1
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Slidell MB, McAteer J, Miniati D, Sømme S, Wakeman D, Rialon K, Lucas D, Beres A, Chang H, Englum B, Kawaguchi A, Gonzalez K, Speck E, Villalona G, Kulaylat A, Rentea R, Yousef Y, Darderian S, Acker S, St Peter S, Kelley-Quon L, Baird R, Baerg J. Management of Gastroschisis: Timing of Delivery, Antibiotic Usage, and Closure Considerations (A Systematic Review From the American Pediatric Surgical Association Outcomes & Evidence Based Practice Committee). J Pediatr Surg 2024; 59:1408-1417. [PMID: 38796391 DOI: 10.1016/j.jpedsurg.2024.03.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 03/08/2024] [Accepted: 03/17/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND No consensus exists for the initial management of infants with gastroschisis. METHODS The American Pediatric Surgical Association (APSA) Outcomes and Evidenced-based Practice Committee (OEBPC) developed three a priori questions about gastroschisis for a qualitative systematic review. We reviewed English-language publications between January 1, 1970, and December 31, 2019. This project describes the findings of a systematic review of the three questions regarding: 1) optimal delivery timing, 2) antibiotic use, and 3) closure considerations. RESULTS 1339 articles were screened for eligibility; 92 manuscripts were selected and reviewed. The included studies had a Level of Evidence that ranged from 2 to 4 and recommendation Grades B-D. Twenty-eight addressed optimal timing of delivery, 5 pertained to antibiotic use, and 59 discussed closure considerations (Figure 1). Delivery after 37 weeks post-conceptual age is considered optimal. Prophylactic antibiotics covering skin flora are adequate to reduce infection risk until definitive closure. Studies support primary fascial repair, without staged silo reduction, when abdominal domain and hemodynamics permit. A sutureless repair is safe, effective, and does not delay feeding or extend length of stay. Sedation and intubation are not routinely required for a sutureless closure. CONCLUSIONS Despite the large number of studies addressing the above-mentioned facets of gastroschisis management, the data quality is poor. A wide variation in gastroschisis management was documented, indicating a need for high quality RCTs to provide an evidence-based approach when caring for these infants. TYPE OF STUDY Qualitative systematic review of Level 1-4 studies.
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Affiliation(s)
- Mark B Slidell
- Division of Pediatric Surgery, Johns Hopkins Children's Center, 1800 Orleans St, Baltimore, MD 21287, USA.
| | - Jarod McAteer
- Providence Hospital, 101 West 8th Avenue, Spokane, WA 99204, USA
| | - Doug Miniati
- Division of Pediatric Surgery, Kaiser Permanente Northern California, 1600 Eureka Road, Roseville, CA 95661, USA
| | - Stig Sømme
- Division of Pediatric Surgery, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Derek Wakeman
- University of Rochester Medical Center, School of Medicine and Dentistry, 601 Elmwood Ave, Box Surg, Rochester, NY 14642, USA
| | - Kristy Rialon
- Division of Pediatric Surgery, Texas Children's Hospital, 6701 Fannin Street, Houston, TX 77030, USA
| | - Don Lucas
- Division of Pediatric Surgery, Department of General Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134, USA
| | - Alana Beres
- Division of Pediatric Surgery, St. Christopher's Hospital for Children, 160 E Erie Ave, Philadelphia, PA 19134, USA
| | - Henry Chang
- Johns Hopkins All Children's Hospital, 501 6th Avenue South, St. Petersburg, FL 33701, USA
| | - Brian Englum
- University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201, USA
| | - Akemi Kawaguchi
- Department of Pediatric Surgery at McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin Street, Houston, TX 77030, USA
| | | | - Elizabeth Speck
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, 1540 E Hospital Dr, Ann Arbor, MI 48109, USA
| | - Gustavo Villalona
- Division of Pediatric Surgery, Nemours Children's Health, 807 Children's Way, Jacksonville, FL 32207, USA
| | - Afif Kulaylat
- Division of Pediatric Surgery, Penn State Hershey Children's Hospital, 200 Campus Dr Ste 400, Hershey, PA 17033, USA
| | - Rebecca Rentea
- Pediatric Surgery Division, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Yasmine Yousef
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, 1001 Decarie Boulevard, Montreal, Quebec, Canada H4A 3J1
| | - Sarkis Darderian
- Pediatric Surgery Division, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Shannon Acker
- Pediatric Surgery Division, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Shawn St Peter
- Pediatric Surgery Division, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Lorraine Kelley-Quon
- Pediatric Surgery Division, Children's Hospital, 4650 W Sunset Blvd, Los Angeles, CA 90027, USA
| | - Robert Baird
- Division of Pediatric General Surgery, Department of Surgery, Faculty of Medicine, University of British Columbia, 2775 Laurel Street, 11th Floor, Vancouver, British Columbia V5Z 1M9, Canada
| | - Joanne Baerg
- Division of Pediatric Surgery, Presbyterian Health System, 201 Cedar St SE Ste 4660, Albuquerque, NM 87106, USA
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2
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Muniz TD, Rolo LC, Araujo Júnior E. Gastroschisis: embriology, pathogenesis, risk factors, prognosis, and ultrasonographic markers for adverse neonatal outcomes. J Ultrasound 2024; 27:241-250. [PMID: 38553588 PMCID: PMC11178761 DOI: 10.1007/s40477-024-00887-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 02/26/2024] [Indexed: 06/15/2024] Open
Abstract
Gastroschisis is the most common congenital defect of the abdominal wall, typically located to the right of the umbilical cord, through which the intestinal loops and viscera exit without being covered by the amniotic membrane. Despite the known risk factors for gastroschisis, there is no consensus on the cause of this malformation. Prenatal ultrasound is useful for diagnosis, prognostic prediction (ultrasonographic markers) and appropriate monitoring of fetal vitality. Survival rate of children with gastroschisis is more than 95% in developed countries; however, complex gastroschisis requires multiple neonatal interventions and is associated with adverse perinatal outcomes. In this article, we conducted a narrative review including embryology, pathogenesis, risk factors, and ultrasonographic markers for adverse neonatal outcomes in fetuses with gastroschisis. Prenatal risk stratification of gastroschisis helps to better counsel parents, predict complications, and prepare the multidisciplinary team to intervene appropriately and improve postnatal outcomes.
