Canadian Pediatric Surgical Network: a population-based pediatric surgery network and database for analyzing surgical birth defects. The first 100 cases of gastroschisis

Influence of maternal factors on health outcomes in gastroschisis: a Canadian population-based study

BACKGROUND

Gastroschisis is increasing in incidence worldwide. There is a need for a disease-specific, population-based approach to determining factors linked with gastroschisis and its outcome.

OBJECTIVES

To examine racial, socioeconomic, health and geographic predictors of gastroschisis and its outcome in Canada.

METHODS

535 cases of gastroschisis from the Canadian Pediatric Surgery Network national database were included from May 2005 to May 2010. Baseline characteristics of mothers were compared with those reported by Statistics Canada. Factors associated with adverse neonatal outcomes were examined using regression analyses.

RESULTS

Mothers of infants with gastroschisis are young, often from small communities. Smoking (37%) and illicit drug use are common in this population. Single mothers receive less perinatal care (OR 0.06; 95% CI 0.02-0.28). Geographically isolated mothers are more likely to undergo caesarian section (OR 3.84; 95% CI 1.26-11.74). Cocaine use predicts a lower odds of delivering at a planned center (OR 0.25; 95% CI 0.08-0.79), and is also associated with an increased likelihood of intestinal injury at birth (OR 6.26; 95% CI 1.52-25.72). Infants of mothers from isolated communities will spend a mean of 31.9 days longer in hospital. Aboriginal status is not independently predictive of perinatal or neonatal outcome.

CONCLUSION

Gastroschisis in Canada occurs frequently in young mothers, aboriginals and smokers. Features associated with worse outcomes include single parent status, cocaine use and maternal hometown geographic isolation.

Gastroschisis: one year outcomes from national cohort study

OBJECTIVE

To describe one year outcomes for a national cohort of infants with gastroschisis.

DESIGN

Population based cohort study of all liveborn infants with gastroschisis born in the United Kingdom and Ireland from October 2006 to March 2008.

SETTING

All 28 paediatric surgical centres in the UK and Ireland.

PARTICIPANTS

301 infants (77%) from an original cohort of 393.

MAIN OUTCOME MEASURES

Duration of parenteral nutrition and stay in hospital; time to establish full enteral feeding; rates of intestinal failure, liver disease associated with intestinal failure, unplanned reoperation; case fatality.

RESULTS

Compared with infants with simple gastroschisis (intact, uncompromised, continuous bowel), those with complex gastroschisis (bowel perforation, necrosis, or atresia) took longer to reach full enteral feeding (median difference 21 days, 95% confidence interval 9 to 39 days); required a longer duration of parenteral nutrition (median difference 25 days, 9 to 46 days) and a longer stay in hospital (median difference 57 days, 29 to 95 days); were more likely to develop intestinal failure (81% (25 infants) v 41% (102); relative risk 1.96, 1.56 to 2.46) and liver disease associated with intestinal failure (23% (7) v 4% (11); 5.13, 2.15 to 12.3); and were more likely to require unplanned reoperation (42% (13) v 10% (24); 4.39, 2.50 to 7.70). Compared with infants managed with primary fascial closure, those managed with preformed silos took longer to reach full enteral feeding (median difference 5 days, 1 to 9) and had an increased risk of intestinal failure (52% (50) v 32% (38); 1.61, 1.17 to 2.24). Event rates for the other outcomes were low, and there were no other significant differences between these management groups. Twelve infants died (4%).

CONCLUSIONS

This nationally representative study provides a benchmark against which individual centres can measure outcome and performance. Stratifying neonates with gastroschisis into simple and complex groups reliably predicts outcome at one year. There is sufficient clinical equipoise concerning the initial management strategy to embark on a multicentre randomised controlled trial comparing primary fascial closure with preformed silos in infants suitable at presentation for either treatment to determine the optimal initial management strategy and define algorithms of care.

Developmental outcomes following major surgery: what does the literature say?

