Outcomes of infants with abdominal wall defects over 18years

Is anemia frequently recognized in gastroschisis compared to omphalocele? A multicenter retrospective study in southern Japan

PURPOSE

We compared cases of anemia in gastroschisis versus omphalocele and investigated this clinical question.

METHODS

A multicenter study of five pediatric surgery departments in southern Japan was planned. Sixty patients were collected between 2011 and 2020, with 33 (gastroschisis: n = 19, omphalocele: n = 14) who met the selection criteria ultimately being enrolled. Anemia was evaluated before discharge and at the first outpatient visit.

RESULTS

Despite gastroschisis cases showed more frequent iron administration during hospitalization than omphalocele (p = 0.015), gastroschisis cases tended to show lower hemoglobin values at the first outpatient visit than omphalocele cases (gastroschisis: 9.9 g/dL, omphalocele: 11.2 g/dL). Gastroschisis and the gestational age at birth were significant independent predictors of anemia at the first outpatient visit, (gastroschisis: adjusted odds ratio [OR] 19.00, p = 0.036; gestational age at birth: adjusted OR 0.341, p = 0.028). A subgroup analysis for gastroschisis showed that the ratio of anemia in the 35-36 weeks group (8/10, 80.0%) and the > 37 weeks group (6/6, 100%) was more than in the < 34 weeks group (0/3, 0.0%).

CONCLUSIONS

Gastroschisis may carry an increased risk of developing anemia compared with omphalocele due to the difference of direct intestinal exposure of amnion fluid in utero.

Use of breast milk in infants with uncomplicated gastroschisis: A retrospective cohort study

BACKGROUND

Infants with gastroschisis often experience slow return of bowel function following closure. The purpose of this study was to determine whether exclusive breast milk is associated with decreased time to enteral autonomy.

METHODS

We conducted a retrospective cohort study of infants with uncomplicated gastroschisis from a tertiary pediatric hospital. The primary outcome was enteral autonomy, defined as days from initiating enteral feeds to stopping parenteral nutrition. Secondary outcomes included days of parenteral nutrition, length of stay, positive culture, necrotizing enterocolitis, cholestasis, additional surgery, readmission, and mortality.

RESULTS

We identified 100 infants with gastroschisis treated from 2005 to 2019. Twenty-five were excluded due to gestational age <32 weeks, birth weight <1500 g, or gastroschisis-associated complications (e.g., intestinal atresia). Seventy-five were included in the analysis. Mean gestational age was 36 weeks, 48% were female, and all were diagnosed antenatally. Sixty-five infants (87%) received exclusive maternal (n = 64) or donor (n = 1) breast milk, while 10 others (13%) were fed formula for 1-16 days (mean 7 days). Two infants received formula only. Demographics and gastroschisis prognostic scores were similar between groups. Infants who were given breast milk exclusively demonstrated decreased time to enteral autonomy (median 18 versus 25 days, p = 0.023) and shorter duration of parenteral nutrition (median 20 versus 26 days, p = 0.037).

CONCLUSION

Exclusive breast milk may be associated with improved outcomes among infants with gastroschisis. Further research is needed to evaluate the economic impact of this association and explore possible confounders. These efforts may expand the role of donor breast milk for these patients.

The effect of standardized feeding protocol on early outcome following gastroschisis repair: A systematic review and meta-analysis

BACKGROUND

Improved post-operative outcomes following gastroschisis repair are attributed to advancement in perioperative and post-operative care and early enteral feeding. This study evaluates the role of standardized postoperative feeding protocols in gastroschisis.

STUDY DESIGN

A systematic review and meta-analysis of studies published from January 2000 to April 2019 in MEDLINE, EMBASE, Cochrane Library databases and Google Scholar was conducted. Primary outcomes were duration to full enteral feeding and cessation of parenteral nutrition. Secondary outcomes included days to first enteral feeding, length of stay, compliance, complication and mortality rates. Meta-analysis was done using the RevMan Analysis Statistical Package in Review Manager (Version 5.3) using a random effects model and reported as pooled Risk Ratio and Mean Difference. p-value < 0.05 was considered statistically significant.