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Affiliation(s)
- Thalita Diógenes Muniz
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), Rua Belchior de Azevedo, 156 Apto. 111 Torre Vitoria, Vila Leopoldina, São Paulo, SP, CEP 05089-030, Brazil
| | - Liliam Cristine Rolo
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), Rua Belchior de Azevedo, 156 Apto. 111 Torre Vitoria, Vila Leopoldina, São Paulo, SP, CEP 05089-030, Brazil
| | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), Rua Belchior de Azevedo, 156 Apto. 111 Torre Vitoria, Vila Leopoldina, São Paulo, SP, CEP 05089-030, Brazil.
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3
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Cullis PS, Fouad D, Goldstein AM, Wong KKY, Boonthai A, Lobos P, Pakarinen MP, Losty PD. Major surgical conditions of childhood and their lifelong implications: comprehensive review. BJS Open 2024; 8:zrae028. [PMID: 38776252 PMCID: PMC11110943 DOI: 10.1093/bjsopen/zrae028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/18/2023] [Accepted: 01/30/2024] [Indexed: 05/24/2024] Open
Abstract
BACKGROUND In recent decades, the survival of children with congenital anomalies and paediatric cancer has improved dramatically such that there has been a steady shift towards understanding their lifelong health outcomes. Paediatric surgeons will actively manage such conditions in childhood and adolescence, however, adult surgeons must later care for these 'grown-ups' in adulthood. This article aims to highlight some of those rare disorders encountered by paediatric surgeons requiring long-term follow-up, their management in childhood and their survivorship impact, in order that the adult specialist may be better equipped with skills and knowledge to manage these patients into adulthood. METHODS A comprehensive literature review was performed to identify relevant publications. Research studies, review articles and guidelines were sought, focusing on the paediatric management and long-term outcomes of surgical conditions of childhood. The article has been written for adult surgeon readership. RESULTS This article describes the aforementioned conditions, their management in childhood and their lifelong implications, including: oesophageal atresia, tracheo-oesophageal fistula, malrotation, short bowel syndrome, duodenal atresia, gastroschisis, exomphalos, choledochal malformations, biliary atresia, Hirschsprung disease, anorectal malformations, congenital diaphragmatic hernia, congenital lung lesions and paediatric cancer. CONCLUSION The increasing survivorship of children affected by surgical conditions will translate into a growing population of adults with lifelong conditions and specialist healthcare needs. The importance of transition from childhood to adulthood is becoming realized. It is hoped that this timely review will enthuse the readership to offer care for such vulnerable patients, and to collaborate with paediatric surgeons in providing successful and seamless transitional care.
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Affiliation(s)
- Paul S Cullis
- Department of Paediatric Surgery, Royal Hospital for Children Edinburgh, Edinburgh, UK
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Dina Fouad
- Department of Paediatric Surgery, Leicester Children’s Hospital, Leicester, UK
| | - Allan M Goldstein
- Department of Paediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kenneth K Y Wong
- Department of Paediatric Surgery, Queen Mary’s Hospital, University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Ampaipan Boonthai
- Department of Paediatric Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pablo Lobos
- Department of Paediatric Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Mikko P Pakarinen
- The New Children’s Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Department of Surgery, University of Southern Denmark, Odense, Denmark
| | - Paul D Losty
- Department of Paediatric Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
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Rivero-Arias O, Buckell J, Knight M, Craig BM, Ramakrishnan R, Kenny S, Allin B. Defining treatment success in children with surgical conditions. Arch Dis Child 2024; 109:377-386. [PMID: 38135491 DOI: 10.1136/archdischild-2023-326156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023]
Abstract
OBJECTIVES Develop a score summarising how successfully a child with any surgical condition has been treated, and test the clinical validity of the score. DESIGN Discrete choice experiment (DCE), and secondary analysis of data from six UK-wide prospective cohort studies. PARTICIPANTS 253 people with lived experience of childhood surgical conditions, 114 health professionals caring for children with surgical conditions and 753 members of the general population completed the DCE. Data from 1383 children with surgical conditions were used in the secondary analysis. MAIN OUTCOME MEASURES Normalised importance value of attribute (NIVA) for number/type of operations, hospital-treated infections, quality of life and duration of survival (reference attribute). RESULTS Quality of life and duration of survival were the most important attributes in deciding whether a child had been successfully treated. Parents, carers and previously treated adults placed equal weight on both attributes (NIVA=0.996; 0.798 to 1.194). Healthcare professionals placed more weight on quality of life (NIVA=1.469; 0.950 to 1.987). The general population placed more weight on survival (NIVA=0.823; 95% CI 0.708 to 0.938). The resulting score (the Children's Surgery Outcome Reporting (CSOR) Treatment Success Score (TSS)) has the best possible value of 1, a value of 0 describes palliation and values less than 0 describe outcomes worse than palliation. CSOR TSSs varied clinically appropriately for infants whose data were included in the UK-wide cohort studies. CONCLUSIONS The CSOR TSS summarises how successfully children with surgical conditions have been treated, and can therefore be used to compare hospitals' observed and expected outcomes.
