Prenatal diagnosis of abdominal wall defects and their prognosis

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.

Muscle imbalance as a cause of scoliosis: a study in a fetal lamb abdominal wall defect model

BACKGROUND

We created abdominal wall defects (AWD) in fetal lambs to investigate possible causes of scoliosis.

METHODS

We incised the upper abdominal wall (including Rectus) in 60-day gestation fetal lambs, from the midline to either the right (Group A) or left (Group B) costal margin, in 14 lambs carried by 7 ewes. They were delivered by cesarean section at term (about 145 days). Scoliosis was evaluated by anterio-posterior X-rays, determining the Cobb angle.

RESULTS

Four fetuses in Group A and 3 in Group B survived. There were 3 successful AWD lambs Group A and 2 in Group B. One lamb in each group survived with the AWD covered with a thick capsule. The convexity of spinal curve was the direction of scoliosis. Right scoliosis was only seen in the 4 Group A lambs. Left scoliosis was only seen in Group B lambs (2/3, 67%). The mean Cobb angle was 41.7 ± 11.5° in Group A and in Group B the Cobb angles were 59.6^o and 60.6°. Overall, 4/5 lambs with organ prolapse (80%) and both lambs without organ prolapse had scoliosis.

CONCLUSION

Muscle imbalance may contribute to the development of scoliosis in a fetal lamb AWD model.

A multi-country study of prevalence and early childhood mortality among children with omphalocele

BACKGROUND

Omphalocele is the second most common abdominal birth defect and often occurs with other structural and genetic defects. The objective of this study was to determine omphalocele prevalence, time trends, and mortality during early childhood, by geographical region, and the presence of associated anomalies.

METHODS

We conducted a retrospective study with 23 birth defect surveillance systems in 18 countries who are members of the International Clearinghouse for Birth Defects Surveillance and Research that submitted data on cases ascertained from 2000 through 2012, approximately 16 million pregnancies were surveyed that resulted in live births, stillbirths, or elective terminations of pregnancy for fetal anomalies (ETOPFA) and cases with omphalocele were included. Overall prevalence and mortality rates for specific ages were calculated (day of birth, neonatal, infant, and early childhood). We used Kaplan-Meier estimates with 95% confidence intervals (CI) to calculate cumulative mortality and joinpoint regression for time trend analyses.

RESULTS

The prevalence of omphalocele was 2.6 per 10,000 births (95% CI: 2.5, 2.7) and showed no temporal change from 2000-2012 (average annual percent change = -0.19%, p = .52). The overall mortality rate was 32.1% (95% CI: 30.2, 34.0). Most deaths occurred during the neonatal period and among children with multiple anomalies or syndromic omphalocele. Prevalence and mortality varied by registry type (e.g., hospital- vs. population-based) and inclusion or exclusion of ETOPFA.

CONCLUSIONS

The prevalence of omphalocele showed no temporal change from 2000-2012. Approximately one-third of children with omphalocele did not survive early childhood with most deaths occurring in the neonatal period.

Giant Gastroschisis with Complete Liver Herniation: A Case Report of Two Patients

Introduction

There are no reported survivors of gastroschisis with complete liver herniation. We describe a case report of two patients, one of whom survived.

Case #1

The patient was born with gastroschisis and herniation of the entire liver. Along with silo placement, the abdominal fascia was attached to an external traction system for growth. Complete closure was achieved at 5 months. Due to pulmonary hypoplasia, high-frequency ventilation was required. The patient is doing well, on a home ventilator wean, at 20 months.

Case #2

The patient was born prematurely with gastroschisis, total liver herniation, and a defect extending to the pericardium. A silo was attached to the fascia to provide growth of the abdominal cavity. The patient developed respiratory failure, diffuse anasarca, and renal failure. She died at 38 days of life.

Discussion

We report the first survivor of gastroschisis with complete liver herniation, contrasting it with a death of a similar case. The associated pulmonary hypoplasia may require long-term ventilation, the inflammatory response can lead to anasarca, and renal injury can occur from acute-on-chronic compartment syndrome.

Conclusion

External fascial traction systems can help induce growth of the abdominal wall, allowing closure of the challenging abdomen. While critical care management is complex, survival is possible.

