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Predicting adverse neonatal outcomes in fetuses with abdominal wall defects using prenatal risk factors. Am J Obstet Gynecol 2009; 201:383.e1-6. [PMID: 19716531 DOI: 10.1016/j.ajog.2009.06.032] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2009] [Revised: 05/08/2009] [Accepted: 06/11/2009] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The aim of this study was to determine whether prenatal variables can predict adverse neonatal outcomes in fetuses with abdominal wall defects. STUDY DESIGN A retrospective cohort study that used ultrasound and neonatal records for all cases of gastroschisis and omphalocele seen over a 16-year period. Cases with adverse neonatal outcomes were compared with noncases for multiple candidate predictive factors. Univariable and multivariable statistical methods were used to develop the prediction models, and effectiveness was evaluated using the area under the receiver operating characteristic curve. RESULTS Of 80 fetuses with gastroschisis, 29 (36%) had the composite adverse outcome, compared with 15 of 33 (47%) live neonates with omphalocele. Intrauterine growth restriction was the only significant variable in gastroschisis, whereas exteriorized liver was the only predictor in omphalocele. The areas under the curve for the prediction models with gastroschisis and omphalocele are 0.67 and 0.74, respectively. CONCLUSION Intrauterine growth restriction and exteriorization of the liver are significant predictors of adverse neonatal outcome with gastroschisis and omphalocele.
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Rao SC, Pirie S, Minutillo C, Gollow I, Dickinson JE, Jacoby P. Ward reduction of gastroschisis in a single stage without general anaesthesia may increase the risk of short-term morbidities: results of a retrospective audit. J Paediatr Child Health 2009; 45:384-8. [PMID: 19490405 DOI: 10.1111/j.1440-1754.2009.01505.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Ward reduction of gastroschisis in a single stage without the need for general inhalational anaesthesia (ward reduction) has been reported by some authors to be effective and safe. We introduced this practice to our neonatal unit 2 years ago. AIM To compare the short-term outcomes of this new practice with the standard procedure of reduction under general anaesthesia (GA). METHODS Retrospective case series of all infants with gastroschisis between January 2004 and January 2008. RESULTS Twenty-seven infants were managed with the traditional approach and 11 infants underwent ward reduction without GA. Infants in the ward reduction group had an increased frequency for all the three major adverse events (ischemic necrosis of bowel: 27.3% vs. 3.7%, odds ratio (OR) 10.72, 95% confidence interval (CI): 0.72, 159.6; need for total parenteral nutrition (TPN) more than 60 days: 18% vs. 3.7%, OR 4.13, 95% CI: 0.28, 61.55; and unplanned return to theatre: 27.3% vs. 7.4%, OR 3.88, 95% CI: 0.44, 34.08), although none of these events reached statistical significance. There were no significant differences between the groups for the outcomes of time to reach full feeds, duration of hospital stay and number of days on antibiotics. CONCLUSIONS These results raise concerns over the role of ward reduction of gastroschisis in a single sitting without the use of GA. Randomised trials with appropriate design and sample size are needed before embracing this method as a standard practice.
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Affiliation(s)
- Shripada C Rao
- Department of Neonatology, King Edward Memorial Hospital for Women, Western Australia, Australia.
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Saxonhouse MA, Kays DW, Burchfield DJ, Hoover R, Islam S. Gastroschisis with jejunal and colonic atresia, and isolated colonic atresia in dichorionic, diamniotic twins. Pediatr Surg Int 2009; 25:437-9. [PMID: 19308430 DOI: 10.1007/s00383-009-2353-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/09/2009] [Indexed: 10/21/2022]
Abstract
Despite the increasing incidence of gastroschisis, the cause remains unknown. Genetic factors may contribute to bowel anomalies as demonstrated by cases of gastroschisis in twins and siblings, and other types of bowel anomalies in twins. Atresia of the colon represents one of the rarest causes of neonatal intestinal obstruction. We present the first case of dichorionic, diamniotic male twins in which there was gastroschisis with jejunal and colonic atresia in Twin A and isolated colonic atresia in Twin B.