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Affiliation(s)
- Oliver Rivero-Arias
- Nuffield Department of Population Health, National Perinatal Epidemiology Unit (NPEU), University of Oxford, Oxford, UK
- Nuffield Department of Population Health, Health Economics Research Centre (HERC), University of Oxford, Oxford, UK
| | - John Buckell
- Nuffield Department of Population Health, Health Economics Research Centre (HERC), University of Oxford, Oxford, UK
| | - Marian Knight
- Nuffield Department of Population Health, National Perinatal Epidemiology Unit (NPEU), University of Oxford, Oxford, UK
| | - B M Craig
- Department of Economics, University of South Florida, Tampa, Florida, USA
| | - Rema Ramakrishnan
- Nuffield Department of Population Health, National Perinatal Epidemiology Unit (NPEU), University of Oxford, Oxford, UK
| | - Simon Kenny
- Department of Paediatric Surgery, Alder Hey Children's Hospital, Liverpool, UK
| | - Benjamin Allin
- Nuffield Department of Population Health, National Perinatal Epidemiology Unit (NPEU), University of Oxford, Oxford, UK
- Chelsea and Westminster Hospital, London, UK
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5
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O'Shea K, Harwood R, O’Donnell S, Baillie C. Does time to theater matter in simple gastroschisis? WORLD JOURNAL OF PEDIATRIC SURGERY 2023; 6:e000575. [PMID: 37671120 PMCID: PMC10476109 DOI: 10.1136/wjps-2023-000575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 07/18/2023] [Indexed: 09/07/2023] Open
Abstract
Objective A recent publication has suggested that expedited time to theater in gastroschisis results in higher rates of primary closure and decreases the length of stay (LOS). This study primarily aims to assess the impact of time to first management of neonates with gastroschisis on the LOS. Methods Neonates admitted between August 2013 and August 2020 with gastroschisis were included. Data were collected retrospectively, and neonates with complex gastroschisis were excluded. Variables including gestation, birth weight, time of first management, primary/delayed closure and use of patch were evaluated as possible confounding variables. The outcome measures were time to full feeds, time on parenteral nutrition (PN) and LOS. Univariate and multivariate linear regression analyses were performed. P<0.05 was regarded as significant. Results Eighty-six neonates were identified, and 16 were then excluded (eight patients with complex gastroschisis, eight patients with time to first management not documented). The median LOS for those who underwent primary closure was 21 days (interquartile range (IQR) =16-29) and for those who underwent silo placement and delayed closure was 59 days (IQR=44-130). The mean time to first management was 473 min (standard deviation (SD) =146 min), with only 20% of these infants being operated on at less than 6 hours of age. Univariate and multivariate analyses demonstrated no relationship between time to first management and LOS (r2=0.00, p=0.82) but did demonstrate a consistent positive association between time to first feed and LOS and delayed closure, resulting in a longer time to full feeds and a longer time on PN. Conclusions The time to first management was not associated with a change in LOS in these data. Further prospective evaluation of the impact of reducing the time to first feed on the LOS is recommended. Level of evidence IV.
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Affiliation(s)
- Kathryn O'Shea
- Paediatric Surgery, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Rachel Harwood
- Paediatric Surgery, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
- Cellular and Molecular Physiology, University of Liverpool, Liverpool, UK
| | - Sean O’Donnell
- Paediatric Surgery, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Colin Baillie
- Paediatric Surgery, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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6
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Olutoye OO, Joyeux L, King A, Belfort MA, Lee TC, Keswani SG. Minimally Invasive Fetal Surgery and the Next Frontier. Neoreviews 2023; 24:e67-e83. [PMID: 36720693 DOI: 10.1542/neo.24-2-e67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Oluyinka O Olutoye
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Luc Joyeux
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Alice King
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Michael A Belfort
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Timothy C Lee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Sundeep G Keswani
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
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Tiruneh C, Gebremeskel T, Necho M, Teshome Y, Teshome D, Belete A. Birth prevalence of omphalocele and gastroschisis in Sub-Saharan Africa: A systematic review and meta-analysis. SAGE Open Med 2022; 10:20503121221125536. [PMID: 36161211 PMCID: PMC9500260 DOI: 10.1177/20503121221125536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 08/24/2022] [Indexed: 11/16/2022] Open
Abstract
Objective: To systematically summarize the burden of gastroschisis and omphalocele in Sub-Saharan Africa. Methods: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, systematically reviewed and meta-analyzed literatures from Medline (PubMed), Cochrane Library, HINARI, and Google Scholar that investigated at the prevalence of major congenital abdominal wall malformation. The pooled prevalence of major abdominal wall defects was estimated using a weighted inverse variance random-effects model. The Q statistic and the I2 statistics were used to examine for heterogeneity among the included studies. The funnel plot and Egger’s regression test were used to check for publication bias. Results: A total of 1951 studies were identified; 897 from PubMed, 26 from Cochrane Library, 960 from Google Scholar, and 68 from other sources. Fourteen articles that met the eligibility criteria were selected for this meta-analysis with 242,462 total enrolled participants and 4693 births with congenital anomaly. The pooled prevalence of ompahalocele among congenital defect patients in Sub-Saharan Africa was found to be 4.47% (95% confidence interval: 3.04–5.90; I2 = 88.3%; p < 0.001). The pooled prevalence of omphalocele among births with congenital defect was found to be 4.04% (95% confidence interval: 2.62–5.46) in cross-sectional studies and 4.43% (95% confidence interval: 306–5.81) in cohort studies. The average prevalence of omphalocele among births with congenital defect was found to be 8% (95% confidence interval: 5.53–10.47) in Uganda and 6.65% (95% confidence interval: 4.18–9.13) in Nigeria. The pooled prevalence of gastroschisis among congenital birth defect in Sub-Saharan Africa was found to be 3.22% (95% confidence interval: 1.83–4.61; I2 = 33.1%; p = 0.175). Conclusion: Based on this review, the pooled prevalence of omphalocele and gastroschisis in sub-Saharan Africa are high. Therefore, a perinatal screening program for congenital anomalies should be implemented. In addition, early referral of suspected cases of congenital anomalies is required for better management until advanced diagnostic centers are established in various locations of Sub-Saharan Africa.
