A randomised controlled trial of amnioexchange for fetal gastroschisis

Prenatal repair of gastroschisis using partial carbon dioxide insufflation fetoscopy: lessons learned

We report the long-term outcomes of a case of prenatal gastroschisis repair using a fully percutaneous fetoscopic approach with partial carbon dioxide insufflation. Surgery was performed as an experimental procedure before the scheduled elective birth. The fetal intestines were successfully returned to the abdominal cavity without any fetal or maternal complications. Ultrasonography performed 24 hours later revealed bowel peristalsis and no signs of fetal distress. After 48 hours, partial extrusion of the small bowel was observed, and the fetus was delivered. Gastroschisis repair was immediately performed upon delivery using the EXIT-like procedure as per our institutional protocol. The newborn did not require assisted mechanical ventilation, was discharged at 14 days of age and was then exclusively breastfed. At 3-year follow-up, the patient had no associated gastroschisis-related complications. This is the first case of prenatal repair of gastroschisis, which provides baseline knowledge for future researchers on the potential hurdles and management of prenatal repair.

Minimally Invasive Fetal Surgery and the Next Frontier

Most patients with congenital anomalies do not require prenatal intervention. Furthermore, many congenital anomalies requiring surgical intervention are treated adequately after birth. However, there is a subset of patients with congenital anomalies who will die before birth, shortly after birth, or experience severe postnatal complications without fetal surgery. Fetal surgery is unique in that an operation is performed on the fetus as well as the pregnant woman who does not receive any direct benefit from the surgery but rather lends herself to risks, such as hemorrhage, abruption, and preterm labor. The maternal risks involved with fetal surgery have limited the extent to which fetal interventions may be performed but have, in turn, led to technical innovations that have significantly advanced the field. This review will examine congenital abnormalities that can be treated with minimally invasive fetal surgery and introduce the next frontier of prenatal management of fetal surgical pathology.

Relationship between volume and outcome for gastroschisis: A systematic review

BACKGROUND

Newborns with gastroschisis need surgery to reduce intestines into the abdominal cavity and to close the abdominal wall. Due to an existing volume-outcome relationship for other high-risk, low-volume procedures, we aimed at examining the relationship between hospital or surgeon volume and outcomes for gastroschisis.

METHODS

We conducted a systematic literature search in Medline, Embase, CENTRAL, CINAHL and Biosis Previews in June 2021 and searched for additional literature. We included (cluster-) randomized controlled trials (RCTs) and prospective or retrospective cohort studies analyzing the relationship between hospital or surgeon volume and mortality, morbidity or quality of life. We assessed risk of bias of included studies using ROBINS-I and performed a systematic synthesis without meta-analysis and used GRADE for assessing the certainty of the evidence.

RESULTS

We included 12 cohort studies on hospital volume. Higher hospital volume may reduce in-hospital mortality of neonates with gastroschisis, while the evidence is very uncertain for other outcomes. Findings are based on a low certainty of the evidence for in-hospital mortality and a very low certainty of the evidence for all other analyzed outcomes, mainly due to risk of bias and imprecision. We did not identify any study on surgeon volume.

CONCLUSION

The evidence suggests that higher hospital volume reduces in-hospital mortality of newborns with gastroschisis. However, the magnitude of this effect seems to be heterogeneous and results should be interpreted with caution. There is no evidence on the relationship between surgeon volume and outcomes.

Predicting Factors of Protracted Intestinal Failure in Children with Gastroschisis

OBJECTIVE

To identify prenatal and neonatal predictors of short bowel syndrome-related intestinal failure (SBS-IF) in gastroschisis.

STUDY DESIGN

This retrospective study included all patients with gastroschisis born between 2000 and 2017 who were enrolled in our home parenteral nutrition program, and all patients with gastroschisis born in our institution who survived 2 weeks, during the same time period. Prenatal ultrasound features, neonatal status, anatomic features, oral feeding, and parenteral nutrition dependency were analyzed.

