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Hawkins RB, Raymond SL, St. Peter SD, Downard CD, Qureshi FG, Renaud E, Danielson PD, Islam S. Immediate versus silo closure for gastroschisis: Results of a large multicenter study. J Pediatr Surg 2020; 55:1280-1285. [PMID: 31472924 PMCID: PMC7731615 DOI: 10.1016/j.jpedsurg.2019.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 08/07/2019] [Accepted: 08/13/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND/PURPOSE The optimal method to repair gastroschisis defects continues to be debated. The two primary methods are immediate closure (IC) or silo placement (SP). The purpose of this study was to compare outcomes between each approach using a multicenter retrospective analysis. We hypothesized that patients undergoing SP for ≤5 days would have largely equivalent outcomes compared to IC patients. METHODS Gastroschisis patient data were collected over a 7-year period. The cohort was separated into IC and SP groups. The SP group was further stratified based on time to closure (≤5 days, 6-10 days, >10 days). Characteristics and outcomes were compared between groups. Multivariate logistic regression was also performed. RESULTS 566 neonates with gastroschisis were identified including 224 patients in the IC group and 337 patients in the SP group. Among SP patients, 130 were closed within 5 days, 140 in 6-10 days, and 57 in >10 days. There were no significant differences in mortality, sepsis, readmission, or days to full enteral feeds between IC patients and SP patients who had a silo ≤5 days. IC patients had a significantly higher incidence of ventral hernias. Multivariate analysis revealed time to closure as a significant independent predictor of length of stay, ventilator duration, time to full enteral feeds, and TPN duration. CONCLUSIONS Our data show largely equivalent outcomes between patients who undergo immediate closure and those who have silos ≤5 days. We propose that closure within 5 days avoids many of the risks commonly attributed to delay in closure. LEVEL OF EVIDENCE Level II retrospective study.
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Affiliation(s)
- Russell B. Hawkins
- University of Florida College of Medicine, Department of Surgety, Division of Pediatric Surgery, Gainesville, FL, USA
| | - Steven L. Raymond
- University of Florida College of Medicine, Department of Surgety, Division of Pediatric Surgery, Gainesville, FL, USA
| | | | - Cynthia D. Downard
- University of Louisville, Department of Surgery, Division of Pediatric Surgery, Louisville, KY, USA
| | - Faisal G. Qureshi
- University of Texas Southwestern, Department of Surgery, Division of Pediatric Surgery, Dallas, TX, USA
| | - Elizabeth Renaud
- Alpert Medical School of Brown University, Department of Surgery, Division of Pediatric Surgery, Providence, RI, USA
| | | | - Saleem Islam
- University of Florida College of Medicine, Department of Surgery, Division of Pediatric Surgery, Gainesville, FL, 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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Pratheeppanyapat T, Tepmalai K, Singhavejsakul J, Khorana J. The factors associated with successful early enteral feeding in gastroschisis. Pediatr Surg Int 2018; 34:743-748. [PMID: 29802444 DOI: 10.1007/s00383-018-4282-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/22/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Gastroschisis is the most common congenital abdominal wall defect. Due to the exposure of midgut to amniotic fluid, the recovery of bowel function is often delayed. This study aimed to identify the factors associated with the successful early enteral feeding in gastroschisis and to develop further guidelines of treatment. METHODS A retrospective cohort study of gastroschisis babies from January 2006 to December 2015 was done. Exclusion criteria were incomplete data and death. Successful early enteral feeding was defined when full feeding was achieved within 21 days of life. RESULTS One hundred and five gastroschisis patients were divided into a successful early-feeding group (n = 56, 53%) and a non-successful early-feeding group (n = 49, 46%). In multivariable analysis, significant factors for successful feeding clustered by primary treatment were female (RR = 1.38, P value < 0.001), gestational age > 36 weeks (RR = 1.23, P value < 0.001), age at surgery less than 10 h (RR = 1.15, P value < 0.001), postoperative extubation time < 4 days (RR = 1.39, P value < 0.001), and age when feeding started less than 10 days (RR = 35.69, P value < 0.001). CONCLUSION Several factors were found to be associated with successful early enteral feeding. The modifiable factors found in this study were surgery within 10 h, early postoperative extubation within 4 days, and feeding started before 10 days of life. These will guide the management of gastroschisis to achieve successful early enteral feeding.