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Affiliation(s)
- Chalachew Tiruneh
- Department of Biomedical Science, College of Medicine and Health Sciences, Injibara University, Injibara, Ethiopia
| | - Teshome Gebremeskel
- Department of Anatomy, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Mogesie Necho
- Department of Psychiatry, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Yossef Teshome
- Department of Anatomy, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Daniel Teshome
- Department of Anatomy, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Asmare Belete
- Department of Psychiatry, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
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Anderson C, Li H, Cheboiwo V, Fisher S, Chepkemoi E, Rutto E, Carpenter K, Keung C, Saula P, Gray B. Uncomplicated gastroschisis care in the US and Kenya: Treatment at two tertiary care centers. J Pediatr Surg 2022; 57:1664-1670. [PMID: 34749982 DOI: 10.1016/j.jpedsurg.2021.09.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 09/08/2021] [Accepted: 09/21/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Gastroschisis is a common birth defect with < 5% mortality in high income countries, but mortality in sub Saharan Africa remains high. We sought to compare gastroschisis management strategies and patient outcomes at tertiary pediatric referral centers in the United States and Kenya. METHODS This retrospective chart review examined uncomplicated gastroschisis patients treated at Riley Hospital for Children in Indianapolis, USA (n = 110), and Shoe4Africa Children's Hospital in Eldoret, Kenya (n = 75), from 2010 to 2018. Analyzed were completed using Chi square, Fisher's exact, and independent samples t tests and medians tests at the 95% significance level. RESULTS Survival in the American cohort was double that of the Kenyan cohort (99.1% vs 45.3%, p< 0.001). Sterile bag use for bowel containment was lower in Kenya (81.3% vs 98.1%, p< 0.001), but silo use was comparable at both institutions (p = 0.811). Kenyan patients had earlier median enteral feeding initiation (4vs 10 days, p< 0.001) and accelerated achievement of full enteral feeding (10vs 23 days, p< 0.001), but none received TPN. Despite earlier feeding, Kenyan patients displayed a higher prevalence of wound infections (70.8% vs 17.1%, p< 0.001) and sepsis (43.9% vs 4.8%, p< 0.001). In Kenya, survivors and non survivors displayed no difference in sterile bag use, hemodynamic stability, all cause infection rates, or antibiotic free hospital days. Defect closure (p< 0.001) and enteral feeding initiation (p< 0.001) were most predictive of survival. CONCLUSION Improving immediate response strategies for gastroschisis in Kenya could improve survival and decrease infection rates. Care strategies in the US can center on earlier enteral feeding initiation to reduce time to full feeding. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Cassandra Anderson
- Section of Pediatric Surgery, Riley Hospital for Children, 705 Riley Hospital Drive RI2500, Indianapolis, IN 46202, USA
| | - Helen Li
- Section of Pediatric Surgery, Riley Hospital for Children, 705 Riley Hospital Drive RI2500, Indianapolis, IN 46202, USA
| | - Vivian Cheboiwo
- Moi Teaching and Referral Hospital, P.O. Box 3-30100, Nandi Road, Uasin Gishu County, Eldoret, Kenya; Central and Southern Africa (COSECSA), College of Surgeons of East, 157 Olorien, Nijro Road ECSA HC, P.O. Box 1009, Arusha, Tanzania
| | - Sarah Fisher
- Section of Pediatric Surgery, Riley Hospital for Children, 705 Riley Hospital Drive RI2500, Indianapolis, IN 46202, USA
| | - Eunice Chepkemoi
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606 30100, Nandi Road, Uasin Gishu County, Eldoret, Kenya
| | - Emmy Rutto
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606 30100, Nandi Road, Uasin Gishu County, Eldoret, Kenya
| | - Kyle Carpenter
- Section of Pediatric Surgery, Riley Hospital for Children, 705 Riley Hospital Drive RI2500, Indianapolis, IN 46202, USA
| | - Connie Keung
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606 30100, Nandi Road, Uasin Gishu County, Eldoret, Kenya; Department of Surgery, Indiana University, School of Medicine, 545 Barnhill Dr., Emerson Hall, Indianapolis, IN 46202, USA
| | - Peter Saula
- Moi Teaching and Referral Hospital, P.O. Box 3-30100, Nandi Road, Uasin Gishu County, Eldoret, Kenya; Department of Surgery, Moi University, School of Medicine, P.O. Box 4606 30100, Nandi Road, Uasin Gishu County, Eldoret, Kenya
| | - Brian Gray
- Section of Pediatric Surgery, Riley Hospital for Children, 705 Riley Hospital Drive RI2500, Indianapolis, IN 46202, USA; Department of Surgery, Indiana University, School of Medicine, 545 Barnhill Dr., Emerson Hall, Indianapolis, IN 46202, USA.
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9
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Goldstein MJ, Bailer JM, Gonzalez-Brown VM. Preterm vs term delivery in antenatally diagnosed gastroschisis: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2022; 4:100651. [PMID: 35462060 DOI: 10.1016/j.ajogmf.2022.100651] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/11/2022] [Accepted: 04/12/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To review the evidence regarding gestational age at birth, length of stay, sepsis incidence, days on mechanical ventilation, and mortality between preterm and term deliveries in pregnancies complicated by gastroschisis. DATA SOURCES We conducted database searches of PubMed, Cochrane Central Register of Controlled Trials, Embase, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov without language restrictions through August 16, 2021. References of all relevant articles were reviewed. STUDY ELIGIBILITY CRITERIA Randomized controlled trials, nonrandomized controlled trials, and observational studies were evaluated comparing length of stay, sepsis, days on mechanical ventilation, and mortality between either elective preterm delivery and expectant management (Group 1) or preterm gestational age and term gestational age (Group 2). METHODS Two researchers independently selected studies and evaluated risk of bias with the Risk of Bias 2 tool for randomized controlled trials and the Newcastle-Ottawa Scale for cohort studies. Mean differences and odds ratios were calculated using a random-effects model for inclusion and methodological quality. The primary outcome was length of stay. Secondary outcomes were incidence of sepsis, mortality, days on mechanical ventilation, and gestational age. RESULTS Thirty studies with a total of 7409 patients were included in the systematic review, of which 25 were included in the analysis. Group 1 studies found no difference in length of stay or mortality and a trend toward fewer days on mechanical ventilation (mean difference, -0.40; 95% confidence interval, -0.89 to -0.10; P=.12; I2=35%). Subgroup analysis excluding premature delivery demonstrated lower sepsis incidence in elective preterm delivery (odds ratio, 0.46; 95% confidence interval, 0.25-0.84; P=.01; I2=0%). Group 2 studies found increased length of stay (mean difference, 15.44; 95% confidence interval, 8.44-21.83; P<.00001; I2=94%), sepsis (odds ratio, 1.69; 95% confidence interval, 1.15-2.50; P=.008; I2=51%), days on mechanical ventilation (mean difference, 1.38; 95% confidence interval, 0.10-2.66; P=.03; I2=66%), and mortality (odds ratio, 2.97; 95% confidence interval, 1.59-5.55; P=.0007; I2=0%). Gestational age was significantly lower in Group 2 studies than in Group 1 studies. CONCLUSION Data continue to be conflicting, but subgroup analysis suggested a possible reduction in sepsis incidence and mean days on mechanical ventilation with elective early term delivery.
