Management of a giant omphalocele with an external skin closure system

Use of a new vertical traction device for early traction-assisted staged closure of congenital abdominal wall defects: a prospective series of 16 patients

PURPOSE

Abdominal wall closure in patients with giant omphalocele (GOC) and complicated gastroschisis (GS) remains to be a surgical challenge. To facilitate an early complete abdominal wall closure, we investigated the combination of a staged closure technique with continuous traction to the abdominal wall using a newly designed vertical traction device for newborns.

METHODS

Four tertiary pediatric surgery departments participated in the study between 04/2022 and 11/2023. In case primary organ reduction and abdominal wall closure were not amenable, patients underwent a traction-assisted abdominal wall closure applying fasciotens®Pediatric. Outcome parameters were time to closure, surgical complications, infections, and hernia formation.

RESULTS

Ten patients with GOC and 6 patients with GS were included. Complete fascial closure was achieved after a median time of 7 days (range 4-22) in GOC and 5 days (range 4-11) in GS. There were two cases of tear-outs of traction sutures and one skin suture line dehiscence after fascial closure. No surgical site infection or signs of abdominal compartment syndrome were seen. No ventral or umbilical hernia occurred after a median follow-up of 12 months (range 4-22).

CONCLUSION

Traction-assisted staged closure using fasciotens®Pediatric enabled an early tension-less fascial closure in GOC and GS in the newborn period.

Utility of a Continuous External Tissue Expander in Complex Pediatric Wound Reconstruction

BACKGROUND

Soft tissue reconstruction following traumatic injury can be devastating. Reconstructive treatment modalities can prove to be complex. DermaClose (Synovis Micro Companies Alliance, Inc) is a relatively novel wound closure device that has gained popularity for continuous external tissue expansion (CETE).

METHODS

A single-institution case series of 3 traumatic pediatric soft tissue injuries in which DermaClose was used for soft tissue reconstruction as an alternative to free tissue transfer was presented. A review of the literature to identify similar reported cases was also conducted.

RESULTS

The authors report their success with the use of this continuous external tissue expander in the management of pediatric soft tissue injuries. Open tibial fractures were sustained by 2 patients, and 1 patient suffered an avulsion injury to the scalp; sequential DermaClose application was successfully utilized to achieve wound closure in all cases.

CONCLUSIONS

The minimal amount of data currently available in the literature that document the use of this continuous external tissue expander in pediatric patients suggest that its safety and efficacy are inadequately investigated in this population. The cases included in this report suggest DermaClose may be an alternative to traditional methods for complex soft tissue closure in pediatric patients. For larger wounds, repeat applications with sequential closure should be expected and is described in an algorithm within this report.

Management of Large Pediatric Wound Defects Using a Continuous External Tissue Expander

Both internal and external tissue expanders take advantage of the innate adaptive mechanisms the skin exerts in response to mechanical tension, known as the stress-relaxation phenomenon. Internal tissue expander use is time-consuming and can be complicated by infection and extrusion. In this case series, continuous external tissue expanders used to manage large pediatric wounds were assessed. Fourteen patients (ages: 4 days to 17 years) with large wounds underwent continuous external tissue expansion intraoperatively. The success of wound closure was assessed. In addition, the size of the patient’s wounds, duration of device application, and postoperative complications were evaluated. The continuous external tissue expander was applied to wound sizes ranging from 14.7 to 560 cm² for 5 to 10 days until the wound was amenable for direct closure. In 11 of the 14 patients, delayed primary closure was achieved. The device significantly reduced the wound sizes of the remaining three cases (average 80% size reduction). There was no incidence of wound dehiscence or infection. This case series demonstrates the benefit of the continuous external tissue expansion in managing pediatric wounds that would not otherwise be amenable to primary closure. The method allows for timely closure with limited risk of infection or extrusion, and should be in the armamentarium of reconstructive plastic surgeons.

Management of giant omphalocele with a simple and efficient nonsurgical silo

INTRODUCTION

Giant omphaloceles can be a challenge for pediatric surgeons and neonatologists worldwide. It is a rare and low-frequency congenital anomaly with no standardized management schemes or treatment protocols. Over the past few decades, we have developed a simple and efficient staged management for giant omphaloceles that allows definitive closure in the neonatal period, the results of which we outline in this report.