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Affiliation(s)
- Theerayuth Pratheeppanyapat
- Division of Pediatric Surgery, Department of Surgery, Chiang Mai University Hospital, 110 Intavaroros Road, Muang Chiang Mai District, Chiang Mai, 50200, Thailand
| | - Kanokkan Tepmalai
- Division of Pediatric Surgery, Department of Surgery, Chiang Mai University Hospital, 110 Intavaroros Road, Muang Chiang Mai District, Chiang Mai, 50200, Thailand
| | - Jesda Singhavejsakul
- Division of Pediatric Surgery, Department of Surgery, Chiang Mai University Hospital, 110 Intavaroros Road, Muang Chiang Mai District, Chiang Mai, 50200, Thailand
| | - Jiraporn Khorana
- Division of Pediatric Surgery, Department of Surgery, Chiang Mai University Hospital, 110 Intavaroros Road, Muang Chiang Mai District, Chiang Mai, 50200, Thailand.
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Gurien LA, Dassinger MS, Burford JM, Saylors ME, Smith SD. Does timing of gastroschisis repair matter? A comparison using the ACS NSQIP pediatric database. J Pediatr Surg 2017; 52:1751-1754. [PMID: 28408077 DOI: 10.1016/j.jpedsurg.2017.02.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 02/10/2017] [Accepted: 02/11/2017] [Indexed: 10/20/2022]
Abstract
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).
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Affiliation(s)
- Lori A Gurien
- Department of Pediatric Surgery, Arkansas Children's Hospital, 1 Children's Way, Slot 837, Little Rock, AR 72202, USA.
| | - Melvin S Dassinger
- Department of Pediatric Surgery, Arkansas Children's Hospital, 1 Children's Way, Slot 837, Little Rock, AR 72202, USA
| | - Jeffrey M Burford
- Department of Pediatric Surgery, Arkansas Children's Hospital, 1 Children's Way, Slot 837, Little Rock, AR 72202, USA
| | - Marie E Saylors
- Department of Biostatistics, Arkansas Children's Hospital Research Institute, 13 Children's Way, Little Rock, AR 72202, USA
| | - Samuel D Smith
- Department of Pediatric Surgery, Arkansas Children's Hospital, 1 Children's Way, Slot 837, Little Rock, AR 72202, USA
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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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Lap CCMM, Brizot ML, Pistorius LR, Kramer WLM, Teeuwen IB, Eijkemans MJ, Brouwers HAA, Pajkrt E, van Kaam AH, van Scheltema PNA, Eggink AJ, van Heijst AF, Haak MC, van Weissenbruch MM, Sleeboom C, Willekes C, van der Hoeven MA, van Heurn EL, Bilardo CM, Dijk PH, van Baren R, Francisco RPV, Tannuri ACA, Visser GHA, Manten GTR. Outcome of isolated gastroschisis; an international study, systematic review and meta-analysis. Early Hum Dev 2016; 103:209-218. [PMID: 27825040 DOI: 10.1016/j.earlhumdev.2016.10.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Revised: 10/02/2016] [Accepted: 10/09/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine outcome of children born with isolated gastroschisis (no extra-gastrointestinal congenital abnormalities). STUDY DESIGN International cohort study and meta-analysis. PRIMARY OUTCOME time to full enteral feeding (TFEF); secondary outcomes: Duration of mechanical ventilation, length of stay (LOS), mortality and differences in outcome between simple and complex gastroschisis (complex; born with bowel atresia, volvulus, perforation or necrosis). To compare the cohort study results with literature three databases were searched. Studies were eligible for inclusion if cases were born in developed countries with isolated gastroschisis after 1990, number of cases >20 and TFEF was reported. RESULTS The cohort study included 204 liveborn cases of isolated gastroschisis. The TFEF, median duration of ventilation and LOS was, 26days (range 6-515), 2days (range 0-90) and 33days (range 11-515), respectively. Overall mortality was 10.8%. TFEF and LOS were significantly longer (P<0.0001) and mortality was fourfold higher in the complex group. Seventeen studies, amongst the current study, were included for further meta-analysis comprising a total of 1652 patients. Mean TFEF was 35.3±4.4days, length of ventilation was 5.5±2.0days, LOS was 46.4±5.2days and mortality risk was 0.06 [0.04-0.07 95%CI]. Outcome of simple and complex gastroschisis was described in five studies. TFEF, ventilation time, LOS were significant longer and mortality rate was 3.64 [1.95-6.83 95%CI] times higher in complex cases. CONCLUSIONS These results give a good indication of the expected TFEF, ventilation time and LOS and mortality risk in children born with isolated gastroschisis, although ranges remain wide. This study shows the importance of dividing gastroschisis into simple and complex for the prediction of outcome.