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Affiliation(s)
| | - Jessica Marie Bailer
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Veronica Mayela Gonzalez-Brown
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, San Antonio Uniformed Services Health Education Consortium, San Antonio, TX
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10
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Rivero-Arias O, Buckell J, Allin B, Craig BM, Ayman G, Knight M. Using stated-preferences methods to develop a summary metric to determine successful treatment of children with a surgical condition: a study protocol. BMJ Open 2022; 12:e062833. [PMID: 35680263 PMCID: PMC9185585 DOI: 10.1136/bmjopen-2022-062833] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Wide variation in the management of key paediatric surgical conditions in the UK has likely resulted in outcomes for some children being worse than they could be. Consequently, it is important to reduce unwarranted variation. However, major barriers to this are the inability to detect differences between observed and expected hospital outcomes based on the casemix of the children they have treated, and the inability to detect variation in significant outcomes between hospitals. A stated-preference study has been designed to estimate the value key stakeholders place on different elements of the outcomes for a child with a surgical condition. This study proposes to develop a summary metric to determine what represents successful treatment of children with surgical conditions. METHODS AND ANALYSIS Preferences from parents, individuals treated for surgical conditions as infants/children, healthcare professionals and members of the public will be elicited using paired comparisons and kaizen tasks. A descriptive framework consisting of seven attributes representing types of operations, infections treated in hospital, quality of life and survival was identified. An experimental design has been completed using a D-efficient design with overlap in three attributes and excluding implausible combinations. All participants will be presented with an additional choice task including a palliative scenario that will be used as an anchor. The survey will be administered online. Primary analysis will estimate a mixed multinomial logit model. A traffic light system to determine what combination of attributes and levels represent successful treatment will be created. ETHICS AND DISSEMINATION Ethics approval to conduct this study has been obtained from the Medical Sciences Inter-Divisional Research Ethics Committee (IDREC) at the University of Oxford (R59631/RE001-05). We will disseminate all of our results in peer-review publications and scientific presentations. Findings will be additionally disseminated through relevant charities and support groups and professional organisations.
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Affiliation(s)
- Oliver Rivero-Arias
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - John Buckell
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Benjamin Allin
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Chelsea and Westminster Hospital, London, UK
| | - Benjamin M Craig
- Department of Economics, University of South Florida, Tampa, Florida, USA
| | - Goher Ayman
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Siyotula T, Arnold M. An analysis of neonatal mortality following gastro-intestinal and/or abdominal surgery in a tertiary hospital in South Africa. Pediatr Surg Int 2022; 38:721-729. [PMID: 35235014 DOI: 10.1007/s00383-022-05100-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Thirty-day, 6-month and 12-month post-operative mortality and assessment of factors associated with 30 day post-operative mortality were ascertained. METHOD A retrospective medical record audit for neonates who underwent gastrointestinal or abdominal wall surgery within the neonatal period at a tertiary free standing paediatric hospital during the 12-year period from 1 January 2007 to 31 December 2018. RESULTS The 30-day post-operative mortality rate was 83/762 (11%). Mortality resulted from: sepsis (74%), palliation due to ultra-short bowel length (12%), ventilation-associated pneumonia (10%), associated congenital cardiac lesions (3%) and intestinal failure-associated liver disease (1%). Surgery for necrotizing enterocolitis had the greatest 30-day post-operative mortality (28%). Most neonates (69%) who died were prematurely born. Mean age at surgery was ten days and mean age at death was six days. Abdominal compartment syndrome was noted post operatively in 15% patients. Risk factors for sepsis included central line-associated bloodstream infections (65%), respiratory tract infections (41%) and surgical complications [anastomotic breakdown (7%) and wound infection (24%)]. Mortality in patients from referral hospitals more than an hour's drive away was high (15/39, 38%). CONCLUSION Mortality is double that of high-income countries, although significantly lower than most African settings. Strategic quality-improvement interventions are required to optimize outcomes.
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Affiliation(s)
- Thozama Siyotula
- Division of Paediatric Surgery at Red Cross War Memorial Children's Hospital, University of Cape Town, Klipfontein Rd, Rondebosch, Cape Town, 7700, South Africa.
| | - Marion Arnold
- Division of Paediatric Surgery at Red Cross War Memorial Children's Hospital, University of Cape Town, Klipfontein Rd, Rondebosch, Cape Town, 7700, South Africa
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Predictors of Survival: A Retrospective Review of Gastroschisis and Intestinal Atresia in Rwanda. J Surg Res 2022; 273:138-146. [DOI: 10.1016/j.jss.2021.12.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 11/22/2021] [Accepted: 12/27/2021] [Indexed: 11/21/2022]
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13
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Merritt RJ. Gastroschisis: Progress and Challenges. J Pediatr 2022; 243:8-11. [PMID: 34958830 DOI: 10.1016/j.jpeds.2021.12.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/21/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Russell J Merritt
- Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California.
