Gastroschisis closure--does method really matter?

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.

The association between gestational age at delivery, closure type and perinatal outcomes in neonates with isolated gastroschisis

Objective: The objective of this study was to examine the association between gestational age at delivery and closure type for neonates with gastroschisis. In addition, we compared perinatal outcomes among the cases of gastroschisis based on the following two factors: gestational age at delivery and abdominal wall closure technique.Methods: This was a retrospective cohort study of all fetuses with isolated gastroschisis that were diagnosed prenatally and delivered between September 2000 and January 2017, in a single tertiary care center. Neonates were compared based on the gestational age at the time of delivery: early preterm (less than 35^0/7 weeks), late preterm (35^0/7 - 36^6/7 weeks), and early term (37^0/6 - 38^6/7 weeks), using bivariate and multivariate analyses. The primary outcome was the type of abdominal wall closure: primary surgical closure or delayed closure using spring-loaded silo. Secondary outcomes included length of ventilatory support, length of parenteral nutrition, and length of hospital stay.Results: The analysis included 206 pregnancies complicated by gastroschisis. In univariate analysis, no differences were detected in primary closure rates of gastroschisis among the gestational age at delivery groups (67.4%, at <35 weeks, 70.8% at 35^0/7-36^6/7 weeks, 73.7% at 37^0/6-38^6/7 weeks, p = .865). However, for every additional 100 grams of neonatal live birth weight there was an associated 9% increased odds of primary closure (OR 1.09, 95% CI 1.14-1.19, p = .04). Delivery in the early preterm period compared to the other two groups, was associated with longer duration of ventilation support and longer dependence on the parenteral nutrition. Neonates who underwent primary closure had shorter ventilation support, shorter time to initiation of enteral feeds and to discontinue parenteral nutrition, and shorter length of stay. In multivariate analyses, controlling for gestational age at delivery and presence of bowel atresia, primary closure continued to be associated with the shorter duration of ventilation (by 5 days), earlier initiation of enteral feeds (by 7 days), shorter hospital stay (by 17 days) and lower odds of wound infection (OR = 0.37, 95% CI 0.15-0.97).Conclusions: Our study did not find an association between gestational age at delivery and the rates of primary closure of the abdominal wall defect; however later gestational age at delivery was associated with shorter duration of ventilatory support and parenteral nutrition dependence. In addition, we found that primary closure of gastroschisis, compared with delayed closure technique, was associated with improved neonatal outcomes, including shorter time to initiate enteral feeds and discontinue parenteral nutrition, shorter hospital stay, and lower risk of surgical wound infection. Therefore, postponing delivery of fetuses with gastroschisis until 37 weeks may be considered. Other factors besides the gestational age at delivery should be explored as predictors of primary closure in neonates with gastroschisis.

Clinical features and practice patterns of gastroschisis: a retrospective analysis using a Japanese national inpatient database

PURPOSE

The number of infants with gastroschisis is increasing worldwide, but advances in neonatal intensive care and parenteral nutrition have reduced gastroschisis mortality. Recent clinical data on gastroschisis are often from Western nations. This study aimed to examine clinical features and practice patterns of gastroschisis in Japan.

METHODS

We examined treatment options, outcomes, and discharge status among inpatients with simple gastroschisis (SG) and complex gastroschisis (CG), 2010-2016, using a national inpatient database in Japan.

RESULTS

The 247 eligible patients (222 with SG) had average birth weight of 2102 g and average gestational age of 34 weeks; 30% had other congenital anomalies. Digestive anomalies were most common, followed by circulatory anomalies. In-hospital mortality was 8.1%. The median age at start of full enteral feeding was 30 days. The median length of stay was 46 days. There were no significant differences in outcomes except for length of stay, starting full enteral feeding and total hospitalization costs between the SG and CG groups. About 80% of patients were discharged to home without home medical care. The readmission rate was 28%.

CONCLUSION

This study's findings on the clinical characteristics and outcomes of gastroschisis are useful for the clinical management of gastroschisis.