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Affiliation(s)
- Matthew A Saxonhouse
- Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine, P.O. Box 100296, Gainesville, FL 32610-0296, USA.
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Boutros J, Regier M, Skarsgard ED. Is timing everything? The influence of gestational age, birth weight, route, and intent of delivery on outcome in gastroschisis. J Pediatr Surg 2009; 44:912-7. [PMID: 19433169 DOI: 10.1016/j.jpedsurg.2009.01.026] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Accepted: 01/15/2009] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- John Boutros
- Department of Surgery, Division of Pediatric General Surgery, University of British Columbia, Vancouver, British Columbia, Canada
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Risk stratification in gastroschisis: can prenatal evaluation or early postnatal factors predict outcome? Pediatr Surg Int 2009; 25:319-25. [PMID: 19277683 DOI: 10.1007/s00383-009-2342-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2009] [Indexed: 10/21/2022]
Abstract
PURPOSE The prenatal or postnatal factors that predict complex gastroschisis in patients (atresia, volvulus, necrotic bowel and bowel perforation) remain controversial. We evaluated the prognostic value of prenatal ultrasonographic parameters and early postnatal factors in predicting clinical outcomes. METHODS We analyzed maternal and neonatal records of 46 gastroschisis patients treated from 1998 to 2007. Information regarding demographics, prenatal ultrasound data when available, intrapartum and postnatal course was abstracted from medical records. Outcome variables included survival, ventilator days, TPN days, time to full enteral feeds, complications and length of stay. Univariate or multivariate analysis was used, with P < 0.05 considered as significant. RESULT A total of 75% of complex patients were categorized within 1 week of life. Interestingly, prenatal bowel dilation (>17 mm) and thickness (>3 mm) did not correlate with outcome or risk stratification into simple versus complex (P < 0.05). Complex patients had increased morbidity compared to simple patients (sepsis 58 versus 18%; P = 0.021, NEC 42 versus 9%; P = 0.020, short bowel syndrome 58 versus 3%; P = 0.0001, ventilator days 24 versus 10; P = 0.021; TPN days 178 versus 38; P = 0.0001 and days to full feeds 171 versus 31; P = 0.0001; and length of stay 90 versus 39 days, P = 0.0001). CONCLUSIONS Prenatal bowel wall dilation and/or thickness did not predict complex patients or adverse outcome. Complex gastroschisis patients can be identified postnatally and have substantial morbidity.
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Successful vaginal delivery following laparoscopic abdominal wall reconstruction in an adult survivor of an omphalocele without prior surgical repair: report of a case. Hernia 2008; 13:431-4. [PMID: 19085039 DOI: 10.1007/s10029-008-0456-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2008] [Accepted: 11/05/2008] [Indexed: 10/21/2022]
Abstract
We report the case of a successful vaginal delivery following laparoscopic abdominal wall reconstruction in an adult survivor of an omphalocele without prior surgical repair. Untreated omphaloceles are rare in adulthood. A 30-year-old female patient presented with a large anterior abdominal wall defect due to an untreated omphalocele, who expressed a desire to have a baby in the near future. A laparoscopic herniorrhaphy was performed with a double-layered expanded polytetrafluoroethylene (ePTFE, Gore-Tex) mesh. The patient delivered a full-term healthy baby vaginally 2 years after surgical repair of the omphalocele.