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14
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The role of feeding advancement strategy on length of stay and hospital costs in newborns with gastroschisis. J Pediatr Surg 2022; 57:356-359. [PMID: 34020775 DOI: 10.1016/j.jpedsurg.2021.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/25/2021] [Accepted: 04/10/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Infants with gastroschisis require prolonged hospitalization for surgical repair and gradual advancement of feeds. The present study explores the effect of a change in a protocolized enteral feeding regimen with length of hospital stay (LOS) and total costs in newborns with gastroschisis. METHODS A retrospective review was performed in neonates with uncomplicated gastroschisis at a free-standing pediatric institution from 2012 to 2020. The effect of two different enteral feed advancement protocols on clinical outcomes and hospital costs was analyzed. RESULTS Seventy-four patients were identified, of which 50 (68%) underwent 10 ml/kg/day feeding advancements, and 24 (32%) underwent 20 ml/kg/day feeding advancements. Compared to neonates who underwent 10 ml/kg/day enteral advancements, neonates receiving 20 ml/kg/day advancements reached goal feeds faster (14 vs 20 days, p<0.001), were younger at goal feeds (26 vs 34 days, p = 0.001), required fewer days of parenteral nutrition (22 vs 29 days, p = 0.001), and had shorter LOS (30 vs 36 days, p = 0.001). On multivariable analysis, total costs decreased by 9.77% in the 20 ml/kg/day advancement cohort (p = 0.071). CONCLUSION In neonates with uncomplicated gastroschisis who underwent primary repair, a nutritional protocol that incorporated 20 ml/kg/day feeding advancements was safe and resulted in faster attainment of goal feeds and shorter LOS. LEVEL OF EVIDENCE II/III.
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15
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Ho PSY, Quigley MA, Tucker DF, Kurinczuk JJ. Risk factors for hospitalisation in Welsh infants with a congenital anomaly. BMJ Paediatr Open 2022; 6:10.1136/bmjpo-2021-001238. [PMID: 36053619 PMCID: PMC8845320 DOI: 10.1136/bmjpo-2021-001238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 01/12/2022] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To investigate risk factor associated with hospitalisation of infants with a congenital anomaly in Wales, UK. DESIGN A population-based cohort study. SETTING Data from the Welsh Congenital Anomaly Register and Information Service linked to the Patient Episode Database for Wales and livebirths and deaths from the Office for National Statistics. PATIENTS All livebirths between 1999 and 2015 with a diagnosis of a congenital anomaly, which was defined as a structural, metabolic, endocrine or genetic defect, as well as rare diseases of hereditary origin. MAIN OUTCOME MEASURES Adjusted OR (aOR) associated with 1 or 2+ hospital admissions in infancy versus no admissions were estimated for sociodemographic, maternal and infant factors using multinomial logistic regression for the subgroups of all, isolated, multiple and cardiovascular anomalies. RESULTS 25 523 infants affected by congenital anomalies experienced a total of 50 705 admissions in infancy. Risk factors for ≥2 admissions were younger maternal age ≤24 years (aOR: 1.17; 95% CI 1.06 to 1.30), maternal smoking (aOR: 1.20; 1.10 to 1.31), preterm birth (aOR: 2.52; 2.25 to 2.83) and moderately severe congenital heart defects (aOR: 6.25; 4.47 to 8.74). Girls had an overall decreased risk of 2+ admissions (aOR: 0.84; 0.78 to 0.91). Preterm birth was a significant risk factor for admissions in all anomaly subgroups but the effect of the other characteristics varied according to anomaly subgroup. CONCLUSIONS Over two-thirds of infants with an anomaly are admitted to hospital during infancy. Our findings identified sociodemographic and clinical characteristics contributing to an increased risk of hospitalisation of infants with congenital anomalies.
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Affiliation(s)
- Peter S Y Ho
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Maria A Quigley
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,National Institute for Health Research (NIHR) Policy Research Unit- Maternal Health and Care, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - David F Tucker
- Public Health Wales, Public Health Knowledge & Research, Congenital Anomaly Register & Information Service for Wales, Public Health Wales, Swansea, UK
| | - Jennifer J Kurinczuk
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,National Institute for Health Research (NIHR) Policy Research Unit- Maternal Health and Care, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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16
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Egger PA, de Souza MP, Riedo CDO, Dutra ADC, da Silva MT, Pelloso SM, Carvalho MDDB. Gastroschisis annual incidence, mortality, and trends in extreme Southern Brazil. J Pediatr (Rio J) 2022; 98:69-75. [PMID: 34115974 PMCID: PMC9432054 DOI: 10.1016/j.jped.2021.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 03/06/2021] [Accepted: 04/02/2021] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To analyze gastroschisis annual incidence, mortality rates, and trends in the Brazilian state of Rio Grande do Sul from the year 2000 to the year 2017. METHOD Population-based study with the analysis of the temporal trend of gastroschisis annual incidence and mortality rates. Data were obtained from the Live Birth Information System and the Mortality Information System, with the analysis performed by polynomial regression modeling. RESULTS There were 2,612,532 live births, 705 hospitalizations, and 233 deaths due to gastroschisis. The annual incidence of gastroschisis was 2.69 per 10,000 live births. The annual incidence rate increased by 85% in the total period (p = 0.003), and mortality was 33% in the 2000-2017 period. Maternal age < 25 years was a risk factor for gastroschisis (p < 0.001). Children were more likely to be born weighing < 2,500 g (p < 0.001) and with a gestational age < 37 weeks (p < 0.001). The annual incidence trend was to increase, and the mortality trend was to decrease. CONCLUSION Similar to what has been described in several regions/countries, there was a trend showing an 85% increase in the annual incidence of gastroschisis (p = 0.003) and the mortality was 33% with a trend of decreasing (p = 0.002).
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Affiliation(s)
- Paulo Acácio Egger
- Universidade Estadual de Maringá, Centro de Ciências da Saúde, Maringá, PR, Brazil.
