Congenital abdominal wall defects: gastroschisis and omphalocele

Combined negative pressure wound therapy with irrigation and dwell time and artificial dermis prevents infection and promotes granulation formation in a ruptured giant omphalocele: a case report

Background

Omphalocele is a congenital abdominal wall defect of the umbilical cord insertion site. A giant omphalocele, with a fascial defect > 5 cm in diameter and/or containing > 50% of the liver within the hernia sac, can be challenging for pediatric surgeons. Recently, negative pressure wound therapy has been reported as an effective management for giant omphaloceles; however, it is not recommended for an infected wound with necrotic tissue as it may exacerbate infection. We adopted negative pressure wound therapy with irrigation and dwell time (NPWTi-d) for a case of a ruptured giant omphalocele. Artificial membranes, followed by artificial dermis, were used to promote fibrous capsule formation, and then NPWTi-d was used to promote granulation while controlling infection. However, studies have not been conducted regarding NPWTi-d for ruptured giant omphaloceles; hence, we present our treatment experience with NPWTi-d for a giant omphalocele.

Case presentation

The patient was a boy born at 38 weeks and 3 days of gestation, weighing 1896 g. He was diagnosed with a ruptured giant omphalocele with a total liver and intestine defect hole of 10 cm × 10 cm. The patient underwent silo placement using an artificial mesh, followed by plicating the artificial mesh at 4 days of age. The herniated viscera were gradually reduced into the abdominal cavity; however, the defect size was still large. Hence, a collagen-based artificial dermis was patched on the defect hole. After creating a fresh and smooth granulated tissue, NPWTi-d was applied at 33 days of age to promote granulation and control infection. We used the 3 M™ V.A.C.® Ulta Therapy Unit with 3 M™ VeraFlo™ therapy. NPWTi-d was stopped at 60 days of age when the granulation tissue was well formed including at the artificial dermis site. The wound was managed with prostandin ointment and appropriate debridement, resulting in complete epithelialization at 5 months of age.

Conclusions

Artificial membranes followed by artificial dermis were used to promote a fibrous capsule and artificial dermis granulation, which protects against organ damage. NPWTi-d achieved better control of infection and promoted wound healing. NPWTi-d combined with artificial dermis can effectively treat ruptured giant omphaloceles.

Nonoperative management of giant omphalocele leading to early fascial closure

PURPOSE

We describe our series of giant omphalocele patients treated with a serial taping method for gradual reduction of the abdominal contents and early fascial closure.

METHODS

Between 2010 and 2017 we cared for ten newborns with giant omphaloceles. The average gestational age was 35.5 weeks (range 29-38) and average birthweight was 2.84 kg. Seven infants had other major anomalies, including one with a variant of Pentology of Cantrell. Four had abnormal chromosomes. None had any attempt to primarily close the defect. Omphalocele defects were serially taped at bedside in the NICU with the child awake until the viscera were completely reduced, and the defect could be closed.

RESULTS

Mean time to closure was 13.7 days (median 14 days). Six were closed primarily without a patch. The remaining four infants required Gore-Tex patch (covered by skin) which was later removed and fascia closed in three infants (at 70 days, 75 days, and 11 months of age). Total length of stay was a mean 71.8 days (median 71).

CONCLUSIONS

Serial taping achieves early fascial closure and avoids complications of a staged surgical approach, such as multiple anesthetics, loss of fascial margin integrity, silo dehiscence, and fistula formation. Compression of the viscera is slow enough to avoid abdominal compartment syndrome and the fascia and amnion are left intact leaving the option available to use escharotic agents if required.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level III.

Dressed for success? Silver impregnated nanocrystalline dressing for initial treatment of giant omphalocele

OBJECTIVE

The purpose of this study was to describe outcomes and resource utilization in patients treated with twice-weekly silver impregnated (SI) nanocrystalline dressings for initial non-operative management of giant omphalocele (GO).

METHODS

A retrospective review of patients with GO treated with SI dressings was undertaken. Clinical parameters, cost, and complications were recorded.