RESULTS

Among 180 patients, 35 required long-term parenteral nutrition (SBS-IF group) and 145 acquired full oral feeding within 6 months (oral feeding group). The mean follow-up was 7.9 years (IQR, 1.6-17.5 years) and 5.0 years (IQR, 0.1-18.2 years), respectively. Both bowel matting (OR, 14.23; 1.07-16.7; P = .039) and secondarily diagnosed atresia or stenosis (OR, 17.78; 3.13-100.98; P = .001) were independent postnatal predictors of SBS-IF. Eighteen children (51% of the SBS-IF group) were still dependent on artificial nutrition at the last follow-up. patients with SBS-IF who achieved full oral feeding had a median residual small-bowel length of 74 cm (IQR, 51-160 cm) vs 44 cm (IQR, 10-105 cm) for those still dependent on artificial nutrition (P = .02). An initial residual small bowel length of more than 50 cm was the best predictive cut-off for nutritional autonomy, with a sensitivity of 67% and a specificity of 100%.

CONCLUSIONS

Bowel matting, complex gastroschisis, and secondary intestinal obstruction were associated with SBS-IF in gastroschisis. For patients with SBS-IF, a small bowel length of more than 50 cm was predictive of secondary nutritional autonomy.

Fetal Surgery for Gastroschisis—A Review with Emphasis on Minimally Invasive Procedures

(1) Background: The morbidity of gastroschisis is defined by exposure of unprotected intestines to the amniotic fluid leading to inflammatory damage and consecutive intestinal dysmotility, the viscero-abdominal disproportion which results in an abdomen too small to incorporate the herniated and often swollen intestine, and by associated pathologies, such as in complex gastroschisis. To prevent intestinal damage and to provide for growth of the abdominal cavity, fetal interventions such as amnio exchange, gastroschisis repair or covering have been evaluated in several animal models and human trials. This review aims to evaluate the reported techniques for the fetal treatment of gastroschisis by focusing on minimally invasive procedures. (2) Methods: We conducted a systematic database search, quality assessment and analyzed relevant articles which evaluate or describe surgical techniques for the prenatal surgical management of gastroschisis in animal models or human application. (3) Results: Of 96 identified reports, 42 eligible studies were included. Fetal interventions for gastroschisis in humans are only reported for EXIT procedures and amnio exchange. In animal models, particularly in the fetal sheep model, several techniques of open or minimally invasive repair of gastroschisis or covering the intestine have been described, with fetoscopic covering being the most encouraging. (4) Discussion: Although some promising minimally invasive techniques have been demonstrated in human application and animal models, most of them are still associated with relevant fetal morbidity and mortality and barely appear to be currently applicable in humans. Further research on specific procedures, instruments and materials is needed before any human application.

Complex gastroschisis: a new indication for fetal surgery?

Gastroschisis (GS) is a congenital abdominal wall defect, in which the bowel eviscerates from the abdominal cavity. It is a non-lethal isolated anomaly and its pathogenesis is hypothesized to occur as a result of two hits: primary rupture of the 'physiological' umbilical hernia (congenital anomaly) followed by progressive damage of the eviscerated bowel (secondary injury). The second hit is thought to be caused by a combination of mesenteric ischemia from constriction in the abdominal wall defect and prolonged amniotic fluid exposure with resultant inflammatory damage, which eventually leads to bowel dysfunction and complications. GS can be classified as either simple or complex, with the latter being complicated by a combination of intestinal atresia, stenosis, perforation, volvulus and/or necrosis. Complex GS requires multiple neonatal surgeries and is associated with significantly greater postnatal morbidity and mortality than is simple GS. The intrauterine reduction of the eviscerated bowel before irreversible damage occurs and subsequent defect closure may diminish or potentially prevent the bowel damage and other fetal and neonatal complications associated with this condition. Serial prenatal amnioexchange has been studied in cases with GS as a potential intervention but never adopted because of its unproven benefit in terms of survival and bowel and lung function. We believe that recent advances in prenatal diagnosis and fetoscopic surgery justify reconsideration of the antenatal management of complex GS under the rubric of the criteria for fetal surgery established by the International Fetal Medicine and Surgery Society (IFMSS). Herein, we discuss how conditions for fetoscopic repair of complex GS might be favorable according to the IFMSS criteria, including an established natural history, an accurate prenatal diagnosis, absence of fully effective perinatal treatment due to prolonged need for neonatal intensive care, experimental evidence for fetoscopic repair and maternal and fetal safety of fetoscopy in expert fetal centers. Finally, we propose a research agenda that will help overcome barriers to progress and provide a pathway toward clinical implementation. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Number and quality of randomized controlled trials in obstetrics published in the top general medical and obstetrics and gynecology journals