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Affiliation(s)
- Chiara C M M Lap
- University Medical Center Utrecht, Division Woman and Baby, Department of Obstetrics, Utrecht, The Netherlands..
| | - Maria L Brizot
- Department of Obstetrics and Gynaecology, Hospital das Clínicas, São Paulo University Medical School, São Paulo, SP, Brazil..
| | - Lourens R Pistorius
- University Medical Center Utrecht, Division Woman and Baby, Department of Obstetrics, Utrecht, The Netherlands.; University of Stellenbosch, Department of Obstetrics and Gynaecology, Stellenbosch, South Africa..
| | - William L M Kramer
- University Medical Center Utrecht, Department of Paediatric Surgery, Utrecht, The Netherlands..
| | - Ivo B Teeuwen
- Maastricht University Medical Center+, Department of Anesthesiology, Maastricht, The Netherlands..
| | - Marinus J Eijkemans
- University Medical Center Utrecht, Biostatistics and Research Support, Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands..
| | - Hens A A Brouwers
- University Medical Center Utrecht, Division Woman and Baby, Department of Neonatology, Utrecht, The Netherlands..
| | - Eva Pajkrt
- Academic Medical Center Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam, The Netherlands..
| | - Anton H van Kaam
- Emma Children's Hospital, Academic Medical Center Amsterdam, Department of Neonatology, Amsterdam, The Netherlands..
| | | | - Alex J Eggink
- Radboud University Medical Center, Department of Obstetrics and Gynaecology, Nijmegen, The Netherlands.; Erasmus MC University Medical Centre Rotterdam, Department of Obstetrics and Gynaecology, Rotterdam, The Netherlands..
| | - Arno F van Heijst
- Radboud University Medical Center, Department of Neonatology, Nijmegen, The Netherlands..
| | - Monique C Haak
- Leiden University Medical Center, Department of Obstetrics and Gynaecology, Leiden, The Netherlands.; VU University Medical Center Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam, The Netherlands..
| | | | - Christien Sleeboom
- Pediatric Surgical Center of Amsterdam, Emma Children's Hospital University Medical Center and VU Medical Center, Amsterdam, the Netherlands..
| | - Christine Willekes
- Maastricht University Medical Center+, Department of Obstetrics and Gynaecology, Maastricht, The Netherlands..
| | - Mark A van der Hoeven
- Maastricht University Medical Center+, Department of Neonatology, Maastricht, The Netherlands..
| | - Ernst L van Heurn
- Maastricht University Medical Center+, Department of Paediatric Surgery, Maastricht, The Netherlands.; Pediatric Surgical Center of Amsterdam, Emma Children's Hospital University Medical Center and VU Medical Center, Amsterdam, The Netherlands..
| | - Catherina M Bilardo
- University Medical Center Groningen, Department of Obstetrics and Gynaecology, Groningen, The Netherlands..
| | - Peter H Dijk
- University Medical Center Groningen, University of Groningen, Department of Neonatology Beatrix Children's Hospital, Groningen, The Netherlands..
