Sutureless vs Sutured Gastroschisis Closure: A Prospective Randomized Controlled Trial

Management of Gastroschisis: Timing of Delivery, Antibiotic Usage, and Closure Considerations (A Systematic Review From the American Pediatric Surgical Association Outcomes & Evidence Based Practice Committee)

BACKGROUND

No consensus exists for the initial management of infants with gastroschisis.

METHODS

The American Pediatric Surgical Association (APSA) Outcomes and Evidenced-based Practice Committee (OEBPC) developed three a priori questions about gastroschisis for a qualitative systematic review. We reviewed English-language publications between January 1, 1970, and December 31, 2019. This project describes the findings of a systematic review of the three questions regarding: 1) optimal delivery timing, 2) antibiotic use, and 3) closure considerations.

RESULTS

1339 articles were screened for eligibility; 92 manuscripts were selected and reviewed. The included studies had a Level of Evidence that ranged from 2 to 4 and recommendation Grades B-D. Twenty-eight addressed optimal timing of delivery, 5 pertained to antibiotic use, and 59 discussed closure considerations (Figure 1). Delivery after 37 weeks post-conceptual age is considered optimal. Prophylactic antibiotics covering skin flora are adequate to reduce infection risk until definitive closure. Studies support primary fascial repair, without staged silo reduction, when abdominal domain and hemodynamics permit. A sutureless repair is safe, effective, and does not delay feeding or extend length of stay. Sedation and intubation are not routinely required for a sutureless closure.

CONCLUSIONS

Despite the large number of studies addressing the above-mentioned facets of gastroschisis management, the data quality is poor. A wide variation in gastroschisis management was documented, indicating a need for high quality RCTs to provide an evidence-based approach when caring for these infants.

TYPE OF STUDY

Qualitative systematic review of Level 1-4 studies.

Race and Ethnicity of Infants Enrolled in Neonatal Clinical Trials: A Systematic Review

Importance

Representativeness of populations within neonatal clinical trials is crucial to moving the field forward. Although racial and ethnic disparities in research inclusion are well documented in other fields, they are poorly described within neonatology.

Objective

To describe the race and ethnicity of infants included in a sample of recent US neonatal clinical trials and the variability in this reporting.

Evidence Review

A systematic search of US neonatal clinical trials entered into Cochrane CENTRAL 2017 to 2021 was conducted. Two individuals performed inclusion determination, data extraction, and quality assessment independently with discrepancies adjudicated by consensus.

Findings

Of 120 studies with 14 479 participants that met the inclusion criteria, 75 (62.5%) included any participant race or ethnicity data. In the studies that reported race and ethnicity, the median (IQR) percentage of participants of each background were 0% (0%-1%) Asian, 26% (9%-42%) Black, 3% (0%-12%) Hispanic, 0% (0%-0%) Indigenous (eg, Alaska Native, American Indian, and Native Hawaiian), 0% (0%-0%) multiple races, 57% (30%-68%) White, and 7% (1%-21%) other race or ethnicity. Asian, Black, Hispanic, and Indigenous participants were underrepresented, while White participants were overrepresented compared with a reference sample of the US clinical neonatal intensive care unit (NICU) population from the Vermont Oxford Network. Many participants were labeled as other race or ethnicity without adequate description. There was substantial variability in terms and methods of reporting race and ethnicity data. Geographic representation was heavily skewed toward the Northeast, with nearly one-quarter of states unrepresented.

Conclusions and Relevance

These findings suggest that neonatal research may perpetuate inequities by underrepresenting Asian, Black, Hispanic, and Indigenous neonates in clinical trials. Studies varied in documentation of race and ethnicity, and there was regional variation in the sites included. Based on these findings, funders and clinical trialists are advised to consider a 3-point targeted approach to address these issues: prioritize identifying ways to increase diversity in neonatal clinical trial participation, agree on a standardized method to report race and ethnicity among neonatal clinical trial participants, and prioritize the inclusion of participants from all regions of the US in neonatal clinical trials.