BACKGROUND

There has been an increasing number of randomized controlled trials published in obstetrics and maternal-fetal medicine to reduce biases of treatment effect and to provide insights on the cause-effect of the relationship between treatment and outcomes.

OBJECTIVE

This study aimed to identify obstetrical randomized controlled trials published in top weekly general medical journals and monthly obstetrics and gynecology journals, to assess their quality in reporting and identify factors associated with publication in different journals.

STUDY DESIGN

The 4 weekly medical journals with the highest 2019 impact factor (New England Journal of Medicine, The Lancet, The Journal of the American Medical Association, and British Medical Journal), the top 4 monthly obstetrics and gynecology journals with obstetrics-related research (American Journal of Obstetrics & Gynecology, Ultrasound in Obstetrics & Gynecology, Obstetrics & Gynecology, and the British Journal of Obstetrics and Gynaecology), and the American Journal of Obstetrics & Gynecology Maternal-Fetal Medicine were searched for obstetrical randomized controlled trials in the years 2018 to 2020. The primary outcome was the number of obstetrical randomized controlled trials published in the obstetrics and gynecology journals vs the weekly medical journals and the percentage of trials published, overall and per journal. The secondary outcomes included the proportion of positive vs negative trials overall and per journal and the assessment of the study characteristics of published trials, including quality assessment criteria.

RESULTS

Of the 4024 original research articles published in the 9 journals during the 3-year study period, 1221 (30.3%) were randomized controlled trials, with 137 (11.2%) randomized controlled trials being in obstetrics (46 in 2018, 47 in 2019, and 44 studies in 2020). Furthermore, 33 (24.1%) were published in weekly medical journals, and 104 (75.9%) were published in obstetrics and gynecology journals. The percentage of obstetrical randomized controlled trials published ranged from 1.5% to 9.6% per journal. Overall, 34.3% of obstetrical trials were statistically significant or "positive" for the primary outcome. Notably, 24.8% of the trials were retrospectively registered after the enrollment of the first study patient. Trials published in the 4 weekly medical journals enrolled significantly more patients (1801 vs 180; P<.001), received more often funding from the federal government (78.8% vs 35.6%; P<.001), and were more likely to be multicenter (90.9% vs 42.3%; P<.001), non-United States based (69.7% vs 49.0%; P=.03), and double blinded (45.5% vs 18.3%; P=.003) than trials published in the obstetrics and gynecology journals. There was no difference in study type (noninferiority vs superiority) and trial quality characteristics, including pretrial registration, ethics approval statement, informed consent statement, and adherence to the Consolidated Standards of Reporting Trials guidelines statement between studies published in weekly medical journals and studies published in obstetrics and gynecology journals.

CONCLUSION

Approximately 45 trials in obstetrics are being published every year in the highest impact journals, with one-fourth being in the weekly medical journals and the remainder in the obstetrics and gynecology journals. Only about a third of published obstetrical trials are positive. Trials published in weekly medical journals are larger, more likely to be funded by the government, multicenter, international, and double blinded. Quality metrics are similar between weekly medical journals and obstetrics and gynecology journals.

Novel Approach for Laparoscopically Placed Chronic Amniotic Fluid Catheters in Sheep

INTRODUCTION

Several fetal therapies involve repeated amniotic fluid intervention. We hypothesize that a minimally invasive approach can be used to safely implant an intrauterine catheter infusion system in a fetal ovine model for chronic use during pregnancy.