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Negash S, Temesgen F. Primary closure of gastroschisis aided by ileostomy: A new management approach for low resource settings. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022. [DOI: 10.1016/j.epsc.2021.102135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Park BY, Boles I, Monavvari S, Patel S, Alvarez A, Phan M, Perez M, Yao R. The association between wildfire exposure in pregnancy and foetal gastroschisis: A population-based cohort study. Paediatr Perinat Epidemiol 2022; 36:45-53. [PMID: 34797578 DOI: 10.1111/ppe.12823] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 09/08/2021] [Accepted: 09/12/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Global climate change has led to an increase in the prevalence and severity of wildfires. Pollutants released into air, soil and groundwater from wildfires may impact embryo development leading to gastroschisis. OBJECTIVE The objective of this study was to determine the association between wildfire exposure before and during pregnancy and the risk of foetal gastroschisis development. METHODS This was a retrospective cohort study using The California Office of Statewide Health Planning and Development Linked Birth File linked to The California Department of Forestry and Fire Protection data between 2007 and 2010. Pregnancies complicated by foetal gastroschisis were identified by neonatal hospital discharge ICD-9 code. Pregnancies were considered exposed to wildfire if the mother's primary residence zip code was within 15 miles to the closest edge of a wildfire. The exposure was further stratified by trimester or if exposed within 30 days prior to pregnancy. Multivariable log-binomial regression analyses were performed to estimate the association between wildfire exposure in each pregnancy epoch and foetal gastroschisis. RESULTS Between 2007 and 2010, 844,348 (40%) births were exposed to wildfire in California. Compared with births without wildfire exposure, those with first-trimester exposure were associated with higher rates of gastroschisis, 7.8 vs. 5.7 per 10,000 births (adjusted relative risk [aRR] 1.28, 95% confidence interval [CI] 1.07, 1.54). Furthermore, those with prepregnancy wildfire exposure were also found to have higher rates of gastroschisis, 12.5 vs. 5.7 per 10,000 births, (aRR 2.17, 95% CI 1.42, 3.52). In contrast, second- and third-trimester wildfire exposures were not associated with foetal gastroschisis. CONCLUSIONS Wildfire exposure within 30 days before pregnancy was associated with more than two times higher risk of foetal gastroschisis, whereas a 28% higher risk was demonstrated if exposure was in the first trimester.
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Affiliation(s)
- Bo Young Park
- Department of Public Health, California State University - Fullerton, Fullerton, CA, USA.,Department of Obstetrics and Gynecology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Ian Boles
- Center for Demographic Research, Fullerton, CA, USA
| | - Samira Monavvari
- Department of Obstetrics and Gynecology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Shivani Patel
- Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Arriel Alvarez
- Department of Public Health, California State University - Fullerton, Fullerton, CA, USA
| | - Mie Phan
- Department of Public Health, California State University - Fullerton, Fullerton, CA, USA
| | - Maria Perez
- St. George's University School of Medicine, St George's, Grenada
| | - Ruofan Yao
- Department of Obstetrics and Gynecology, Loma Linda University School of Medicine, Loma Linda, CA, USA
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Davenport M, Jawaid WB, Losty PD. UK paediatric surgical academic output (2005-2020): A cause for concern? J Pediatr Surg 2021; 56:2142-2147. [PMID: 34392970 DOI: 10.1016/j.jpedsurg.2021.07.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/21/2021] [Accepted: 07/28/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND The publication record can be regarded as a key metric of the academic output of a craft surgical speciality with an almost exponential increase in the number of such publications worldwide over the past 20 years (Ashfaq et al. J Surg Res 2018;229:10-11). We aimed to examine and explore if this was the experience within UK paediatric surgery centres. METHODS The academic search engine Scopus™ (Elsevier) was used to track every paediatric surgeon's (NHS or University) publication history between Jan. 2005 - Dec. 2020. This was validated by an algorithmic search of PubMed™. The h-index (citations/publication), considered a validated metric of career academic output, was also calculated for each individual surgeon. A Field-Weighted Citation Index (Scopus™) (FWCI) was used to assess impact of individual publications. Textbooks, book chapters, abstracts, duplications ("double dipping") and output attributed to UK BAPS-CASS national studies were excluded. Some output(s), not considered as relevant to "paediatric surgery", was edited. Data are quoted as median(range). RESULTS During this 16-year period, there were 3838 publications identified from 26 centres with a "top ten" listing of those paediatric surgical units contributing over half the output (n = 2189, 57%). To look for evidence of trend(s) we analysed the output from these surgical centres in two 5-year periods (2005-9 and 2015-19) and showed an overall fall in output(s) - [730 (53.4%) to 645 (46.4%)] with 6/10 (60%) ' top ten ' centres here recording a reduction in publications. The median h-index of the 232 contributing paediatric surgical consultants was 12 (range 1-56). The best performing publication from the "top ten" centres had 96.5(51-442) citations with the FWCI being 4.5 (2.2 - 30.2). CONCLUSIONS This study highlights current paediatric surgery publication output metrics in UK centres. There is evidence of a relative reduction in outputs overall which is a cause for concern for the future, although individual publications from the 10 most active units in the UK remain highly cited. These findings may serve purpose in several ways: (i) UK paediatric surgical centre rankings may be helpful for guiding residency / trainee application; (ii) surgical research funding for the top performing units may be better facilitated and finally (iii) UK centres showing a ' fertile ground ' for nurturing and training paediatric surgeons with academic aspirations could be useful for future workforce planning.
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Affiliation(s)
- Mark Davenport
- Department of Paediatric Surgery, Kings College Hospital, Denmark Hill, London SE5 9RS, United Kingdom.
| | - Wajid B Jawaid
- Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, United Kingdom
| | - Paul D Losty
- Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, United Kingdom; Faculty Of Health And Life Sciences, University Of Liverpool, , United Kingdom
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Joyeux L, Belfort MA, De Coppi P, Basurto D, Valenzuela I, King A, De Catte L, Shamshirsaz AA, Deprest J, Keswani SG. Complex gastroschisis: a new indication for fetal surgery? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:804-812. [PMID: 34468062 DOI: 10.1002/uog.24759] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/16/2021] [Accepted: 08/19/2021] [Indexed: 06/13/2023]
Abstract
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.