Gastroschisis for the Gastroenterologist: Updates on Epidemiology, Management, and Outcomes

Gastroschisis is a common congenital abdominal wall defect, likely influenced by environmental factors in utero, with increasing prevalence in the United States. Early detection of gastroschisis in utero has become the standard with improved prenatal care and screening. There are multiple surgical management techniques, though sutureless closure is being used more frequently. Postoperative feeding difficulty is common and requires vigilance for complications, such as necrotizing enterocolitis. Infants with simple gastroschisis are expected to have eventual catch-up growth and normal development, while those with complex gastroschisis have higher morbidity and mortality. Management requires collaboration amongst several perinatal disciplines, including obstetrics, maternal fetal medicine, neonatology, pediatric surgery, and pediatric gastroenterology for optimal care and long-term outcomes.

Predictors of length of stay for simple gastroschisis: analysis of ACS NSQIP-P database

PURPOSE

We aimed to assess predictors of length of stay for simple gastroschisis utilizing the NSQIP-Pediatric Database.

METHODS

The NSQIP-P Participant Use Data File was queried to identify patients with simple gastroschisis. We defined short length of stay (LOS) as patients discharged home ≤ 30 days from birth. We compared patients with short LOS versus prolonged LOS > 30 days. Predictors and outcomes were evaluated.

RESULTS

There were 888 patients with simple gastroschisis identified. Half of patients had LOS ≤ 30 days. Patients with LOS ≤ 30 were younger at repair (median age 1 day vs. 3 days, p = 0.0001), had higher birth weight (median 2.5 kg vs. 2.4 kg, p = 0.0001), and were less premature (37 week vs. 36 weeks, p = 0.0001). However, only gestational age and weight at birth were significant predictors of LOS on multivariate analysis (p = 0.0001). Prolonged LOS patients had more instances of ventilation, oxygen supplementation, sepsis (n = 2/446 or 0.4% vs. n = 9/442 or 2%, p = 0.003), bleeding/transfusion (n = 7/446 or 1.6% vs. n = 43/442 or 9.7%, p = 0.0001), line infections (n = 1/446 or 0.2% vs. n = 12/442, p = 0.001), and reoperations (n = 9/446 or 2% vs. n = 26/442 or 5.9%, p = 0.003).

CONCLUSION

Prematurity and birth weight are significant predictors of length of stay in simple gastroschisis patients. Prenatal counseling should continue to be one of the main factors to improve the outcomes for patients with gastroschisis. Type of study Retrospective cohort study. Level of evidence Level IV.

A Suture-less Underlay Ventral Herniorrhaphy Technique for High-Risk Complex Abdominal Wall Reconstruction

INTRODUCTION

Many factors increase the complexity of abdominal wall reconstruction including attenuated fascia, loss-of-domain, prior hernia surgeries, multiple fascial defects, enterocutaneous fistulas, and mesh infections. We describe our experience of using a suture-less mesh fixation underlay ventral herniorrhaphy technique to combat such issues in high-risk ventral hernia repair.

METHODS

This is a prospective-observational study. Patients from 2019 onward undergoing emergent or elective cases were included. The technique: A large porcine acellular-dermal-matrix (ADM) alone or sutured to a light-weight, macroporous polypropylene mesh is created and placed with ADM facing the bowel. Fibrin glue is sprayed over the mesh, fascia and skin closed. An abdominal binder is placed pre-extubation and left undisturbed for 5 postoperative days.

RESULTS

Of 34 included patients, the average demographic was a Caucasian (62.9%) female (65.7%), with class-I or greater obesity (76.5%), hypertension (74.3%), dyslipidemia (48.6%), non-skin malignancy (40.0%), type II diabetes mellitus (34.3%), a ventral hernia working group class of III-IV (55.9%), a mean of 3 ± 2.2 prior surgeries, and mean fascial defect size of 12.3 x 13.5cm. Five were prior solid-organ transplant recipients. Four patients underwent simultaneous tumor extirpations and herniorrhaphy. Five cases (14.7%) were emergent. Removal of prior mesh was performed in 48.5% of cases-seven had infected mesh. Median length of stay was 7 days, with 141 days median follow-up time. Fifteen patients (44.1%) developed a complication. Hernia-specific complications were limited to healing problems. There were no recurrences.

CONCLUSION

This technique is easy and safe to employ in patients requiring high-risk complex abdominal reconstructions with minimal hernia-specific complications.