Relative to the wealth of information in the medical literature regarding developmental outcome for infants who have had cardiac surgery available, few studies specifically detail how those who have undergone major surgery grow and develop. The few published studies tend to be disease specific, making their results difficult to translate to a more general setting. As mortality for most infants who require surgery in infancy continues to decrease, the focus for researchers and clinicians should be on how these children will grow and develop. As parents realise that their infant will survive, this becomes their next major concern. The most common conditions requiring early major surgery have been reviewed in relation to data on infant developmental outcomes.

Predictors of postnatal outcome in neonates with gastroschisis

BACKGROUND/PURPOSE

The optimal management of neonates with gastroschisis is unclear, and there is a significant morbidity. We performed a review of neonates with gastroschisis treated at our center of pediatric surgery over the last 21 years to determine predictive factors of outcome.

METHODS

Single-center retrospective analysis of 79 neonates with gastroschisis (1989-2009) was done. Length of hospital stay (LOS), days of parenteral nutrition (PN), and survival were outcome measures. Univariate and multiple regression analyses were used.

RESULTS

Overall survival was 92%, and primary closure was achieved in 80%. Median LOS was 25 days, and median duration on PN, 17 days. Intestinal atresia, closed gastroschisis, secondary closure, and sepsis were the primary variables associated with poor outcome independent of other variables, but prematurity also affected outcome. Route of delivery and associated malformations were not related to poorer outcome. Necrotizing enterocolitis did not occur in any of our patients.

CONCLUSION

Outcome in our patients was favorable as measured by survival, LOS, and days on PN. Primary predictors of poor outcome were factors related to short bowel syndrome and secondary closure, indicating a need to further improve treatment of short bowel syndrome.

The cholinergic response is increased in isolated ileum from gastroschisis rat model

INTRODUCTION

Babies with gastroschisis (G) have high morbidity rate and long hospital stay due to bowel hypomotility caused by chronic exposure of the bowel to the amniotic fluid. Our aim was to evaluate the reactivity of isolated ileum in fetal rats selected for experimental gastroschisis.

METHOD

G was surgically created at 18.5 days of gestation (term = 22 days). Concentration-dependent curve to the muscarinic agonist methacholine (1-30 μM) and contractions induced by electrical field stimulation (EFS, 1-16 Hz, 50 V, 1 ms) were carried out in isolated ileum of groups control (C), sham (S) and gastroschisis (G) (n = 30). Protein expression for M(3) was assessed by western blot analysis.

RESULTS

The frequency and amplitude of spontaneous contractions were decreased in G (p < 0.001). Methacholine produced concentration-dependent contractions being the maximal response values higher in G (p < 0.01). EFS-induced frequency-dependent contractions showed 1.8 times higher in G as well as an increase of M(3) expression.

CONCLUSION

The frequency and the amplitude of rhythmic contractions were reduced along with an increase in the contraction induced by mucarinic agonist and by EFS in G. These results suggest the occurrence of an adaptative supersensitivity to cholinergic response via increases in the protein expression for M(3) receptor.

Neonatal abdominal wall defects

Gastroschisis and omphalocele are the two most common congenital abdominal wall defects. Both are frequently detected prenatally due to routine maternal serum screening and fetal ultrasound. Prenatal diagnosis may influence timing, mode and location of delivery. Prognosis for gastroschisis is primarily determined by the degree of bowel injury, whereas prognosis for omphalocele is related to the number and severity of associated anomalies. The surgical management of both conditions consists of closure of the abdominal wall defect, while minimizing the risk of injury to the abdominal viscera either through direct trauma or due to increased intra-abdominal pressure. Options include primary closure or a variety of staged approaches. Long-term outcome is favorable in most cases; however, significant associated anomalies (in the case of omphalocele) or intestinal dysfunction (in the case of gastroschisis) may result in morbidity and mortality.

Gastroschisis and extreme prematurity: a report of two survivors

Extreme prematurity is not commonly associated with gastroschisis, and there are no reports of babies surviving with both gastroschisis and extreme prematurity. We report 2 such cases.

