The outcome of newborns with abdominal wall defects according to the method of abdominal closure: the experience of a single center

Three-Dimensional Ultrasound Evaluation of Lung Volume in Fetuses with Abdominal Wall Defect

INTRODUCTION

Abdominal wall defects (AWDs) interfere with postnatal respiratory parameters. We aimed to evaluate lung volume (LV) in fetuses with AWD using three-dimensional (3D) ultrasound (US) and to correlate AWD with the type (omphalocele and gastroschisis) and size of the defect and neonatal morbidity and mortality.

METHODS

This prospective observational study included 72 pregnant women with fetuses with AWD and a gestational age <25 weeks. The data on abdominal volume, 3D US LV, and herniated volume were acquired every 4 weeks up to 33 weeks. LV was compared with normal reference curves and correlated with abdominal and herniated volumes.

RESULTS

Omphalocele (p < 0.001) and gastroschisis (p < 0.001) fetuses had smaller LV than normal fetuses. LV was positively correlated with abdominal volume (omphalocele, r = 0.86; gastroschisis, r = 0.88), whereas LV was negatively correlated with omphalocele-herniated volume/abdominal volume (p < 0.001, r = -0.51). LV was smaller in omphalocele fetuses that died (p = 0.002), were intubated (p = 0.02), or had secondary closure (p < 0.001). In gastroschisis, a smaller LV was observed in fetuses discharged using oxygen (p = 0.002).

CONCLUSION

Fetuses with AWD had smaller 3D LV than normal fetuses. Fetal abdominal volume was inversely correlated with LV. In omphalocele fetuses, a smaller LV was associated with neonatal mortality and morbidity.

Using acellular porcine dermal matrix (XCM Biologic® Tissue Matrix) to repair a giant omphalocele: A case report

RATIONALE

An omphalocele is an abdominal wall birth defect, and a giant omphalocele (GO) is defined as an omphalocele having a diameter >5 cm or containing a herniated liver. GOs are usually treated in stages and in this case, during the silo reduction, dehiscence occurred at the suture site of the axis ring and skin edge, which was repaired using synthetic absorbable mesh.

PATIENT CONCERNS

A girl infant was born at 36 weeks with a GO of 8 cm diameter, and herniated multiple organs such as the small bowel, cecum, appendix, and the entire liver. Even after the staged repair technique for the GO silo, wound dehiscence between the ring of the silo and the edge of the skin occurred and gradual reduction failed.

DIAGNOSIS

A GO of 8 cm diameter, which was found during prenatal ultrasonography.

INTERVENTIONS

Revision was performed to repair the defect. The small bowel and liver were still prolapsed, and there were severe adhesions. After adhesiolysis, the muscle layer of the abdominal wall was repaired using the tissue matrix, but the skin could not be repaired. After the second operation, the defect wound was dressed as sterilely as possible.

OUTCOMES

The abdominal wall defect was repaired completely; there were no residual complications.

LESSONS

Repair of GOs using an acellular porcine dermal matrix can be considered a viable treatment option.

Abdominal Wall Defects: A Review of Current Practice Guidelines

The 2 most common congenital abdominal wall defects are gastroschisis and omphalocele. Gastroschisis is a defect in the abdominal wall with exposed abdominal contents. Mortality rates are low but lengths of stay are often prolonged by bowel dysmotility and other intestinal abnormalities in complicated cases. Omphalocele is a defect through the umbilical cord with herniated abdominal contents covered by a sac. It is associated with other genetic abnormalities and other anomalies that can lead to significant morbidity and mortality. Prenatal diagnosis in both conditions allows for improved prenatal consultation and coordinated perinatal care to improve clinical outcomes.

Does meconium contaminated amniotic fluid affect intestinal wall thickness and functional outcome in patients with anterior abdominal wall defects?

BACKGROUND

Gastroschisis (GS) and omphalocele (OC) are congenital abdominal wall defects, the main difference between is the direct exposure of intestinal loops in amniotic fluid in children with a GS. This leads to a reduced primary closure rate and a higher number of intraoperative abnormalities and post-operative complications.

