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General Surgery

Answer 2
  1. Preoperative fluid resuscitation. Based on the clinical presentation, this patient has hypertrophic pyloric stenosis (HPS). HPS typically affects infants aged 2 weeks to 2 months and is characterized by projectile vomiting soon after feeding; the vomitus looks like undigested food. A palpable epigastric mass that resembles an olive is considered sufficient for diagnosis, but ultrasonographic evaluation of the pyloric length and thickness (transverse muscle thickness ≥ 4 mm) confirms the diagnosis. HPS is not an emergent condition, and the best outcomes are achieved by preoperative resuscitation aimed at rehydration and correction of metabolic alkalosis.2 Achieving a urine output of at least 1 mL/kg/hr and normalization of serum bicarbonate decreases the risk of respiratory depression, a potentially fatal complication of pyloromyotomy. Perioperative cefazolin administration is common, but antibiotics have little effect on outcomes because the incidence of surgical site infection is low (∼2%) and infections are typically mild and superficial. Postoperative feeding is safe once infants have fully recovered from anesthesia. Bouts of emesis are to be expected and typically resolve after 1 or 2 post¬≠operative feedings. Supplemental oxygen is a routine component of postanesthetic care but does not impact the hypoventilation caused by dehydration and metabolic alkalosis. Fundoplication is used to treat gastroesophageal reflux.

    2. Aspelund G, Langer JC. Current management of hypertrophic pyloric stenosis. Semin Pediatr Surg 2007;16:27-33.

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