Institutional practice and outcome variation in the management of congenital diaphragmatic hernia and gastroschisis in Canada: a report from the Canadian Pediatric Surgery Network

BACKGROUND

Perinatal management of congenital diaphragmatic hernia (CDH) and gastroschisis (GS) remains nonstandardized and institution specific. This analysis describes practice and outcome variation across a national network.

METHODS

A national, prospective, disease-specific database for CDH and GS was evaluated over 4 years. Centers were evaluated individually and defined as low (low-volume center [LVC]) or high (high-volume center [HVC]) volume based on case mean.

RESULTS

Congenital diaphragmatic hernia. Two hundred fifteen liveborn cases were studied (mean, 14.3 cases/center) across 15 centers (8 LVCs and 7 HVCs). Significant interinstitutional practice variation was noted in rates of termination (0%-40%) and cesarean delivery (0%-61%). Centers demonstrated marked variation in ventilation strategies, vasodilator and paralytic use, timing of surgery, and rates of primary closure. Overall survival was 81.4% (LVC, 76.9%; HVC, 82.4%; P = .43). Gastroschisis. Four hundred sixteen cases were investigated (mean, 26 cases/center; range, 6-72) across 16 centers (10 LVCs and 6 HVCs). Cesarean delivery rates varied widely between centers (0%-86%) as did timing of closure (early vs delayed, 1%-100%). There was no difference in length of stay, days on total parenteral nutrition, and overall survival (94.3% vs 97.2%; P = .17) between LVCs and HVCs.

CONCLUSIONS

The existence of perinatal practice and outcome variation for GS and CDH suggests targets for improved delivery of care and justifies efforts to standardize treatment on a national basis.

Noblesse oblige - the pediatric surgeon (h)as the key to quality control and improvement. The Fred MacLoed Lecture

The trust crisis in health care demands action by health care professionals. Trust is based on quality, candor, and accountability. The pediatric surgeon, as the expert in the field, should be in control of quality management. By improving quality, the trust in the health care system can be restored. Quality is defined as being on target with minimal variation. To assess these targets, performance indicators have been developed by the Association of Pediatric Surgeons in The Netherlands for 7 neonatal conditions. Variation can be distinguished as special-cause and common-cause variation using the control chart method of Walter Shewhart. The various activities in this field that have been developed and are ongoing in The Netherlands are presented.

Evolution of critically ill patients with gastroschisis from three tertiary centers

OBJECTIVES AND INTRODUCTION: Gastroschisis is a congenital abdominal wall defect with increasing occurrence worldwide over the past 20-30 years. Our aim was to analyze the morbidity of newborns after gastroschisis closure, with emphasis on metabolic and hydroelectrolyte disturbances in patients at three tertiary university centers.

METHODS

From January 2003 to June 2009, the following patient data were collected retrospectively: (A) Background maternal and neonatal data: maternal age, prenatal diagnosis, type of delivery, Apgar scores, birth weight, gestational age and sex; (B) Surgical modalities: primary or staged closure; and (C) Hospital course: levels of serum sodium and levels of serum albumin in the two first postoperative days, number of ventilation days, other postoperative variables and survival. Statistical analyses were used to examine the associations between some variables.

RESULTS

163 newborns were included in the study. Primary closure of the abdominal defect was performed in 111 cases (68.1%). The mean serum sodium level was 127.4 ± 6.7 mEq/L, and the mean serum albumin level was 2.35 ± 0.5 g/dL. Among the correlations between variables, it was verified that hyponatremia and hypoalbuminemia correlated with the number of days on the ventilator but not with the number of days on total parenteral nutrition (TPN); mortality rate correlated with infection. The final survival rate was 85.9%.

CONCLUSION

In newborns with gastroschisis, more aggressive attention to hyponatremia and hypoalbuminemia would improve the outcome.

Preterm elective caesarean section and early enteral feeding in gastroschisis

AIMS

To evaluate the effect of elective caesarean section (CS) before term and early enteral nutrition on length of parenteral nutrition and hospital stay in infants with gastroschisis.