Impact of Multidisciplinary Standardization of Care for Gastroschisis: Treatment, Outcomes, and Cost

BACKGROUND/PURPOSE

Elimination of unnecessary practice variation through standardization creates opportunities for improved outcomes and cost-effectiveness. A quality improvement (QI) initiative at our institution used evidence and consensus to standardize management of gastroschisis (GS) from birth to discharge.

METHODS

An interdisciplinary team utilized best practice evidence and expert opinion to standardize GS care. Following stakeholder engagement and education, care standardization was implemented in September 2014. A comparative cohort study was conducted on consecutive patients treated before (n=33) and after (n=24) standardization. Demographic, treatment, and outcome measures were collected from a prospective GS registry. Direct costs were estimated, and protocol compliance was audited.

RESULTS

BW, GA, and bowel injury severity were comparable between groups. Key practice changes were: closure technique (pre-88% primary fascial, post-83% umbilical cord flap; p<0.001), closure location (pre-97% OR, post-67% NICU; p<0.001), and GA avoidance (pre-0%, post-48%; p<0.001). Median post-closure ventilation days were shorter (pre-4, post-1; p<0.001), and SSI rates trended lower (pre-21%, post-8%; p=0.3) in the post-implementation group with no differences in TPN days or LOS. No significant difference was seen in average per-patient costs: pre-$85,725 ($29,974-221,061), post-$76,329 ($14,205-176,856).

CONCLUSION

Care standardization for GS enables practice transformation, cost-effective outcome improvement, and supports an organizational culture dedicated to continuous improvement.

LEVEL OF EVIDENCE

III.

Sutureless elastic ring silo for the gastroschisis

Background: The definitive surgical management of gastroschisis is the return of the eviscerated abdominal content into the abdomen as soon as possible. Objectives: Assess the efficacy of using a sutureless elastic ring silo (SERS) for the management of gastroschisis. Methods: Neonates with gastroschisis were enrolled at Songklanagarind Hospital between January 2006 and December 2008. A primary repair (PR) was attempted in all cases. If this was not possible due to concerns about abdominal compartment syndrome, a stage abdominal closure with a silo pouch was fashioned: a traditional silo (TS) or SERS. When the bowel was completely reduced, a second-stage closure was performed in the operating room. Data collected included general demographic data, size of defect, associated anomalies, hospital course, mode of gastroschisis closure, duration of parenteral nutrition (PN) and ventilator, first feeding age, complications, and length of hospital stay (LOS). Results: Twenty-nine children with gastroschisis were treated (PR: 9, TS: 9, and SERS: 11). There were no differences (p >0.05) concerning gender, mode of delivery, APGAR scores, gestational age, birth weight, or defect size. A preformed silo was employed in 20 of 29 cases, TS in nine (31%), and SERS in 11 (38%) cases in an average operative time of 80.6 and 40 minutes, respectively, a significantly shorter operative time in the SERS (p =0.007). Overall, there were no differences (p >0.05) concerning duration of ventilator support (10.2 days), duration of PN (21.3 days), first feeding age (15 days), LOS (26.5 days), and complication. Conclusion: The use of a sutureless elastic ring silo with readily available inexpensive materials is simple, safe and efficacious in our setting.

Does timing of gastroschisis repair matter? A comparison using the ACS NSQIP pediatric database

BACKGROUND

There is no consensus on optimal timing of gastroschisis repair. The 2012-2014 ACS NSQIP Pediatric Participant Use Data File was used to compare outcomes of primary versus staged gastroschisis repair.

METHODS

Cases were divided into primary repair (0-1day) and staged repair (4-14days). Baseline characteristics and outcomes were compared for primary versus staged closure using Fisher's exact tests for categorical variables and Wilcoxon rank-sum tests for continuous variables. Length of stay was compared after controlling for prematurity.