Gastroschisis: Impact of Bedside Closure on Ventilator-Associated Outcomes

AIM

 In our practice, preformed silos are routine rather than reserved for difficult cases. We aimed to identify whether silo and bedside closure can minimize: general anesthetic (GA) exposure, need for intubation and ventilation, or days intubated for neonates with simple gastroschisis (SG).

METHODS

 After approval, patients were identified via the neonatal discharge log (April 2010 to April 2019). Data were collected by case-note review and analyzed with respect to GA, ventilation, and core outcomes.

RESULTS

 Of 104 patients (50 female, mean birth weight 2.43 kg, mean gestational age 36 + 2 weeks), 85 were SG and 19 complex. Silo application was initial management in 70 SG, 57 completed successful bedside closure (by day 4 of life-median). Fifteen SG had initial operative closure.Of the 70 SG managed with silo, 46 (66%) had no GA as neonates. Twelve required GA for line insertion. Thirteen patients with initial silo had closure in theater (7 opportunistic at time of GA for line). Nine required intubation and ventilation out-with the operating theater during neonatal management. Seven had already been intubated at delivery; 3 because of meconium aspiration.One-hundred percent of those treated with operative closure had GA, 1 patient subsequently required surgery for subglottic stenosis. Time to full feeds did not differ between groups.

CONCLUSION

 Silo and bedside closure allow the majority of SG neonates to avoid GA or intubation in the neonatal period, without increased risk of complication. However, it is important that the nursing expertise required to manage these patients safely is not underestimated.

Implementing a standardized gastroschisis protocol significantly increases the rate of primary sutureless closure without compromising closure success or early clinical outcomes

PURPOSE

Standardized protocols have been shown to improve outcomes in several pediatric surgical conditions. We implemented a multi-disciplinary gastroschisis practice bundle at our institution in 2013. We sought to evaluate its impact on closure type and early clinical outcomes.

METHODS

We performed a retrospective review of uncomplicated gastroschisis patients treated at our institution between 2008-2019. Patients were divided into two groups: pre- and post-protocol implementation. Multivariate logistic regression was used to compare closure location, method, and success.

RESULTS

Neonates (pre-implementation n = 53, post-implementation n = 43) were similar across baseline variables. Successful immediate closure rates were comparable (75.5% vs. 72.1%, p = 0.71). The proportion of bedside closures increased significantly after protocol implementation (35.3% vs. 95.4%, p < 0.01), as did the proportion of sutureless closures (32.5% vs. 71.0%, p < 0.01). Median postoperative mechanical ventilation decreased significantly (4 days IQR [3, 5] vs. 2 days IQR [1, 3], p < 0.01). Postoperative complications and duration of parenteral nutrition were equivalent. After controlling for potential confounding, infants in the post-implementation group had a 44.0 times higher odds of undergoing bedside closure (95% CI: 9.0, 215.2, p < 0.01) and a 7.7 times higher odds of undergoing sutureless closure (95% CI: 2.3, 25.1, p < 0.01).

CONCLUSIONS

Implementing a standardized gastroschisis protocol significantly increased the proportion of immediate bedside sutureless closures and decreased the duration of mechanical ventilation, without increasing postoperative complications. Level of Evidence III Type of Study Retrospective comparative study.

The medical and surgical management of gastroschisis

Gastroschisis (GS) is a full-thickness abdominal wall defect in which fetal intestine herniates alongside the umbilical cord into the intrauterine cavity, resulting in an intestinal injury of variable severity. An increased prevalence of gastroschisis has been observed across several continents and is a focus of epidemiologic study. Prenatal diagnosis of GS is common and allows for delivery planning and treatment in neonatal intensive care units (NICUs) by collaborative interdisciplinary teams (neonatology, neonatal nursing and pediatric surgery). Postnatal treatment focuses on closure of the defect, optimized nutrition, complication avoidance and a timely transition to enteral feeding. Babies born with complex GS are more vulnerable to complications, have longer and more resource intensive hospital stays and benefit from standardized care pathways provided by teams with expertise in managing infants with intestinal failure. This article will review the current state of knowledge related to the medical and surgical management and outcomes of gastroschisis with a special focus on the role of the neonatologist in supporting integrated team-based care.