METHODS

Retrospective review of all infants with gastroschisis treated in a regional level III hospital from 1993 to 2008. During 1993-97, there was no established standard for management of pregnancy or delivery while a protocol on close foetal monitoring and early elective CS was adhered to for 1998-2008. Introduction of human milk on the first day after complete closure of the abdominal wall and rapid increase was the policy during the whole period.

RESULTS

With early elective CS, no foetal deaths occurred after 28-week gestational age (GA). Ten infants were born during the first period and 20 during the second period at a median GA (range) of 36.5 (34-40) and 35 (34-37) weeks (p = 0.013). Seven and 20, respectively, were born by CS. Median (range) days before full enteral feeds and hospital stay were 11.5 (7-39) and 13.0 (7-46) (p = 0.85), and 17.5 (12-36) and 22.5 (13-195) (p = 0.67), respectively. One child died of volvulus after discharge.

CONCLUSION

Close surveillance of pregnancy, elective preterm caesarean section, early surgery and active approach to primary closure and early enteral feeds appears to be a safe and effective line of management in gastroschisis.

Elements of successful intestinal rehabilitation

PURPOSE

The optimal therapy for intestinal failure (IF) is unknown. The results of a systematic, protocol-driven management strategy by a multidisciplinary team are described.

METHODS

Intestinal failure was defined as bowel length of less than 40 cm or parenteral nutrition (PN) for more than 42 days. A multidisciplinary team and protocol to prevent PN-associated liver disease (PNALD) were instituted in 2006. Data were gathered prospectively with consent and ethics board approval.

RESULTS

From 1998 to 2006, 33 patients were treated (historical cohort) with an overall survival of 72%. Rotating prophylactic antibiotics for bacterial overgrowth were given to 27% of patients; 6% had lipid-sparing PN, and none received fish oil-based lipids. Median time to intestinal rehabilitation was 7 ± 3.1 months, and 27% of patients who developed PNALD died. From 2006 to 2009, 31 patients were treated. Seventy-seven percent received PAB; 60%, lipid-sparing PN; and 47%, parenteral fish oil emulsion. Eighty-seven percent weaned from PN at 3.9 ± 3.8 months, and no patients developed PNALD with 100% survival. Novel lipid therapies were associated with changes in essential fatty acid profile and one case of clinical essential fatty acid deficiency.

CONCLUSION

The institution of a multidisciplinary team and a protocol-driven strategy to prevent PNALD improves survival in IF. Further studies are recommended.

Perinatal management of congenital diaphragmatic hernia: when and how should babies be delivered? Results from the Canadian Pediatric Surgery Network

PURPOSE

A prenatal diagnosis of congenital diaphragmatic hernia (CDH) enables therapeutic decision making during the intrapartum period. This study seeks to identify the gestational age and delivery mode associated with optimal outcomes.

PATIENTS AND METHODS

A national data set was used to study CDH babies born between 2005 and 2009. The primary outcome was survival to discharge. Primary and secondary outcomes were analyzed by categorical gestational age (preterm, <37 weeks; early term, 37-38 weeks; late term, >39 weeks) by intended and actual route of delivery and by birth plan conformity, regardless of route.

RESULTS

Of 214 live born babies (gestational age, 37.6 ± 4.0 weeks; birth weight, 3064 ± 696 g), 143 (66.8%) had a prenatal diagnosis and 174 (81.3%) survived to discharge. Among 143 prenatally diagnosed pregnancies, 122 (85.3%) underwent abdominal delivery (AD) and 21 (14.6%) underwent cesarean delivery (CS). Conformity between intended and actual delivery occurred in 119 (83.2%). Neither categorical gestational age nor delivery route influenced outcome. Although babies delivered by planned CS had a lower mortality than those delivered by planned AD (2/21 and 36/122, respectively; P = .04), this difference was not significant by multivariate analysis. Conformity to any birth plan was associated with a trend toward improved survival.

CONCLUSION

Our data do not support advocacy of any specific delivery plan or route nor optimal gestational age for prenatally diagnosed CDH.

Perinatal predictors of outcome in gastroschisis

OBJECTIVE

To identify perinatal risk variables predictive of outcome in gastroschisis.

