Immediate versus staged repair of omphaloceles

Giant omphalocele: A novel approach for primary repair in the neonatal period using botulinum toxin

INTRODUCTION

Giant omphalocele (GO) is a complex condition for which many surgical treatments have been developed; however, no consensus on its treatment has been reached. The benefits and efficacy of botulinum toxin A (BTA) in the repair of large abdominal wall defects in adults has been proven, and its reported use in children has recently grown. The goal of this study is to describe a novel technique for primary repair of GO using BTA during the neonatal period and report our initial experience.

METHODS

patients were followed from August 2020 to July 2022. BTA was applied to the lateral abdominal wall in the first days of life followed by surgical repair of the abdominal defect.

RESULTS

while awaiting surgery, patients had minimal manipulation, without requiring mechanical ventilation, were on full enteral feeding, and in contact with their parents. The midline was approximated without tension and without the need for additional techniques or the use of a prosthesis. Patients were discharged with repaired defects.

CONCLUSION

this approach represents a middle ground between staged and the nonoperative delayed repairs. It does not require aggressive interventions early in life, allowing maintenance of mother-child bonding and discharge of the patient with a repaired defect without the need for additional techniques or the use of a prosthesis. We believe that this technique should be considered as a new possible asset when managing this complex condition.

Omphalocele and Cardiac Abnormalities-The Importance of the Association

Omphalocele is the most common ventral abdominal wall defect. Omphalocele is associated with other significant anomalies in up to 80% of cases, among which the cardiac ones are the most frequent. The aim of our paper is to highlight, through a review of the literature, the importance and frequency of association between the two malformations and what impact this association has on the management and evolution of patients with these pathologies. We reviewed the titles, the available abstracts, and the full texts of 244 papers from the last 23 years, from three medical databases, to extract data for our review. Due to the frequent association of the two malformations and the unfavorable effect of the major cardiac anomaly on the prognosis of the newborn, the electrocardiogram and echocardiography must be included in the first postnatal investigations. The timing of surgery for abdominal wall defect closure is mostly dictated by the cardiac defect severity, and usually the cardiac defect takes priority. After the cardiac defect is medically stabilized or surgically repaired, the omphalocele reduction and closure of the abdominal defect are performed in a more controlled setting, with improved outcomes. Compared to omphalocele patients without cardiac defects, children with this association are more likely to experience prolonged hospitalizations, neurologic, and cognitive impairments. Major cardiac abnormalities such as structural defects that require surgical treatment or result in developmental delay will significantly increase the death rate of patients with omphalocele. In conclusion, the prenatal diagnosis of omphalocele and early detection of other associated structural or chromosomal anomalies are of overwhelming importance, contributing to the establishment of antenatal and postnatal prognosis.

Using acellular porcine dermal matrix (XCM Biologic® Tissue Matrix) to repair a giant omphalocele: A case report

RATIONALE

An omphalocele is an abdominal wall birth defect, and a giant omphalocele (GO) is defined as an omphalocele having a diameter >5 cm or containing a herniated liver. GOs are usually treated in stages and in this case, during the silo reduction, dehiscence occurred at the suture site of the axis ring and skin edge, which was repaired using synthetic absorbable mesh.

PATIENT CONCERNS

A girl infant was born at 36 weeks with a GO of 8 cm diameter, and herniated multiple organs such as the small bowel, cecum, appendix, and the entire liver. Even after the staged repair technique for the GO silo, wound dehiscence between the ring of the silo and the edge of the skin occurred and gradual reduction failed.

DIAGNOSIS

A GO of 8 cm diameter, which was found during prenatal ultrasonography.

INTERVENTIONS

Revision was performed to repair the defect. The small bowel and liver were still prolapsed, and there were severe adhesions. After adhesiolysis, the muscle layer of the abdominal wall was repaired using the tissue matrix, but the skin could not be repaired. After the second operation, the defect wound was dressed as sterilely as possible.

OUTCOMES

The abdominal wall defect was repaired completely; there were no residual complications.

LESSONS

Repair of GOs using an acellular porcine dermal matrix can be considered a viable treatment option.