RESULTS

There were 627 subjects included, with 364 neonates in the primary group and 263 in the staged group. The primary group demonstrated shorter hospital length of stay (LOS) (5.1days; p<0.001) and had less surgical site infections (OR=0.27; p=0.003), but had longer ventilator days (1.9days; p<0.001). Neonates in the primary repair group were less likely to be discharged home versus transferred to another hospital (OR=0.24; p=0.006) and more likely to require nutritional support at discharge (OR=1.74; p=0.034). No significant differences were identified for mortality, readmissions, postoperative LOS, sepsis or other outcomes.

CONCLUSION

Staged repair of gastroschisis has longer LOS attributed to preoperative timing, but less ventilator days. Outcomes for these closure techniques are equivocal and support surgeons performing the closure technique they are most experienced with.

LEVEL OF EVIDENCE

III (Treatment: retrospective comparative study).

Gastroschisis: Bellwether for neonatal surgery capacity in low resource settings?

INTRODUCTION

Economic disadvantage may adversely influence the outcomes of infants with gastroschisis (GS). Gastroschisis International (GiT) is a network of seven paediatric surgical centres, spanning two continents, evaluating GS treatment and outcomes.

MATERIAL AND METHODS

A 2-year retrospective review of GS infants at GiT centres. Primary outcome was mortality. Sites were classified into high, middle and low income country (HIC, MIC, and LIC). MIC and LIC were sometimes combined for analysis (LMIC). Disability adjusted life years (DALYs) were calculated and centres with the highest mortality underwent a needs assessment.

RESULTS

Mortality was higher in the LICs and LMICs: 100% in Uganda and Cote d'Ivoire, 75% in Nigeria and 60% in Malawi. 29% and 0% mortality was reported in South Africa and the UK, respectively. Septicaemia was the commonest cause of death. Averted and non-avertable DALYs were nil in Uganda and Cote d'Ivoire (no survivors). In the UK (100% survival) averted DALYs (met need) was highest, representing death and disability prevented by surgical intervention. Performance improvement measures were agreed: a prospectively maintained GS register; clarification of the key team members of a GS team and management pathway.

CONCLUSIONS

We propose the use of GS as a bellwether condition for assessing institutional capacity to deliver newborn surgical care. Early access to care, efficient multidisciplinary team working, appropriate resuscitation, avoidance of abdominal compartment syndrome, stabilization prior to formal closure and proactive nutritional interventions may reduce GS-associated burden of disease in low resource settings.

Umbilical hernia following gastroschisis closure: a common event?

PURPOSE

To assess incidence and natural history of umbilical hernia following sutured and sutureless gastroschisis closure.

METHODS

With audit approval, we undertook a retrospective clinical record review of all gastroschisis closures in our institution (2007-2013). Patient demographics, gastroschisis closure method and umbilical hernia occurrence were recorded. Data, presented as median (range), underwent appropriate statistical analysis.

RESULTS

Fifty-three patients were identified, gestation 36 weeks (31-38), birth weight 2.39 kg (1-3.52) and 23 (43 %) were male. Fourteen patients (26 %) underwent sutureless closure: 12 primary, 2 staged; and 39 (74 %) sutured closure: 19 primary, 20 staged. Sutured closure was interrupted sutures in 24 patients, 11 pursestring and 4 not specified. Fifty patients were followed-up over 53 months (10-101) and 22 (44 %) developed umbilical hernias. There was a significantly greater hernia incidence following sutureless closure (p = 0.0002). In sutured closure, pursestring technique had the highest hernia rate (64 %). Seven patients underwent operative hernia closure; three secondary to another procedure. Seven patients had their hernias resolve. One patient was lost to follow-up and seven remain under observation with no reported complications.

CONCLUSIONS

There is a significant umbilical hernia incidence following sutureless and pursestring sutured gastroschisis closure. This has not led to complications and the majority have not undergone repair.

Development of a core outcome set for use in determining the overall success of gastroschisis treatment

BACKGROUND

Gastroschisis research is limited in quality by the presence of significant heterogeneity in outcome measure reporting (PloS One 10(1):e0116908, 2015). Using core outcome sets in research is one proposed method for addressing this problem (Trials 13:103, 2012; Clin Rheumatol 33(9):1313-1322, 2014; Health Serv Res Policy 17(1):1-2, 2012). Ultimately, standardising outcome measure reporting will improve research quality and translate into improvements in patient care.