AIMS AND OBJECTIVES

We analysed abdominal wall defect patients over an 11-year period, aiming to assess the influence of meconium-contaminated amniotic fluid. This study has different objectives to show the consequence of functional outcome of abdominal wall defects (AWD) children in reliance to colour of amniotic fluid, to assess the effect of reduced bowel exposure time to meconium contaminated amniotic fluid on edematous inflammatory thickening of the bowel loops, to show an positively influence in the number of primary AWD closures, to demonstrate a reduced incidence of post-natal complications and to verify a better outcome of OC children because of failing exposure to amniotic fluid.

METHODS

A retrospective, observational case-control design was used to compare GS (n = 36) and OC (n = 18) children. Physical data, colour of amniotic fluid, pre- and perinatal problems, operative complications and surgical technique, post-operative complications, duration of intensive care unit (ICU) stay, mechanical ventilation, parenteral nutrition, commencement of oral feeding and total hospital stay were collected. Data were analysed with descriptive methods, t-test and non-parametric tests such as Wilcoxon and Kruskal-Wallis were performed in addition to the analysis of variance, including post hoc testing accepting a confidence interval of 95% (P < 0.05) by using IBM SPSS software, version 23 (IBM, Illinois, USA).

RESULTS

Rate of meconium-contaminated amniotic fluid is significantly higher in GS compared to OC (P < 0.001), delivery problems such as congenital infections are also significantly higher (P < 0.001), this yields in significantly more bowel loops anomalies and problems during surgery (P < 0.036) but had no significant influence on primary abdominal wall closures rate (P = 0.523). The post-surgical outcome of OC was significantly better as compared to GS. Within the GS, those with swollen intestines had significantly longer ICU stays (P = 0.045) due to extended mechanical ventilation (P = 0.007), parenteral nutrition (P = 0.011) and delayed initiation of oral feeding (P < 0.001. Same results were found for the duration of ICU stay (P = 0.008), mechanical ventilation (P = 0.006), parenteral nutrition (P = 0.011) and delayed initiation of oral feeding (P < 0.001) in secondary closures as compared to primary abdominal wall closures in the GS group.

CONCLUSIONS

Worsen functional short-term outcome of GS children was directly addicted to meconium contamination of amniotic fluid due to swollen intestines and because of this more post-surgical problem including significantly extended hospital stays were observed.

The incidence of different forms of ileus following surgery for abdominal birth defects in infants: a systematic review with a meta-analysis method

Objectives

Ileus following surgery can arise in different forms namely as paralytic ileus, adhesive small bowel obstruction or as anastomotic stenosis. The incidences of these different forms of ileus are not well known after abdominal birth defect surgery in infants. Therefore, this review aims to estimate the incidence in general between abdominal birth defects.

Content

Studies reporting on paralytic ileus, adhesive small bowel obstruction or anastomotic stenosis were considered eligible. PubMed and Embase were searched and risk of bias was assessed. Primary outcome was the incidence of complications. A meta-analysis was performed to pool the reported incidences in total and per birth defect separately.

Summary

This study represents a total of 11,617 patients described in 152 studies of which 86 (56%) had a follow-up of at least half a year. Pooled proportions were calculated as follows; paralytic ileus: 0.07 (95%-CI, 0.05-0.11; I 2=71%, p≤0.01) ranging from 0.14 (95% CI: 0.08-0.23) in gastroschisis to 0.05 (95%-CI: 0.02-0.13) in omphalocele. Adhesive small bowel obstruction: 0.06 (95%-CI: 0.05-0.07; I 2=74%, p≤0.01) ranging from 0.11 (95% CI: 0.06-0.19) in malrotation to 0.03 (95% CI: 0.02-0.06) in anorectal malformations. Anastomotic stenosis after a month 0.04 (95%-CI: 0.03-0.06; I 2=59%, p=0.30) ranging from 0.08 (95% CI: 0.04-0.14) in gastroschisis to 0.02 (95% CI: 0.01-0.04) in duodenal obstruction. Anastomotic stenosis within a month 0.03 (95%-CI 0.01-0.10; I 2=81%, p=0.02) was reviewed without separate analysis per birth defect.