RESULTS

Eight observational cohort studies were identified and their data analyzed. Significant heterogeneity was noted for some outcomes. Standardized feeding protocols resulted in fewer days to first enteral feeding by 3.19 days (95% CI: -4.73, -1.66, p < 0.0001) than non-protocolized feeding, less complication rates, reduced mortality and better compliance to care. The duration of parenteral nutrition and time to full enteral feeding were not significantly affected.

CONCLUSION

Protocolized feeding post-gastroschisis repair is associated with early initiation of enteral feeding. There is a likelihood of reduced rates of sepsis; shorter duration of parenteral nutrition, length of hospital stay and time to full enteral feeding. However, the latter trends are not statistically significant and will require further studies best accomplished with a prospective randomized trial or more cohort studies.

Risk factors for perioperative hypothermia and infectious outcomes in gastroschisis patients

INTRODUCTION

Prior data suggest that infants with gastroschisis are at high risk for hypothermia and infectious complications (ICs). This study evaluated the associations between perioperative hypothermia (PH) and ICs in gastroschisis using a multi-institutional cohort.

METHODS

Retrospective review of infants with gastroschisis who underwent abdominal closure from 2013-2017 was performed at 7 children's hospitals. Any-IC and surgical site infection (SSI) were stratified against the presence or absence of PH, and perioperative characteristics associated with PH and SSI were determined using multivariable logistic regression.

RESULTS

Of 256 gastroschisis neonates, 42% developed PH, with 18% classified as mild hypothermia (35.5-35.9 °C), 10.5% as moderate (35.0-35.4 °C), and 13% severe (<35 °C). There were 82 (32%) ICs with 50 (19.5%) being SSIs. No associations between PH and any-IC (p = 0.7) or SSI (p = 0.98) were found. Pulmonary comorbidities (odds ratio (OR)=3.76, 95%CI:1.42-10, p = 0.008) and primary closure (OR=0.21, 95%CI:0.12-0.39, p<0.001) were associated with PH, while silo placement (OR=2.62, 95%CI:1.1-6.3, p = 0.03) and prosthetic patch (OR=3.42, 95%CI:1.4-8.3, p = 0.007) were associated with SSI on multivariable logistic regression.

CONCLUSIONS

Primary abdominal closure and pulmonary comorbidities are associated with PH in gastroschisis, however PH was not associated with increased risk of ICs. Independent risk factors for SSI include silo placement and prosthetic patch closure.

Decentralized surgery of abdominal wall defects in Germany

PURPOSE

Neonatal surgery for abdominal wall defects is not performed in a centralized manner in Germany. The aim of this study was to investigate whether treatment for abdominal wall defects in Germany is equally effective compared to international results despite the decentralized care.

METHODS

All newborn patients who were clients of the major statutory health insurance company in Germany between 2009 and 2013 and who had a diagnosis of gastroschisis or omphalocele were included. Mortality during the first year of life was analysed.

RESULTS

The 316 patients with gastroschisis were classified as simple (82%) or complex (18%) cases. The main associated anomalies in the 197 patients with omphalocele were trisomy 18/21 (8%), cardiac anomalies (32%) and anomalies of the urinary tract (10%). Overall mortality was 4% for gastroschisis and 16% for omphalocele. Significant factors for non-survival were birth weight below 1500 g for both groups, complex gastroschisis, volvulus and anomalies of the blood supply to the intestine in gastroschisis, and female gender, trisomy 18/21 and lung hypoplasia in omphalocele.

CONCLUSIONS

Despite the fact that paediatric surgical care is organized in a decentralized manner in Germany, the mortality rates for gastroschisis and omphalocele are equal to those reported in international data.