METHODS/DESIGN

Candidate outcome measures have been identified through systematic reviews. These outcome measures will form the starting point for an online, three-phase Delphi process that will be carried out in parallel by three panels of experts. Panel 1 is a neonatal panel, panel 2 is a non-neonatal panel and panel 3 is a lay panel. In round 1, experts will be asked to score the previously identified outcome measures from 1-9 based on how important they think the measures are in determining the overall success of their/their child's/their patient's gastroschisis treatment. In round 2, experts will be presented with the same list of outcome measures and with graphical representations of how their panel scored that outcome in round 1. They will be asked to re-score the outcome measure taking into account how important other members of their panel felt it to be. In round 3, experts will again be asked to re-score each outcome measure, but this time they will receive a graphical representation of the distribution of scores from all three panels which they should take into account when re-scoring. Following round 3 of the Delphi process, 40 experts will be invited to attend a face-to-face consensus meeting. Participants will be invited in a purposive manner to obtain balance between the different panels. The results of the Delphi process will be discussed, and outcomes re-scored. Outcome measures where > 70 % of the participants at the meeting scored them as 7-9 and < 15 % scored them as 1-3 will form the core outcome set.

DISCUSSION

Development of a core outcome set will help to reduce the heterogeneity of the outcome measure reporting in gastroschisis. This will increase the quality of research taking place and ultimately improve care provided to infants with gastroschisis.

Contemporary trends in the use of primary repair for gastroschisis in surgical infants

BACKGROUND

Gastroschisis is a newborn anomaly requiring emergent surgical intervention. We review our experience with gastroschisis to examine trends in contemporary surgical management.

METHODS

Infants who underwent initial surgical management of gastroschisis from 1996 to 2014 at a pediatric hospital were reviewed. Closure techniques included primary fascial repair using suture or sutureless umbilical closure, and staged repair using sutured or spring-loaded silo (SLS). Data were separated into 3 clinical eras: pre-SLS (1996 to 2004), SLS (2005 to 2008), and umbilical closure (2009 to 2014).

RESULTS

In the pre-SLS era, 60% (34/57) of infants with gastroschisis underwent primary repair. With the advent of SLS, there was a decrease in primary repair (15%, 10/68, P < .0001). Following introduction of sutureless umbilical closure, 61% (47/77) of infants have undergone primary repair. On multivariate regression, primary repair was associated with shorter intensive care unit stays (P < .001) and time to initiate enteral nutrition (P < .01).

CONCLUSIONS

Following introduction of a less invasive technique for gastroschisis repair, most infants with gastroschisis were able to be repaired primarily. Primary repair should be considered in all babies with gastroschisis and favorable anatomy.

Challenges of improving the evidence base in smaller surgical specialties, as highlighted by a systematic review of gastroschisis management

Objective

To identify methods of improving the evidence base in smaller surgical specialties, using a systematic review of gastroschisis management as an example.

Background

Operative primary fascial closure (OPFC), and silo placement with staged reduction and delayed closure (SR) are the most commonly used methods of gastroschisis closure. Relative merits of each are unclear.

Methods

A systematic review and meta-analysis was performed comparing outcomes following OPFC and SR in infants with simple gastroschisis. Primary outcomes of interest were mortality, length of hospitalization and time to full enteral feeding.

Results

751 unique articles were identified. Eight met the inclusion criteria. None were randomized controlled trials. 488 infants underwent OPFC and 316 underwent SR. Multiple studies were excluded because they included heterogeneous populations and mixed intervention groups. Length of stay was significantly longer in the SR group (mean difference 8.97 days, 95% CI 2.14–15.80 days), as was number of post-operative days to complete enteral feeding (mean difference 7.19 days, 95%CI 2.01–12.36 days). Mortality was not statistically significantly different, although the odds of death were raised in the SR group (OR 1.96, 95%CI 0.71–5.35).