| | - Robertine van Baren
- University Medical Center Groningen, University of Groningen, Department of Paediatric Surgery, Groningen, The Netherlands..
| | - Rossana P V Francisco
- Department of Obstetrics and Gynaecology, Hospital das Clínicas, São Paulo University Medical School, São Paulo, SP, Brazil..
| | - Ana C A Tannuri
- Department of Pediatric, Pediatric Surgery Division, São Paulo University Medical School, São Paulo, SP, Brazil
| | - Gerard H A Visser
- University Medical Center Utrecht, Division Woman and Baby, Department of Obstetrics, Utrecht, The Netherlands..
| | - Gwendolyn T R Manten
- University Medical Center Utrecht, Division Woman and Baby, Department of Obstetrics, Utrecht, The Netherlands..
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Abstract
Neonatal surgery is recognized as an independent discipline in general surgery, requiring the expertise of pediatric surgeons to optimize outcomes in infants with surgical conditions. Survival following neonatal surgery has improved dramatically in the past 60 years. Improvements in pediatric surgical outcomes are in part attributable to improved understanding of neonatal physiology, specialized pediatric anesthesia, neonatal critical care including sophisticated cardiopulmonary support, utilization of parenteral nutrition and adjustments in fluid management, refinement of surgical technique, and advances in surgical technology including minimally invasive options. Nevertheless, short and long-term complications following neonatal surgery continue to have profound and sometimes lasting effects on individual patients, families, and society.
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Affiliation(s)
- Mauricio A Escobar
- Pediatric Surgery, Mary Bridge Children׳s Hospital, PO Box 5299, MS: 311-W3-SUR, 311 South, Tacoma, Washington 98415-0299.
| | - Michael G Caty
- Section of Pediatric Surgery, Department of Surgery, Yale-New Haven Children׳s Hospital, New Haven, Connecticut
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Bonasso PC, Lucke-Wold B, Hobbs GR, Vaughan RA, Shorter NA, Nakayama DK. Excessive Postoperative Fluid Administration in Infants with Gastroschisis. Am Surg 2016. [DOI: 10.1177/000313481608200828] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Careful fluid management is a cornerstone of neonatology because the cardiovascular, respiratory, and gastrointestinal systems in the newborn are sensitive to overhydration. Fluid management in gastroschisis is complicated by insensible fluid loss and postoperative third-space fluid shifts. Study of perioperative fluid management in gastroschisis is limited and has not undergone careful scrutiny. We reviewed perioperative fluid administration and urine output in all infants with gastroschisis over a 5-year period. Data included whether the patient underwent primary closure or staged repair, weight, and events during hospitalization (length of hospitalization and duration of gastric decompression, parenteral nutrition, and ventilator support). Paired t test gave statistical comparisons with significance at P < 0.05. From 2010 to 2014, 24 patients underwent abdominal closure, 17 had primary and 7 had staged closures. Fluid administration exceeded 100 mL/kg/d after primary closure, and was significantly higher (>150 mL/kg/d; P < 0.05) after staged closure on postoperative days 0 to 5. Postoperative urinary output exceeded 75 mL/kg/d for all patients, with higher volumes reaching 100 mL/kg/d after staged closure on postoperative days 4 to 6 ( P < 0.05). Two patients died of sepsis. All survivors were discharged with intestinal continuity and gaining weight on oral feeding. Patients with gastroschisis received large volumes of fluid after operation despite similarly high urine output and positive daily fluid balances. The amounts of fluid administered after both primary and staged closure may be excessive and potentially deleterious.