Outlook

This review is the first to aggregate the known literature in order approximate the incidence of different forms of ileus for different abdominal birth defects. We showed these complications are common and the distribution varies between birth defects. Knowing which birth defects are most at risk can aid clinicians in taking prompt action, such as nasogastric tube placement, when an ileus is suspected. Future research should focus on the identification of risk factors and preventative measures. The incidences provided by this review can be used in those studies as a starting point for sample size calculations.

The incidence of abdominal surgical site infections after abdominal birth defects surgery in infants: A systematic review with meta-analysis

BACKGROUND

Surgical site infections (SSI) are a frequent and significant problem understudied in infants operated for abdominal birth defects. Different forms of SSIs exist, namely wound infection, wound dehiscence, anastomotic leakage, post-operative peritonitis and fistula development. These complications can extend hospital stay, surge medical costs and increase mortality. If the incidence was known, it would provide context for clinical decision making and aid future research. Therefore, this review aims to aggregate the available literature on the incidence of different SSIs forms in infants who needed surgery for abdominal birth defects.

METHOD

The electronic databases Pubmed, EMBASE, and Cochrane library were searched in February 2020. Studies describing infectious complications in infants (under three years of age) were considered eligible. Primary outcome was the incidence of SSIs in infants. SSIs were categorized in wound infection, wound dehiscence, anastomotic leakage, postoperative peritonitis, and fistula development. Secondary outcome was the incidence of different forms of SSIs depending on the type of birth defect. Meta-analysis was performed pooling reported incidences in total and per birth defect separately.

RESULTS

154 studies, representing 11,786 patients were included. The overall pooled percentage of wound infections after abdominal birth defect surgery was 6% (95%-CI:0.05-0.07) ranging from 1% (95% CI:0.00-0.05) for choledochal cyst surgery to 10% (95%-CI:0.06-0.15) after gastroschisis surgery. Wound dehiscence occurred in 4% (95%-CI:0.03-0.07) of the infants, ranging from 1% (95%-CI:0.00-0.03) after surgery for duodenal obstruction to 6% (95%-CI:0.04-0.08) after surgery for gastroschisis. Anastomotic leakage had an overall pooled percentage of 3% (95%-CI:0.02-0.05), ranging from 1% (95%-CI:0.00-0.04) after surgery for duodenal obstruction to 14% (95% CI:0.06-0.27) after colon atresia surgery. Postoperative peritonitis and fistula development could not be specified per birth defect and had an overall pooled percentage of 3% (95%-CI:0.01-0.09) and 2% (95%-CI:0.01-0.04).

CONCLUSIONS

This review has systematically shown that SSIs are common after correction for abdominal birth defects and that the distribution of SSI differs between birth defects.

A standardized guideline for antibiotic prophylaxis in surgical neonates. Semin Pediatr Surg 2019;28:53-56. [PMID: 30824135 DOI: 10.1053/j.sempedsurg.2019.01.009]

Infection following surgical procedures leads to increased morbidity and mortality in all populations. Guidelines to aid providers in the proper use of prophylactic antibiotics exist for adults, but are rare in the neonatal surgical population. A recent emphasis on appropriate antibiotic stewardship had led to the development of more guidelines without a coincident increase in surgical site infection. Robust data from randomized, controlled trials, however, remain sparse.

Postnatal outcomes of infants with gastroschisis: a 5-year follow-up in a tertiary referral center in Brazil

OBJECTIVE

The aim of this study was to evaluate postnatal outcomes in fetuses with gastroschisis.

METHODS

This is a retrospective study (2009-2013) of patients with gastroschisis at the Hospital São Paulo (Federal University of São Paulo, Brazil).