Increasing prevalence, time trend and seasonality of gastroschisis in São Paulo state, Brazil, 2005-2016

To estimate the gastroschisis seasonality and trend of prevalence in recent years, stratified by maternal age and geographical clusters of São Paulo state, a population-based study was designed. We used data from the Live Births Information System (SINASC) in São Paulo state, Brazil, from 2005 to 2016. Trends of prevalence were evaluated for the specific subgroups using the Prais-Winsten regression model, and the Durbin-Watson test was used, to estimate the regression coefficient, the annual percent change (APC), and 95% confidence interval (CI). We observed 1576 cases of gastroschisis among 7,317,657 live births (LB), a prevalence of 2.154 (95% CI: 2.047-2.260) per 10,000 LB which included, 50.6% males, 67.4% Caucasians, 53.4% preterm births, and 80.9% caesarean births. The prevalence of gastroschisis significantly increased by 2.6% (95% CI: 0.0-5.2) per year, and this trend was higher in mothers aged 30-34 years (APC: 10.2, 95% CI: 1.4-19.4) than in mothers of other age groups. Between 2011 and 2016, we identified the existence of seasonality based on the date of conception in the middle months of the year (p = 0.002). This is the first and largest population-based study summarizing current epidemiology and identifying trend of prevalence of gastroschisis in São Paulo state.

Low and decreased prevalence of congenital abdominal wall defect in Taiwan

PURPOSE

This study aims to identify the prevalence of Congenital abdominal wall defects (AWD), hospital outcomes, and related congenital abnormalities in Taiwan by using the National Health Insurance Research Database (NHIRD).

MATERIALS AND METHODS

From 1998 through 2013, all pediatric patients with AWD were collected via ICD-9-CM diagnostic code 756.7x ("congenital anomalies of abdominal wall") or procedure codes (54.71, 54.72 for Gastroschisis repair (GS-repair); 54.63, 53.41, 53.49 for other abdominal wall repair (O-AWD)) recoded in NHIRD. We used public national birth data for calculating the prevalence. We used CDC/BPA coding rubrics to identify accompanying congenital abnormalities.

RESULTS

A total 594 babies with AWD, including 179 patients in GS-repair group and 326 patients in O-AWD-repair group, are identified with 113.5 months median followed-up. The overall prevalence for AWD was 1.65 in 10,000 births and decreased over time. The prevalences of GS-repaired and O-AWD-repaired are 0.50 and 0.90 in 10,000 births. The 1-year-mortality rates of GS-repair and O-AWD-repair are 6.15% and 7.23%. 24.58% GS-repair patients and 30.06% O-AWD-repair patients have congenital abnormalities. 8.38% GS-repair patients and 6.44% O-AWD-repair patients received the following groin hernia-repair procedures.

CONCLUSION

Our results showed that the prevalence of AWD was low and decreased over time in Taiwan.

LEVEL OF EVIDENCE

Level II: Prognosis Study, Retrospective study.

Error traps and culture of safety in the treatment of abdominal wall defects

The importance of defining and implementing a culture of safety in pediatric surgery is being increasingly seen as essential to decreasing complications and improving outcomes. The concept of a safety culture is a universal one, but the elements of such a culture are different for every disease and anomaly treated. In this paper, I will review these elements as they pertain to the treatment of abdominal wall defects starting from fetal evaluation to post-discharge care.

A randomised controlled trial of amnioexchange for fetal gastroschisis

OBJECTIVE

Morbidity in fetuses affected by gastroschisis is mainly the result of bowel ischaemic and inflammatory processes. Experimental studies on animal models show that clearing amniotic fluid from the digestive secretions by amnioexchange procedures reduces the inflammatory process. We evaluated the benefit of the amnioexchange procedure for fetal gastroschisis in humans.

DESIGN

Prospective, interventional, randomised study.

SETTING

Eight referral centres for fetal medicine.

POPULATION

Pregnant women carrying a fetus with gastroschisis.

METHODS

We compared, in utero, amnioexchange with a sham procedure. The protocol included, in both arms, steroid injections at 30 weeks of gestation and the use of postnatal minimal enteral feeding.

MAIN OUTCOME MEASURES

The primary outcome was a composite variable based on the duration of ventilation and parenteral nutrition. Secondary outcomes were the effectiveness and safety of the amnioexchange procedure, including the rate of perinatal death, time to full enteral feeding, primary closure, and late feeding disorders.

