Ramstedt Operation
Description
Surgical correction of hypertrophic pyloric stenosis, involving longitudinal splitting of the hypertrophic pylorus and leaving the defect open. This is in contrast to previous procedures which involved closure of the muscle.
History of the Ramstedt Operation
Pyloric Stenosis:
1627 – Fabricius Hildanus wrote
...a small, wasted, six months child, the eldest son of Henry Otho, Esq. This child’s stomach had been, for days, crammed by the nurse or mother with a thick and viscid pultraceous feed…since he was vomiting up everything given by the mouth and was passing nothing through the lower passages, I prescribed one or two nutrient enemata for every day, made from broth to which was added the yolk of an egg and a small quantity of mixed sugars…now perfectly well. Not every obstruction, therefore, of the lower orifice of the stomach is to be considered incurable
Observatio singularis de obstructione pylori XXXIV
1717 – Patrick Blair (1665-1728) reported to the Royal Society the clinical history and autopsy report of a 5-month-old boy with pyloric stenosis.
…The Pylorus, and almost half of the Duodenum were cartilaginous, and something inclin’d to an Ossification, so that no Nourishment could have passed into the Intestines, tho’ the Stomach had been capable of containing it, which makes it no wonder that the Body was so emaciated...
An Account of the Dissection of a Child
Further autopsy and clinical accounts including George Armstrong (1777); Hezekiah Beardsley (1787)
1888 – Harald Hirschsprung provided the most definitive description in the autopsy findings in two infants:
…I thought it would be of interest to present to the Society two cases of undoubted congenital pyloric stenosis in nurslings. A third case (chronologically be considered in this report since the not been preserved
1888; 28: 61-68
1910 – Case reports rapidly grew to 600 in conjunction with epidemiological studies and alternate operative approaches to arrest the associated high infant mortality.
Early Management: Late 1800’s Medical versus Surgical Medical approach (believing ‘spasm’ caused ‘hypertrophy’).
- Relieve spasm with antispasmodic drugs (e.g. belladonna, cocaine, atropine)
- Remove gastric acid (believed to cause spasm) with frequent bicarbonate gastric lavages
- Maintain diet with iced milk and thickened feeds
- Maintain nutrients with nutrient milk/saline enemas
Surgical approach (believing congenital hypertrophy was the root of the problem)
- 1898 – Karl Löbker (1854-1912) performed gastro-enterostomy. (7 operations, three deaths)
- 1889 – James Nicholl – divulsion of the pylorus (Loreta’s operation) using a mechanical dilator introduced through the stomach. (9 operations, 3 deaths)
- 1902 – Clinton Dent complete pyloroplasty with longitudinal incision extending through all the layers of the pylorus, including the mucosa, was converted into a transverse one with 75% success rate
Pyloromyotomy
- 1907 – Pierre Frédet is widely credited as performing the first “extramucosal pyloroplasty” on October 12, 1907 in which the mucosa was left intact during division of the pyloric muscle [1907; 24(2): 1221-1228]
- 1910 – Sir Harold Stiles (1863–1946) performed the first recorded pylorotomy for pyloric stenosis on February 3 1910 at the Royal Hospital for Sick Children, Edinburgh. Although he did not publish the case, the Operation Note remains.
- 1911 – Ramstedt performed his operation 17 months later on the 28 July 1911 and published in 1912
Opération imaginée par Frédet 1910, pratiquée par Ramstedt 1912.
Marfan 1923
Associated Persons
- Conrad Ramstedt (1867 – 1963)
- Pierre Frédet (1870-1946)
- Sir Harold Stiles (1863–1946)
Alternative names
- Ramstedt’s Pyloromyotomy
- Ramstedt’s operation
- Frédet-Rammstedt operation (Marfan 1923)
References
Original articles
- Blair P. An Account of the Dissection of a Child. Communicated in a Letter to Dr. Brook Taylor. 1717
- Armstrong G. An Account of the Diseases Most Incident to Children. 1777: 49.
- Hirschsprung H. Fälle von Angeborenen Pylorusstenose, Beobachtet bei Säuglingen. Jahrbuch für Kinderheilkunde und physische Erziehung 1888; 28: 61-68
- Treves F. A Successful Case of Loreta’s Operation on the Stomach. Br Med J. 1889 May 18;1(1481):1105-7.
- Dufour H, Frédet P. La sténose hypertrophique du pylore chez le nourrisson: et son traitement chirurgical. Bulletins et Mémoires de la Société médicale des hôpitaux de Paris. 1907; 24(2): 1221-1228.
- Sutherland GA. Clinical Society of London meeting, Congenital Pyloric Stenosis. Br Med J 1907; 1: 627-630
- Hutchison R. The Schorstein Lecture: On Congenital pyloric stenosis. Br Med J. 1910 Oct 8; 2(2597): 1021–1024
- Rammstedt C. Zur Operation der angeborenen Pylorusstenose. Medizinische Klinik 1912; 8: 1702–5
- Caulfield E. An early case of pyloric stenosis. Am J Dis Child. 1930; 40(5): 1069-1075
Review articles
- Mack HC. A history of hypertrophic pyloric stenosis and its treatment: Part I. Bulletin of the History of Medicine 1942; 12(3): 465–485
- Mack HC. A history of hypertrophic pyloric stenosis and its treatment: Part II. Bulletin of the History of Medicine 1942; 12(4): 595-615
- Mack HC. A history of hypertrophic pyloric stenosis and its treatment: Part III. Bulletin of the History of Medicine 1942; 12(5): 666-689
- Brown JJ. Sir Harold Stiles and the surgery of congenital pyloric stenosis; an historical note. J R Coll Surg Edinb. 1956 Jun;1(4):316-8.
- Raffensperger J. Pierre Fredet and pyloromyotomy. J Pediatr Surg. 2009 Sep;44(9):1842-5
- Ranells JD, Carver JD, Kirby RS. Infantile hypertrophic pyloric stenosis: epidemiology, genetics, and clinical update. Adv Pediatr. 2011;58(1):195-206
- Georgoula C, Gardiner M. Pyloric stenosis a 100 years after Ramstedt. Arch Dis Child. 2012 Aug;97(8):741-5
- Keys C, Johnson C, Teague W, MacKinlay G. One hundred years of pyloric stenosis in the Royal Hospital for Sick Children Edinburgh. J Pediatr Surg. 2015 Feb;50(2):280-4
- Taghavi K, Powell E, Patel B, McBride CA. The treatment of pyloric stenosis: Evolution in practice. J Paediatr Child Health. 2017 Nov;53(11):1105-1110.