RESULTS

Five patients with GO were treated with SI dressings between 2014 and 2016. Clinical characteristic (mean ± SD) included gestational age 36 ± 4 weeks, birth weight 2.6 ± 0.63 kg, GO size 10.2 ± 4.7 cm, ventilator days 7.5 ± 8.7 d, days in NICU 41 ± 20 d, days to full feeds, 30 ± 15 d, and LOS 62 ± 41 d. The average in-hospital cost of SI dressings was $110 CAD/week. This is comparable to daily silver sulfadiazine dressings ($109CAD/week) which were used historically. All patients were discharged with once- or twice-weekly dressing changes. No ruptures occurred. There was one mortality secondary to pulmonary sepsis.

CONCLUSIONS

For initial non-operative management of GO, twice weekly SI nanocrystalline dressings is safe and effective. Use of SI dressings results in decreased handling of infants, reduced physician and nursing resource utilization, and favourable outcomes.

LEVEL OF EVIDENCE

IV (Retrospective Case Series).

Gastroschisis in monochorionic male twins

We report a case of gastroschisis in male twins. Both twins were preterm and low birth weight, with intestinal malrotation; they were diagnosed by antenatal ultrasound at 20 weeks of gestation. Immediately after delivery, they underwent evaluation and early surgical one-stage repair under anesthesia. One of the twins was found to have duodenal perforation at laparotomy, at the horizontal part near Treitz ligament. Both twins stayed in hospital for 30 days and were in good health at discharge.

Management of giant omphaloceles: A systematic review of methods of staged surgical vs. nonoperative delayed closure

PURPOSE

Despite the numerous methods of closure for giant omphaloceles, uncertainty persists regarding the most effective option. Our purpose was to review the literature to clarify the current methods being used and to determine superiority of either staged surgical procedures or nonoperative delayed closure in order to recommend a standard of care for the management of the giant omphalocele.

METHODS

Our initial database search resulted in 378 articles. After de-duplification and review, we requested 32 articles relevant to our topic that partially met our inclusion criteria. We found that 14 articles met our criteria; these 14 studies were included in our analysis. 10 studies met the inclusion criteria for nonoperative delayed closure, and 4 studies met the inclusion criteria for staged surgical management.

RESULTS

Numerous methods for managing giant omphaloceles have been described. Many studies use topical therapy secondarily to failed surgical management. Primary nonoperative delayed management had a cumulative mortality of 21.8% vs. 23.4% in the staged surgical group. Time to initiation of full enteric feedings was lower in the nonoperative delayed group at 14.6days vs 23.5days.

CONCLUSION

Despite advances in medical and surgical therapies, giant omphaloceles are still associated with a high mortality rate and numerous morbidities. In our analysis, we found that nonoperative delayed management with silver therapy was associated with lower mortality and shorter duration to full enteric feeding. We recommend that nonoperative delayed management be utilized as the primary therapy for the newborn with a giant omphalocele.

Gastrostomy and gastrojejunostomy tube placements: outcomes in children with gastroschisis, omphalocele, and congenital diaphragmatic hernia

PURPOSE

To retrospectively evaluate the technical success, safety, and outcomes of radiologically guided retrograde percutaneous gastrostomy and gastrojejunostomy tube placements in terms of weight gain and growth in children with gastroschisis, omphalocele, and/or congenital diaphragmatic hernia (CDH).

MATERIALS AND METHODS

Research ethics board approval, with waived informed patient consent, was obtained for review of the data of 37 children (17 male, 20 female; age range, 1-20 months; mean age, 4.3 months) in whom gastrostomy or gastrojejunostomy tubes were inserted between 1995 and 2004. Twenty-two patients had CDH, eight had gastroschisis, five had omphalocele, and two had both CDH and omphalocele. The technical success and complications of the procedures were recorded. Tube maintenance problems were analyzed separately from postprocedural complications. Initial and final patient growth percentiles were compared by using a one-sided paired Student t test.

RESULTS

Thirty-six of the 38 procedures performed in the 37 patients were successful. There were three intraprocedural complications (two cases of access difficulty, one case of bleeding) and three major complications (one skin and prosthetic material infection, one track loss during tube replacement, one delayed gastrostomy track closure necessitating surgery). Sixteen patients had at least one minor complication (cellulitis, feeding intolerance, skin-site bleeding, intussusception). Twenty-two patients had at least one tube maintenance problem. All patients gained weight (mean weight gain, 4.7 kg) after the procedure, with a significant increase in growth percentile (average increase, 6.5%; P = .029).