RESULTS

Sixty-four patients were randomised. There was no difference in the composite criteria between the amnioexchange and control groups. Based on an intention-to-treat analysis, there were no significant between-group differences in pregnancy outcome or complications. When studying the relationship between digestive compounds and amniotic fluid inflammatory markers, a clear correlation was found between bile acid and both ferritin and interleukin 1β (IL1β).

CONCLUSIONS

In humans, amnioexchange, as described in our protocol, is not an option for fetal care; however, we provide supplementary proof of the involvement of inflammation in the pathogenicity of gastroschisis and suggest that future research should aim at reducing inflammation. ClinicalTrials.gov: NCT00127946.

TWEETABLE ABSTRACT

A prospective, interventional, randomised study shows no benefit of amnioexchange for fetal gastroschisis in humans.

Mode of delivery and mortality among neonates with gastroschisis: A population-based cohort in Texas

BACKGROUND

Mode of delivery is hypothesised to influence clinical outcomes among neonates with gastroschisis. Results from previous studies of neonatal mortality have been mixed; however, most studies have been small, clinical cohorts and have not adjusted for potential confounders.

OBJECTIVES

To evaluate whether caesarean delivery is associated with mortality among neonates with gastroschisis.

METHODS

We studied liveborn, nonsyndromic neonates with gastroschisis delivered during 1999-2014 using data from the Texas Birth Defect Registry. Using multivariable Cox proportional hazards regression, we separately assessed the relationship between caesarean and death during two different time periods, prior to 29 days (<29 days) and prior to 365 days (<365 days) after delivery, adjusting for potential confounders. We also updated a recent meta-analysis on this relationship, combining our estimates with those from the literature.

RESULTS

Among 2925 neonates with gastroschisis, 63% were delivered by caesarean. No associations were observed between caesarean delivery and death <29 days (adjusted hazard ratio [aHR] 1.00, 95% confidence interval [CI] 0.63, 1.61) or <365 days after delivery (aHR 0.99, 95% CI 0.70, 1.41). The results were similar among those with additional malformations and among those without additional malformations. When we combined our estimate with prior estimates from the literature, results were similar (combined risk ratio [RR] 1.00, 95% CI 0.84, 1.19).

CONCLUSIONS

Although caesarean rates among neonates with gastroschisis were high, our results suggest that mode of delivery is not associated with mortality among these individuals. However, data on morbidity outcomes (eg intestinal damage, infection) were not available in this study.

Congenital Heart Defects Coexisting with Omphalocele - the Important Prognostic Factor

Introduction: The aim of this study was to evaluate the following parameters of fetuses and neonates with omphalocele: the prevalence of coexisting congenital heart defects (CHD), abnormalities in heart function and the impact of coexisting CHD on fetal and neonatal survival. Material and methods: The study group consisted of 69 fetuses with omphalocele diagnosed and monitored at the Department of Prenatal Cardiology in our Institute in the years 2007-2017. The retrospective analisis of patients' data was performed. For statistical analysis we used Chi-square test, t-Student test and U Mann-Whitney test.. Results: In the studied group omphalocele was an isolated defect in 31.9% of the cases (22/69), in 68.1% (47/69) coexisting defects were present, in 49.3% (34/69) the coexisting defect was CHD. The most common CHD coexisting with omphalocele were ventricular septal defect (VSD), double outlet right ventricle (DORV) and atrio-ventricular septal defect (AVSD). Abnormalities of heart function were present in 43.5% (30/69) of fetuses with omphalocele: 23.5% (8/34) with normal heart anatomy and in 62.9% (22/35) with CHD. Statistically significant differences between the group with normal heart anatomy and the group with CHD regarded: Cardiovascular Profile Score (CVPS) (median 10 points vs median 9 points, U Mann-Whitney test p=0.034), neonatal birth weight(mean 3253 g vs median 2700 g, U Mann-Whitney test p=0.003), Apgar score (median 8 vs median 7, U Mann-Whitney test p=0.038) and survival rate until discharge from hospital (85% vs 52.9%, Chi-square test p=0.034). The comparison of data from 2007-2017 with data obtained from similar analysis performed in our center in 1999-2006, revealed significant improvement in the early detection of omphalocele (median 14.5 weeks of gestation vs mean 25.4 weeks of gestation), gestational age of delivery (mean 38 weeks of gestation vs mean 34 weeks of gestation) and survival rate until discharge both in neonates with normal heart anatomy and coexisting CHD (85% and 52.9% vs 70% and 23% respectively) . Conclusions: 1. The presence of coexisting CHD is an important prognostic factor in fetuses and neonates with omphalocele, so early fetal echocardiography should be performed in every case of omphalocele. 2. During the last decade (2007-2017), in contrast to years 1999-2006, we observed significant improvement in early and complete prenatal diagnosis of omphalocele. 3. We observed improvement in strategy of obstetrical management resulting in delivering neonates in a more advanced gestational age both in the group with normal heart anatomy and the group with coexisting CHD.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Cognition and behaviour in children with congenital abdominal wall defects

