Staged reduction of gastroschisis using preformed silos: practicalities and problems

Improved Mortality of Patients with Gastroschisis: A Historical Literature Review of Advances in Surgery and Critical Care from 1960-2020

The improved survival of gastroschisis patients is a notable pediatric success story. Over the past 60 years, gastroschisis evolved from uniformly fatal to a treatable condition with over 95% survival. We explored the historical effect of four specific clinical innovations—mechanical ventilation, preformed silos, parenteral nutrition, and pulmonary surfactant—that contributed to mortality decline among gastroschisis infants. A literature review was performed to extract mortality rates from six decades of contemporary literature from 1960 to 2020. A total of 2417 publications were screened, and 162 published studies (98,090 patients with gastroschisis) were included. Mortality decreased over time and has largely been <10% since 1993. Mechanical ventilation was introduced in 1965, preformed silo implementation in 1967, parenteral nutrition in 1968, and pulmonary surfactant therapy in 1980. Gastroschisis infants now carry a mortality rate of <5% as a result of these interventions. Other factors, such as timing of delivery, complex gastroschisis, and management in low- and middle-income countries were also explored in relation to gastroschisis mortality. Overall, improved gastroschisis outcomes serve as an illustration of the benefits of clinical advances and multidisciplinary care, leading to a drastic decline in infant mortality among these patients.

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.

Use of Human Umbilical Cord and Its Byproducts in Tissue Regeneration

The fresh or cryopreserved human umbilical cord (HUC) and its byproducts, such as cells and extracts, have different uses in tissue regeneration. Defining what HUC byproduct is more effective in a particular application is a challenge. Furthermore, the methods of isolation, culture and preservation, may affect cell viability and regenerative properties. In this article, we review the HUC and its byproducts' applications in research and clinical practice. We present our results of successful use of HUC as a patch to treat gastroschisis and its potential to be applied in other conditions. Our in vitro results show an increase in proliferation and migration of human fibroblasts by using an acellular HUC extract. Our goal is to promote standardization of procedures and point out that applications of HUC and its byproducts, as well as the resulting advances in regenerative medicine, will depend on rigorous quality control and on more research in this area.

Serial Reduction of an Extremely Large Gastroschisis using Vacuum-Assisted Closure

We herein describe a case of serial reduction of an extremely large and complex gastroschisis using vacuum-assisted closure (VAC) therapy in a boy born at 35 ^5/7 weeks' gestation. A spring-loaded silicone silo was placed at birth. By day of life (DOL) 22, minimal visceral contents had been reduced, and the silo was difficult to maintain due to the size of the fascial defect and loss of abdominal domain. A bespoke VAC dressing was constructed, and biweekly dressing changes allowed gradual reduction of the gastroschisis until the viscera were consolidated. By DOL 50, the viscera were completely reduced, and VAC therapy was discontinued. Feeds were commenced on DOL 57 and increased to goal by DOL 86. The baby was discharged home on DOL 115. We conclude that VAC dressings can be used to aid gradual reduction of an extremely large gastroschisis, particularly in medical fragile infants.

Single center protocol driven care in 150 patients with gastroschisis 1998-2017: collaboration improves results

PURPOSE

The treatment of gastroschisis (GS) using our collaborative clinical pathway, with immediate attempted abdominal closure and bowel irrigation with a mucolytic agent, was reviewed.

METHODS

A retrospective review of the past 20 years of our clinical pathway was performed on neonates with GS repair at our institution. The clinical treatment includes attempted complete reduction of GS defect within 2 h of birth. In the operating room, the bowel is evaluated and irrigated with mucolytic agent to evacuate the meconium and decompress the bowel. No incision is made and a neo-umbilicus is created. Clinical outcomes following closure were assessed.