CONCLUSION

Radiologically guided percutaneous gastrostomy and gastrojejunostomy tube placements in children with gastroschisis, omphalocele, and/or CDH are associated with high success rates and low major complication rates. Although tube maintenance problems and minor complications are common, use of gastrostomy and gastrojejunostomy tubes effectively improves nutritional support.

Hepatic omphalocele in an adult

The finding of an untreated omphalocele in adulthood is extremely rare. We report the case of a 29-year-old patient, who presented to us with a congenital defect of the abdominal wall and protrusion of underlying viscera.

The contemporary outcome of gastroschisis

BACKGROUND

The aim of this study was to evaluate the contemporary outcome in the management of gastroschisis.

METHODS

A retrospective analysis was conducted of 91 babies admitted over a 7-year period to a single neonatal surgical unit with a diagnosis of gastroschisis.

RESULTS

An antenatal diagnosis was made in 89 (98%) cases. Surgical intervention occurred in 90 babies, at a mean of 5 hours (range, 0.5 to 17) postdelivery. In 72 (80%) cases, primary closure of the abdominal defect was achieved, with a silo fashioned in the remaining 18 (20%). One child died before abdominal closure. The median time to full oral feeding was 30 days (range, 5 to 160 days), and to discharge was 42 days (range, 11 to 183 days). Those children who required a silo, took longer to feed (P =.008) and stayed longer in the hospital (P =.021). The 8 (8.8%) children with an intestinal atresia, required significantly more operative procedures (P =.0001) and took significantly longer to achieve full oral feeding (P =.04), but the presence of an atresia was not an independent risk factor for mortality. There were 7 deaths (7.7%), 3 within the first 7 days. Of the deaths, 5 (71%) were caused by overwhelming sepsis.

CONCLUSIONS

The contemporary mortality rate from gastroschisis is less than 8%, and minimizing septic complications would contribute significantly to reducing this. Strategies designed to improve morbidity must focus on optimizing management of those factors associated with a prolonged recovery, namely intestinal atresia, prematurity, and the use of a silo.

The influence of gestational age and mode of delivery on infants with gastroschisis

BACKGROUND/PURPOSE

It has been proposed that preterm and prelabor cesarean section may improve the outcome of infants with gastroschisis. The purpose of this study is to examine the impact of gestation and delivery method on infants with gastroschisis.

METHODS

The medical records of 60 infants with gastroschisis treated at a tertiary care center from 1985 through 1995 were reviewed retrospectively. The gestational age, the mode of delivery, the type of operative repair, and the length of hospital stay were recorded for each patient.

RESULTS

Infants born vaginally were more likely to require silo stage repair than those delivered by cesarean section (21 of 29 v. 11 of 31, P<.01). Infants born vaginally also had longer hospital stay than those delivered by cesarean section (53 v. 39 days, P = .19). Infants born before 33 weeks' of gestation stayed longer in the hospital than those born after 33 weeks. After 33 weeks' gestation, infants had similar hospital stay regardless of the gestational age.

CONCLUSIONS

Cesarean section delivery was beneficial for infants with gastroschisis. Preterm delivery did not shorten the length of hospital stay. The role of elective cesarean section delivery at term should be considered for infants with gastroschisis diagnosed antenatally.

Treatment of congenital abdominal wall defects -a 25-year review of 132 patients

The outcome data of 132 patients treated at the Department of Pediatric Surgery in Mainz during the last 25 years were reviewed. Prenatal diagnosis of abdominal wall defects (AWDs) and associated malformations led to increasing selection of the patient population. The aim of primary closure of the abdominal wall can be achieved more frequently in gastroschisis (GS) than omphalocele (OC), while the postoperative course is more complicated and of longer duration in GS. Delayed or secondary closure extended the hospitalization period but had no negative effects on the outcome. Reoperations or planned secondary operations were performed in 23 patients with GS and 14 with OC. Early mortality was 15/55 for OC and 21/77 for GS over the period of 25 years. In recent years, a drastic reduction in mortality has occurred, and mortality is now mainly due to additional malformations. Further development and quality of life are not significantly reduced after survival of an isolated AWD. Malpositioning of parenchymatous organs after closure of AWDs has to be considered during pregnancy and abdominal operations.