RESULTS

A total of 44 infants with gastroschisis were examined. The mean maternal age was 21.1 years and mean gestational age at delivery was 36.1 weeks. Delivery occurred before 34 weeks in 13.6%, between 34 and 36 weeks and 6 d in 40.9%, and after 37 weeks in 45.5%. The mean birth weight was 2349 g, with 37.2% small-for-gestational age infants. The mean umbilical cord blood pH was 7.32. Bowel resection and delayed fascial closure was performed in 14.6% and 19.5%, respectively. The mean hospitalization time in the neonatal intensive care unit was 52.7 d. Neonatal infection was detected in 52.4%, with a positive blood culture; 77.3% of those cases were coagulase negative staphylococci. The overall rate of mortality was 25%; 18.2% before birth, 45.4% during the neonatal period, and 36.4% in infants. The main cause of postnatal death was septicemia (55.5%).

CONCLUSIONS

Despite advances in perinatal care and surgical techniques, infants with gastroschisis still present high rates of complications and death.

An 18 years' review of exomphalos highlighting the association with malrotation

INTRODUCTION

This was a retrospective 18 years' review of infants with exomphalos with particular attention to its association with malrotation.

MATERIALS AND METHODS

We reviewed all exomphalos cases presenting to our neonatal surgery unit, from October 1991 to September 2009. Data were presented as median and range values. Categorical data were analyzed using Fisher's exact tests and P value of ≤0.05 was considered as significant.

RESULTS

Forty-two infants with exomphalos (E. major 23, E. minor 19) were treated during this period. The incidence of surgically confirmed malrotation was 45% in E. major and 31% in E. minor.

CONCLUSION

The association of malrotation in exomphalos major and exomphalos minor infants is alarmingly high and supports the need to actively exclude this abnormality, either operatively or radiologically.

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.

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.

Past and current surgical treatment of giant omphalocele: outcome of a questionnaire sent to authors

PURPOSE

Operative treatment of giant omphalocele (OC) is still a challenge for pediatric surgeons. We were interested to ascertain whether published operative techniques for giant OC once advocated by their authors were still being used by these authors and whether the techniques had been modified or even abandoned for other techniques.

METHODS

Relevant studies concerning the treatment of giant OC were identified by an electronic search. Publication date of the articles was from 1967 to 2009. A questionnaire was sent to the first author or coauthor, unless contact details were unavailable. The described surgical techniques were categorized into primary closure, staged closure, and delayed closure.

RESULTS

Almost half of the authors (42%), independent of the initial technique used (primary, staged, or delayed closure), changed or stopped using their technique after the publication of the article. The change was not to one particular proven better technique. Herniation rate was lower in delayed closure (9% delayed vs 18% staged vs 58% primary).

CONCLUSIONS

The results of the questionnaire did not show a generally accepted method of treatment after more than 30 years of innovations in managing patients with a giant OC. There are generally 2 main treatment modalities: staged closure and delayed closure. Because of the lack of large patient numbers and late follow-up, long-term results of the published techniques are needed, and randomized multicenter trials based on these outcomes are recommended. Until then, we remain dependent on expert opinions.

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.

Does staged closure have a worse prognosis in gastroschisis?

INTRODUCTION

Correction of gastroschisis can be accomplished by primary or staged closure. There is, however, no consensus regarding the best approach or criteria to favor one method over the other has been established.

OBJECTIVE

To compare the outcome of primary and staged closure in newborns with gastroschisis using intravesical pressure (IVP) as the decision criterion.

PATIENTS & METHODS

We prospectively analyzed 45 newborns with gastroschisis. An IVP with a threshold of 20 cm H(2)O was used to indicate primary or staged closure, and the outcomes between the two methods were compared.

RESULTS AND DISCUSSION

Newborns in whom primary closure was feasible were born at a lower gestational age. There was no significant difference in the frequency of complications, time to begin oral feeding, length of parenteral nutrition or length of hospital stay. Compared with previous reports, our data showed higher rates of prenatal diagnosis and cesarean delivery, a lower average birth weight, a higher rate of small gestational age babies and a more frequent association with intestinal atresia. Conversely, our data showed a lower rate of postoperative necrotizing enterocolitis and a lower average length of hospital stay.