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Affiliation(s)
- Patrick C. Bonasso
- Department of Surgery, West Virginia University School of Medicine, Morgantown, West Virginia
| | | | - Gerald R. Hobbs
- Department of Orthopedics, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Richard A. Vaughan
- Department of Surgery, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Nicholas A. Shorter
- Department of Surgery, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Don K. Nakayama
- Department of Surgery, Herbert Wertheim College of Medicine, Florida International University, Florida
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Effectiveness of Wharton’s jelly stem cells in gastroschisis repair using the inner surface of the umbilical cord as a patch. ANNALS OF PEDIATRIC SURGERY 2015. [DOI: 10.1097/01.xps.0000469365.66626.4a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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10
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Ross AR, Eaton S, Zani A, Ade-Ajayi N, Pierro A, Hall NJ. The role of preformed silos in the management of infants with gastroschisis: a systematic review and meta-analysis. Pediatr Surg Int 2015; 31:473-83. [PMID: 25758783 DOI: 10.1007/s00383-015-3691-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/03/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND The pre-formed silo (PFS) is increasingly used in the management of gastroschisis, but its benefits remain unclear. We performed a systematic review and meta-analysis of the literature comparing use of a PFS with alternate treatment strategies. METHODS Studies comparing the use of a PFS with alternate strategies were identified and data extracted. The primary outcome measure was length of time on a ventilator. Mean difference (MD) between continuous variables and 95% confidence intervals were calculated. Risk difference and 95% CI were determined for dichotomous data. RESULTS Eighteen studies, including one randomised controlled trial, were included. Treatment strategy and outcome measures reported varied widely. Meta-analysis demonstrated no difference in days of ventilation, but a longer duration of parenteral nutrition (PN) requirement [MD 6.4 days (1.3, 11.5); p = 0.01] in infants who received a PFS. Subgroup analysis of studies reporting routine use of a PFS for all infants demonstrated a significantly shorter duration of ventilation with a PFS [MD 2.2 days (0.5, 3.9); p = 0.01] but no difference in duration of PN requirement. Other outcomes were similar between groups. CONCLUSION The quality of evidence comparing PFS with alternate treatment strategies for gastroschisis is poor. Only routine use of PFS is associated with fewer days on a ventilator compared with other strategies. No strong evidence to support a preference for any strategy was demonstrated. Prospective studies are required to investigate the optimum management of gastroschisis. Standardised outcome measures for this population should be established to allow comparison of studies.
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Affiliation(s)
- Andrew R Ross
- Department of Paediatric Surgery, Great Ormond Street Hospital, London, UK
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11
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Ma M, Garingo A, Jensen AR, Bliss D, Friedlich P. Complication risks associated with lower versus upper extremity peripherally inserted central venous catheters in neonates with gastroschisis. J Pediatr Surg 2015; 50:556-8. [PMID: 25840062 DOI: 10.1016/j.jpedsurg.2014.08.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 07/07/2014] [Accepted: 08/29/2014] [Indexed: 11/18/2022]
Abstract
PURPOSE To compare the complication rates of lower extremity (LE) and upper extremity (UE) peripherally inserted central catheters (PICCs) in neonates with gastroschisis. METHODS In this retrospective comparative study, neonates with gastroschisis admitted to a level IIId NICU between 2004 and 2013 were identified. Catheter dwell time and complication rates (infiltration, phlebitis, occlusion, migration, infection and thrombosis) between the initial UE and LE PICCs were compared. RESULTS Forty (31%) and eighty-nine (69%) neonates with gastroschisis had their initial PICCs placed from their LE and UE, respectively. Complication rates were significantly higher when PICCs were inserted from LE, especially during silo-reduction and within 5 days after abdominal closure (LE: 20% vs. UE: 3.4%, p<0.01). LE PICCs were 5.0 times more likely to have complications than UE PICCs (OR 95% CI: 1.2-21.5) during this time period. In particular LE PICCs had significantly higher rates of infiltration (LE: 11.5% vs. UE: 1.4%; p=0.025) and phlebitis (LE: 11.5% vs. UE: 0%; p<0.01) in patients who underwent silo-reduction. CONCLUSION LE PICCs are associated with significantly increased risks of infiltration and phlebitis in neonates with gastroschisis during silo-reduction and within 5 days after abdominal closure.
