned, was inflated to 1 atm ofpressure and held for 60 seconds. Thiswas followed by 3 dilations each of 3atm. The radiologic criterion for com-pleteness of dilation was elimination ofthe “waist” in the balloon (Figs. 1 and2). All patients fulfilled this criterion.Water-soluble contrast was then in-stilled into the stomach to detect anyextravasation, indicating rupture of thepyloric channel.A method of endoscopically

guided dilation has been described.10

To compare the procedures, 1 patientunderwent a combined endoscopicand radiologic procedure so that theendoscopic procedure could be mon-itored radiologically. The balloon wasplaced endoscopically and, with en-doscopic protocol, was inflated untilblanching of the pyloric mucosa wasobserved; this occurred at a pressureof 1 atm and was maintained for 1minute. The endoscopic procedurewas simultaneously observed with flu-oroscopy, and at the completion ofthe dilation, a residual waist at the py-lorus could be clearly seen. Dilationwas repeated 2 months later (becauseof persistent symptoms, see Results),this time using radiologic criteria andunder simultaneous endoscopic mon-itoring. In addition to blanching ofthe mucosa, there was fracture of themucosa with bleeding. The degree ofbleeding was comparable to that seenwhen multiple biopsies are taken.Two children underwent repeat ra-

diologic dilations when their symp-toms did not improve. Of the original7 patients, 4 underwent a postdilationnuclear medicine gastric emptyingstudy 6 weeks after dilation to assess

the efficacy of balloon pyloroplasty innormalizing gastric emptying time.The outcomes of these patients

were evaluated by symptoms andphysical findings, gastric emptyingstudies and complication rates (TableII). The follow-up period ranged from4 to 11 months for 6 children, and 1child was lost to follow-up.

RESULTS

Clinical outcomes

The clinical outcomes were mixed.Three children were asymptomatic, 2children improved but still suffered

from occasional postprandial vomiting,and 1 child was worse, with more fre-quent vomiting and failure to thrive.The youngest child, who had hadpostprandial vomiting since infancy,had no vomiting at the time of the ini-tial follow-up. This child underwentplacement of a percutaneous endo-scopic gastrostomy tube concurrentlywith the pyloric dilation. Four monthsafter the dilation he had moved fromthe 40th to the 80th percentile forweight. Two children underwent 2 ra-diologic dilations each, in both casesfor persistent symptoms. After the sec-ond procedure, 1 child became asymp-tomatic and 1 child improved.

BALLOON PYLOROPLASTY FOR DELAYED GASTRIC EMPTYING


CJS, Vol. 41, No. 2, April 1998 153


Table II

Summary of Dilations Used in Balloon Pyloroplasty and Clinical Outcomes

Patient no.

1

2

3

4

5 18-mm balloon(endoscopic) 20-mm balloon(radiologic) 2 mo later

20-mm balloon

18-mm balloon

15-mm balloon.

18-mm balloon 5 mo later

15-mm balloon,PEG at same time

Dilation

No improvement after1st dilation Some lessening ofvomiting, gainingweight

No vomiting

Lost to follow-up

No change after 1stprocedure Still vomiting; lessfrequent, smallerquantities after 2ndprocedure

No vomiting, gainingweight

Clinical outcome

58†

NR

NR

NR

68

Gastric emptyinghalf-time, min*

6 18-mm balloon Vomiting morefrequent, weight lossrequiring PEG.Hematemesis.Esophagitis onendoscopy

78

7 25-mm balloon

25-mm balloon 5 mo later

No change. Scintiscanstill showing delayedemptying No vomiting, somenausea

70†

PEG = percutaneous endoscopic gastrostomy, NR = no repeat*Normal < 90 min†After last dilation

Gastric emptying scintiscans

Scintiscanning was carried out afterdilation to correlate clinical findingswith an objective measure of gastricemptying. Only 4 of the 7 childrenunderwent postdilation scintiscan-ning; 1 child was lost to follow-up andthe parents of 2 others refused a re-peat study. All 4 children showed nor-malization of the gastric emptying

time, although 1 patient required 2 ra-diologic dilations to achieve this (Fig.3). Interestingly, this child showed noclinical improvement after the first di-lation, and a repeat scintiscan (be-tween the first and second dilations)showed persistent delay.

Complications

There were no complications from

this procedure. In particular, there wasno extravasation of contrast materialafter dilation.