Sutureless closure for the management of gastroschisis

Gastroschisis is a common congenital anomaly in which the midgut fails to return to the abdominal cavity resulting in exposed intestines, which are not covered by a membrane in a neonate. The incidence of gastroschisis has been increasing worldwide resulting in an evolving medical and surgical management. Gastroschisis can be either simple or complicated. Complicated gastroschisis occurs when gastroschisis is associated with gastrointestinal conditions such as intestinal atresia, volvulus, stenosis or perforation. In this instance, the mortality and morbidity of patients significantly increases. Initial management of gastroschisis requires a multi-modal, interdisciplinary approach in order to successfully care for a neonate. Patients should be managed in a neonatal intensive care unit under the care of intensivists, respiratory therapists and pediatric surgeons. Temperature regulation, hydration and protection of the bowel are of the utmost priorities. Surgical management of gastroschisis focuses on reduction of the bowel and closure of the abdominal wall defect. Initially, the defect was closed primarily with suture, however, more recently, a sutureless closure has become prevalent. This, in conjunction with use of a silo, has led to a shift from the operating room and general anesthesia to the bedside. This article aims to discuss the presentation, diagnosis and management of gastroschisis.

Abdominal Wall Defects

The 2 most common congenital abdominal wall defects are gastroschisis and omphalocele. Both are usually diagnosed prenatally with fetal ultrasonography, and affected patients are treated at a center with access to high-risk obstetric services, neonatology, and pediatric surgery. The main distinguishing features between the 2 are that gastroschisis has no sac and the defect is to the right of the umbilicus, whereas an omphalocele typically has a sac and the defect is at the umbilicus. In addition, patients with an omphalocele have a high prevalence of associated anomalies, whereas those with gastroschisis have a higher likelihood of abnormalities related to the gastrointestinal tract, with the most common being intestinal atresia. As such, the prognosis in patients with omphalocele is primarily affected by the severity and number of other anomalies and the prognosis for gastroschisis is correlated with the amount and function of the bowel. Because of these distinctions, these defects have different management strategies and outcomes. The goal of surgical treatment for both conditions consists of reduction of the abdominal viscera and closure of the abdominal wall defect; primary closure or a variety of staged approaches can be used without injury to the intra-abdominal contents through direct injury or increased intra-abdominal pressure, or abdominal compartment syndrome. Overall, the long-term outcome is generally good. The ability to stratify patients, particularly those with gastroschisis, based on risk factors for higher morbidity would potentially improve counseling and outcomes.

Gastroschisis: A State-of-the-Art Review

Gastroschisis, the most common type of abdominal wall defect, has seen a steady increase in its prevalence over the past several decades. It is identified, both prenatally and postnatally, by the location of the defect, most often to the right of a normally-inserted umbilical cord. It disproportionately affects young mothers, and appears to be associated with environmental factors. However, the contribution of genetic factors to the overall risk remains unknown. While approximately 10% of infants with gastroschisis have intestinal atresia, extraintestinal anomalies are rare. Prenatal ultrasound scans are useful for early diagnosis and identification of features that predict a high likelihood of associated bowel atresia. The timing and mode of delivery for mothers with fetuses with gastroschisis have been somewhat controversial, but there is no convincing evidence to support routine preterm delivery or elective cesarean section in the absence of obstetric indications. Postnatal surgical management is dictated by the condition of the bowel and the abdominal domain. The surgical options include either primary reduction and closure or staged reduction with placement of a silo followed by delayed closure. The overall prognosis for infants with gastroschisis, in terms of both survival as well as long-term outcomes, is excellent. However, the management and outcomes of a subset of infants with complex gastroschisis, especially those who develop short bowel syndrome (SBS), remains challenging. Future research should be directed towards identification of epidemiological factors contributing to its rising incidence, improvement in the management of SBS, and obstetric/fetal interventions to minimize intestinal damage.

Sutureless vs sutured abdominal wall closure for gastroschisis: Operative characteristics and early outcomes from the Midwest Pediatric Surgery Consortium

PURPOSE

To report outcomes of sutured and sutureless closure for gastroschisis across a large multi-institutional cohort.