Current concepts in inguinal hernia in infants and children

Trends are changing in the management of infants and children with indirect inguinal hernias. Advances in neonatal intensive care have resulted in the survival of many small premature infants who have a high incidence of inguinal hernia. The rate of incarceration, strangulation, and gonadal infarction in these babies is twice that of the general pediatric age group. Respiratory immaturity, apnea, bradycardia, and associated neonatal conditions require special management at the time of hernia repair, usually performed just before discharge from the neonatal intensive care unit. New information concerning volume loss and depletion of germ cells beginning at 6 months of age in boys with undescended testes has stimulated the performance of orchiopexy when the patient is 1 year of age. More than 90% of boys with cryptorchid testes at the age of 1 year have an associated hernia that requires concomitant repair at the time of orchiopexy. The use of the peritoneal cavity for fluid absorptive purposes in hydrocephalus treated by venticuloperitoneal shunts or of peritoneal dialysis for renal failure and metabolic diseases such as hyperammonemia and lactic acidosis causes increased intraabdominal pressure and results in the appearance of a previously unrecognized hernia. Recognition of these and other conditions associated with a high incidence of hernial occurrence should allow early diagnosis and treatment before the development of complications. Most elective repairs of hernias are safely performed in the outpatient setting; however, some infants and children with concurrent illnesses are best managed in a "morning admissions" program, in which hospital admission occurs postoperatively.

Intrauterine Diagnosis of Abdominal Wall Defects

Ultrasound is an important tool in the evaluation of fetal development and detection of fetal abnormalities. The ability to detect abnormalities in utero can help improve perinatal care; therefore, a detailed sonographic examination of the fetus should always be obtained. Abdominal wall defects that can be recognized by sonography include omphalocele, gastroschisis, umbilical cord hernia, and limb/body wall complex. The sonographer should attempt to give a detailed description of the defect including the organs involved, the presence of a sac, the site of cord insertion, and the presence of any associated anomalies. This information can aid the physician and parents in determining the course of management of the pregnancy.

Gastroschisis and extraabdominal ectopic testis: simultaneous repair

During a 10-year span, three males with gastroschisis were seen in whom one of the testes exited through the paraumbilical opening with the exteriorized intestine. In each case, prior to correction of the abdominal wall defect, the testes (left side in 2, right side in 1) were placed into the ipsilateral scrotum and anchored. In the first child, the undescended gonad, very small at birth, continued hypoplastic at 1 year. The second patient (8 years) required a second stage orchidopexy at age 2 years. The third child, a 1.3-kg premature infant, has good testicular size and position at 6 1/2 years. Undoubtedly because of the magnitude of the main pathology, recommendations on how to handle the gonad in this association are not available. This report focuses on the simplicity of concomitant repair. A similar approach was employed in two children with omphalocele and undescended testes.

Renal malposition in patients with omphalocele

We describe a boy with a history of omphalocele who presented with gross hematuria. Subsequent evaluation revealed a cephalad right kidney malposition and the hematuria was of lower tract origin. To investigate the frequency of this radiographic finding the medical records of 15 patients with omphalocele who presented between 1979 and 1985 were reviewed. Studies of the urinary tract were performed after omphalocele closure. Of 7 cases (46 per cent) with abnormal cephalad renal displacement the kidney was on the right side only in 3 and it was bilateral in 4. The omphalocele contents consisted of gastrointestinal tract only in 9 patients, and liver and gastrointestinal tract in 6. All 6 patients with omphaloceles that included the liver had cephalad renal displacement. One patient with small bowel alone in the omphalocele had right kidney displacement. Clinicians should be aware of this variation to avoid confusion and further unnecessary evaluation.

Surgical options in the management of large omphaloceles

Forty-six neonates with omphaloceles seen at the Children's Hospital and Medical Center in Seattle from 1975 to 1985 were reviewed. There was an 87 percent survival rate in those surgically managed. The 23 neonates who underwent primary closure all survived. The 13 neonates with giant omphaloceles with the liver in the defect who received silon chimneys had a 46 percent mortality rate and a high complication rate, with prolonged hospitalization. Two neonates with giant omphaloceles were managed by leaving the sac intact, and silver sulfadiazine cream was used as an escharotic agent. We believe it is a safer alternative than the silon chimney in neonates whose defects cannot be closed primarily.