DISCUSSION

Of those children with documentedDGE who have failed medical treat-ment, many will undergo surgical py-loroplasty, often combined with an an-tireflux procedure for coexistentgastroesophageal reflux. This hasproven effective.5 Several authors havedescribed balloon dilation of the py-lorus for hypertrophic pyloric stenosis,6

for peptic pyloric stenosis,7 for pyloricstenosis due to caustic ingestion8 andfor DGE due to accidental vagotomy.9

To our knowledge, there has been noprevious report of radiologicallyguided balloon dilation of the pylorusfor the treatment of DGE in children.Of 7 children who underwent radi-

ologic balloon dilation in this series, 3were rendered asymptomatic and 2more were symptomatically improved.Four children underwent scintigraphyafter dilation. The scintigram showednormalization of the gastric emptyingtime. There were no complications re-lated to the procedure.Table III shows the recommended

safe initial balloon diameters for eachage group. We recommend the dila-tion protocol as outlined in the Meth-ods section.Our comparison, in 1 patient, of en-

doscopic and then radiologic balloondilation of the pylorus suggests that a

SKARSGARD, BLAIR, CULHAM


154 JCC, Vol. 41, No 2, avril 1998


FIG. 3. Gastric emptying half-time before and after balloon pyloroplasty shows normalization of pro-longed gastric emptying in 4 patients. Black bars = before dilation, shaded bars = after dilation. * =2 dilations, the first being endoscopic; ** = 2 radiologic dilations.

Gastric

emptying

half-tim

e, m

in.

Patient no.

FIG. 1. Contrast-filled balloon inflated to 0.5 atmdemonstrates residual pyloric waist (arrow).

FIG. 2. Contrast-filled balloon inflated to 3 atmshows elimination of the pyloric waist (arrow).

Table III

20–25

18–20

18

15

Balloon size, mm

Recommended Safe Initial Balloon SizeAccording to Age

Age group, yr

1–4

5–8

9–12

> 12

more extensive pyloric dilation isachieved radiologically. With endo-scopic dilation there is no means to de-termine obliteration of the pyloric waist,nor is there a reliable means, endoscop-ically, to check for leaks after dilation.Our institution has specific criteria

for diagnosing DGE based on thescintiscan. However, because thesecriteria depend on technique andequipment, they may vary from onehospital to the next. Readers are en-couraged to speak to their radiologistcolleagues in this regard.This initial experience with radio-

logic balloon dilation of the pylorushas convinced us that it is a safe andeasily tolerated procedure. Based onthe findings of those children who hadpostdilation scintiscanning, we con-clude that balloon dilation can be ef-fective in normalizing gastric empty-ing time. Although the clinicaloutcomes in these patients weremixed, balloon pyloroplasty does showpromise as a therapeutic modality. Werecommend further study to evaluate

its effectiveness and its role in the man-agement of children with upper gas-trointestinal dysmotility.

References

1. Papaila JG, Wilmot D, Grosfeld JL,Rescorla RJ, West KW, Vane DW.Increased incidence of delayed gastricemptying in children with gastro -esophageal reflux. A prospective eval-uation. Arch Surg 1989;124:933-6.

2. Richards RD, Valenzuela GA, Daven-port KG, Fisher KL, McCallum RW.Objective and subjective results of a ran-domized, double-blind, placebo-con-trolled trial using cisapride to treat gas-troparesis. Dig Dis Sci 1993;38: 811-6.

3. Maddern GJ, Jamieson GG, MyersJC, Collins PJ. Effect of cisapride ondelayed gastric emptying in gastro - oesophageal reflux disease. Gut 1991;32:470-4.

4. Di Lorenzo C, Reddy SN, Villanueva-Meyer J, Mena I, Martin S, Hyman PE:Cisapride in children with chronic in-testinal pseudoobstruction. An acute,double-blind, crossover, placebo -

controlled trial. Gastroen terology 1991;101: 1564-70.

5. Fonkalsrud EW, Ament ME, VargasJ. Gastric antroplasty for the treat-ment of delayed gastric emptying andgastroesophageal reflux in children.Am J Surg 1992;164:327-31.

6. Hayashi AH, Giacomantonio JM, LauHYC, Gillis DA. Balloon catheter di-latation for hypertrophic pyloric steno-sis. J Pediatr Surg 1990;25:1119-21.

7. Chan KL, Saing H. Balloon catheterdilatation of peptic pyloric stenosis inchildren. J Pediatr Gastroenterol Nutr1994;18:465-8.

8. Treem WR, Long WR, Friedman D,Watkins JB. Successful managementof an acquired gastric outlet obstruc-tion with endoscopy guided balloondilatation. J Pediatr GastroenterolNutr 1987;6:992-6.

9. Heymans HSA, Bartelsman JWFM,Herweijer TJ: Endoscopic balloon di-latation as treatment of gastric outletobstruction in infancy and childhood.J Pediatr Surg 1988;23:139-40.

10. Benjamin SB, Glass RL, Cattau ELJr, Miller WB. Preliminary experiencewith balloon dilation of the pylorus.Gastrointest Endosc 1984;30:93-5.

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CJS, Vol. 41, No. 2, April 1998 155


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