METHOD

Five pregnant sheep underwent operation between gestational days 110 and 115 (term 145 days). A Codman® implantable infusion pump was adapted for intrauterine use. The chamber was placed in the maternal flank and the tunneled catheter laparoscopically inserted into the amniotic cavity, secured with a pursestring. Three had an additional uterine anchoring suture. Ewes were sacrificed after natural delivery, and the uterus underwent gross and microscopic analyses.

RESULTS

There were no maternal mortalities, abortions, or preterm labor. Pumps were accessed and remained functional throughout gestation. Four ewes delivered healthy term lambs; the other delivered twins with failure to progress and demise. On necropsy, catheters secured with an anchoring suture remained in place, while the other 2 dislodged during labor. There was no chorioamnionitis by culture or histology.

CONCLUSION

Laparoscopically placed intra-amniotic infusion catheters were implanted safely and remained functional until delivery in an ovine model. This novel approach has promise in providing safe, durable amniotic fluid access for the potential treatment of fetal disease.

Abdominal wall defects

Abdominal wall defects are common congenital anomalies with the most frequent being gastroschisis and omphalocele. Though both are the result of errors during embryologic development of the fetal abdominal wall, gastroschisis and omphalocele represent unique disorders that have different clinical sequelae. Gastroschisis is generally a solitary anomaly with postnatal outcomes related to the underlying integrity of the prolapsed bowel. In contrast, omphalocele is frequently associated with other structural anomalies or genetic syndromes that contribute more to postnatal outcomes than the omphalocele defect itself. Despite their embryological differences, both gastroschisis and omphalocele represent anomalies of fetal development that benefit from multidisciplinary and translational approaches to care, both pre- and postnatally. While definitive management of abdominal wall defects currently remains in the postnatal realm, advancements in prenatal diagnostics and therapies may one day change that. This review focuses on recent advancements, novel techniques, and current controversies related to the prenatal diagnosis and management of gastroschisis and omphalocele.

Multiple cytokine analysis in gastroschisis: Association with adverse outcomes including fetal brain damage

OBJECTIVES

To investigate the distribution of multiple cytokines in gastroschisis and reveal its association with clinical outcomes, including gastrointestinal disorders and fetal brain damage caused by chronic inflammation in gastroschisis.

METHODS

We obtained amniotic fluid and arterial cord blood from 10 patients with gastroschisis, and evaluated the profile of 40 cytokines via multiplex immunoassay. The possible relationship of the cytokines with the time taken to attain full enteral nutrition and cord S100B, a surrogate marker of brain damage, was estimated. Associations among the relevant cytokines were also assessed.

RESULTS

Although clinical characteristics in our cohort had no relevance, several cytokines in cord blood, especially IL-2, IL-8, CCL1, CCL7, CXCL1, CXCL2, and CXCL6, were clearly elevated in patients who took a longer time to attain full enteral nutrition, whereas only IL-16 in cord blood was significantly related to cord S100B and strongly correlation with cord S100B levels. Moreover, our data indicated that IL-16 was considerably less correlated with the other cytokines associated with adverse outcomes.

CONCLUSIONS

We investigated the cytokine characteristics of both amniotic fluid and cord blood in gastroschisis, and found that certain cytokines could affect the adverse outcomes, including fetal brain damage. These findings provide important information that could further clarify the pathophysiology of gastroschisis and propose a novel clinical implication of gastroschisis that could be used to predict adverse outcomes, especially neurodevelopmental disorders.

Is there a role for fetal interventions in gastroschisis management? - An updated comprehensive review

We conducted a comprehensive evidence-based review on the epidemiology and current standard of care of gastroschisis management as well as the pathophysiology, rationale and feasibility of fetal therapy as a viable alternative. Gastroschisis is a periumbilical abdominal wall defect characterized by abdominal viscera herniation in utero. It affects 4 in 10 000 live births, but the prevalence has steadily increased in recent years. Gastroschisis is typically diagnosed on routine second-trimester ultrasound. The overall prognosis is favorable, but complex gastroschisis, which accounts for about 10% to 15% of cases, is associated with a higher mortality, significant disease burden and higher healthcare costs due to long- and short-term complications. The current standard of care has yet to be established but generally involves continued fetal surveillance and multidisciplinary perinatal care. Postnatal surgical repair is achieved with primary closure, staged silo closure or sutureless repair. Experimental animal studies have demonstrated the feasibility of in utero closure, antiinflammatory therapy and prenatal regenerative therapy. However, reports of early preterm delivery and amnioinfusion trials have failed to show any benefit in humans. Further experimental studies and human trials are necessary to demonstrate the potential benefit of fetal therapy in gastroschisis.