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Rasmussen SA, Frías JL. Non-genetic risk factors for gastroschisis. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2008; 148C:199-212. [DOI: 10.1002/ajmg.c.30175] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Hunter AG, Stevenson RE. Gastroschisis: Clinical presentation and associations. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2008; 148C:219-30. [DOI: 10.1002/ajmg.c.30178] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Suver D, Lee SL, Shekherdimian S, Kim SS. Left-sided gastroschisis: higher incidence of extraintestinal congenital anomalies. Am J Surg 2008; 195:663-6; discussion 666. [DOI: 10.1016/j.amjsurg.2007.12.042] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2007] [Revised: 12/20/2007] [Accepted: 12/20/2007] [Indexed: 10/22/2022]
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Sangkhathat S, Patrapinyokul S, Chiengkriwate P, Chanvitan P, Janjindamai W, Dissaneevate S. Infectious complications in infants with gastroschisis: an 11-year review from a referral hospital in southern Thailand. J Pediatr Surg 2008; 43:473-8. [PMID: 18358284 DOI: 10.1016/j.jpedsurg.2007.10.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED MAIN PURPOSES: The study aimed to (1) examine the incidence of infectious complications (ICs) in our referral hospital in southern Thailand in infants with gastroschisis, with analysis of the impact of these complications on outcomes, and (2) identify associated factors to improve the practice at our institution for dealing with this condition. METHODS A retrospective review of consecutive gastroschisis cases at the major teaching and referral hospital in southern Thailand was conducted for an 11-year period (1996-2006). Cases referred after a primary operation at other hospitals were excluded. The study focused on postoperative nosocomial infections as identified by Centers for Disease Control and Prevention criteria. RESULTS Sixty-eight patients with gastroschisis were operated on. Twenty-seven patients (39.71%) underwent primary closure. Mortality was 4 of 68 patients (5.9%). Infectious complication occurred in 43 patients (63.2%). The complications significantly increased mechanical ventilation days (10.8 vs 3.8 days in noncomplicated cases), need for parenteral nutrition (25.3 vs 14.5 days), and postoperative stay (33.7 vs 21.1 days). Common ICs were wound infection (32.35%), isolated septicemia (19.1%), and pneumonia (13.24%). Univariate analysis identified an association between the occurrence of IC and birth order (multigravida), time from birth until arrival at our center (5 hours or more), hypoalbuminemia, hypoglycemia, type of operation (staged closure), use of central venous line, and prolonged use of ventilator. On multiple logistic regression, prolonged referral time, use of a central venous line, multigravida, and staged closure independently predicted the risk of IC. CONCLUSION Infectious complication was significantly related to outcome in gastroschisis cases and should not be overlooked. Our data suggest that prompt referral, limiting central line practice on a selective basis, and an attempt to reduce wound infection in cases that require a temporary silo may improve the overall outcomes.
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Affiliation(s)
- Surasak Sangkhathat
- Pediatric Surgery Unit, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat-Yai, Songkhla 90110, Thailand.
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Entérocolite sévère chez deux nourrissons présentant un laparoschisis. Arch Pediatr 2008; 15:149-52. [DOI: 10.1016/j.arcped.2007.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2007] [Revised: 07/06/2007] [Accepted: 11/29/2007] [Indexed: 11/21/2022]
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Sun J, Liu YH, Chen H, Nguyen MP, Mishina Y, Upperman JS, Ford HR, Shi W. Deficient Alk3-mediated BMP signaling causes prenatal omphalocele-like defect. Biochem Biophys Res Commun 2007; 360:238-43. [PMID: 17588538 PMCID: PMC1987715 DOI: 10.1016/j.bbrc.2007.06.049] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2007] [Accepted: 06/08/2007] [Indexed: 11/28/2022]
Abstract
BMP signaling plays important roles in many embryonic developmental processes. Alk3 is one of two BMP type I receptors that transduces BMP signal from the cell surface into cell. Conventional knockout of Alk3 resulted in early embryonic lethality around E7.5-E9.5. In this study, we have generated embryonic mesoderm-specific Alk3 conditional knockout by crossing Dermo1-Cre and floxed Alk3 mice. Abrogation of Alk3-mediated BMP signaling in this mouse resulted in severe defect of secondary ventral body wall formation, replicating the omphalocele phenotype in human. Our finding suggests that Alk3 plays an essential role in the formation of embryonic ventral abdominal wall, and abrogation of BMP signaling activity due to gene mutations in its signaling components could be one of the underlying causes of omphalocele at birth.