METHODS

A retrospective study of infants with uncomplicated gastroschisis at 11 children's from 2014 to 2016 was performed. Outcomes of sutured and sutureless abdominal wall closure were compared.

RESULTS

Among 315 neonates with uncomplicated gastroschisis, sutured closure was performed in 248 (79%); 212 undergoing sutured closure after silo and 36 undergoing primary sutured closure. Sutureless closure was performed in 67 (21%); 37 primary sutureless closure, 30 sutureless closure after silo placement. There was no significant difference in gestational age, gender, birth weight, total days on TPN, and time from closure to initial oral intake or goal feeds. Sutureless closure patients had less general anesthetics, ventilator use/time, time from birth to final closure, antibiotic use after closure, and surgical site/deep space infections. Subgroup analysis demonstrated primary sutureless closure had less ventilator use and anesthetics than primary sutured closure. Sutureless closure after silo led to less ventilator use/time, anesthetics, and antibiotics compared to those with sutured closure after silo.

CONCLUSION

Sutureless abdominal wall closure of neonates with gastroschisis was associated with less general anesthetics, antibiotic use, surgical site/deep space infections, and decreased ventilator time. These findings support further prospective study by our group.

LEVEL OF EVIDENCE

Level III.

Sutureless Approach for Gastroschisis Patients in Palestine

Gastroschisis is a ventral abdominal wall congenital defect with bowel herniation outside the abdominal cavity. Gastroschisis traditional management is the primary operative closure surgery (POCS), but the sutureless silo approach (SSA), a novel alternative, gains wide acceptance in the developed countries and across nations. This study describes the first-ever gastroschisis patient managed with the sutureless silo approach in Palestine. In addition, we shall use this case as the very first nucleus for the upcoming gastroschisis management in our referral hospital because the SSA yields a reduced hospital stay which is fundamental to our institution due to the limited number of beds and lower management costs to the hospital and families.

Gastroschisis in the neonatal period: A prospective case-series in a Brazilian referral center

BACKGROUND/PURPOSE

Gastroschisis is increasing in incidence and has low mortality and high morbidity. We describe the clinical and surgical characteristics of gastroschisis patients in a Brazilian referral center.

METHODS

Single-center prospective case series of gastroschisis patients. The following two groups were formed depending on the intestinal characteristics: simple and complex patients.

RESULTS

In total, 79 patients were enrolled, 89% of whom were classified as simple and 11% as complex. The baseline characteristics were similar between the groups, with the exception of the illness severity score. The complex group had a significantly smaller defect size, more reoperations and worse clinical outcomes than the simple group, with the initiation of feeding taking 1.5 times longer, the duration of total parenteral nutrition taking twice as long, and the length of hospitalization being 2.5 times longer; the complex group also included all the deaths that occurred. Overall, the survival rate was 96%. Patients who underwent the sutureless technique had significantly fewer wound infections and a decreased duration of mechanical ventilation than sutured patients.

CONCLUSIONS

This study provides a comprehensive picture of gastroschisis during the neonatal period in a Brazilian referral center, emphasizing the significantly higher risk for morbidity and mortality among complex patients than among simple patients and the few advantages of the sutureless technique over the sutured technique in terms of closing the defect.

TYPE OF STUDY

Prognostic.

LEVEL OF EVIDENCE

IV.

Multidisciplinary Development of a Low-Cost Gastroschisis Silo for Use in Sub-Saharan Africa

BACKGROUND

Gastroschisis silos are often unavailable in sub-Saharan Africa (SSA), contributing to high mortality. We describe a collaboration between engineers and surgeons in the United States and Uganda to develop a silo from locally available materials.

METHODS

Design criteria included the following: < $5 cost, 5 ± 0.25 cm opening diameter, deformability of the opening construct, ≥ 500 mL volume, ≥ 30 N tensile strength, no statistical difference in the leakage rate between the low-cost silo and preformed silo, ease of manufacturing, and reusability. Pugh scoring matrices were used to assess designs. Materials considered included the following: urine collection bags, intravenous bags, or zipper storage bags for the silo and female condom rings or O-rings for the silo opening construct. Silos were assembled with clothing irons and sewn with thread. Colleagues in Uganda, Malawi, Tanzania, and Kenya investigated material cost and availability.