Relationship between volume and outcome for gastroschisis: a systematic review protocol

BACKGROUND

Gastroschisis is a congenital anomaly that needs surgical management for repositioning intestines into the abdominal cavity and for abdominal closure. Higher hospital or surgeon volume has previously been found to be associated with better clinical outcomes for different especially high-risk, low volume procedures. Therefore, we aim to examine the relationship between hospital or surgeon volume and outcomes for gastroschisis.

METHODS

We will perform a systematic literature search from inception onwards in Medline, Embase, CENTRAL, CINAHL, and Biosis Previews without applying any limitations. In addition, we will search trial registries and relevant conference proceedings. We will include (cluster-) randomized controlled trials (RCTs) and prospective or retrospective cohort studies analyzing the relationship between hospital or surgeon volume and clinical outcomes. The primary outcomes will be survival and mortality. Secondary outcomes will be different measures of morbidity (e.g., severe gastrointestinal complications, gastrointestinal dysfunctions, and sepsis), quality of life, and length of stay. We will systematically assess risk of bias of included studies using RoB 2 for individually or cluster-randomized trials and ROBINS-I for cohort studies, and extract data on the study design, patient characteristics, case-mix adjustments, statistical methods, hospital and surgeon volume, and outcomes into standardized tables. Title and abstract screening, full text screening, critical appraisal, and data extraction of results will be conducted by two reviewers independently. Other data will be extracted by one reviewer and checked for accuracy by a second one. Any disagreements will be resolved by discussion. We will not pool results statistically as we expect included studies to be clinically and methodologically very diverse. We will conduct a systematic synthesis without meta-analysis and use GRADE for assessing the certainty of the evidence.

DISCUSSION

Given the lack of a comprehensive summary of findings on the relationship between hospital or surgeon volume and outcomes for gastroschisis, this systematic review will put things right. Results can be used to inform decision makers or clinicians and to adapt medical care.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework (DOI: https://doi.org/10.17605/OSF.IO/EX34M ; https://doi.org/10.17605/OSF.IO/HGPZ2 ).

Antenatal corticosteroids and outcomes in gastroschisis: A multicenter retrospective cohort study

OBJECTIVE

In gastroschisis, there is evidence to suggest that gut dysfunction develops secondary to bowel inflammation; we aimed to evaluate the effect of maternal antenatal corticosteroids administered for obstetric reasons on time to full enteral feeds in a multicenter cohort study of gastroschisis infants.

METHODS

A three center, retrospective cohort study (1992-2013) with linked fetal/neonatal gastroschisis data was conducted. The primary outcome measure was time to full enteral feeds (a surrogate measure for bowel function) and secondary outcome measure was length of hospital stay. Analysis included Mann-Whitney and Cox regression.

RESULTS

Of 500 patients included in the study, 69 (GA at birth 34 [25-38] weeks) received antenatal corticosteroids and 431 (GA at birth 37 [31-41] weeks) did not. Antenatal corticosteroids had no effect on the rate of reaching full feeds (Hazard ratio HR 1.0 [95% CI: 0.8-1.4]). However, complex gastroschisis (HR 0.3 [95% CI: 0.2-0.4]) was associated with an increased time to reach full feeds and later GA at birth (HR 1.1 per week increase in GA [95% CI: 1.1-1.2]) was associated with a decreased time to reach full feeds.

CONCLUSION

Maternal antenatal corticosteroids use, under current antenatal steroid protocols, in gastroschisis is not associated with an improvement in neonatal outcomes such as time to full enteral feeds or length of hospital stay.