CONCLUSION

No significant difference was observed in the outcome of newborns who underwent primary closure or staged closure of gastroschisis when using an IVP below 20 cm H(2)O as the criterion for primary closure.

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.

Neonatal care in patients with giant ompholocele: arduous management but favorable outcomes

OBJECTIVES

The objectives of the study were to provide a review of patients with giant omphalocele managed in a single institution (2001-2006), focusing on medical management in the neonatal period, and to evaluate short-term outcomes.

METHODS

Data from 14 neonates with giant ompholocele (abdominal wall defect >5 cm and/or containing liver) and the absence of malformation and chromosomal anomalies during fetal screening were retrospectively reviewed. All were intubated and sedated before surgical treatment. Initial management consisted of progressive reduction of the herniated organs by gentle compression. After sequential reduction, abdominal wall closure was attempted at the skin and fascia level and, when necessary, with a Gore-Tex patch.

RESULTS

Median gestational age was 39 weeks (38-40), and median birth weight was 3100 g (2470-3700). Median age at closure was 6 days (0-20). A central Gore-Tex patch was inserted in 10 cases. Median ventilation length was 26 days (2-78). Full enteral diet was achieved after an average of 33 days (8-82), and median time until discharge from the intensive care unit was 24.5 days (11-85). Nine patients developed sepsis in the postoperative course. In 10 patients, at least 1 associated malformation was diagnosed in the postnatal course, among which cardiac and diaphragmatic defects were the most common. Survival rate was 85.7%.

CONCLUSION

Mortality rate of giant omphalocele without chromosomal anomaly or major malformations is low when treated by gradual reduction of the contents. Parents should be informed of the long hospitalization in the intensive care unit at birth, the potential nonthreatening associated malformations to be diagnosed after birth, and the high risk of sepsis.

No free ride? The hidden costs of delayed operative management using a spring-loaded silo for gastroschisis

PURPOSE

The ideal management of gastroschisis (primary vs staged closure) has not yet been established. Despite the ease of silo placement, anecdotal experience shows that silos do not always offer benefit. The aim of this study was to highlight concerns regarding use of spring loaded silos and compare outcomes to primary closure.

METHODS

Thirty-seven neonates with gastroschisis treated with either primary (n = 10) or staged closure with a spring-loaded silo (n = 27) were reviewed (1998-2007). Variables included ventilator days, daily intravenous fluid, hospital days, and complication rates. SPSS (SPSS Inc, Chicago, Ill) was used to perform t test and chi(2) analyses (significance P < .05).

RESULTS

Survival for primary closure was 100% (10/10) compared to 89% (24/27) for staged closure (P = .548). Patients managed with silos required prolonged ventilation (16.1 +/- 4 days vs 3.6 +/- 1 days; P < or = .05) and greater intravenous fluids on days 3, 4, and 5 of life (132 +/- 25 mL/kg per day vs 104 +/- 18 mL/kg per day; P < or = .01). Although there was no difference in the complication rates between the groups, several problems were evident in the silo group: 15% (4/27) required silo replacement, 44% (12/27) required fascial defect enlargement for silo placement, and 19% (5/27) required mesh at closure. No significant differences in recovery of intestinal function were observed. Three silo patients developed ischemic complications because of vascular insufficiency at the level of the abdominal wall, leading to significant intestinal loss, ventilator and total parenteral nutrition dependence, and increased hospital stay.

CONCLUSIONS

Patients managed with a silo had longer ventilator requirements and greater fluid needs. This Specific technical complications leading to bowel ischemia were notable in the silo group. The silo should be carefully placed to avoid bowel twisting and the funnel effect. Larger prospective studies should be performed to provide decision-making criteria for the use of a silo vs primary closure.