Early surgical management for giant omphalocele: Results and prognostic factors

OBJECTIVES

Giant omphalocele often represents a major surgical challenge and is reported with high mortality and morbidity rates. The aim of this study was to assess the outcome of neonates with giant omphalocele managed with early operative surgical treatment, and subsequently to identify possible factors that could alter the prognosis.

METHODS

We reviewed the medical records of 29 consecutive newborns with prenatally diagnosed giant omphalocele. In these cases one of two procedures had been performed: either staged closure after silo, or immediate closure with a synthetic patch. The cases were separated into 2 groups: Isolated giant omphalocele (IO group) and giant omphalocele associated with malformation (NIO group).

RESULTS

Infants in the IO group had a lower size of the omphalocele (p<0,001), a shorter hospital stay (95 days [45-915] vs. 41.5 days [10-110] p= 0, 02), and a shorter median ventilation length (10 days [1-33] vs. 27, 5 [6-65] p = 0, 05). In the NIO group, 5 cases displayed a significantly more difficult course than the others. They were compared to the remaining cases for prenatal and anatomic features. Four factors associated with greater morbidity were identified: CONCLUSIONS: Isolated omphalocele, even containing the whole liver, has a very good prognosis with early surgical treatment. Without associated anomalies, 95% of giant omphaloceles can be discharged with a median of 41.5 days in hospital. However, associated anomalies (especially cardiopathies) may burden the prognosis and should be both carefully assessed during pregnancy and taken into account in parental information.

TYPE OF STUDY

Retrospective Study LEVEL OF EVIDENCE: Level I.

Delayed Closure of Giant Omphaloceles in West Africa: Report of Five Cases

Giant omphalocele (GO) management is controversial and not easy. Conservative management at birth and delayed surgical closure is usually mandatory. Postponed surgery may be challenging and carry the risk of intensive care treatment. We report on five children who were treated in our department for GO between 2000 and 2010. Initially, the patients were managed conservatively in West Africa. Delayed closure of the ventral hernia was performed in Switzerland after patient transfer through a nongovernmental organization. Fascial closure was performed at the median age of 23 months. Median diameter of the hernias was 10 × 10 cm ranging from 10 × 8 cm to 24 × 15 cm. Four (80%) patients had associated anomalies. Three children needed mechanical ventilation in the intensive care unit after surgery. Median hospitalization was 19 days. Complications were seen in two patients. The follow-up showed no recurrence of ventral hernia. There was no mortality.

This report shows that conservative management of a GO at birth with delayed closure of the ventral hernia after transferring the patients to a European center is a safe approach for West African children and avoids life-threatening procedures. Delayed closure of a GO may be nevertheless challenging everywhere.

High Prevalence of Pulmonary Hypertension Complicates the Care of Infants with Omphalocele

BACKGROUND

Omphalocele is one of the most common abdominal wall defects. Many newborn infants born with omphalocele present with significant respiratory distress at birth, requiring mechanical ventilatory support, and have clinical evidence of pulmonary hypertension. Little information exists on the prevalence of and risk factors associated with pulmonary hypertension in this cohort of infants.

OBJECTIVES

To describe the prevalence of and risk factors associated with pulmonary hypertension among infants with omphalocele.

METHODS

This is a multicenter retrospective chart review of demographic data and clinical characteristics of infants with omphalocele admitted to the neonatal intensive care units of Loma Linda University Children's Hospital and Children's Mercy Hospital between 1994 and 2011. Echocardiogram images were reviewed for pulmonary hypertension, and statistical analyses were performed to identify risk factors associated with the presence of pulmonary hypertension.

RESULTS

Pulmonary hypertension was diagnosed in 32/56 (57%) infants with omphalocele. Compared to infants without pulmonary hypertension, infants with pulmonary hypertension were more likely to have a liver-containing defect (16/32 [50%] vs. 5/24 [21%], p = 0.03), require intubation at birth (18/32 [56%] vs. 6/24 [17%], p = 0.03), and die during initial hospitalization (12/32 [38%] vs. 2/24 [8%], p = 0.01).

CONCLUSION

The majority of infants with omphalocele have evidence of pulmonary hypertension which is associated with increased mortality. Echocardiograms to screen for pulmonary hypertension should be obtained at ≥2 days of life in infants with omphalocele, especially in those with liver within the omphalocele sac and/or in those infants who require intubation at birth to screen for pulmonary hypertension.