RESULTS

150 babies with gastroschisis were reviewed: 109 (77%) with a primary repair, 33 (23%) with a spring-loaded silo repair. 8 babies had a delayed closure and were not included in the statistical analysis. Successful primary repair and time to closure had a significant relationship with all outcome variables-time to extubation, days to initiate feeds, days to full feeds, and length of stay.

CONCLUSION

Early definitive closure of the abdominal defect with mucolytic bowel irrigation shortens time to first feeds, total TPN use, time to extubation, and length of stay.

A Gastroschisis bundle: effects of a quality improvement protocol on morbidity and mortality

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.

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.

Multi-institutional practice patterns and outcomes in uncomplicated gastroschisis: a report from the University of California Fetal Consortium (UCfC)

BACKGROUND/PURPOSE

Gastroschisis is a resource-intensive birth defect without consensus regarding optimal surgical and medical management. We sought to determine best-practice guidelines by examining differences in multi-institutional practices and outcomes.

METHODS

Site-specific practice patterns were queried, and infant-maternal chart review was retrospectively performed for gastroschisis infants treated at 5 UCfC institutions (2007-2012). The primary outcome was length of stay. Univariate analysis was done to assess variation practices and outcomes by site. Multivariate models were constructed with site as an instrumental variable and with sites grouped by silo practice pattern adjusting for confounding factors.

RESULTS

Of 191 gastroschisis infants, 164 infants were uncomplicated. Among uncomplicated patients, there were no deaths and only one case of necrotizing enterocolitis. Bivariate analysis revealed significant differences in practices and outcomes by site. Despite wide variations in practice patterns, there were no major differences in outcome among sites or by silo practice, after adjusting for confounding factors.

CONCLUSIONS

Wide variability exists in institutional practice patterns for infants with gastroschisis, but poor outcomes were not associated with expeditious silo or primary closure, avoidance of routine paralysis, or limited central line and antibiotic durations. Development of clinical pathways incorporating these practices may help standardize care and reduce health care costs.

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.

Staged gastroschisis closure using Alexis wound retractor: first experiences

INTRODUCTION

The aim of this study is to analyze the effectiveness of an Alexis wound retractor (AWR) device for staged gastroschisis closures.

PATIENTS AND METHODS

AWR device was used to cover unreduced viscera of a gastroschisis when primary abdominal wall closure was not convenient. The eviscerated organs were covered with one of the two spring-loaded rings of the AWR inserted underneath the abdominal wall. Gradual reduction was guaranteed through careful traction on the external ring. We retrospectively analyzed the prenatal, post-natal and operative data of the first patients treated with AWR and report their post-operative outcomes.

RESULTS

The AWR device was used for staged closure in eight cases. Complete reduction and fascial closure were performed at a median of 3.5 ± 1.6 days. Ventilatory support was necessary for 4.0 ± 3 days and full parenteral feeds for 7.5 ± 6.1 days after fascial closure. Median full enteral feeding was observed at 18 ± 12.5 days after closure allowing discharge in a median period of 30.5 ± 15.6 days after closure.

CONCLUSION

The AWR device is not only a safe and efficient silo for a progressive reduction of severe gastroschisis, but also an interesting tool for continuous stretching leading to an increase of the peritoneal cavity volume, enhancing the equalizing of the viscero-abdominal disproportion.

Long-term review of sutureless ward reduction in neonates with gastroschisis in the neonatal unit

BACKGROUND

A sutureless ward reduction (SWR) protocol was implemented in the neonatal intensive care unit of a tertiary level hospital in 1999. Although the short-term outcomes associated with SWR have been documented, the long-term outcomes are unknown.

METHODS

Retrospective data were collected from the medical records of all neonates with gastroschisis from September 1999 to December 2010. Data on their growth and development and the prevalence of any health problems were collected.