RESULTS

Urine collection bags and female condom rings were chosen as the most accessible materials. Silos were estimated to cost < $1 in SSA. Silos yielded a diameter of 5.01 ± 0.11 cm and a volume of 675 ± 7 mL. The iron + sewn seal, sewn seal, and ironed seal on the silos yielded tensile strengths of 31.1 ± 5.3 N, 30.1 ± 2.9 N, and 14.7 ± 2.4 N, respectively, compared with the seal of the current standard-of-care silo of 41.8 ± 6.1 N. The low-cost silos had comparable leakage rates along the opening and along the seal with the spring-loaded preformed silo. The silos were easily constructed by biomedical engineering students within 15 min. All silos were able to be sterilized by submersion.

CONCLUSIONS

A low-cost gastroschisis silo was constructed from materials locally available in SSA. Further in vivo and clinical studies are needed to determine if mortality can be improved with this design.

Evaluation of Clinical Outcomes of Sutureless vs Sutured Closure Techniques in Gastroschisis Repair

Importance

Sutureless gastroschisis repair offers an alternative to the traditional sutured method and has been associated with decreased intubation time. Published study results are inconsistent regarding the advantages of sutureless closure.

Objective

To compare the clinical outcomes of sutureless and sutured gastroschisis repair.

Design, Setting, and Participants

A single-center cohort review was performed of all consecutive patients (n = 97) who underwent gastroschisis repair from February 1, 2007, to April 30, 2017, at the University of California, San Francisco. Patients' medical records were evaluated for clinical characteristics and outcomes. Cases with incomplete data during initial hospitalization were excluded.

Main Outcomes and Measures

Length of hospital stay, time to full enteral feeds, total parenteral nutrition duration, days requiring intravenous analgesia, days intubated, wound infection rate, antibiotic treatment duration, rate of umbilical hernias that required an operation, and readmission rate.

Results

In total, 97 patients (47 [48%] were female and 50 [52%] were male with a mean [SD] age of 2.8 [2.8] days) underwent gastroschisis repair, of which 7 were excluded for incomplete medical record. Of the 90 patients included in the study, 50 (56%) underwent sutured closure and 40 (44%) underwent sutureless closure. No statistical difference was found between the sutured and sutureless groups in length of hospital stay (mean [SD] days, 43.9 [40.4] vs 36.7 [21.2]; P = .71), time to full enteral feeds (mean [SD] days, 31.4 [20.2] vs 27.9 [17.3]; P = .22), total parenteral nutrition duration (mean [SD] days, 33.5 [29.8] vs 27.4 [18.2]; P = .23), wound infection rates (14 [28%] vs 10 [25%]; P = .81), and readmission rates (5 [10%] vs 7 [18%]; P = .36). The sutureless group, compared with the sutured group, had substantially fewer days receiving antibiotics (mean [SD], 7.2 [6.4] vs 12.4 [13.2]; P = .003), fewer days intubated (mean [SD], 2.8 [3.3] vs 6.8 [1.3]; P = .001), fewer days receiving intravenous analgesia (mean [SD], 4.2 [4.0] vs 7.1 [4.5]; P = .003), and fewer patients that required silo reduction (25 [63%] vs 48 [96%]; P < .001). Sutureless closures, compared with the sutured technique, had considerably more umbilical hernias requiring surgical repair (5 [13%] vs 0; P = .02).

Conclusions and Relevance

Sutureless repair of gastroschisis appears to be associated with a statistically significant reduction in mechanical ventilation duration and pain medication requirements but may increase umbilical hernia risk. Multicenter randomized clinical trials are necessary to determine the true advantages of the sutureless approach.

A 25-year study of gastroschisis outcomes in a middle-income country

BACKGROUND

Survival of newborns with gastroschisis is significantly higher in high-income versus low and middle-income countries. We reviewed treatment and outcomes of gastroschisis in a middle-income country setting with increasing protocolized management.

METHODS

All newborns with gastroschisis treated during the period 1989-2013 at a single Brazilian academic surgical service were studied retrospectively. Protocolized diagnosis, delivery, nutrition, medical interventions, and surgical interventions were introduced in 2002. Outcomes before and after protocol introduction were studied using univariate and multivariate analysis.