Conclusions

Despite showing some benefit of OPFC over SR, our results are tempered by the low quality of the available studies, which were small and variably reported. Coordinating research through a National Paediatric Surgical Trials Unit could alleviate many of these problems. A similar national approach could be used in other smaller surgical specialties.

The association of type of surgical closure on length of stay among infants with gastroschisis born≥34 weeks' gestation

BACKGROUND/PURPOSE

The optimal surgical approach in infants with gastroschisis (GS) is unknown. The purpose of this study was to estimate the association between staged closure and length of stay (LOS) in infants with GS.

DESIGN/METHODS

We used the Children's Hospital Neonatal Database to identify surviving infants with GS born ≥34 weeks' gestation referred to participating NICUs. Infants with complex GS, bowel atresia, or referred after 2 days of age were excluded. The primary outcome was LOS; multivariable linear regression was used to quantify the relationship between staged closure and LOS.

RESULTS

Among 442 eligible infants, staged closure occurred in 68.1% and was associated with an increased median LOS relative to odds ration (OR):primary closure (37 vs. 28 days, p<0.001). This association persisted in the multivariable equation (β=1.35, 95% CI: 1.21, 1.52, p<0.001) after adjusting for the presence of necrotizing enterocolitis, short bowel syndrome, and central-line associated bloodstream infections.

CONCLUSIONS

In this large, multicenter cohort of infants with GS, staged closure was independently associated with increased LOS. These data can be used to enhance antenatal and pre-operative counseling and also suggest that some infants who receive staged closure may benefit from primary repair.

Practice variation in gastroschisis: factors influencing closure technique

BACKGROUND

Little is known about the factors influencing surgical practice variation in newborns with gastroschisis. The purpose of this study was to correlate prognostic variables with the intended and actual abdominal closure technique and assess related outcomes.

METHODS

GS cases were abstracted from a national database. Variables evaluated included GA, BW, bowel injury severity (GPS), neonatal illness severity (SNAP-II), inborn status, center volume and training status, and admission time. Evaluated outcomes by closure method included duration of TPN, LOS, and complications. Descriptive, univariate and multivariable regression analyses were conducted.

RESULTS

The cohort consisted of 679 patients. A total of 372 (55%) underwent attempted PR, of which 300 (81%) were successful, while 307 (45%) had a silo placed intentionally. Patients undergoing attempted PR were more likely to be inborn, have daytime admissions, and higher SNAP-II scores. Successful PR was predicted by low risk GPS and high volume center. With the exception of higher rates of SSI in the planned silo group, outcomes in the successful PR and planned silo groups were comparable.

CONCLUSION

Practice variation related to type of closure is predicted by situational and institutional factors (outborn, nighttime admission, and center volume), while outcome variation is attributable to patient factors rather than practice variation.

Cholestasis and growth in neonates with gastroschisis

PURPOSE

The aim of this study was to determine the incidence of cholestasis and the correlation between cholestasis and weight-for-age z scores in parenteral nutrition-dependent neonates with gastroschisis.

METHODS

A single-center retrospective review of 59 infants born with gastroschisis from January 2000 to June 2007 was conducted. Demographic and clinical data were collected and analyzed. Subjects were divided into cholestatic and noncholestatic groups. Statistical analyses included the Student t test, Wilcoxon rank sum test, Fisher exact test, and a general linear model.

RESULTS

Fifty-nine neonates with gastroschisis were identified, and 16 (28%) of 58 patients developed cholestasis. Younger gestational age and cholestasis were found to be independently associated with weight-for-age z score in 30 of 58 patients with available long-term follow-up data.

CONCLUSIONS

Parenteral nutrition-dependent neonates with gastroschisis remain at considerable risk for the development of cholestasis. Both gestational age and cholestasis were found to be independent risk factors, predisposing these neonates to poor postnatal growth.

Infectious complications in the management of gastroschisis

BACKGROUND/PURPOSE

Neonates with gastroschisis make up an increasing proportion of prolonged surgical NICU admissions. While infectious complications are known to increase patient morbidity, it is unclear whether they vary according to abdominal closure method, or can be predicted by initial patient assessment.