STUDY DESIGN

Gastroschisis cases were collected over a 3-year period from a national database. Risk variables evaluated included gestational age (GA), birth weight, time of birth, admission illness severity (score for neonatal acute physiology-II, SNAP-II) score, and abdominal closure type. Mortality and survival outcomes were analyzed. Multivariate analyses were performed.

RESULT

In all, 239 infants were survived (96%). SNAP-II score predicted mortality (relative risk (RR)=1.07, 95% confidence interval (CI)=1.0 to 1.1). Length of hospital stay (LOS) and ventilation days were predicted by GA and by SNAP-II score. SNAP-II score predicted total parenteral nutrition (TPN) days (P=0.006). Severe cholestasis (conjugated bilirubin of >10 mg per 100 ml) was inversely related to GA (RR=0.77, 95% CI=0.61 to 0.97) and directly to categorical SNAP-II score (RR=3.4, 95% CI=1.2 to 10.1). Urgent closure predicted fewer TPN days (P=0.003) and shorter LOS (P=0.0002).

CONCLUSION

SNAP-II scores significantly predict mortality and survival outcomes. Urgent closure favors fewer TPN days and shorter LOS. Our data refute routine preterm delivery in gastroschisis.

Gastroschisis: an update

Gastroschisis (GS) continues to increase in frequency, with several studies now reported an incidence of between 4 and 5 per 10,000 live births. The main risk factor would seem to be young maternal age, and it is in this group that the greatest increase has occurred. Whilst various geographical regions confer a higher risk, the impact of several other putative risk factors, including smoking and illicit drug use, may be less important than when first identified in early epidemiological studies. Over 90% of cases of GS will now be diagnosed on antenatal ultrasound, but its value in determining the need for early delivery remains unclear. There would appear no clear evidence for either routine early delivery or elective caesarean section for infants with antenatally diagnosed GS. Delivery at a centre with paediatric surgical facilities reduces the risk of subsequent morbidity and should represent the standard of care. The relative roles of primary closure, staged closure and ward reduction, with or without general anaesthesia, appear less clear with considerable variation between centres in both the use of these techniques and subsequent surgical outcomes. Survival rates continue to improve, with rates well in excess of 90% now routine. The limited long-term developmental data available would suggest that normal or near-normal outcomes may be expected although there remains a need for further studies.

Gastroschisis: a national cohort study to describe contemporary surgical strategies and outcomes

BACKGROUND

Information on adoption of newer surgical strategies for gastroschisis and their outcomes is largely limited to hospital-based studies. The aim of this study was to use a new UK national surveillance system to identify cases and thus to describe the contemporary surgical management and outcomes of gastroschisis.

METHODS

We conducted a national cohort study using the British Association of Paediatric Surgeons Congenital Anomalies Surveillance System to identify cases between October 2006 and March 2008.

RESULTS

All 28 surgical units in the United Kingdom and Ireland participated (100%). Data were received for 95% of notified cases of gastroschisis (n = 393). Three hundred thirty-six infants (85.5%) had simple gastroschisis; 45 infants (11.5%) had complex gastroschisis. For 12 infants (3.0%), the type of gastroschisis could not be categorized. Operative primary closure (n = 170, or 51%) and staged closure after a preformed silo (n = 120, or 36%) were the most commonly used intended techniques for simple gastroschisis. Outcomes for infants with complex gastroschisis were significantly poorer than for simple cases, although all deaths occurred in the simple group.

CONCLUSIONS

This study provides a comprehensive picture of current UK practice in the surgical management of gastroschisis. Further follow-up data will help to elucidate additional prognostic factors and guide future research.

Laparoscopic-assisted anorectal pull-through for anorectal malformations: a systematic review and the need for standardization of outcome reporting

INTRODUCTION

Laparoscopic-assisted anorectal pull-through (LAARP) is becoming an increasingly common procedure to correct high and intermediate anorectal malformations (ARMs). The aim of this review was to evaluate worldwide experiences with LAARP with regard to indications, outcomes, and quality of reporting.