MATERIAL AND METHODS

With IRB approval, a retrospective and multicentric cohort study was carried out between 1994 and 2019 with patients with giant omphalocele defined as an abdominal wall defect greater than 5 cm in diameter and/or that contains more than 50% of the liver within the sac. We included all patients managed with the nonsurgical silo technique. Data on demographics, gestational age, associated malformations, amnion reduction and inversion time, anatomic closure, requirement of a mesh, intra- and post-silo complications, mortality and follow-up were collected. The technique consists of the construction of a silo with an adhesive hydrocolloid dressing (DuodermⓇ) to achieve an omphalocele staged-reduction until complete abdominal reintegration of the liver and bowel preservation of the amnion sac. This also enables the simulation of abdominal closure before definitive surgical closure, being managed in the neonatal intensive care unit (NICU).

RESULTS

Forty patients, 21 of whom were female, were managed with this technique. The average weight was 2900 gs (890-3900), and the median gestational age was 38 weeks (28-40). In total, 37.5% of cases had an associated comorbidity. The average silo reduction time was 7.3 days (0-35), the average time of amnion inversion was 5 days (2-9), and the average time to closure was 14.6 days (6-38). Anatomical closure was achieved in 95% of cases. In 4 patients, an absorbable mesh was used to reinforce the anatomical closure, and in 2 patients (5%), a mesh (DualmeshⓇ) was required to achieve an abdominal closure. There was no mortality associated with this nonsurgical silo technique. The average follow-up time was 60 (6 - 288) months.

CONCLUSION

The staged silo management of giant omphalocele in this series is safe and effective and reduces the time to closure and potential morbidity and mortality compared with traditional surgical or medical management.

The use of a skin-stretching device combined with vacuum sealing drainage for closure of a large skin defect: a case report

Background

This case report presents the treatment of a large infected skin defect, which was caused by an accidental explosion, through a skin-stretching device combined with vacuum sealing drainage. To the best of our knowledge, the area of the wound that we treated may currently be the largest.

Case presentation

A 41-year-old Asian man was transferred to the Center of Trauma Surgery of our hospital for the closure of an open infected wound with a large skin defect in his right lower limb caused by an accidental explosion of 100 pieces of blasting cap. The wounds located in his right gluteal were approximately 40 cm × 35 cm. On admission, the wounds had hemorrhaged, exhibiting a darkened appearance, and included scattered metallic foreign bodies. Debridement of his right gluteal area was conducted 6 hours after injury. Subsequently, a skin-stretching device combined with vacuum sealing drainage was applied to reduce the skin defect. This treatment proved to be valuable for the closure of the skin defect and to attain successful functional rehabilitation without sciatic nerve entrapment or amputation in this case.

Conclusions

It is difficult to close large skin defects, especially when they are infected. The application of a skin-stretching device combined with vacuum sealing drainage should be commonly applied to treat infected wounds because it is a safe and easy operative technique.

The risk of midgut volvulus in patients with abdominal wall defects: A multi-institutional study

BACKGROUND

The management of malrotation in patients with congenital abdominal wall defects has varied among surgeons. We were interested in investigating the risk of midgut volvulus in patients with gastroschisis and omphalocele to help determine if these patients may benefit from undergoing a Ladd procedure.

METHODS

A retrospective chart review was performed for all patients managed at three institutions born between 1/1/2000 and 12/31/2008 with a diagnosis of gastroschisis or omphalocele. Patient charts were reviewed through 12/31/2012 for occurrence of midgut volvulus or need for second laparotomy.

RESULTS

Of the 414 patients identified with abdominal wall defects, 299 patients (72%) had gastroschisis, and 115 patients (28%) had omphalocele. The mean gestational age at birth was 36.1±2.3weeks, and the mean birth weight was 2.57±0.7kg. There were a total of 8 (1.9%) cases of midgut volvulus: 3 (1.0%) patients with gastroschisis compared to 5 patients (4.4%) with omphalocele (p=0.04).