Systemic hypertension in giant omphalocele: An underappreciated association

PURPOSE

To evaluate the incidence, severity and duration of systemic hypertension in infants born with giant omphalocele (GO).

METHODS

A retrospective review of patients born from 2003 through 2013 with a GO or intestinal atresia (control population) and managed at a single institution was performed. The hospital course was reviewed including all blood pressures, method of omphalocele repair, requirement for antihypertensive medications and renal function.

RESULTS

Forty-five GO and 20 control patients met criteria for the study. Thirty-three GO patients underwent Schuster repair and 12 GO patients underwent delayed repair after epithelialization. Overall, 78% of GO patients had episodes of hypertension (82% Schuster and 67% delayed repair) compared to 15% of control patients (P<0.001). The majority of episodes were transient and occurred in the postoperative period (97%). Hypertension was persistent in 4 GO patients. These patients required antihypertensive medication at discharge, which was discontinued as an outpatient. No patient demonstrated significant evidence of renal abnormalities as indicated by renal ultrasound, urinalysis and/or serum creatinine level at the time of hypertension.

CONCLUSION

Episodes of systemic hypertension are frequent in patients with GO. Episodes are often post-operative, transient and can be present in patients undergoing either a delayed or Schuster repair. A small subset of patients will have persistent hypertension requiring antihypertensive medication that can be weaned off in an outpatient setting.

Metaanalysis of the prevalence of intrauterine fetal death in gastroschisis

OBJECTIVE

The objective of this study was to review the medical literature that has reported the risk for intrauterine fetal death (IUFD) in pregnancies with gastroschisis.

STUDY DESIGN

We systematically searched the literature to identify all published studies of IUFD and gastroschisis through June 2011 that were archived in MEDLINE, PubMed, or referenced in published manuscripts. The MESH terms gastroschisis or abdominal wall defect were used.

RESULTS

Fifty-four articles were included in the metaanalysis. There were 3276 pregnancies in the study and a pooled prevalence of IUFD of 4.48 per 100. Those articles that included gestational age of IUFD had a pooled prevalence of IUFD of 1.28 per 100 births at ≥36 weeks' gestation. The prevalence did not appear to increase at >35 weeks' gestation.

CONCLUSION

The overall incidence of IUFD in gastroschisis is much lower than previously reported. The largest risk of IUFD occurs before routine and elective early delivery would be acceptable. Risk for IUFD should not be the primary indication for routine elective preterm delivery in pregnancies that are affected by gastroschisis.

Assessment of early pulmonary function abnormalities in giant omphalocele survivors

PURPOSE

Infants with giant omphalocele (GO) are at increased risk for persistent respiratory insufficiency, yet information regarding the systematic assessment of their lung function is limited. We performed a group of pulmonary function tests (PFTs) including spirometry, fractional lung volume measurements, assessment of bronchodilator responsiveness, and passive respiratory mechanics in GO survivors during infancy and early childhood to evaluate the nature and degree of pulmonary dysfunction.

MATERIAL AND METHODS

Between July 2004 and June 2008, 30 consecutive GO survivors were enrolled in our interdisciplinary follow-up program. Forty-seven percent (14/30) underwent PFT during follow-up evaluation using the raised volume rapid thoracic compression technique to measure forced expiratory flows and bronchodilator responsiveness, body plethysmography to calculate lung volumes, and the single breath occlusion technique to measure passive mechanics of the respiratory system.

RESULTS

The mean age at PFT assessment was 19.3 ± 19.7 months (range, 1.0-58). Mean forced vital capacity and mean forced expiratory volume in the first 0.5 second were significantly reduced compared with published normative values (P = .03 and P < .01, respectively). Total lung capacity was significantly reduced (P < .001), whereas functional residual capacity, residual volume, and residual volume to total lung capacity ratio were within the normative range (P = .21, P = .34, and P = .48, respectively). Among the 46% who demonstrated significant bronchodilator responsiveness, there were greater increases in the mean percentage changes in flow at 25% to 75% (P = .01), flow at 75% (P < .001), and flow at 85% (P < .001) compared with those participants that did not respond. Specific compliance was reduced, whereas specific conductance increased, compared with published normal results.

