Splanchnic perfusion pressure: a better predictor of safe primary closure than intraabdominal pressure in neonatal gastroschisis

High Abdominal Perfusion Pressure Using Umbilical Cord Flap in the Management of Gastroschisis

Background: Gastroschisis management remains a controversy. Most surgeons prefer reduction and fascial closure. Others advise staged reduction to avoid a sudden rise in intra-abdominal pressure (IAP). This study aims to evaluate the feasibility of using the umbilical cord as a flap (without skin on the top) for tension-free repair of gastroschisis. Methods: In a prospective study of neonates with gastroschisis repaired between January 2018 to October 2020 in Tanta University Hospital, we used the umbilical cord as a flap after the evacuation of all its blood vessels and suturing the edges of the cord with the skin edges of the defect. They were guided by monitoring abdominal perfusion pressure (APP), peak inspiratory pressure (PIP), central venous pressure (CVP), and urine output during 24 and 48 h postoperatively. The umbilical cord flap is used for tension-free closure of gastroschisis if PIP > 24 mmHg, IAP > 20 cmH₂O (15 mmHg), APP <50 mmHg, and CVP > 15cmH₂O. Results: In 20 cases that had gastroschisis with a median age of 24 h, we applied the umbilical cord flap in all cases and then purse string (Prolene Zero) with daily tightening till complete closure in seven cases, secondary suturing after 10 days in four cases, and leaving skin creeping until complete closure in nine cases. During the trials of closure, the range of APP was 49-52 mmHg. The range of IAP (IVP) was 15-20 cmH₂O (11-15 mmHg), the range of PIP was 22-25 cmH₂O, the range of CVP was 13-15 cmH₂O, and the range of urine output was 1-1.5 ml/kg/h. Conclusion: The umbilical cord flap is an easy, feasible, and cheap method for tension-free closure of gastroschisis with limiting the PIP ≤ 24 mmHg, IAP ≤ 20 cmH₂O (15 mmHg), APP > 50 mmHg, and CVP ≤ 15cmH₂O.

Primary fascial closure versus staged closure with silo in patients with gastroschisis: a meta-analysis

BACKGROUND/PURPOSE

Gastroschisis is the most common congenital abdominal wall defect. Despite advances in the surgical closure of gastroschisis, consensus is lacking as to which method results in the best patient outcomes. The purpose of this meta-analysis was to compare short-term outcomes associated with primary fascial closure and staged repair with a silo in patients with gastroschisis.

METHODS

We reviewed Medline citations, as well as the Cochrane Database of Systematic Reviews, between January 1, 1996 and June 1, 2012. Articles were identified using the search term "gastroschisis" and [("treatment outcome" or "prognosis") or randomized controlled trials]. Case reports, reviews, letters, abstracts only, non-English abstracts, and studies that did not address at least one of the outcomes of interest were excluded from the meta-analysis. Two independent reviewers identified relevant articles for final inclusion. A standard data collection form created by the authors was used to extract study information, including study design, patient characteristics, and reported patient outcomes. The data were analyzed using standard meta-analytic techniques.

RESULTS

Twenty studies were included in the meta-analysis. In the five studies that selected closure method randomly or as a temporal shift in practice, silo was associated with better outcomes, with a significant reduction in ventilator days (p<0.0001), time to first feed (p=0.04), and infection rates (p=0.03). When all studies were included, primary closure was associated with improved outcomes.

CONCLUSIONS

Silo closure is associated with better clinical outcomes in the studies with the least selection bias. Larger prospective studies are needed to definitively determine the best closure technique.

Monitoring intravesical pressure during gastroschisis closure. Does it help to decide between delayed primary or staged closure?

INTRODUCTION AND OBJECTIVE

Correction of gastroschisis may be accomplished by either primary or staged closure or even delayed primary closure after the use of a preformed silo. However, there is neither a consensus on the best approach nor established criteria to favor one method over the other. The aim of this paper was to investigate the role of intravesical pressure (IVP) as a tool to prevent abdominal compartment syndrome in newborns undergoing correction of abdominal wall defects.

METHODS

We retrospectively analyzed 45 newborns with gastroschisis in whom trans-operative intravesical pressure was used to choose between primary or staged closure. A threshold of 20 cm H(2)O was used and the outcomes between the two methods were compared.

RESULTS

In 24 children delayed primary closure was achieved while the remaining 21 underwent staged reduction and closure. There was no difference in the frequency of complications, time to begin oral feeding, length of parenteral nutrition or length of hospital stay between the children of the two groups. The incidence of temporary oliguria or anuria, averaged 33% and it was similar in both groups of children.

CONCLUSION

The data here presented suggests that monitoring intraoperative IVP during correction of gastroschisis may help to select children in whom staged closure is necessary, keeping their complication rate and overall outcome similar to that of children undergoing delayed primary closure. Further prospective studies should investigate more deeply the correlation between type of closure and the development of a compartment syndrome.

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.

Contemporary postnatal surgical management strategies for congenital abdominal wall defects

Early definitive closure of abdominal wall defects is possible in most cases. Staged reduction does offer distinct advantages, and mortality and morbidity may be better. Risk stratification may produce outcome and tailor management of difficult cases in the form of a clinical pathway. Stem cell technology may, in the future, offer the ideal allogenic prosthesis in complex cases.