RESULTS

Eighty-eight patients with gastroschisis were managed over an 11 year period. Forty-four of these patients received SWR, with 2 deaths in the neonatal period. In the 42 survivors, 35 patients were reviewed at a median age of 7 years and 10 months (range, 6-134 months; interquartile range, 37-124 months). One patient experienced failure to thrive and developmental delay, and later died of a medical complication. Thirty-two patients (91.4%) developed an umbilical hernia, only 2 of whom required umbilical herniotomy. Four patients (11.4%) developed small bowel obstruction, all within the first year.

CONCLUSION

Most patients with SWR exhibited normal growth with minimal bowel complications. Despite the high incidence of umbilical hernia, the majority resolved spontaneously and did not require subsequent herniotomy.

Bowel-defect disproportion in gastroschisis: does the need to extend the fascial defect predict outcome?

BACKGROUND/PURPOSE

Validated outcome prediction for gastroschisis (GS) permits early risk stratification. The aim of our study was to determine whether the need for GS defect extension: (a) correlates with bowel injury severity at birth, and (b) predicts outcome.

METHODS

A national dataset was used to study GS babies born between 2005 and 2010. The primary outcome was days of parenteral nutrition (PN). Outcomes were analyzed according to the need for fascial extension to facilitate closure or silo placement as follows: Group 1, no extension; Group 2A, extension <2 cm; Group 2B, extension >2 cm. Univariate and where appropriate, multivariate analyses were used.

RESULTS

Of 507 cases, 402 had complete defect extension data: Group 1, 297 (73%); Group 2A, 67 (17%); Group 2B, 42 (10%). Group 2B patients had higher rates of atresia, perforation and severe matting (P = 0.001) and required more days on PN compared to Group 1 (63.0 ± 100.4 vs. 39.7 ± 44.5 days: CI 1.2-45.1; P = 0.03). Multivariate analysis revealed that the presence of atresia (P = 0.01) and surgical site (P = 0.001) or bloodstream (P = 0.001) infections were predictive of prolonged PN; however, the need for fascial extension was not.

CONCLUSIONS

GS newborns who require fascial extension are more likely to have complicated GS and are at greater risk for adverse outcome, although it is not an independent predictor of the latter.

The jury is still out: changes in gastroschisis management over the last decade are associated with both benefits and shortcomings

PURPOSE

Management of gastroschisis has shifted from early primary closure to preformed silo placement and delayed closure. We aimed to identify how closure techniques have changed and how outcomes have been affected.

METHODS

Records of patients undergoing gastroschisis closure at a single institution from 2000 to 2009 were reviewed. Patient characteristics and outcomes were collected and compared among those undergoing primary closure vs preformed silo placement. Outcomes were also compared in an era when primary closure predominated (2000-2002) vs one when primary silo predominated (2003-2009).

RESULTS

From 2000 to 2009, 203 patients underwent gastroschisis closure. Primary closure was performed in 50% of patients from 2000 to 2002 vs 12.3% from 2003 to 2009. Preformed silos were placed in 34.7% of patients from 2000 to 2002 vs 84.4% from 2003 to 2009. Patients treated from 2000 to 2002 experienced shorter hospital stays and shorter time to achievement of full enteral nutrition. Patients treated from 2003 to 2009 developed fewer ventral hernias and wound infections and required less ventilator days. Patients undergoing early primary closure developed ventral hernias at higher rates compared with those treated with preformed silos. Intensive care unit stay was longer for patients receiving preformed silos.

CONCLUSION

Change in our management strategy has resulted in prolonged intensive care unit stay and time to full feeds but reduced postoperative hernias and wound infections.

Fetal counselling for surgical conditions

Foetal counselling is best achieved by a multidisciplinary team that can favourably influence the perinatal management of prenatally diagnosed anomalies and provide this information to prospective parents. Prenatal diagnosis has remarkably improved our understanding of surgically correctable congenital malformations. It has allowed us to influence the delivery of the baby, offer prenatal surgical management and discuss the options of termination of pregnancy for seriously handicapping or lethal conditions. Antenatal diagnosis has also defined an in utero mortality for some lesions such as diaphragmatic hernia and sacrococcygeal teratoma so that true outcomes can be measured. The limitation of in-utero diagnosis cannot be ignored. The aim of prenatal counselling is to provide information to prospective parents on foetal outcomes, possible interventions, appropriate setting, time and route of delivery and expected postnatal outcomes, immediate and long term.

