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Baerg J, McAteer J, Miniati D, Somme S, Slidell M. Improving outcomes for uncomplicated gastroschisis: clinical practice guidelines from the American Pediatric Surgical Association Outcomes and Evidence-based Practice Committee. Pediatr Surg Int 2024; 40:246. [PMID: 39222260 DOI: 10.1007/s00383-024-05819-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND The authors sought better outcomes for uncomplicated gastroschisis through development of clinical practice guidelines. METHODS The authors and the American Pediatric Surgical Association Outcomes and Evidenced-based Practice Committee used an iterative process and chose two questions to develop clinical practice guidelines regarding (1) standardized nutrition protocols and (2) postnatal management strategies. An English language search of PubMed, MEDLINE, OVID, SCOPUS, and the Cochrane Library Database identified literature published between January 1, 1970, and December 31, 2019, with snowballing to 2022. The Appraisal of Guideline, Research and Evaluation reporting checklist was followed. RESULTS Thirty-three studies were included with a Level of Evidence that ranged from 2 to 5 and recommendation Grades B-D. Nine evaluated standardized nutrition protocols and 24 examined postnatal management strategies. The adherence to gastroschisis-specific nutrition protocols promotes intestinal feeding and reduces TPN administration. The implementation of a standardized postnatal clinical management protocol is often significantly associated with shorter hospital stays, less mechanical ventilation use, and fewer infections. CONCLUSIONS There is a lack of comparative studies to guide practice changes that improve uncomplicated gastroschisis outcomes. The implementation of gastroschisis-specific feeding and clinical care protocols is recommended. Feeding protocols often significantly reduce TPN administration, although the length of hospital stay may not consistently decrease.
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Affiliation(s)
- Joanne Baerg
- Division of Pediatric Surgery, Presbyterian Healthcare Services, Albuquerque, NM, USA.
| | - Jarod McAteer
- Division of Pediatric Surgery, Providence Sacred Heart Children's Hospital, Spokane, WA, USA
| | - Doug Miniati
- Division of Pediatric Surgery, Kaiser Permanente Northern California, Roseville, CA, USA
| | - Stig Somme
- Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Mark Slidell
- Division of Pediatric Surgery, Johns Hopkins Children's Center, Baltimore, MD, USA
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Slidell MB, McAteer J, Miniati D, Sømme S, Wakeman D, Rialon K, Lucas D, Beres A, Chang H, Englum B, Kawaguchi A, Gonzalez K, Speck E, Villalona G, Kulaylat A, Rentea R, Yousef Y, Darderian S, Acker S, St Peter S, Kelley-Quon L, Baird R, Baerg J. 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). J Pediatr Surg 2024; 59:1408-1417. [PMID: 38796391 DOI: 10.1016/j.jpedsurg.2024.03.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 03/08/2024] [Accepted: 03/17/2024] [Indexed: 05/28/2024]
Abstract
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.
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Affiliation(s)
- Mark B Slidell
- Division of Pediatric Surgery, Johns Hopkins Children's Center, 1800 Orleans St, Baltimore, MD 21287, USA.
