Nonoperative management of a giant omphalocele using a silver impregnated hydrofiber dressing: a case report

Choice of topical substances in the conservative management of Exomphalos - A systematic review

AIM

Exomphalos is a congenital anomaly found in 1/4500 newborns. Choice of non-operative management of exomphalos major unamenable to primary repair is controversial. This study aims at reviewing conservative management modalities and compare outcomes and complications.

METHODS

A systematic review was performed according to PRISMA guidelines of all English publications in MEDLINE and EMBASE databases. Search words were exomphalos OR omphalocoele AND conservative OR non-operative AND management. Studies were scrutinised for patient demographics, co-morbidities, mode of treatment, time to full feeds, time to full epithelialisation, length of stay, complications and mortality. Studies not specifically describing mode of management and/or describing primary or staged surgical repairs were excluded.

RESULTS

Initial search resulted in 1243 studies. Forty-two studies were deemed suitable offering 822 patients for analysis after excluding duplicates and non-eligible studies. Management methods varied including painting with Alcohol, Mercurochrome, silver products, Povidone Iodine, honey and other materials. Mortality was mostly due to associated anomalies. There was mixed reporting of alcohol, silver, Povidone Iodine and mercury toxicity as well as infection during the course of treatment.

CONCLUSION

This report has recognised the variations in topical substances employed for conservative management with no clear consensus. Reports on safety of different methods remain unclear.

Paint and wait management of giant omphaloceles

Management of the very large defect or those in patients with severe comorbidities has evolved to the use of methods that result in escharification and eventual skin coverage over the viscera. This treatment strategy employs principles that were described in the early 20th century. This review will describe the history, principles, methods, and outcomes from the so called 'paint and wait' management of omphalocele.

Repair of a Giant Omphalocele in an Infant With a Pericardial Implant Crosslinked With Oligourethane

The giant omphalocele (GO) represents a challenge for the pediatric surgeon in its management and wall abdominoplasty. Here, we report the outcome of a case in which a GO in a newborn patient was repaired with an implant derived from decellularized bovine pericardium crosslinked with oligourethane. The implantation time was extended for 6 months. This was then followed up by the retrieval of the implant and the subsequent reconstruction in a second surgical time by the closure of the abdominal wall fascia. A short hospital stay, early integration into the patient's family environment, as well as early onset of the oral route without special care of the implant or reconstructed wall nor food restrictions were observed. The reduced presence of the complications described in the literature after application of surgical meshes suggests that this implant can be an effective and safe alternative method in the treatment of abdominal wall defects such as GO.

Silver-impregnated hydrofiber dressing followed by delayed surgical closure for management of infants born with giant omphaloceles

OBJECTIVE

We successfully employed silver-impregnated hydrofiber dressing for management of giant omphaloceles (GO) followed by delayed surgical closure.

STUDY DESIGN

Between 2005 and 2008, eight consecutive GO infants were cared for at Driscoll Children's Hospital. Four patients had additional congenital anomalies including Beckwith-Wiedemann (n = 1), tetralogy of Fallot (n = 1), pulmonary hypoplasia (n = 1), and ruptured omphalocele (n=1). Infants underwent amnion epithelization using a silver-impregnated hydrofiber dressing over the course of several months followed by delayed surgical closure. Mean ± SD of parameters including maternal age, gestational age, infant weight, size of GO, preoperative intubation, preoperative hospitalization, time to epithelization, days to surgical closure, postoperative hospitalization, postoperative intubation and months of follow-up were studied.

RESULTS

Five patients underwent successful closure, 2 were lost to follow-up and 1 was lost because of withdrawal of support. The maternal age, gestation age and weight of infant were 28 ± 5.3 years, 34 ± 4 weeks and 2.5 ± 0.62 kg, respectively. The GO size was 11 cm in length and 11 cm in width, respectively. Preoperative hospitalization days were 78 ± 74 days. Preoperative intubation was 3.5 ± 3.1 days with 2 neonates requiring tracheostomy and home ventilation owing to additional congenital abnormalities. Time to epithelization was 2.9 ± 0.9 months. Days to surgical closure and postoperative hospitalization were 331 ± 119 days and 5 ± 3.4 days, respectively. Average follow-up was 37 ± 27 months. No treatment associated morbidities are noted.

CONCLUSIONS

Silver-impregnated hydrofiber mediated epithelization of GO followed by delayed surgical closure is safe for management of infants.

Abdominal wall defects: prenatal diagnosis, newborn management, and long-term outcomes

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.

Advances in surgery for abdominal wall defects: gastroschisis and omphalocele

Abdominal wall defects (AWDs) are a common congenital surgical problem in fetuses and neonates. The incidence of these defects has steadily increased over the past few decades due to rising numbers of gastroschisis. Most of these anomalies are diagnosed prenatally and then managed at a center with available pediatric surgical, neonatology, and high-risk obstetric support. Omphaloceles and gastroschisis are distinct anomalies that have different management and outcomes. There have been a number of recent advances in the care of patients with AWDs, both in the fetus and the newborn, which will be discussed in this article.