CONCLUSIONS

Abnormalities of pulmonary function in GO survivors include lung volume restriction without airway obstruction, an increased likelihood of airway hyperresponsivness, and reduced respiratory system specific compliance. Early recognition of pulmonary functional impairment in GO survivors could help to develop targeted treatment strategies to reduce the risk of subsequent pulmonary morbidity.

Perinatal outcome in the live-born infant with prenatally diagnosed omphalocele

We compared perinatal outcomes between live-born nonisolated and isolated omphaloceles diagnosed during a prenatal ultrasound. Fetuses (n = 86) with omphalocele were identified between 1995 and 2007 at a single institution. Inclusion criteria were an omphalocele >14 weeks' gestation, available fetal and/or neonatal karyotype, and a live-born infant (n = 46). Perinatal outcomes were compared in nonisolated (n = 23) and isolated omphaloceles (n = 23). For all omphaloceles, the majority delivered after 34 weeks by cesarean. Mean birth weight (2782 versus 2704 g), median length of stay (27 versus 25 days), and mortality (two deaths in each group) were not different between the nonisolated and isolated groups (p > 0.05). In the nonisolated group, seven major anomalies were not confirmed postnatally. Of the prenatally diagnosed isolated omphaloceles, 8 (35%) were diagnosed with a syndrome or other anomalies after birth. The outcomes were similar in nonisolated and isolated prenatally diagnosed omphaloceles, but ultrasound did not always accurately determine the presence or absence of associated anomalies.

Current status of negative treatment decision-making for fetuses with a prenatal diagnosis of neonatal surgical disease at a single Japanese institution

BACKGROUND/PURPOSE

The termination of pregnancy because of fetal abnormalities in Japan has not been described. The aim of the present study was to analyze the current status and to evaluate the medical and ethical relevance in our institution for negative treatment decision-making for fetuses demonstrating neonatal surgical disease with a prenatal diagnosis.

MATERIALS AND METHODS

The medical records of 209 fetuses with a prenatal diagnosis from 1999 to 2008 were retrospectively reviewed. The cases with a negative treatment policy were analyzed according to the potential for survival. The negative treatment policies were defined as those in which the pregnancy was not actively continued, including elective termination of pregnancy and palliative or limited treatment that are primarily provided after birth.

RESULTS

The selected treatment policies were active in 162 cases and negative in 46 cases. Thirty-three cases with negative policies were in the second-half period of pregnancy. The potential for survival was high in 5 cases, moderate in 11 cases, and nonviable in 30 cases. Eight of the nonviable cases underwent either limited or palliative treatment, whereas the remaining 38 fetuses were aborted.

CONCLUSIONS

The negative treatment policies in the nonviable fetuses were considered to be medically and ethically relevant. However, the number of cases with negative policies increased over the last 5 years and is therefore associated with complex ethical issues.

Conservative management of giant omphalocele with topical povidone-iodine and its effect on thyroid function

PURPOSE

The aim of the study was to evaluate topical povidone-iodine as a bridge to delayed fascial closure of giant omphaloceles with emphasis on its effect on thyroid function.

METHODS

Newborns from a single institution with giant omphaloceles treated with topical povidone-iodine for a 10-year period were reviewed. Recorded data included sex, associated anomalies, length of stay, frequency of povidone-iodine application, thyroid function tests, frequency of laboratory draws, and thyroid supplementation administration.

RESULTS

Six neonates with giant omphaloceles were treated with povidone-iodine. Thyroid function testing occurred weekly as inpatients and monthly as outpatients, with abnormal values normalized by the subsequent laboratory draw. One patient demonstrated persistent hypothyroidism and subsequently died secondary to cardiac complications, but this infant's newborn thyroid screening suggested congenital hypothyroidism. Five patients remained euthyroid and ultimately achieved fascial closure without the need for a prosthetic implant. None of these patients had abnormal outpatient thyroid tests nor did they require thyroid hormone supplementation.

CONCLUSION

Topical povidone-iodine promotes escharification and epithelialization of the omphalocele sac. Because transient hypothyroidism may occur, thyroid function studies may guide inpatient therapy. After sac desiccation, systemic effects of iodine are minimal and thyroid supplementation is not necessary. Topical povidone-iodine is an effective initial strategy for giant omphaloceles and does not produce clinically significant hypothyroidism.