Systemic Inflammation Is Associated with Pulmonary Hypertension in Isolated Giant Omphalocele: A Population-Based Study

Our objective is to determine perinatal factors contributing to the development of pulmonary hypertension (PH) in patients with isolated giant omphaloceles (GO). All cases of omphaloceles that underwent prenatal and postnatal care at the University Hospital of Lille between 1996 and 2021 were reviewed. We included all infants with isolated GO, including at least a part of the liver, who were treated by delayed surgical closure. Prenatal and postnatal data were recorded and correlated with postnatal morbidities. We compared outcomes between a group of infants with GO who developed PH and infants with GO with no PH. We identified 120 infants with omphalocele. Fifty isolated GO cases fulfilled the inclusion criteria of our study. The incidence of PH was 30%. We highlighted a prolonged inflammatory state, defined as a CRP superior to 15 mg/L, platelets higher than 500 G/L, and white blood cells higher than 15 G/l for more than 14 days in patients who developed PH. This event occurred in 73% of patients with PH versus 21% of patients without PH (p < 0.05). Late-onset infection was not different between the two groups. We speculate that prolonged inflammatory syndrome promotes PH in infants with GO treated with delayed surgical closure.

Short and Medium-term Outcomes of Omphalocele and Gastroschisis: A Survey from a Tertiary Center

OBJECTIVE

 To characterize and compare the outcomes of omphalocele and gastroschisis from birth to 2 years of follow-up in a recent cohort at a tertiary center.

METHODS

 This is a retrospective clinical record review of all patients with gastroschisis and omphalocele admitted to the Neonatal Intensive Care Unit between January 2009 and December 2019.

RESULTS

 There were 38 patients, 13 of whom had omphalocele, and 25 of whom had gastroschisis. Associated anomalies were present in 6 patients (46.2%) with omphalocele and in 10 (41.7%) patients with gastroschisis. Compared with patients with omphalocele, those with gastroschisis had younger mothers (24.7 versus 29.6 years; p = 0.033), were born earlier (36 versus 37 weeks, p = 0.006), had lower birth weight (2365 ± 430.4 versus 2944.2 ± 571.9 g; p = 0.001), and had a longer hospital stay (24 versus 9 days, p = 0.001). The neonatal survival rate was 92.3% for omphalocele and 91.7% for gastroschisis. Thirty-four patients were followed-up over a median of 24 months; 13 patients with gastroschisis (59.1%) and 8 patients with omphalocele (66.7%) had at least one adverse event, mainly umbilical hernia (27.3% vs 41.7%), intestinal obstruction (31.8% vs 8.3%), or additional surgical interventions (27.3% vs 33.3%).

CONCLUSION

 Despite the high proportion of prematurity, low birth weight, and protracted recovery, gastroschisis and omphalocele (without chromosomal abnormalities) may achieve very high survival rates; on the other hand, complications may develop in the first years of life. Thus, a very positive perspective in terms of survival should be transmitted to future parents, but they should also be informed that substantial morbidity may occur in the medium term.

Practice Summary of Antimicrobial Therapy for Commonly Encountered Conditions in the Neonatal Intensive Care Unit: A Canadian Perspective

Neonates are highly susceptible to infections owing to their immature cellular and humoral immune functions, as well the need for invasive devices. There is a wide practice variation in the choice and duration of antimicrobial treatment, even for relatively common conditions in the NICU, attributed to the lack of evidence-based guidelines. Early decisive treatment with broad-spectrum antimicrobials is the preferred clinical choice for treating sick infants with possible bacterial infection. Prolonged antimicrobial exposure among infants without clear indications has been associated with adverse neonatal outcomes and increased drug resistance. Herein, we review and summarize the best practices from the existing literature regarding antimicrobial use in commonly encountered conditions in neonates.

Giant omphalocele associated pulmonary hypertension: A retrospective study

BACKGROUND

Omphalocele is a common congenital defect of the abdominal wall, management of giant omphalocele (GO) is particularly for pediatric surgeons and neonatologists worldwide. The current study aimed to review and summarize the clinical features and prognosis in neonates with GO complicated with pulmonary hypertension (PH), which is associated with increased mortality, while in hospital.