RESULTS

One hundred fifty-six newborns were treated for gastroschisis: 35 (22.4%) and 121 (77.6%) before and after 2002, respectively. When compared to the earlier cohort, patients treated after 2002 had higher rates of prenatal diagnosis (90.9% vs. 60.0%, p < 0.001), delivery at a tertiary center (90.9% vs. 62.9%, p < 0.001), early closure (65.3% vs. 33.3%, p = 0.001), primary repair (55.4% vs. 31.4%, p = 0.013), monitoring of bladder pressure (62.0% vs. 2.9%, p = 0.001), PICC placement (71.1% vs. 25.7%, p < 0.001), early initiation of enteral feeding (54.5% vs. 20.0%, p < 0.001), and lower rates of electrolyte disturbances (53.7% vs. 85.7%, p = 0.001). Mortality decreased from 34.3% before 2002 to 24.8% (p = .27) after 2002 despite an increase in the complex gastroschisis rate from 11.4% to 15.7% during the same period.

CONCLUSIONS

Gastroschisis outcomes in a middle-income country can be gradually improved through targeted interventions and management protocols.

TYPE OF STUDY

Therapeutic.

LEVEL OF EVIDENCE

III.

Sutureless closure: a versatile treatment for the diverse presentations of gastroschisis

OBJECTIVE

Case series have demonstrated sutureless closures to be safe for the correction of gastroschisis. We hypothesize that sutureless closure is efficacious in patients requiring silo reduction without need for intubation.

STUDY DESIGN

We conducted a retrospective case control study of infants who underwent gastroschisis repair at our institution (January 2011-August 2018). Patient characteristics and clinical outcomes were compared between sutureless closure and primary fascial repair groups.

RESULTS

Seventeen patients in the sutureless group and 28 patients in the primary fascial repair group were included. Success of sutureless closure was 94%. Mechanical ventilation was reduced by 2.8 days in the sutureless group (P < 0.0001) and fewer patients required general anesthesia (29.4% vs. 100%, P < 0.0001).

CONCLUSIONS

Sutureless closure is effective for the diverse presentations of gastroschisis. Given the concerns of effects of general anesthesia on the developing brain, sutureless closure should be strongly considered.

Safety and usefulness of plastic closure in infants with gastroschisis: a systematic review and meta-analysis

PURPOSE

Recently, plastic closure of abdominal defect in infants with gastroschisis has been used. Timing of gastroschisis closure can be mainly divided into two groups: primary closure and delayed closure after silo forming. Safety and usefulness of plastic closure in gastroschisis remains unclear. We aimed to evaluate the current evidence for plastic closure in infants with gastroschisis.

METHODS

The analysis was done for primary closure as well as closure after silo. Outcomes were mortality, wound infection, duration of ventilation, time to feeding, and length of hospital stay (LOS). The quality of evidence was summarized using the GRADE approach.

RESULTS

In the "primary" group, there was no significant difference in mortality, time to feeding initiation and LOS. In the "silo" group, wound infection was significantly lower in plastic closure (Odds ratio 0.24, 95%CI 0.09-0.69, p = 0.008). Duration of ventilation, time to feeding initiation and LOS were significantly shorter after plastic closure (Ventilation; mean difference (MD) - 5.76, p = 0.03. Feeding initiation; MD - 9.42, p < 0.0001. LOS; MD - 14.06, p = 0.002). Quality of evidence was very low for all outcomes.

CONCLUSIONS

Current results suggest that plastic closure may be beneficial for infants with gastroschisis requiring silo formation. However, this evidence is suboptimal and further studies are needed.

Suture choice to reduce occurrence of surgical site infection, hernia, wound dehiscence and sinus/fistula: a network meta-analysis

BACKGROUND

There are many options and little guiding evidence when choosing suture types with which to close the abdominal wall fascia. This network meta-analysis investigated the effect of suture materials on surgical site infection, hernia, wound dehiscence and sinus/fistula occurrence after abdominal surgery. The aim was to provide clarity on whether previous recommendations on suture choice could be followed with confidence.