METHOD

A systematic review was conducted. The search was limited to studies reported in English and performed in humans. In addition to Medline and PubMed, a manual search of the Journal of Pediatric Surgery, Pediatric Surgery International, Surgical Endoscopy, and the Journal of Laparoendoscopic & Advanced Surgical Techniques published between June 2000 and April 2008 was conducted.

RESULTS

Seventeen studies were included in the final analysis. Of the included studies, none were randomized, 2 were prospective in nature, and 4 compared outcomes of posterior sagittal anorectoplasty and LAARP. The studies included 124 patients (96 males, 28 females) with 80% reported as having high/intermediate malformations. All studies reported short-term outcomes. Reported outcomes included continence, rectal prolapse, the position of the rectum (7 studies using Kelly score), manometry (1 study), contrast enema (1 study), postanal endosonography (3 studies), and postoperative magnetic resonance imaging (3 studies). Outcomes varied widely between reports precluding a meta-analysis.

CONCLUSION

The number of studies dealing with LAARP is low. There is a need for both a standardization and improvement in the quality of reporting in LAARP research. This will ultimately allow for evidence-based surgical decision making.

Effect of hospital case volume on outcome in congenital diaphragmatic hernia: the experience of the Canadian Pediatric Surgery Network

PURPOSE

Despite advances in neonatal care of congenital diaphragmatic hernia (CDH), a significant variation exists in the mortality rates reported by individual centers. Center experience (reflected by case volume) may contribute to this variation in outcome. The aim of the study was to determine whether CDH mortality is affected by hospital case volume.

METHODS

The CDH cases were abstracted from a disease-specific, 16-hospital, national network. Thirteen hospitals participated in this study. Anonymized hospitals were categorized as either high (>6 cases) or low-volume (<or=6 cases) centers (HVC, n = 6; LVC, n = 7) according to the median case number per center. Risk-adjusted (Score for Neonatal Acute Physiology, version II [SNAP-II] score) mortality rates were compared between HVC and LVC.

RESULTS

One hundred twenty-one CDH cases were identified. Overall in-hospital survival was 81%. No significant difference in SNAP-II score was observed between HVC and LVC. Of 97 (15%) infants treated in 6 HVC, 15 (15%) died compared to 8 (33%) of 24 in 7 LVC (P < .05).

CONCLUSION

Hospital case volume may be partially responsible for mortality rate variation in CDH. This result requires careful analysis, as case volume may merely be a surrogate for other predictive variables.

Classification and appraisal of the level of clinical evidence of publications from the Canadian Association of Pediatric Surgeons for the past 10 years

INTRODUCTION

Increasing evidence is placed on the evidence-based quality of publications. We classified the publication type and assessed the reporting quality of the highest evidence level publications from the Canadian Association of Pediatric Surgeons between 1998 and 2007.

METHODS

All publications from Canadian Association of Pediatric Surgeons issues in the Journal of Pediatric Surgery from 1998 to 2007 were classified by study type and level of evidence (Oxford Center for Evidence-based Medicine Levels of Evidence). Cohort studies (level 2) were evaluated by 2 independent assessors using the Newcastle-Ottawa Quality Assessment Scale (NOQAS). Reliability and chi(2) analyses were performed.

RESULTS

Three hundred two publications were classified by level of evidence as follows: level 2, 46; level 3, 13; level 4, 109; and level 5, 134. The median NOQAS score of the 46 level-2 cohort studies was 8 (range, 5-9), and the interrater reliability was 0.94 (95% confidence interval, 0.89-0.96). There was a significant increase in the number of level-2 evidence publications (P = .001) over the study period.

CONCLUSIONS

Level-2 evidence cohort studies met a high scientific standard as assessed by the NOQAS and significantly increased in number over the study period. However, there were no level-1 evidence (randomized controlled trial) publications, and most were in the lower evidence classification levels (3-5).

Predicting the outcome of newborns with gastroschisis

OBJECTIVE

The objective of the study was to determine factors predicting outcome in newborns with gastroschisis.