AIM

To characterise neurodevelopment at age two years and cognition and behaviour at age five years in children born with abdominal wall defects (gastroschisis or exomphalos).

STUDY DESIGN

Participants were treated as neonates for gastroschisis or exomphalos and invited for routine clinical follow-up at ages two and five years. Thirty-nine two year-olds and 20 five year-olds with gastroschisis and 20 two year-olds and 10 five year-olds with exomphalos returned for age-appropriate assessments of development (two years) and intellectual functioning (IQ), executive function, and behavioural problems. Results were compared with normative data from the tests and published data from local term-born children.

RESULTS

For both gastroschisis and exomphalos two year-olds, neurodevelopment was in line with the test normative data, but below the level of local normative data for all domains (effect sizes from -0.4 to -1.4 standard deviations). At five years, children with gastroschisis performed similarly to the normative mean for IQ but had high rates of various executive functioning problems on parent report (18-41% compared with 7% expected from norms). There was also a tendency for increased frequency of internalising problems (33% compared with normative expectation of 16%). Five year-olds with exomphalos also performed similarly to the normative mean for IQ and had low rates of executive and behavioural problems.

CONCLUSIONS

Survivors of gastroschisis and exomphalos may be at risk of poor neurodevelopment in toddlerhood, depending on the reference group, and children with gastroschisis may be particularly at risk for executive functioning difficulties despite an IQ within normal limits.

Infectious outcomes of gastroschisis patients with intraoperative hypothermia

BACKGROUND

Perioperative hypothermia decreases nutrient and oxygen delivery to tissues and, in adult studies, increases the risk of infectious complications (ICs). Gastroschisis (GS) places newborns at risk for hypothermia by nature of exposed viscera and excessive heat loss. Although hypothermia is a known cause of mortality in GS, the rate of ICs in this at-risk cohort has not yet been delineated.

MATERIALS AND METHODS

A retrospective cohort study was performed at our single tertiary-referral hospital, evaluating patient and operative characteristics of all GS infants who underwent operative closure. Intraoperative temperatures were recorded, defining hypothermia as mild (35.5°C-35.9°C), moderate (35.0°C-35.4°C), or severe (<35°C). Temperature nadirs, procedural and anesthesia duration were observed. The primary outcome was 30-d surgical site infections. Secondary measures included other ICs.

RESULTS

Among 43 GS neonates, 21 (48.8%) had intraoperative hypothermia, classified as mild in 2 (4.7%), moderate in 8 (18.6%), and severe in 11 (25.6%). Nineteen ICs occurred in 35.9% of patients, including 10 (23.3%) surgical site infections. There was no association between hypothermia and ICs. Patient and operative characteristics were similar between normothermic and hypothermic groups, except that normothermic infants were more likely to have silos placed with delayed closure than hypothermic patients (63.6% versus 23.8%, P = 0.01).

CONCLUSIONS

Infants with GS are at high risk for hypothermia and ICs, though newborns with silos were less subject to temperature lability. A multiinstitutional study with greater power is needed to further investigate the relationship between perioperative hypothermia and surgical ICs.