MATERIALS AND METHODS

Medical records of infants with GO between July 2015 and June 2020 were retrospectively analyzed. The patients enrolled were divided into PH and non-PH groups based on the presence or absence of PH, and patients with PH were divided into death and survival groups based on survival status. Clinical characteristics and outcomes were compared between groups, respectively. The risk factors for PH were analyzed by binary logistic regression.

RESULTS

In total, 67 neonates were identified as having GO and 24 (35.8%) were complicated with PH. Infants with PH were associated with intubation within 24 h after birth (p = 0.038), pulmonary dysplasia (p = 0.020), presence of patent ductus arteriosus (PDA; p = 0.028), a staged operation (p = 0.002), longer mechanical ventilation days (p < 0.001), oxygen requirement days (p < 0.001), parenteral nutrition (PN) days (p < 0.001), length of neonatal intensive care unit (NICU) or hospital stay (p = 0.001 and 0.002, respectively), and mortality (p = 0.001). The results of multivariable logistic regression analysis revealed that a staged operation was independently associated with PH. In addition, PH patients with lower birth weight, higher peak of pulmonary arterial systolic pressure, and refractory to pulmonary vasodilators (PVD) had increased mortality.

CONCLUSION

Pulmonary hypertension is a serious complication and significantly increases the mortality and morbidities in infants with a GO. In addition, early and serial assessment of PH by echocardiography should be a routine screening scheme, especially in the neonatal omphalocele population who required a staged surgical repair. Clinicians should be aware that infants with PH who had low weight, severe and refractory PH have a higher risk of death.

Incidence of surgical procedures for gastrointestinal complications after abdominal wall closure in patients with gastroschisis and omphalocele

PURPOSE

This study aims to define the extent of additional surgical procedures after abdominal wall closure (AWC) in patients with gastroschisis (GS) and omphalocele (OC) with special focus on gastrointestinal related operations.

METHODS

A retrospective chart review was performed including all operations in GS and OC patients in the first year after AWC (2010-2019). The risk for surgery was calculated using the one-year cumulative incidence (CI).

RESULTS

33 GS patients (18 simple GS, 15 complex) and 24 OC patients (12 without (= OCL), 12 OC patients with liver protrusion (= OCL +)) were eligible for analysis. 43 secondary operations (23 in GS, 20 in OC patients) occurred after a median time of 84 days (16-824) in GS and 114.5 days (12-4368) in OC. Patients with complex versus simple GS had a significantly higher risk of undergoing a secondary operation (one-year CI 64.3% vs. 24.4%; p = 0.05). 86.5% of surgical procedures in complex GS and 36.3% in OCL + were related to gastrointestinal complications. Complex GS had a significantly higher risk for GI-related surgery than simple GS. Bowel obstruction was a risk factor for surgery in complex GS (one-year CI 35.7%).

CONCLUSION

Complex GS and OCL + patients had the highest risk of undergoing secondary operations, especially those with gastrointestinal complications.

Modified sequential sac ligation and staged closure technique for the management of giant omphalocele

PURPOSE

This study aimed to describe sac ligation and sequential closure for the management of giant omphalocele (GO) and analyze its outcomes.

METHODS

The medical records of 13 neonates with GO treated at a tertiary general hospital between July 2012 and April 2020 were reviewed. Sac ligation and progressive external compression were performed on most cases immediately after birth. Staged closure with or without a prosthetic patch was conducted after a period of sac suspension.

RESULTS

Sac ligation-traction-compression was performed on 12 cases, of which 10 underwent staged closure, one with delayed closure. One patient with coexistent esophageal atresia was deemed ineligible for surgery. Among those who had undergone staged closure, 9 survived; however, one neonate who complicated with bilateral diaphragmatic eventration and severe ventilator-associated pneumonia died from multiple-organ failure. Pentalogy of Cantrell was excluded. One patient in whom primary closure was performed after birth died aged 29 h. Pneumonia was the most common infection among patients (5/13), with three having ventilator-associated pneumonia. The median durations of mechanical ventilation and hospital stay were 22.2 days (range, 1-151) and 44.2 days (range, 2-152), respectively, and 25.6 days and 46.4 days, respectively, among patients with staged closure. Among five infants who required oxygen support for more than 28 days, four had pulmonary hypoplasia.