METHODS

A retrospective analysis of 155 consecutive cases admitted from 1 January 1990 to 31 December 2007 was performed. Prenatal ultrasound findings were available for 89 of 155 (57%) patients and were compared with final outcome. Both univariate and multiple regression analyses were used.

RESULTS

All patients survived to discharge home. The primary outcome measure was length of stay. Multiple regression identified 4 factors associated with length of stay: (1) gestational age (P = .004), (2) nonelective silo (P < .001), (3) gastrointestinal (GI) complication (intestinal atresia, perforation, or resection) (P < .001), and (4) non-GI anomaly (P = .029). Non-GI anomalies occurred in 17 of 155 (11%) patients and tended to increase the risk of a nonelective silo or GI complication (59% vs 39%, P = .190). Dilated bowel (>10 mm) on prenatal ultrasound was associated with GI complications (22% vs 3%, P = .010). However, 78% of patients with dilated bowel on prenatal ultrasound did not have a GI complication. The absence of dilated bowel on prenatal ultrasound accurately predicted the absence of GI complications in 97% of cases.

CONCLUSION

Prematurity, nonelective silo, GI complications, and non-GI anomalies predict the short-term outcome of newborns with gastroschisis. Prenatal ultrasound serves primarily to predict the absence of GI complications.

Is timing everything? The influence of gestational age, birth weight, route, and intent of delivery on outcome in gastroschisis

BACKGROUND/PURPOSE

Optimal perinatal treatment in gastroschisis remains uncertain. We sought to determine the effect of gestational age (GA), birth weight (BW), and intended and actual route of delivery on outcomes in gastroschisis.

METHODS

Cases were abstracted from a national gastroschisis database. Outcomes analyzed by route of delivery, delivery plan conformity, BW, and GA included survival, closure success, ventilation days, total parenteral nutrition days, and length of hospital stay. Logistic regression for continuous and categorical variables was performed.

RESULTS

One hundred ninety-two babies (56% male) born at mean GA of 36.1 +/- 2.1 weeks, with mean BW of 2536 +/- 557 g, were included. One hundred eighty-three (95%) survived. Of 145 pregnancies with an antenatal delivery plan, vaginal delivery was intended in 77% and actually occurred in 119 pregnancies, with the remainder being planned (33; 17%) or emergency (40; 21%) cesarean deliveries. A delivery conforming to the antenatal plan occurred in 74 (51%). Birth weight and GA were significant inverse predictors of ventilator and total parenteral nutrition days and length of hospital stay, but not survival. Delivery route did not predict any outcome; however, "nonconformers" were born at lower BW and GA than "conformers," and they showed trends toward poorer nonmortality outcomes.

CONCLUSIONS

Gestational age, BW, and conformity to an antenatal birth plan are predictors of outcome in gastroschisis, whereas actual route of delivery is not.

Contemporary postnatal surgical management strategies for congenital abdominal wall defects

Early definitive closure of abdominal wall defects is possible in most cases. Staged reduction does offer distinct advantages, and mortality and morbidity may be better. Risk stratification may produce outcome and tailor management of difficult cases in the form of a clinical pathway. Stem cell technology may, in the future, offer the ideal allogenic prosthesis in complex cases.

Clinical care outcomes in abdominal wall defects

PURPOSE OF REVIEW

Abdominal wall defects comprising both gastroschisis and omphalocele remain a source of significant morbidity and mortality, despite the advances in neonatal and pediatric surgical care. Survival has improved over the past few decades, especially with parenteral nutrition and surgical repair. Yet, still, many questions remain regarding the outcome of these anomalies.

RECENT FINDINGS

Outcomes of abdominal wall defects have been discussed more often in the recent publications, with analysis of databases and evaluation of prenatal series. There have been a number of new prenatal interventions in gastroschisis, and a better understanding of gestational outcomes from omphalocele. Papers have discussed the optimal surgical management of these defects as well.

SUMMARY

This review helps to bring together the most recent findings regarding outcomes and interventions for abdominal wall defects. It also illustrates the pressing need for a large prospective database to better understand these anomalies and provide better care.