Staged reduction of gastroschisis using preformed silos: practicalities and problems

PURPOSE

Previous single-center studies have reported favorable outcomes when preformed silos (PFS) are used for the staged reduction of gastroschisis. The aim of this study was to assess the frequency and nature of complications associated with PFS in a large population and provide an insight into the practicalities of their routine use.

METHODS

A retrospective review was carried out of all cases of gastroschisis managed with PFS in 4 UK neonatal surgical units for a 6-year period.

RESULTS

One hundred fifty infants were included, and 139 (92.7%) silos were applied at cot side (no sedation, n = 93). Median silo size was 4 cm, and time of application was 2.5 hours. Enlarging the defect by incision of fascia was required in 17 (11%). Defect closure was performed at a median of 4 days (0-47) with 93 (62%) being at cot side. Methods of closure were adhesive strips/dressings (n = 94), sutures (n = 48), and patch (n = 8). Discoloration of the viscera occurred in 16 (11%), managed successfully by simple methods (change of PFS, aspirating the stomach, or incision of the defect fascia) (n = 8), conversion to operative silo (n = 3), and operative reduction (n = 1). Four required bowel resection. Other complications included missed atresia (n = 5; 3.3%) and nectrotizing enterocolitis (n = 11; 7%). There were 5 deaths in the series (3.3%).

CONCLUSIONS

Staged reduction of gastroschisis with PFS is simple, convenient, and safe. The low rates of associated complications and mortality appear favorable when compared to infants managed with more traditional techniques. We recommend that PFS should be used for the routine management of gastroschisis.

Outcomes of exomphalos: an institutional experience

OBJECTIVE

Abdominal wall defects, particularly exomphalos, in newborn infants are associated with significant morbidity and mortality. The objective of the present study was to review the outcomes of neonates with exomphalos in our neonatal intensive care unit during the last 12 years.

STUDY DESIGN

In this retrospective study 52 neonates with exomphalos were identified from 1996 to 2007. Exomphalos were stratified by the type of defect [exomphalos minor versus major (major defined as defect size more than 5 cm and/or liver in the sac)]. Clinical data, demographic data, and outcome measures of mortality, length of stay (LOS), duration of mechanical ventilation and age at full enteral feeds were studied. Associated anomalies were compared between the two groups.

RESULTS

Of the 52 neonates, 1 was transferred back to referring hospital after surgical repair of the defect and was not analyzed. Exomphalos minor accounted for 24 cases and exomphalos major in 27 cases. Mortality was higher in infants with exomphalos major (n = 9, 33%) compared to infants with exomphalos minor (n = 2, 8%). The median LOS (10 vs. 47 days, P = 0.023), median age at full enteral feeds (5 vs. 23 days, P = 0.004) and median duration of mechanical ventilation (7 vs. 23 days, P = 0.001) were shorter for exomphalos minor compared to exomphalos major. Bacteremia was present in 4 (15%) of neonates with exomphalos major. Syndromic associations were present in 8 neonates (33%) with exomphalos minor compared to 2 neonates (7%) with exomphalos major. Beckwith Wiedemann syndrome was most frequently noted in neonates with syndromic exomphalos minor. Trisomy 13 was the only chromosomal abnormality in the entire cohort (1/51 = 2%) and was seen in a single neonate (1/27 = 3.7%) with exomphalos major. Non-syndromic anomalies were seen in 12 (50%) and 14 neonates (52%) with the minor and major defects, respectively. Only four neonates with exomphalos minor (16%) and ten neonates with exomphalos major (37%) had no associated anomalies. Pulmonary hypoplasia and pulmonary hypertension were identified on either lung biopsy or autopsy (n = 5) as causes of mortality.

CONCLUSION

Neonates with exomphalos minor have better survival, decreased LOS, time to full enteral feeds and shorter duration of mechanical ventilation. Syndromic associations were more common in exomphalos minor. Respiratory failure was the major cause of mortality in infants with exomphalos major.

The female condom as a temporary silo: a simple and inexpensive tool in the initial management of the newborn with gastroschisis

OBJECTIVE

The aim of this study is to report the use of a female condom as a non-surgical silon pouch in the early management of newborns with gastroschisis with large visceroabdominal disproportion.