METHODS

A national, prospective, disease-specific database was evaluated for episodes of wound infection (WI) and catheter-related infection (CRI). Antibiotic use and timing, as well as method and location of abdominal closure were studied. The gastroschisis prognostic score (GPS) was calculated and evaluated as a predictor of infectious complications.

RESULTS

Of 395 patients, 48 (12.6%) had a documented abdominal WI, and 59 patients (14.9%) had at least one episode of CRI-most commonly coagulase negative staphylococcus. Most abdominal closures took place within 6 h of admission (194 = 51.3%), while 132 (34.9%) were delayed greater than 24 h. The WI rate was greater in the delayed group (21.2 vs. 8.2%, p = 0.0006). The GPS was found to predict development of an infectious complication (WI + CRI, p = 0.04).

CONCLUSION

Infectious complications remain an important consideration in the management of gastroschisis. GPS correlates with the development of infectious complications. Prophylaxis for skin flora and early closure, when feasible, may reduce WI rates.

Gastroschisis: one year outcomes from national cohort study

OBJECTIVE

To describe one year outcomes for a national cohort of infants with gastroschisis.

DESIGN

Population based cohort study of all liveborn infants with gastroschisis born in the United Kingdom and Ireland from October 2006 to March 2008.

SETTING

All 28 paediatric surgical centres in the UK and Ireland.

PARTICIPANTS

301 infants (77%) from an original cohort of 393.

MAIN OUTCOME MEASURES

Duration of parenteral nutrition and stay in hospital; time to establish full enteral feeding; rates of intestinal failure, liver disease associated with intestinal failure, unplanned reoperation; case fatality.

RESULTS

Compared with infants with simple gastroschisis (intact, uncompromised, continuous bowel), those with complex gastroschisis (bowel perforation, necrosis, or atresia) took longer to reach full enteral feeding (median difference 21 days, 95% confidence interval 9 to 39 days); required a longer duration of parenteral nutrition (median difference 25 days, 9 to 46 days) and a longer stay in hospital (median difference 57 days, 29 to 95 days); were more likely to develop intestinal failure (81% (25 infants) v 41% (102); relative risk 1.96, 1.56 to 2.46) and liver disease associated with intestinal failure (23% (7) v 4% (11); 5.13, 2.15 to 12.3); and were more likely to require unplanned reoperation (42% (13) v 10% (24); 4.39, 2.50 to 7.70). Compared with infants managed with primary fascial closure, those managed with preformed silos took longer to reach full enteral feeding (median difference 5 days, 1 to 9) and had an increased risk of intestinal failure (52% (50) v 32% (38); 1.61, 1.17 to 2.24). Event rates for the other outcomes were low, and there were no other significant differences between these management groups. Twelve infants died (4%).

CONCLUSIONS

This nationally representative study provides a benchmark against which individual centres can measure outcome and performance. Stratifying neonates with gastroschisis into simple and complex groups reliably predicts outcome at one year. There is sufficient clinical equipoise concerning the initial management strategy to embark on a multicentre randomised controlled trial comparing primary fascial closure with preformed silos in infants suitable at presentation for either treatment to determine the optimal initial management strategy and define algorithms of care.

Hospital readmission among infants with gastroschisis

OBJECTIVE

Infants with gastroschisis have significant perinatal morbidity including long hospitalizations and feeding intolerance. Two thirds are premature and 20% are growth restricted. Despite these known risk factors for post-natal complications, little is known about readmission for infants with gastroschisis. Our objective was to determine the frequency and indication for hospital readmission after initial discharge among infants with gastroschisis.

STUDY DESIGN

Retrospective cohort study. All surviving infants treated for gastroschisis at Cincinnati Children's Hospital Medical Center, born between January 2006 and December 2008 were included. Main outcome measures included the frequency and indication for readmission. Associated neonatal risk factors also were assessed.