Prospective, interdisciplinary follow-up of children with prenatally diagnosed giant omphalocele: short-term neurodevelopmental outcome

PURPOSE

The objective of this study is to determine the short-term neurodevelopmental outcome in infants with giant omphalocele (GO).

MATERIALS AND METHODS

Between January 2002 and December 2007, 31 consecutive infants with GO received prenatal and postnatal care at our institution. Overall survival was 81% (25/31). Twenty (80%) of the survivors were enrolled in a prospective interdisciplinary follow-up program. Fifteen were at least 6 months of age and received detailed neurodevelopmental evaluation using the Bayley Scales of Infant Development II (BSID-II [before 2006, n = 3]) or BSID-III (after 2006, n = 12). Scores were grouped as average, mildly delayed, and severely delayed by SD intervals (115-85, 71-84, <70). Scores were considered mixed if cognitive or language skills were in different ranges.

RESULTS

Median age at evaluation was 12 months (range, 6-26 months). Average, mildly delayed, and severely delayed scores for cognitive and language skills were found in 6 (40%), 2 (13%), and 6 (40%), respectively. One child had mixed scores (severely delayed for cognitive and mildly delayed for language skills). Motor scores were normal, mildly delayed, and severely delayed in 6 (40%), 2 (13%), and 7 (47%), respectively. The neuromuscular examination was abnormal in 8 patients (62%). Five (33%) scored within the average range, whereas 6 (40%) demonstrated severe delays for cognitive, language, and motor outcome. Of the 6 children with severe delays, 2 (13% of total) have autism, 4 required tracheostomy, and 1 was diagnosed with Williams syndrome.

CONCLUSIONS

The presence of GO is associated with deficits in developmental achievements in most of the affected infants ranging from mild to profound delays. These findings underscore the importance of early and standardized neurodevelopmental evaluation throughout childhood for all survivors with GO. Larger studies are warranted for risk factor stratification.

Predicting adverse neonatal outcomes in fetuses with abdominal wall defects using prenatal risk factors

OBJECTIVE

The aim of this study was to determine whether prenatal variables can predict adverse neonatal outcomes in fetuses with abdominal wall defects.

STUDY DESIGN

A retrospective cohort study that used ultrasound and neonatal records for all cases of gastroschisis and omphalocele seen over a 16-year period. Cases with adverse neonatal outcomes were compared with noncases for multiple candidate predictive factors. Univariable and multivariable statistical methods were used to develop the prediction models, and effectiveness was evaluated using the area under the receiver operating characteristic curve.

RESULTS

Of 80 fetuses with gastroschisis, 29 (36%) had the composite adverse outcome, compared with 15 of 33 (47%) live neonates with omphalocele. Intrauterine growth restriction was the only significant variable in gastroschisis, whereas exteriorized liver was the only predictor in omphalocele. The areas under the curve for the prediction models with gastroschisis and omphalocele are 0.67 and 0.74, respectively.

CONCLUSION

Intrauterine growth restriction and exteriorization of the liver are significant predictors of adverse neonatal outcome with gastroschisis and omphalocele.

Correlation between the presence of liver herniation and perinatal outcome in prenatally diagnosed fetal omphalocele

AIMS

To investigate the association between the presence of liver herniation and perinatal course and outcome of fetal omphalocele.

METHODS

Cases of fetal omphalocele managed at our hospital between 1990 and 2006 were retrospectively reviewed and grouped according to the location of the liver.

RESULTS

Thirty-three fetal omphalocele cases were diagnosed. The chromosomal status of 29 of 33 fetuses was determined. The rate of chromosomal abnormalities in cases with an extracorporeal liver was significantly lower (2/18) than in the intracorporeal group (6/11) (P=0.028). In chromosomally normal cases, four with extracorporeal liver resulted in early neonatal death compared to none with intracorporeal liver. Five of the 21 chromosomally normal fetuses showed an abnormal volume of amniotic fluid. All five cases had extracorporeal liver and two of them resulted in neonatal death.

CONCLUSIONS

Fetuses with an extracorporeal liver had a lower rate of chromosomal abnormalities than those in the intracorporeal liver group. However, in chromosomally normal cases, it appeared that extracorporeal livers might be associated with more life-threatening anomalies, amniotic fluid volume abnormalities, and a higher rate of mortality than in the group with an intracorporeal liver. Upon diagnosis of fetal omphalocele, a careful search for liver location should be conducted before counseling.