METHODS AND METHODS

In February 2017, the Cochrane Central Register of Controlled Trials, Medline, EMBASE and Science Citation Index Expanded were searched for randomised controlled trials investigating the effect of suture choice on these four complications in closing the abdomen. A reference search of identified trials was performed. Prisma guidelines and the Cochrane risk of bias tool were followed in the data extraction and synthesis. Two review authors screened titles and abstracts of trials identified. A random effect model was used for the surgical site infection network based on the deviance information criterion statistics.

RESULTS

Thirty-one trials were included (11,533 participants). No suture material reached the predetermined 90% probability threshold for determination of 'best treatment' for any outcome. Pairwise comparisons largely showed no differences between suture types for all outcomes measured. However, nylon demonstrated a reduction in the occurrence of incisional hernias with respect to two commonly used absorbable sutures: polyglycolic acid (odds ratio, OR 1.91; 95% confidence interval, CI, 1.01-3.63) and polyglyconate (OR 2.18; 95% CI 1.17-4.07).

CONCLUSIONS

No suture type can be considered the 'best treatment' for the prevention of surgical site infection, hernia, wound dehiscence and sinus/fistula occurrence.

Closure methods in gastroschisis

The expected outcome of gastroschisis has evolved from an almost certain death of the child prior to the use of parenteral nutrition to almost certain survival. The primary goal of the surgical intervention is return of eviscerated contents into the abdominal cavity. The optimal surgical technique is dependent on the status of the intestine and the accommodation of abdominal domain. In this review, the various surgical techniques for management are discussed as they have evolved. Ironically, a minimalist surgical intervention originally practiced due to the poor expected outcome is now being adopted as a minimalist surgical approach for abdominal wall closure associated with an expected excellent outcome.

Use of quality improvement (QI) methodology to decrease length of stay (LOS) for newborns with uncomplicated gastroschisis

PURPOSE

Gastroschisis is a congenital defect of the abdominal wall leading to considerable morbidity and long hospitalizations. The purpose of this study was to use quality improvement methodology to standardize care in the management of gastroschisis that may contribute to length of stay (LOS).

METHODS

A gastroschisis quality improvement team established a best-practice protocol in order to decrease LOS in infants with uncomplicated gastroschisis. The specific aim was to decrease median LOS from a baseline of 34days. We used statistical process control charts including rational subgroup analysis to monitor LOS.

RESULTS

From December 2008 to December 2016, 119 patients with uncomplicated gastroschisis were evaluated. Retrospective data were obtained on 25 patients prior to protocol implementation. Ninety-four patients with uncomplicated gastroschisis comprised the prospective process stage. The median LOS for this retrospective cohort was 34days (IQR: 30.5-50.5), while the median LOS for the prospective cohort following implementation of the protocol decreased to 29days (IQR: 23-43).

CONCLUSIONS

With the use of quality improvement methodology, including standardization of care and a change in surgical approach, the median LOS for newborns with uncomplicated gastroschisis at our institution decreased from 34days to 29days.

LEVEL OF EVIDENCE

3.

Understanding gastroschisis and its clinical management: where are we?

Gastroschisis is the commonest developmental defect of the anterior abdominal wall in both developed and developing countries. The past 30 years have seen transformational improvements in outcome due to advances in neonatal intensive care and enhanced integration between the disciplines of maternal fetal medicine, neonatology and pediatric surgery. A review of gastroschisis, which emphasizes its epidemiology, multidisciplinary care strategies and contemporary outcomes is timely. Areas covered: This review discusses the current state of knowledge related to prevalence and causation, and postulated embryopathologic mechanisms contributing to the development of gastroschisis. Using relevant, current literature with an emphasis on high level evidence where it exists, we review modern techniques of prenatal diagnosis, pre and postnatal risk stratification, preferred timing and method of delivery, options for abdominal wall closure, nutritional management, and short and long term clinical and neurodevelopmental follow-up. Expert commentary: This section explores controversies in contemporary management which contribute to practice and cost variation and discusses the benefits of novel nutritional therapies and care standardization that target unnecessary practice variation and improve overall cost-effectiveness of gastroschisis care. The commentary concludes with a review of fertile areas of gastroschisis research, which represent opportunities for knowledge synthesis and further outcome improvement.