RESULT

Fifty-eight patients were analyzed. Twenty-three (40%) subjects were readmitted (five with multiple readmissions); 65% of readmissions occurred in the first year and 70% involved complications directly related to gastroschisis. The most common reasons for readmission were bowel obstruction and abdominal distention/pain. Median time to readmission directly related to gastroschisis was 23 weeks (range 5 to 92). All three infants with home parenteral nutrition were readmitted. Readmission was not associated with gestational age, birth weight or length of initial hospitalization.

CONCLUSION

Readmission after initial hospitalization is common in gastroschisis patients. Parental counseling should include education regarding the possibility of complications requiring readmission. Determinants of readmission require further study.

Review of the evidence on the closure of abdominal wall defects

Infants with congenital abdominal wall defects pose an interesting and challenging management issue for surgeons. We attempt to review the literature to define the current treatment modalities and their application in practice. In gastroschisis, the overall strategies for repair include immediate closure or delayed operative repair. The best level of data for gastroschisis is grade C and appears to support that there is no major difference in survival between immediate closure or delayed repair. In patients with omphalocele, the management techniques are more varied consisting of immediate closure, staged closure or delayed closure after epithelialization. The literature is less clear on when to use one technique over the other, consisting of mostly grade D and E data. In patients with omphalocele, a registry to collect information on patients with larger defects may help determine which of the management strategies is optimal.

Laparoscopic-assisted anorectal pull-through for anorectal malformations: a systematic review and the need for standardization of outcome reporting

INTRODUCTION

Laparoscopic-assisted anorectal pull-through (LAARP) is becoming an increasingly common procedure to correct high and intermediate anorectal malformations (ARMs). The aim of this review was to evaluate worldwide experiences with LAARP with regard to indications, outcomes, and quality of reporting.

METHOD

A systematic review was conducted. The search was limited to studies reported in English and performed in humans. In addition to Medline and PubMed, a manual search of the Journal of Pediatric Surgery, Pediatric Surgery International, Surgical Endoscopy, and the Journal of Laparoendoscopic & Advanced Surgical Techniques published between June 2000 and April 2008 was conducted.

RESULTS

Seventeen studies were included in the final analysis. Of the included studies, none were randomized, 2 were prospective in nature, and 4 compared outcomes of posterior sagittal anorectoplasty and LAARP. The studies included 124 patients (96 males, 28 females) with 80% reported as having high/intermediate malformations. All studies reported short-term outcomes. Reported outcomes included continence, rectal prolapse, the position of the rectum (7 studies using Kelly score), manometry (1 study), contrast enema (1 study), postanal endosonography (3 studies), and postoperative magnetic resonance imaging (3 studies). Outcomes varied widely between reports precluding a meta-analysis.

CONCLUSION

The number of studies dealing with LAARP is low. There is a need for both a standardization and improvement in the quality of reporting in LAARP research. This will ultimately allow for evidence-based surgical decision making.

Method to our madness: an 18-year retrospective analysis on gastroschisis closure

BACKGROUND

The advent of preformed silos has facilitated routine bedside placement often without any attempt of intestinal reduction. It is unclear whether a strategy of routine silo (RS) placement with delayed fascial repair is beneficial over attempted primary repair (aPR) and silo placement only for those patients who cannot be reduced. We retrospectively compared clinical outcomes of neonates having aPR to those having RS placement to determine the impact of routine silo use and silo duration on gastroschisis care.

METHODS

Neonatal records from patients with gastroschisis at a single children's hospital between 1990 and 2008 were reviewed. Demographic and outcome data were recorded and subjected to statistical analyses. Documentation of attempted intestinal reduction was used as a surrogate marker for aPR. The remaining patients were placed in the RS group.

RESULTS

Two hundred forty-eight neonates with gastroschisis were identified. Thirteen were excluded for congenital or clinical issues which precluded aPR. Of the remaining 235 patients, neonates with RS had significantly more ventilator days (6.2 vs 4.4; P = .0011), more time of total parenteral nutrition (36.5 vs. 28.5; P = .0018), longer length of stay (LOS, 46.5 vs. 40.5; P = .0011), and greater hospital charges ($216,000 vs $172,000; P < .0001) than patients who had aPR. There was no significant difference observed in complications or survival. Linear regression modeling demonstrated that time to closure was significantly related to LOS as an independent variable. Each day to closure was associated with 2.2 extra days of hospitalization and approximately $9557 in hospital charges.