Prenatal detection of pulmonary hypoplasia in giant omphalocele

Respiratory insufficiency has sometimes been reported in giant omphalocele. To determine whether ultrasonic fetal lung measurements including lung/thorax transverse area ratio (L/T) and chest/trunk length ratio (C/T) may be useful in predicting associated pulmonary hypoplasia, 28 fetuses with abdominal wall defects between 1991 and 2003 were reviewed. Nine patients with gastroschisis and 19 with omphalocele were classified into three groups. A group with neonatal death and postmortem lung/body weight ratio below 0.012, which was defined as pulmonary hypoplasia (PH group), included two ruptured giant omphaloceles and two giant omphaloceles with intact covering membrane in utero. A group with artificial ventilation more than 3 months, which was defined as prolonged ventilation (PV group), included one ruptured giant omphalocele and three giant omphaloceles with intact covering membrane. Others were defined as ordinary group. In 12 fetuses with giant omphalocele, the evisceration rate of the liver (LER) was measured in the fetal transverse abdominal dimension including the base of the liver. The L/T in PH group was significantly decreased to other groups. The C/T in PH group was significantly increased to ordinary group. There was no significant difference in the LER among three groups. A measurement of L/T may be useful in predicting associated pulmonary hypoplasia in giant omphalocele. However, antenatal detection of patients required prolonged ventilation may be difficult and require further study.

[Liver hernia. Prognosis and report of 11 cases]

OBJECTIVES

Exclusive hepatocele is defined as a hernia containing in majority the liver with possibly some intestinal loops. This study was undertaken to evaluate neonatal morbidity and mortality in this series of exclusive hepatoceles.

MATERIALS AND METHODS

We reviewed 11 cases of exclusive hepatoceles with delivery at the hospital Jeanne-de-Flandre in the CHRU of Lille, in France.

RESULTS

The mean gestational age of diagnosis was 14.5+/-3.4 weeks of gestation. Karyotype determination was performed in 100% of cases: it was abnormal in one case of 11. One termination of pregnancy was performed because of trisomy 13. The mean gestational age at delivery was 38+/-1.8 weeks of gestation. Cesarean deliveries were performed in nine cases. Morbidity was important with: one case of fetal growth retardation on total hepatocele, three cases of severe respiratory distress, two cases of severe digestive complications. The mean length of stay was 42.8 days. The mean length of parenteral feeding was 14.4 days. Postnatal mortality concerned one child, which died because of a severe respiratory distress due to pulmonary hypoplasia.

CONCLUSION

In this series, morbidity is thus important, making of exclusive hepatoceles a full entity among the omphaloceles. The multidisciplinary take care is more complex but conceivable.

Visceral coverage with absorbable mesh followed by split-thickness skin graft in the treatment of ruptured giant omphalocele

We report a case of ruptured giant omphalocele in whom herniated organs were successfully covered by an absorbable mesh and a subsequent skin graft. A 2,200 g male baby was born at 35 weeks of gestation. An abdominal wall abnormality was detected by prenatal ultrasound at 21 weeks of gestation. At birth, the entire liver, stomach, and small and large bowel had herniated from the defect of the abdominal wall. The thorax and abdomen were highly underdeveloped, and attempts to reduce the organs into the abdomen were unsuccessful due to the extremely small abdominal cavity and associated pulmonary hypoplasia. To protect the herniated organs and prevent abdominal infections, the organs were covered by a polyglycan mesh and subsequently a meshed split-thickness skin graft. Ten weeks later, it was confirmed that the organs were completely covered by epithelialized tissue. However, the patient suffered from frequent respiratory infections and finally died of respiratory insufficiency. Based on the experience of the patient, we conclude that coverage of the herniated organs with an absorbable mesh and a skin graft is a recommendable treatment in ruptured giant omphalocele.

Staged repair of giant omphalocele in the neonatal period

BACKGROUND/PURPOSE

The aim of this study was to analyze the outcome of giant omphalocele repaired in the neonatal period.

METHODS

Twelve consecutive (1997-2004) neonates with giant omphalocele (defect >6 cm with liver herniation) were reviewed. A silo of Prolene mesh (Ethicon) was attached to the fascia and the defect was closed without opening the amniotic sac after sequential reduction. In 2 neonates with ruptured omphalocele a plastic sheet was inserted below the mesh. Data are reported as median and range.