CONCLUSIONS

Aside from abdominal wall defects, other major comorbidities and pulmonary hypoplasia influence the prognosis of GO. Sac ligation and staged closure is a effective choice for GO.

TYPE OF STUDY

Retrospective Study Level of Evidence: Level IV.

Exomphalos major: Conservative management using Manuka honey dressings and an outreach surgical nursing team

INTRODUCTION

Controversy exists over the best dressing for conservative management of exomphalos major. Here we describe our experience of using Manuka Honey.

METHODS

Our regimen involved covering the sac with Manuka honey (Advancis Medical™) wrapped with gauze and crepe bandage. Initially, dressings were changed 3 times a week and then twice weekly until full epithelialisation. Babies went home after reaching full feeds, with our outreach nurses continuing dressings in clinic until the parents were trained to do them alone. Only patients needing management of co-morbidities were transferred to our unit. Patients would be reviewed by video consultation. Data was prospectively collected.

RESULTS

From 2011-2019, 24 consecutive patients (11:13 M:F; median gestation 37 weeks, birth weight 3.1 kg) with exomphalos major were managed with honey dressings. Fourteen babies had significant associated anomalies of which 10 died of problems unrelated to the exomphalos. Time to full feeds 6 (2-58) days; time to discharge 21(7-66) days if no associated anomalies; time to epithelialisation 73 (27-199) days. Dressings were well tolerated. Definitive closure occurred at 17(11-38) months and was uneventful. No patient required fundoplication and all patients were orally fed. Only one patient developed a clinically significant infection.

CONCLUSION

This is the largest report of using Manuka honey for the management of exomphalos major. Benefits include early feeding, early discharge and a 'normalisation' of the neonatal period. Key to our success was the surgical outreach service supporting parents doing the dressings, first at the local hospital and then at home.

Complex abdominal wall reconstruction after oncologic resection in a sequalae of giant omphalocele: A case report

INTRODUCTION

Trauma injuries and oncologic resection are common aetiologies of complex abdominal wall defect. Reconstruction of abdominal wall is an everlasting question for general, paediatric and reconstructive surgeons. The plethora of techniques, bioprosthetic and engineered tissues offer countless possibilities.

PRESENTATION OF CASE

The patient was a 28 years old woman, with past history of untreated giant liver omphalocele, admitted for a suspicious hepatic tumefaction without specific clinical signs. The thoraco abdominopelvic CT scan revealed lung metastasis and a bilobed left hepatic tumour. Pre-operative cytologic findings of mild differentiated hepatocellular carcinoma differed from the post-operative findings of hepatoblastoma. The full-thickness abdominal wall defect after a radical resection was reconstructed with a combined acellular dermal matrix, NPWT and skin graft solution. A total epithelization was obtained after 8 weeks follow-up.

DISCUSSION

Hepatoblastoma in adult is rare, with no consensus. A radical resection in context of giant untreated omphalocele is an unusual challenge for the surgical team. The pre-operative evaluation, the defect classification and the general conditions of the patient are paramount steps for an appropriate reconstruction. Primary or delayed reconstruction with myocutaneous flap as gold standard, depends on the oncologic management and anticipated post-operative complications. Acellular dermal matrix used for a bridged fascial repair directly on viscera and covered by NPWT, favourited a healthy granulation tissue. The full-thickness defect was then reconstructed with an ADM, NPWT and skin graft instead of an association with the myocutaneous flap. The patient follow-up was emphasized in the hepatoblastoma, but the complications of this reconstruction strategy are unknown. A total epithelization was obtained, the abdominal bulge or hernia is the first complication under surveillance.

CONCLUSION

Delayed reconstruction after an oncologic large abdominal wall resection has the advantage to manage post-operative complications and prepare alternative solutions. Acellular dermal matrix was not first designed for skin tissue regeneration, some authors as us experimented the conclusion that this matrix could be used for permanent abdominal wall reconstruction.