Secular rates and correlates for gastroschisis in California (1968-1977)

This study reports on an epidemiological investigation of gastroschisis using birth certificate data from California for the period of 1968-1977. Gastroschisis has been reported to be on the increase in a number of countries. The distribution of the 166 California gastroschisis cases reported during this time period indicated a clear upward secular trend (P less than .001) with the rate per 1,000 increasing from .006 in 1968 to .089 by 1977. This secular trend was observed in every maternal age group and for gravidity level 1. Gastroschisis also occurred more frequently among younger mothers (P less than .001) and low gravidity mothers (P less than .001). Omphalocele, another eventration defect, was also examined but did not display an upward secular trend.

Association of amyoplasia with gastroschisis, bowel atresia, and defects of the muscular layer of the trunk

We reviewed 225 cases of amyoplasia, and the association of amyoplasia with gastroschisis and with monozygotic twinning was confirmed. In addition, an apparently increased association of bowel atresia and defects in the muscular layer of the trunk wall with amyoplasia was observed. The association of amyoplasia, monozygotic twinning, and these trunk wall defects strongly suggests that the pathogenesis of amyoplasia is linked to some type of vascular compromise.

The missing link in the pathogenesis of gastroschisis

Is gastroschisis embryologically distinct from omphalocele or simply a ruptured small omphalocele (hernia of the umbilical cord)? Serial sonographic imaging of a fetus with a small omphalocele at 27 weeks gestation has now provided the "missing link" in the pathogenesis of gastroschisis by documenting in utero rupture resulting in a gastroschisis.

Inguinal hernia repair in the perinatal period and early infancy: clinical considerations

Contemporary neonatal intensive care has resulted in survival of many seriously ill preterm and older infants that frequently present with symptomatic inguinal hernia. Controversy exists concerning timing and safety of early repair in prematures or other neonates, especially those hospitalized with concurrent illness. This study examines this topic by evaluating predisposing factors, presentation, and postoperative complications in 100 recent consecutive hernia repairs in previously hospitalized infants less than 2 months of age. There were 85 boys and 15 girls. Thirty percent were premature (less than 36 wks gestation). Forty-two infants were hospitalized for RDS with assisted ventilation in 16 infants, hydrocephalus and ventriculoperitoneal (VP) shunt in 7 infants, and congenital heart disease (CHD) in 19 infants. Clinical presentation was on the right side in 44 infants, bilateral in 42, and on the left side in 14. Incarceration occurred in 31 cases with nine babies having overt intestinal obstruction. The incidence of cryptorchidism was 12.9%. All (VP) shunt, CHD patients, and incarcerated cases were treated with preoperative antibiotics. Following discharge, 49 preterm or previously ill infants developed a symptomatic hernia at home and were readmitted. Nine full-term infants were treated as outpatients. Bilateral inguinal exploration was performed in 92 cases with second hernia or patent processus found in 81. Seven of eight with unilateral exploration had acute incarceration with obstruction at the time of the procedure. Three subsequently required a second hernia repair. Two infants with incarceration and cryptorchid testis or ovarian slider had gonadal infarction. There were eight postoperative complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Omphalocele and gastroschisis. Trends in survival across two decades

During the decade from July 1970 through June 1980, 57 patients with omphalocele and 64 with gastroschisis were treated at the Childrens Hospital of Los Angeles. Among the patients with omphalocele, the mortality was not significantly different between those with an abdominal wall defect smaller than 4 cm (5 of 24 patients) and those with a larger defect (6 of 33 patients); between those with a birth weight of less than 2,500 g (3 of 13 patients) and those with a higher birth weight (8 of 44 patients); between patients who had part of their liver in the omphalocele sac (6 of 29 patients) and those who did not (5 of 28 patients); and between patients who had primary fascial closure of the abdominal wall defect (3 of 24 patients) and those who had staged closure (4 of 25 patients). The overall mortality of 19 percent (11 of 57 patients) is not significantly different from that seen in patients treated during the preceding decade, 1960 through 1970 (23 percent, 5 of 22 patients), in our institution. Major chromosomal and other associated anomalies adversely affected the survival rate in these patients. In contrast, the overall survival rate of gastroschisis patients has markedly increased over the past two decades (91 percent in 1975 to 1980). In these patients, the difference in survival between those who had primary fascial closure (73 percent) and those who had staged closure by skin flaps or silon chimney (81 percent) was not statistically significant. Prematurity, bowel complications, and candida septicemia associated with the use of total parenteral nutrition contributed to the mortality.