RESULTS

Gestational age was 38 weeks (range, 32-40 weeks) and birth weight was 2.9 kg (range, 1.0-3.1 kg). The final closure was achieved at 26 days (range, 16-62 days). Three neonates (25%) died before final closure (causes: ruptured omphalocele, lung hypoplasia, cardiac anomalies, and intestinal failure). In the 9 surviving neonates, mechanical ventilation was required for 8 days (range, 2-20 days), hospital stay was 42 days (range, 23-73 days), and full enteral feeding was achieved on day 12 (range, 4-53 days). Complications included wound infection in 5 neonates and midgut volvulus in 1. Prophylactic Ladd's procedure was performed laparoscopically at a later stage in 4 children. At laparoscopy, intraperitoneal adhesions were minimal and the central liver did not preclude the operation. The 9 survivors are all well after 46 months (range, 12-67 months).

CONCLUSIONS

Giant omphalocele can be safely repaired in the neonatal period without opening the amniotic sac. Intestinal malrotation should be excluded and Ladd's procedure can be performed laparoscopically at a later stage.

Pulmonary effects of gastroschisis in a fetal rabbit model

Respiratory insufficiency is a significant cause of mortality and morbidity among infants with anterior abdominal wall defects (AWD). The aim of this study was to evaluate the pulmonary effects in a fetal rabbit model where gastroschisis was induced at midgestation. Gastroschisis (GAS) was created in 20 rabbit fetuses on day 22 or 23 of gestation (pseudoglandular phase; term = 31-32 days). The amniotic sacs of 13 fetuses were subjected to hysterotomy and amniotomy only (HYST), while 13 underwent a sham laparotomy which was immediately closed by sutures (SHAM). Eleven nonoperated littermates served as internal controls (CTR). Fetuses were harvested by cesarean section on day 31 of gestation prior to respiration. Pulmonary response was evaluated by left lung to body weight ratio (LWBWR), airway morphometry, and density of type II pneumocytes, as evaluated by the number of surfactant protein B-positive cells. Fetuses from the GAS group had significantly lower body weights than did CTR (P = 0.0129). Of these fetuses, 27% were growth-restricted, i.e., with a body weight under the 10th percentile of the CTR population. There were no differences in left lung weight and LWBWR among the GAS and CTR groups. Moreover, the GAS group had similar alveolar size, alveolar wall thickness, and type II cell density as CTR fetuses. Only mean terminal bronchiolar density (MTBD), which is inversely related to the alveolar space, was slightly increased in the GAS group, but without reaching significance (P = 0.0821). No effect on lung growth and maturation could be demonstrated in this study.

Omphalocele: beyond the size issue

A small omphalocele was diagnosed and followed up prenatally. Ultrasonography examinations and clinical examination at birth were all consistent with an isolated, small omphalocele. Immediate surgical exploration at birth found an associated type I intestinal atresia. This rare association and the need for immediate postnatal management of omphalocele are discussed, and the literature is reviewed.

Adverse outcome after prenatal diagnosis of gastroschisis: the role of fetal monitoring

Fifty-seven fetuses with gastroschisis presented between 1982 and 1995 were studied by retrospective review of medical records. There were three late intrauterine deaths (IUD). Fetal distress, as determined by reduced fetal movements or abnormal cardiotopograph (CTG), was encountered in 23 of the 54 liveborn infants (43%), all of whom had delivery expedited either by emergency caesarean section (n = 19) or induction (n = 4). Six infants had abnormal neurological outcome: two died in the neonatal period of severe perinatal brain injury, neonatal fits were observed in four, two of whom developed cerebral palsy, and one died at the age of 7 years. All six of these infants had suffered fetal distress. If the three intrauterine deaths are included, 16% of all cases were associated with abnormal neurological outcome. The introduction of regular CTG monitoring from 32 weeks' gestation in 1990 increased the ability to detect fetal distress twofold. This resulted in a similar increase in obstetric intervention and an associated reduction in adverse neurological outcome. Pregnancies associated with gastroschisis should be considered at significant risk of fetal distress, which itself may culminate in late intrauterine death, neonatal death, or adverse neurological outcome. Careful, repeated fetal monitoring in the third trimester is indicated.