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Affiliation(s)
- Meiyun Ma
- Center for Fetal and Neonatal Medicine, USC Division of Neonatal Medicine, Children's Hospital Los Angeles and LAC+USC Medical Center, Los Angeles, CA, 90027, USA
| | - Arlene Garingo
- Center for Fetal and Neonatal Medicine, USC Division of Neonatal Medicine, Children's Hospital Los Angeles and LAC+USC Medical Center, Los Angeles, CA, 90027, USA
| | - Aaron R Jensen
- Division of Pediatric Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90027, USA
| | - David Bliss
- Division of Pediatric Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90027, USA
| | - Philippe Friedlich
- Center for Fetal and Neonatal Medicine, USC Division of Neonatal Medicine, Children's Hospital Los Angeles and LAC+USC Medical Center, Los Angeles, CA, 90027, USA
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12
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Challenges of improving the evidence base in smaller surgical specialties, as highlighted by a systematic review of gastroschisis management. PLoS One 2015; 10:e0116908. [PMID: 25621838 PMCID: PMC4306505 DOI: 10.1371/journal.pone.0116908] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 12/15/2014] [Indexed: 11/19/2022] Open
Abstract
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.
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Abstract
Abdominal wall defects in foetuses include gastroschisis, exomphalos, bladder exstrophy complex, cloacal exstrophy and body stalk syndrome. The defects that occur more commonly are gastroschisis and exomphalos. In this review we assess the current evidence regarding the incidence, perinatal risk factors, antenatal and postnatal management and outcome for both these conditions. A review of the current surgical practices for management of gastroschisis and exomphalos is discussed.
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Affiliation(s)
- Bhanumathi Lakshminarayanan
- Department of Paediatric Surgery, Level 2, Children's Hospital, John Radcliffe Hospital, Headley Way, Oxford, United Kingdom.
| | - Kokila Lakhoo
- Department of Paediatric Surgery, Level 2, Children's Hospital, John Radcliffe Hospital, Headley Way, Oxford, United Kingdom.
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Lusk LA, Brown EG, Overcash RT, Grogan TR, Keller RL, Kim JH, Poulain FR, Shew SB, Uy C, DeUgarte DA. Multi-institutional practice patterns and outcomes in uncomplicated gastroschisis: a report from the University of California Fetal Consortium (UCfC). J Pediatr Surg 2014; 49:1782-6. [PMID: 25487483 PMCID: PMC4261143 DOI: 10.1016/j.jpedsurg.2014.09.018] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 09/05/2014] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Laura A Lusk
- University of California, San Francisco, Department of Pediatrics -Division of Neonatology
| | - Erin G Brown
- Department of Surgery, Division of Neonatology, University of California, Davis.
| | - Rachael T Overcash
- Department of Reproductive Medicine, Division of Maternal-Fetal Medicine, University of California, San Diego.
| | - Tristan R Grogan
- Department of Medicine, Division of Health Services Research, University of California, Los Angeles.
| | - Roberta L Keller
- Department of Pediatrics, Division of Neonatology, University of California, San Francisco.
| | - Jae H Kim
- Department of Pediatrics, Division of Neonatology, University of California, San Diego.
| | - Francis R Poulain
- Department of Pediatrics, Division of Neonatology, University of California, Davis.
| | - Steve B Shew
- Department of Surgery, University of California, Los Angeles.
| | - Cherry Uy
- Department of Pediatrics, Division of Neonatology, University of California, Irvine.
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Gamba P, Midrio P. Abdominal wall defects: prenatal diagnosis, newborn management, and long-term outcomes. Semin Pediatr Surg 2014; 23:283-90. [PMID: 25459013 DOI: 10.1053/j.sempedsurg.2014.09.009] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Omphalocele and gastroschisis represent the most frequent congenital abdominal wall defects a pediatric surgeon is called to treat. There has been an increased reported incidence in the past 10 years mainly due to the diffuse use of prenatal ultrasound. The early detection of these malformations, and related associated anomalies, allows a multidisciplinary counseling and planning of delivery in a center equipped with high-risk pregnancy assistance, pediatric surgery, and neonatology. At present times, closure of defects, even in multiple stages, is always possible as well as management of most of cardiac-, urinary-, and gastrointestinal-associated malformations. The progress, herein discussed, in the care of newborns with abdominal wall defects assures most of them survive and reach adulthood. Some aspects of transition of medical care will also be considered, including fertility and cosmesis.