| | - Jarod McAteer
- Providence Hospital, 101 West 8th Avenue, Spokane, WA 99204, USA
| | - Doug Miniati
- Division of Pediatric Surgery, Kaiser Permanente Northern California, 1600 Eureka Road, Roseville, CA 95661, USA
| | - Stig Sømme
- Division of Pediatric Surgery, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Derek Wakeman
- University of Rochester Medical Center, School of Medicine and Dentistry, 601 Elmwood Ave, Box Surg, Rochester, NY 14642, USA
| | - Kristy Rialon
- Division of Pediatric Surgery, Texas Children's Hospital, 6701 Fannin Street, Houston, TX 77030, USA
| | - Don Lucas
- Division of Pediatric Surgery, Department of General Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134, USA
| | - Alana Beres
- Division of Pediatric Surgery, St. Christopher's Hospital for Children, 160 E Erie Ave, Philadelphia, PA 19134, USA
| | - Henry Chang
- Johns Hopkins All Children's Hospital, 501 6th Avenue South, St. Petersburg, FL 33701, USA
| | - Brian Englum
- University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201, USA
| | - Akemi Kawaguchi
- Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin Street, Houston, TX 77030, USA
| | | | - Elizabeth Speck
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, 1540 E Hospital Dr, Ann Arbor, MI 48109, USA
| | - Gustavo Villalona
- Division of Pediatric Surgery, Nemours Children's Health, 807 Children's Way, Jacksonville, FL 32207, USA
| | - Afif Kulaylat
- Division of Pediatric Surgery, Penn State Hershey Children's Hospital, 200 Campus Dr Ste 400, Hershey, PA 17033, USA
| | - Rebecca Rentea
- Pediatric Surgery Division, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Yasmine Yousef
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, 1001 Decarie Boulevard, Montreal, Quebec, Canada H4A 3J1
| | - Sarkis Darderian
- Pediatric Surgery Division, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Shannon Acker
- Pediatric Surgery Division, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Shawn St Peter
- Pediatric Surgery Division, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Lorraine Kelley-Quon
- Pediatric Surgery Division, Children's Hospital, 4650 W Sunset Blvd, Los Angeles, CA 90027, USA
| | - Robert Baird
- Division of Pediatric General Surgery, Department of Surgery, Faculty of Medicine, University of British Columbia, 2775 Laurel Street, 11th Floor, Vancouver, British Columbia V5Z 1M9, Canada
| | - Joanne Baerg
- Division of Pediatric Surgery, Presbyterian Health System, 201 Cedar St SE Ste 4660, Albuquerque, NM 87106, USA
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Zalles-Vidal C, Peñarrieta-Daher A, Bracho-Blanchet E, Ibarra-Rios D, Dávila-Perez R, Villegas-Silva R, Nieto-Zermeño J. A Gastroschisis bundle: effects of a quality improvement protocol on morbidity and mortality. J Pediatr Surg 2018; 53:2117-2122. [PMID: 30318281 DOI: 10.1016/j.jpedsurg.2018.06.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 05/09/2018] [Accepted: 06/10/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Gastroschisis incidence is rising. Survival in developed countries is over 95%. However, in underdeveloped countries, mortality is higher than 15% often due to sepsis. The aim of this study was to evaluate the effect on morbidity and mortality of a Quality Improvement Protocol for out-born gastroschisis patients. METHODS The protocol consisted in facilitating transport, primary or staged reduction at the bedside and sutureless closure, without anesthesia, PICC lines and early feeding. Data was prospectively collected for the Protocol Group (PG) treated between June 2014 through March 2016 and compared to the last consecutive patients Historical Group (HG). Primary outcome was mortality. SECONDARY OUTCOMES need for and duration of mechanical ventilation (MV), time to first feed (TFF) after closure, parenteral nutrition (TPN), length of stay (LOS) and sepsis. Data were analyzed using χ2 and Mann-Whitney U tests. RESULTS 92 patients were included (46 HG and 46 PG). Demographic data were homogeneous. Mortality decreased from 22% to 2% (p = 0.007). Mechanical ventilation use decreased from 100% to 57% (p = <0.001), ventilator days from 14 to 3 median days (p = <0.0001), TPN days: 27 to 21 median days (p = 0.026), sepsis decreased from 70% to 37% (p = 0.003) and anesthesia from a 100% to 15% (p = <0.001), respectively. No difference was found in NPO or LOS. CONCLUSION A major improvement in the morbidity and mortality rates was achieved, with outcomes comparable to those reported in developed countries. It was suitable for all patients with gastroschisis. We believe this protocol can be implemented in other centers to reduce morbidity and mortality. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Cristian Zalles-Vidal
- Department of Pediatric Surgey, Hospital Infantil de México Federico Gomez, Mexico City, Mexico.