Predictors of postnatal outcome in neonates with gastroschisis

BACKGROUND/PURPOSE

The optimal management of neonates with gastroschisis is unclear, and there is a significant morbidity. We performed a review of neonates with gastroschisis treated at our center of pediatric surgery over the last 21 years to determine predictive factors of outcome.

METHODS

Single-center retrospective analysis of 79 neonates with gastroschisis (1989-2009) was done. Length of hospital stay (LOS), days of parenteral nutrition (PN), and survival were outcome measures. Univariate and multiple regression analyses were used.

RESULTS

Overall survival was 92%, and primary closure was achieved in 80%. Median LOS was 25 days, and median duration on PN, 17 days. Intestinal atresia, closed gastroschisis, secondary closure, and sepsis were the primary variables associated with poor outcome independent of other variables, but prematurity also affected outcome. Route of delivery and associated malformations were not related to poorer outcome. Necrotizing enterocolitis did not occur in any of our patients.

CONCLUSION

Outcome in our patients was favorable as measured by survival, LOS, and days on PN. Primary predictors of poor outcome were factors related to short bowel syndrome and secondary closure, indicating a need to further improve treatment of short bowel 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.

Gastroschisis: a national cohort study to describe contemporary surgical strategies and outcomes

BACKGROUND

Information on adoption of newer surgical strategies for gastroschisis and their outcomes is largely limited to hospital-based studies. The aim of this study was to use a new UK national surveillance system to identify cases and thus to describe the contemporary surgical management and outcomes of gastroschisis.

METHODS

We conducted a national cohort study using the British Association of Paediatric Surgeons Congenital Anomalies Surveillance System to identify cases between October 2006 and March 2008.

RESULTS

All 28 surgical units in the United Kingdom and Ireland participated (100%). Data were received for 95% of notified cases of gastroschisis (n = 393). Three hundred thirty-six infants (85.5%) had simple gastroschisis; 45 infants (11.5%) had complex gastroschisis. For 12 infants (3.0%), the type of gastroschisis could not be categorized. Operative primary closure (n = 170, or 51%) and staged closure after a preformed silo (n = 120, or 36%) were the most commonly used intended techniques for simple gastroschisis. Outcomes for infants with complex gastroschisis were significantly poorer than for simple cases, although all deaths occurred in the simple group.

CONCLUSIONS

This study provides a comprehensive picture of current UK practice in the surgical management of gastroschisis. Further follow-up data will help to elucidate additional prognostic factors and guide future research.

Intestinal atresia in association with gastroschisis: a 26-year review

PURPOSE

We reviewed our experience with gastroschisis (GS) complicated by intestinal atresia over the last 26 years. Our aim was to determine the effect of different management strategies employed and the morbidity associated with this condition in our unit.

METHODS

A retrospective casenote review was carried out. Data regarding the operative management of the GS and atresia was recorded. Primary outcome measures included time to commence and establish full enteral feeds, duration of parenteral nutrition, complications and outcome.

RESULTS

Of 179 neonates with GS, 23 also had intestinal atresia. 13 underwent primary closure of the defect, 5 had patch closure and 5 had a silo placed. 4 atresias were 'missed' at first operation. The 19 recognised atresias were managed either by stoma formation, primary anastomosis or deferred management with subsequent primary anastomosis. There was wide variation in the outcomes of patients in each group.

CONCLUSION

Differences in outcome between the management strategies are likely to reflect an inherent variability in patient condition, site of atresia, and bowel suitability for anastomosis at first surgery, rather than the mode of surgical management. Individual management plans should be tailored to the clinical condition of each patient.