METHODS

Pre-washed, sterile female condoms without spermicide were used as an early approach to treat gastroschisis in 20 newborns with large defects and in whom staged correction was anticipated. The condom was placed in the neonatal intensive care unit using sterile technique, with no anesthesia, and it was removed only at the time of the surgical procedure for gastroschisis correction.

RESULTS

There were no complications associated with the use of a female condom as a temporary silo for gastroschisis. It protected the exposed organs and also allowed a careful evaluation of the bowel and a better pre-operative planning without the need for emergency procedures.

CONCLUSION

The use of a female condom as a silon pouch is a low-cost and simple alternative in the initial management of newborns with gastroschisis in whom primary correction is considered non-feasible.

Neonatal surgery: a ten year audit from a university hospital

Neonatal surgery is the flagship and most challenging component of pediatric surgery, which is the youngest subspeciality of surgery. Neonatal surgery carried a survival rate of only 30% three decades ago. In the last decade there has been a significant change in the scenario. Earlier recognition and referral of these anomalies, availability of neonatal intensive care, better preoperative planning, decision, and techniques have lead to the change in the management. This is an audit into the outcome of neonatal surgery from one of the largest units in India over a ten year period. This audit reveals an across the board survival of 65-70% newborns after surgery on nearly two thousand case over a ten year period. It has an important message that while pediatric surgery units expand, risk stratification of surgical newborns and their treatment in suitable units is mandatory to maintain and improve these figures to match international standards over the next decade.

Gastroschisis closure--does method really matter?

BACKGROUND/PURPOSE

Management of gastroschisis varies. This study aims to determine which aspects of practice influence outcomes.

METHODS

All cases of simple gastroschisis (N = 99) in the Canadian Pediatric Surgery Network database were analyzed looking at methods of preoperative bowel protection, timing of closure, and closure techniques; and outcome measures included time to onset of enteral feeds, duration of parenteral nutrition (PN), and length of stay (LOS).

RESULTS

One third of infants had initial bowel protection using a spring-loaded silo, which was significantly associated with a delay (beyond 24 hours) in establishing primary closure. Neither preoperative bowel protection methods nor defect closure techniques conferred any significant effects on success at establishing primary closure or functional outcomes. After adjusting for all covariates, only failure to establish primary closure was associated with impaired outcomes with significantly delayed initiation of enteral feeds and prolonged LOS. Low birth weight (<2000 g) and younger gestational age (<36 weeks) were associated with a 3-fold increased risk of longer PN dependence and 5-fold risk of extended LOS, respectively. Babies undergoing the sutureless spontaneous closure technique had significant delays in initiating enteral feeds but no increased requirements for PN or LOS.

CONCLUSIONS

Modes of preoperative bowel protection and techniques of abdominal wall closure ultimately have no association with functional outcomes in infants with gastroschisis. Failure to establish primary closure, however, is significantly associated with delays in establishing intestinal function and subsequent time to discharge.

Retrospective case study of team approach to omphalocele orthosis fabrication and implementation

PURPOSE

The purpose of this case report is to describe an interdisciplinary approach to orthotic intervention in a neonate with giant omphalocele.

SUMMARY OF KEY POINTS

An infant with a giant omphalocele was presented to the Neonatal Intensive Care Unit (NICU) for management. An interdisciplinary team including a neonatal surgeon, physical therapists, orthotist, and family collaborated to determine appropriate orthotic intervention. A custom stabilizing orthosis and prone positioning device were fabricated and fit to the infant. The omphalocele was secure and the family felt confident that the omphalocele was protected during physical interaction.

SUMMARY AND RECOMMENDATIONS FOR CLINICAL PRACTICE

In this case, a custom orthosis was shown to be a valuable tool to provide external support for a giant omphalocele and facilitate safe interaction between infant and family. An interdisciplinary approach is recommended to best accommodate the patient's needs.