Abdominal Wall Defects-Current Treatments

Gastroschisis and omphalocele reflect the two most common abdominal wall defects in newborns. First postnatal care consists of defect coverage, avoidance of fluid and heat loss, fluid administration and gastric decompression. Definitive treatment is achieved by defect reduction and abdominal wall closure. Different techniques and timings are used depending on type and size of defect, the abdominal domain and comorbidities of the child. The present review aims to provide an overview of current treatments.

Use of Cryopreserved Human Umbilical Cord and Amniotic Membrane Allograft and Portable Negative Pressure Therapy in Dehisced Giant Omphalocele Repair: A Case Study

BACKGROUND

A giant omphalocele is a rare congenital abdominal wall defect that measures more than 6 to 8 cm in any dimension. The child's abdominal visceral contents as well as the liver which are both covered by the amniotic sac protrude outside the abdomen through the umbilicus. Consequently, closing this defect is extremely challenging due to the risk for wound dehiscence.

CASE

Baby C, a 1-year-old male infant, developed a dehisced abdominal wound after secondary repair of a giant omphalocele. Escharification of the amniotic sac was achieved with silver products, followed by intra-abdominal tissue expansion and skin closure. A conservative approach was undertaken with the use of cryopreserved human umbilical cord and amniotic membrane allograft in conjunction with portable negative pressure therapy.

CONCLUSIONS

To the best of our knowledge, this is the first case study to evaluate the effect of cryopreserved human umbilical cord and amniotic membrane allograft in a dehisced neonatal abdominal wound due to a giant omphalocele or, in fact, neonatal wounds in general. Our experience with this case suggests that cryopreserved human umbilical cord and amniotic membrane allograft may create a superior healing trajectory and regeneration, avoidance of surgical intervention, and an early hospital discharge. Wound-supporting properties of amniotic allograft, in addition to lack of immunologic reactivity, offer an attractive option for a variety of pediatric and neonatal wounds.

Giant Isolated Omphalocele: Role of Prenatal Diagnosis in Prognostic Asessment and Perinatal Management

Omphalocele is a congenital malformation of the abdominal wall consisting of a protrusion of the abdominal contents at the base of the umbilical cord. It has a high association with genetic and structural defects; however, if the latter is ruled out, its prognosis improves significantly. Prenatal diagnosis has a key role in this condition as omphalocele can be diagnosed by ultrasound in the first trimester scan, enabling a coordinated approach strategy to achieve the best perinatal results. We present a case report of a pregnant patient with a fetus having a giant omphalocele in which prenatal diagnosis played a decisive role, allowing the coordination of a multidisciplinary team, which was crucial in the immediate care of the newborn.

Management of Giant Omphalocele Leading to Early Fascial Closure

Objective

The aim of the study was to present the clinical outcomes of patients diagnosed with giant omphalocele, treated with early primary closure combined with bandaging and povidone-iodine staining and powder spray antibiotics.

Materials and methods

The study included a total of 22 infants with omphalocele. The omphalocele sacs of the patients were cleaned daily with topical povidone-iodine. A powdered spray antibiotic combination was then applied topically twice a day and the sac was wrapped in a sterile elastic bandage. Following the observation of eschar formation and epithelization, the patients were operated on in the early period and the sac was removed by placing a graft.

Results

Evaluation was made of a total of 14 female and eight male patients with mean duration of conservative monitoring of 11 days and mean total hospital stay of 35. The mean giant omphalocele (GO) defect size of the patients followed-up was 10 cm. Since seven of the patients in the present study died in the 1^st week, conservative and elastic bandages were applied for the GO treatment of 15 patients for 9-14 days. After the conservative follow-up, it was determined that the patients who were applied with a graft at an average of 11 days were hospitalized for an average of 24 days postoperatively.

Conclusion

In conclusion, it is possible to reduce the length of hospital stay with primary closure in the early period by providing faster epithelialization with the combination of povidone-iodine and antibiotic powder together with elastic bandage application in infants with GO.