| | | | - Eduardo Bracho-Blanchet
- Department of Pediatric Surgey, Hospital Infantil de México Federico Gomez, Mexico City, Mexico
| | - Daniel Ibarra-Rios
- Department of Neonatology, Hospital Infantil de México Federico Gomez, Mexico City, Mexico
| | - Roberto Dávila-Perez
- Department of Pediatric Surgey, Hospital Infantil de México Federico Gomez, Mexico City, Mexico
| | - Raul Villegas-Silva
- Department of Neonatology, Hospital Infantil de México Federico Gomez, Mexico City, Mexico
| | - Jaime Nieto-Zermeño
- Department of Pediatric Surgey, Hospital Infantil de México Federico Gomez, Mexico City, Mexico
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Gonzalez DO, Cooper JN, St Peter SD, Minneci PC, Deans KJ. Variability in outcomes after gastroschisis closure across U.S. children's hospitals. J Pediatr Surg 2018; 53:513-520. [PMID: 28483165 DOI: 10.1016/j.jpedsurg.2017.04.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 04/04/2017] [Accepted: 04/23/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND In patients undergoing gastroschisis closure, the effects of timing of closure and patient and hospital-level characteristics on length of stay (LOS) and time to enteral autonomy are unknown. STUDY DESIGN Using the Pediatric Health Information System, we compared neonates who underwent early (within 1day of birth) versus delayed (>1day after birth) gastroschisis closure from 2005 to 2013. We evaluated the relationship between time to closure and both LOS and days on total parenteral nutrition (TPN). RESULTS Of 4459 neonates with gastroschisis, 43.9% underwent early closure and 56.1% underwent delayed closure. Delayed closure, complicated gastroschisis, government insurance, lower birth weight, older age at closure, and complex chronic conditions were associated with longer LOS and days on TPN (all p<0.05). There was significant inter-hospital variability in both outcomes, after adjusting for patient- and hospital-level characteristics, including hospitals' gastroschisis and neonatal volumes, median age at closure, and percentages of complicated and delayed gastroschisis patients, (p<0.01). CONCLUSION Delayed gastroschisis closure is associated with longer LOS and duration of TPN, even after excluding complicated cases. Furthermore, after controlling for hospital volume, rate of complicated gastroschisis, and timing of closure, the persistent inter-hospital variability suggests that practice variability is partially responsible for these differences. TYPE OF STUDY Retrospective study. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Dani O Gonzalez
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205; Department of Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY, 10029.
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205.
| | - Shawn D St Peter
- Department of Pediatric Surgery, Children's Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO, 64155.
| | - Peter C Minneci
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205; Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205.
| | - Katherine J Deans
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205; Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205.
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Allin BSR, Irvine A, Patni N, Knight M. Variability of outcome reporting in Hirschsprung's Disease and gastroschisis: a systematic review. Sci Rep 2016; 6:38969. [PMID: 27941923 PMCID: PMC5150519 DOI: 10.1038/srep38969] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 11/14/2016] [Indexed: 02/07/2023] Open
Abstract
Heterogeneity in outcome reporting limits identification of gold-standard treatments for Hirschsprung’s Disease(HD) and gastroschisis. This review aimed to identify which outcomes are currently investigated in HD and gastroschisis research so as to counter this heterogeneity through informing development of a core outcome set(COS). Two systematic reviews were conducted. Studies were eligible for inclusion if they compared surgical interventions for primary treatment of HD in review one, and gastroschisis in review two. Studies available only as abstracts were excluded from analysis of reporting transparency. Thirty-five HD studies were eligible for inclusion in the review, and 74 unique outcomes were investigated. The most commonly investigated was faecal incontinence (32 studies, 91%). Seven of the 28 assessed studies (25%) met all criteria for transparent outcome reporting. Thirty gastroschisis studies were eligible for inclusion in the review, and 62 unique outcomes were investigated. The most commonly investigated was length of stay (24 studies, 80%). None of the assessed studies met all criteria for transparent outcome reporting. This review demonstrates that heterogeneity in outcome reporting and a significant risk of reporting bias exist in HD and gastroschisis research. Development of a COS could counter these problems, and the outcome lists developed from this review could be used in that process.
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Affiliation(s)
- Benjamin Saul Raywood Allin
- National Perinatal Epidemiology Unit, Oxford, OX37LF, UK.,Department of Paediatric Surgery, Oxford Children's Hospital, Oxford, OX39DU, UK
| | - Amy Irvine
- University of Oxford Medical School Medical Sciences Divisional Office University of Oxford Level 3, John Radcliffe Hospital Oxford OX3 9DU, UK
| | - Nicholas Patni
- University of Oxford Medical School Medical Sciences Divisional Office University of Oxford Level 3, John Radcliffe Hospital Oxford OX3 9DU, UK
| | - Marian Knight
- National Perinatal Epidemiology Unit, Oxford, OX37LF, UK
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