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Affiliation(s)
- Piergiorgio Gamba
- Pediatric Surgery, Department of Woman and Child Health, University Hospital, Via Giustiniani 3, Padua 35121, Italy.
| | - Paola Midrio
- Pediatric Surgery, Department of Woman and Child Health, University Hospital, Via Giustiniani 3, Padua 35121, Italy
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Kunz SN, Tieder JS, Whitlock K, Jackson JC, Avansino JR. Primary fascial closure versus staged closure with silo in patients with gastroschisis: a meta-analysis. J Pediatr Surg 2013; 48:845-57. [PMID: 23583145 PMCID: PMC4103994 DOI: 10.1016/j.jpedsurg.2013.01.020] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 12/15/2012] [Accepted: 01/07/2013] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Sarah N Kunz
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
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Variability in Gastroschisis Management: A Survey of North American Pediatric Surgery Training Programs. J Surg Res 2012; 176:159-63. [DOI: 10.1016/j.jss.2011.05.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Revised: 04/05/2011] [Accepted: 05/10/2011] [Indexed: 11/19/2022]
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Bucher BT, Mazotas IG, Warner BW, Saito JM. Effect of time to surgical evaluation on the outcomes of infants with gastroschisis. J Pediatr Surg 2012; 47:1105-10. [PMID: 22703778 PMCID: PMC3658821 DOI: 10.1016/j.jpedsurg.2012.03.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 03/05/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE Our goal is to identify the impact of time to surgical intervention on the outcomes of infants with gastroschisis. METHODS After institutional review board approval, we performed a retrospective review of the medical records of all infants admitted to our institution from 2001 to 2010. Transport, bowel stabilization, and closure times were defined as the time from birth to admission, admission to the first-documented operative intervention, and first operative intervention to abdominal closure, respectively. Outcomes included age at full enteral feeds, total parental nutrition days, ventilator days, and hospital length of stay. Multivariate analysis was used to identify independent predictors of the outcomes. RESULTS One hundred eighteen infants with gastroschisis were included in our study. Transport and bowel stabilization times were not predictive of any outcome. However, the time to abdominal wall closure and postnatal gastrointestinal complications were independently predictive of age at full enteral feeds, total parenteral nutrition days, and hospital length of stay. CONCLUSION Time to surgical evaluation/bowel stabilization was not predictive of any clinically relevant outcomes in infants with gastroschisis. These data demonstrate that potential benefits from prenatal regionalization of infants with gastroschisis are not supported by decreased time to operative intervention.
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Ledbetter DJ. Congenital Abdominal Wall Defects and Reconstruction in Pediatric Surgery. Surg Clin North Am 2012; 92:713-27, x. [DOI: 10.1016/j.suc.2012.03.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Bowel-defect disproportion in gastroschisis: does the need to extend the fascial defect predict outcome? Pediatr Surg Int 2012; 28:495-500. [PMID: 22331201 DOI: 10.1007/s00383-012-3055-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2012] [Indexed: 10/28/2022]
Abstract
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.
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Orion KC, Krein M, Liao J, Shaaban AF, Pitcher GJ, Shilyansky J. Outcomes of plastic closure in gastroschisis. Surgery 2011; 150:177-85. [DOI: 10.1016/j.surg.2011.05.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Accepted: 05/11/2011] [Indexed: 10/18/2022]
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Schmidt AF, Gonçalves A, Bustorff-Silva JM, Oliveira Filho AG, Marba ST, Sbragia L. Does staged closure have a worse prognosis in gastroschisis? Clinics (Sao Paulo) 2011; 66:563-6. [PMID: 21655747 PMCID: PMC3093785 DOI: 10.1590/s1807-59322011000400007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Accepted: 12/21/2010] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Augusto Frederico Schmidt
- Discipline of Pediatric Surgery, Department of Surgery, School of Medical Sciences, State University of Campinas, Brazil
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