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Affiliation(s)
- Jianping Sun
- Developmental Biology Program, Childrens Hospital Los Angeles, 4650 Sunset Blvd., Los Angeles, CA 90027
| | - Yi-Hsin Liu
- Department of Ophthalmology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033
| | - Hui Chen
- Developmental Biology Program, Childrens Hospital Los Angeles, 4650 Sunset Blvd., Los Angeles, CA 90027
| | - Manuel P. Nguyen
- Department of Ophthalmology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033
| | - Yuji Mishina
- Molecular Developmental Biology Group, Laboratory of Reproductive and Developmental Toxicology, National Institutes of Health, Research Triangle Park, North Carolina 27709
| | - Jeffrey S. Upperman
- Developmental Biology Program, Childrens Hospital Los Angeles, 4650 Sunset Blvd., Los Angeles, CA 90027
| | - Henri R. Ford
- Developmental Biology Program, Childrens Hospital Los Angeles, 4650 Sunset Blvd., Los Angeles, CA 90027
| | - Wei Shi
- Developmental Biology Program, Childrens Hospital Los Angeles, 4650 Sunset Blvd., Los Angeles, CA 90027
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Arnold MA, Chang DC, Nabaweesi R, Colombani PM, Fischer AC, Lau HT, Abdullah F. Development and validation of a risk stratification index to predict death in gastroschisis. J Pediatr Surg 2007; 42:950-5; discussion 955-6. [PMID: 17560201 DOI: 10.1016/j.jpedsurg.2007.01.028] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Gastroschisis is a rare congenital anomaly, the improved surgical management of which has contributed to a survival rate greater than 90%. Development of an accurate risk stratification system to help identify the subset of patients at greatest risk for death may lead to further improvements in outcome. METHODS Infants with gastroschisis were identified from 16 years of the National Inpatient Sample database and the Kids' Inpatient Database using the International Classification of Diseases, Ninth Revision, Clinical Modification procedure code 54.71 (repair of gastroschisis) and an age of less than 8 days. Logistic regression analysis determined which coexisting diagnoses were significantly associated with death. Odds ratios from the logistic regression model were simplified and used as weighting factors to create an additive index. The index was validated using the 2003 Kids' Inpatient Database data set. RESULTS Intestinal atresia, necrotizing enterocolitis, rare cardiac anomalies, and lung hypoplasia were strongly associated with death and used to create a scoring system with a potential range of 0 to 10. Every point increase on the scale of gastroschisis risk stratification index is associated with a 95% relative increase in the likelihood of death. CONCLUSION We have developed a novel index, which is superior to previous classification systems in identifying patients with gastroschisis who are at highest risk for death.
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Affiliation(s)
- Meghan A Arnold
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA
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Lund CH, Bauer K, Berrios M. Gastroschisis: incidence, complications, and clinical management in the neonatal intensive care unit. J Perinat Neonatal Nurs 2007; 21:63-8. [PMID: 17301669 DOI: 10.1097/00005237-200701000-00013] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This article presents a case study of a newborn with gastroschisis, followed by a retrospective analysis of gastroschisis cases admitted in a single tertiary neonatal intensive care unit over a 5-year period in terms of maternal age, prenatal diagnosis, type of repair, length of stay, and complications. Gastroschisis is an abdominal wall defect resulting from ischemia to blood vessels that supply the abdominal wall during the first trimester of pregnancy. The injury results in an opening in the abdominal wall that allows the abdominal contents, most often intestines and stomach, to develop outside the abdominal cavity. The incidence of gastroschisis is rising, primarily in young mothers aged 20 years or younger. Environmental factors including medication use and nutrition are proposed mechanisms for this association. Surgical management includes techniques for primary repair in which the intestinal contents are immediately closed inside the abdomen, or staged repair if the abdominal cavity is not able to accommodate the volume of intestine. Exposure of the fetal intestine to amniotic fluid can cause inflammation and damage, and significant gastrointestinal problems occur during the neonatal period after closure of the defect. Complications include prolonged ileus, sepsis, associated intestinal atresias, malabsorption, wound infection, and necrotizing enterocolitis.
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Affiliation(s)
- Carolyn Houska Lund
- Intensive Care Nursery, Children's Hospital and Research Center, Division of Neonatology, Oakland, CA 94609, USA.
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