CONCLUSION

Although limited by retrospective biases, this study demonstrates that time to closure is the most significant variable related to LOS in gastroschisis. This relationship is intuitive since longer time to closure is probably determined by the severity of gastroschisis. The method of closure, by primary repair or silo, is of secondary importance. Conversely, unnecessarily increasing the time to closure may increase the LOS. The speed of reduction, whether through primary repair or by silo, should be guided by physiologic principles.

Surgical management of gastroschisis in North Queensland from 1988 to 2007

AIM

To review outcomes of gastroschises originating in North Queensland and repaired in the neonatal centre in Townsville from 1988-2007, and compare these outcomes with published data from other centres.

METHODS

A retrospective chart review of outcomes after primary operative repair (POR) with wound closure in fascial layers in the theatre, primary non-operative repair (PNOR) with apposition of the umbilical cord and adhesive dressing in the ward, secondary repair (SR) after a silo, and complex repair (CR) of cases with obstruction, perforation or atresiae. Epidemiological data of babies originating in North Queensland but managed in Brisbane were secured from Mater Mothers' Hospital and the Royal Hospital for Children.

RESULTS

Fifty cases were treated in Townsville: 16 by PNOR, 22 by POR, 6 by SR and 6 by CR. Outcomes of uncomplicated cases treated by PNOR, POR and SR were similar. Outcomes of complicated cases after CR were significantly worse. No significant differences were found between PNOR in Townsvillle and published outcomes after SR from four overseas units. No differences were detected in outcomes of inborn and outborn babies, those delivered by vaginal or caesarean birth or between indigenous and non-indigenous babies. Three (6%) died. Gastroschisis is increasing in North Queensland, particularly in younger mothers. The incidence is 2-3 times higher in indigenous mothers.

CONCLUSION

No significant differences were found between PNOR and other techniques for uncomplicated cases. PNOR avoids the use of theatre and staff, reducing delay and cost, and the need to transport a sick baby.

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 sutureless gastroschisis closure

INTRODUCTION

A new technique of gastroschisis closure in which the defect is covered with sterile dressings and allowed to granulate without suture repair was first described in 2004. Little is known about the outcomes of this technique. This study evaluated short-term outcomes from the largest series of sutureless gastroschisis closures.

METHODS AND PATIENTS

A retrospective case control study of 26 patients undergoing sutureless closure between 2006 and 2008 was compared to a historical control group of 20 patients with suture closure of the abdominal fascia between 2004 and 2006. Four major outcomes were assessed: (1) time spent on ventilator, (2) time to initiating enteral feeds, (3) time to discharge from the neonatal intensive care unit, and (4) rate of complications.

RESULTS

In multivariate analysis, sutureless closure of gastroschisis defects independently reduced the time to extubation as compared to traditional closure (5.0 vs 12.1 days, P = .025). There was no difference in time to full enteral feeds (16.8 vs 21.4 days, P = .15) or time to discharge (34.8 vs 49.7 days, P = .22) with sutureless closure. The need for silo reduction independently increased the time to extubation (odds ratio, 4.2; P = .002) and time to enteral feeds (odds ratio, 5.2; P < .001). Small umbilical hernias were seen in all patients.

CONCLUSION

Sutureless closure of uncomplicated gastroschisis is a safe technique that reduces length of intubation and does not significantly alter the time required to reach full enteral feeds or hospital discharge.

Commonly encountered surgical problems in the fetus and neonate

Neonatal surgical care requires a current understanding of pre- and postnatal intervention for a myriad of congenital anomalies. This article includes an update of the recent information on commonly encountered fetal and neonatal surgical problems, highlighting specific areas of controversy and challenges in diagnosis. The authors hope that this article is useful for trainees and practitioners involved in any aspect of fetal and neonatal care.