CONCLUSIONS

Patients with omphalocele have a greater risk of developing midgut volvulus, and a Ladd procedure should be considered during definitive repair to mitigate these risks.

LEVEL OF EVIDENCE

III; retrospective comparative study.

Management of giant omphaloceles: A systematic review of methods of staged surgical vs. nonoperative delayed closure

PURPOSE

Despite the numerous methods of closure for giant omphaloceles, uncertainty persists regarding the most effective option. Our purpose was to review the literature to clarify the current methods being used and to determine superiority of either staged surgical procedures or nonoperative delayed closure in order to recommend a standard of care for the management of the giant omphalocele.

METHODS

Our initial database search resulted in 378 articles. After de-duplification and review, we requested 32 articles relevant to our topic that partially met our inclusion criteria. We found that 14 articles met our criteria; these 14 studies were included in our analysis. 10 studies met the inclusion criteria for nonoperative delayed closure, and 4 studies met the inclusion criteria for staged surgical management.

RESULTS

Numerous methods for managing giant omphaloceles have been described. Many studies use topical therapy secondarily to failed surgical management. Primary nonoperative delayed management had a cumulative mortality of 21.8% vs. 23.4% in the staged surgical group. Time to initiation of full enteric feedings was lower in the nonoperative delayed group at 14.6days vs 23.5days.

CONCLUSION

Despite advances in medical and surgical therapies, giant omphaloceles are still associated with a high mortality rate and numerous morbidities. In our analysis, we found that nonoperative delayed management with silver therapy was associated with lower mortality and shorter duration to full enteric feeding. We recommend that nonoperative delayed management be utilized as the primary therapy for the newborn with a giant omphalocele.

Are paediatric operations evidence based? A prospective analysis of general surgery practice in a teaching paediatric hospital

BACKGROUND/AIM

Paediatric surgical practice should be based upon solid scientific evidence. A study in 1998 (Baraldini et al., Pediatr Surg Int) indicated that only a quarter of paediatric operations were supported by the then gold standard of evidence based medicine (EBM) which was defined by randomized controlled trials (RCTs). The aim of the current study was to re-evaluate paediatric surgical practice 16 years after the previous study in a larger cohort of patients.

METHODS

A prospective observational study was performed in a tertiary level teaching hospital for children. The study was approved by the local research ethics board. All diagnostic and therapeutic procedures requiring a general anaesthetic carried out over a 4-week period (24 Feb 2014-22 Mar 2014) under the general surgery service or involving a general paediatric surgeon were included in the study. Pubmed and EMBASE were used to search in the literature for the highest level of evidence supporting the recorded procedures. Evidence was classified according to the Oxford Centre for Evidence Based Medicine (OCEBM) 2009 system as well as according to the classification used by Baraldini et al. Results was compared using Χ (2) test. P < 0.05 was considered statistically significant.

RESULTS

During the study period, 126 operations (36 different types) were performed on 118 patients. According to the OCEBM classification, 62 procedures (49 %) were supported by systematic reviews of multiple homogeneous RCTs (level 1a), 13 (10 %) by individual RCTs (level 1b), 5 (4 %) by systematic reviews of cohort studies (level 2a), 11 (9 %) by individual cohort studies, 1 (1 %) by systematic review of case-control studies (level 3a), 14 (11 %) by case-control studies (level 3b), 9 (7 %) by case series (type 4) and 11 procedures (9 %) were based on expert opinion or deemed self-evident interventions (type 5). High level of evidence (OCEBM level 1a or 1b or level I according to Baraldini et al. PSI 1998) supported 75 (60 %) operations in the current study compared to 18 (26 %) in the study of 1998 (P < 0.0001).

CONCLUSION

The present study shows that nowadays a remarkable number of paediatric surgical procedures are supported by high level of evidence. Despite this improvement in evidence-based paediatric surgical practice, more than a third of the procedures still lack sufficient evidence-based literature support. More RCTs are warranted to support and direct paediatric surgery practice according to the principals of EBM.

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.