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Affiliation(s)
- L Joyeux
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, Division Woman and Child, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
- Department of Pediatric Surgery, Queen Fabiola Children's University Hospital, Brussels, Belgium
- Michael E. DeBakey Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - M A Belfort
- Michael E. DeBakey Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- Department of Obstetrics and Gynecology, Division Maternal-Fetal Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- Texas Children's Fetal Center, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - P De Coppi
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, Division Woman and Child, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
- Specialist Neonatal and Paediatric Surgery Unit and NIHR Biomedical Research Center, Great Ormond Street Hospital, and Great Ormond Street Institute of Child Health, University College London, London, UK
| | - D Basurto
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, Division Woman and Child, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
| | - I Valenzuela
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - A King
- Michael E. DeBakey Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- Texas Children's Fetal Center, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - L De Catte
- Department of Obstetrics and Gynecology, Division Woman and Child, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
| | - A A Shamshirsaz
- Michael E. DeBakey Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- Department of Obstetrics and Gynecology, Division Maternal-Fetal Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- Texas Children's Fetal Center, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - J Deprest
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, Division Woman and Child, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
- Institute of Women's Health, University College London Hospitals, London, UK
| | - S G Keswani
- Michael E. DeBakey Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- Texas Children's Fetal Center, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
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Tauriainen A, Hyvärinen A, Raitio A, Sankilampi U, Gärding M, Tauriainen T, Helenius I, Vanamo K. Different strategies, equivalent treatment approaches in terms of mortality in four university hospitals: a retrospective multicenter study of gastroschisis in Finland. Pediatr Surg Int 2021; 37:1521-1529. [PMID: 34486073 PMCID: PMC8418788 DOI: 10.1007/s00383-021-04980-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/06/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Optimal treatment of gastroschisis is not determined. The aim of the present study was to investigate treatment methods of gastroschisis in four university hospitals in Finland. METHODS The data of neonates with gastroschisis born between 1993 and 2015 were collected. The primary outcomes were short and long-term mortality and the length of stay (LOS). Statistical analyses consisted of uni- and multivariate models. RESULTS Total of 154 patients were included (range from 31 to 52 in each hospital). There were no statistically significant differences in mortality or LOS between centers. Significant differences were observed between the hospitals in the duration of mechanical ventilation (p = 0.046), time to full enteral nutrition (p = 0.043), delay until full defect closure (p = 0.003), central line sepsis (p = 0.025), abdominal compartment syndrome (p = 0.018), number of abdominal operations during initial hospitalization (p = 0.000) and follow-up (p = 0.000), and ventral hernia at follow-up (p = 0.000). In a Cox multivariate analysis, the treating hospital was not associated with mortality. CONCLUSION There were no differences in short or long-term mortality between four university hospitals in Finland. However, some inter-hospital variation in postoperative outcomes was present. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Asta Tauriainen
- Department of Pediatric Surgery, University of Eastern Finland and Kuopio University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland ,Department of Pediatric Surgery and Orthopedics, University of Turku and Turku University Hospital, Turku, Finland
| | - Anna Hyvärinen
- Department of Pediatric Surgery, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Arimatias Raitio
- Department of Pediatric Surgery and Orthopedics, University of Turku and Turku University Hospital, Turku, Finland
| | - Ulla Sankilampi
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland ,School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Mikko Gärding
- Department of Pediatric Surgery, Oulu University Hospital, Oulu, Finland
| | | | - Ilkka Helenius
- Department of Orthopedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kari Vanamo
- Department of Pediatric Surgery, University of Eastern Finland and Kuopio University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland
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The Financial Burden of Surgery for Congenital Malformations-The Austrian Perspective. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182111166. [PMID: 34769683 PMCID: PMC8582705 DOI: 10.3390/ijerph182111166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/15/2021] [Accepted: 10/21/2021] [Indexed: 11/17/2022]
Abstract
Neonatal “surgical” malformations are associated with higher costs than major “non-surgical” birth defects. We aimed to analyze the financial burden on the Austrian health system of five congenital malformations requiring timely postnatal surgery. The database of the Austrian National Public Health Institute for the period from 2002 to 2014 was reviewed. Diagnosis-related group (DRG) points assigned to hospital admissions containing five congenital malformations coded as principal diagnosis (esophageal atresia, duodenal atresia, congenital diaphragmatic hernia, gastroschisis, and omphalocele) were collected and compared to all hospitalizations for other reasons. Out of 3,518,625 total hospitalizations, there were 1664 admissions of patients with the selected malformations. The annual mean number was 128 (SD 17, range 110–175). The mean cost of the congenital malformations per hospital admission expressed in DRG points was 26,588 (range 0–465,772, SD 40,702) and was significantly higher compared to the other hospitalizations (n = 3,516,961; mean DRG 2194, range 0–834,997; SD 6161; p < 0.05). Surgical conditions requiring timely postnatal surgery place a significant financial burden on the healthcare system. The creation of a dedicated national register could allow for better planning of resource allocation, for improving the outcome of affected children, and for optimizing costs.
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Paediatric surgical outcomes in sub-Saharan Africa: a multicentre, international, prospective cohort study. BMJ Glob Health 2021; 6:bmjgh-2020-004406. [PMID: 34475022 PMCID: PMC8413881 DOI: 10.1136/bmjgh-2020-004406] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 01/23/2021] [Accepted: 01/26/2021] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION As childhood mortality from infectious diseases falls across sub-Saharan Africa (SSA), the burden of disease attributed to surgical conditions is increasing. However, limited data exist on paediatric surgical outcomes in SSA. We compared the outcomes of five common paediatric surgical conditions in SSA with published benchmark data from high-income countries (HICs). METHODS A multicentre, international, prospective cohort study was undertaken in hospitals providing paediatric surgical care across SSA. Data were collected on consecutive children (birth to 16 years), presenting with gastroschisis, anorectal malformation, intussusception, appendicitis or inguinal hernia, over a minimum of 1 month, between October 2016 and April 2017. Participating hospitals completed a survey on their resources available for paediatric surgery.The primary outcome was all-cause in-hospital mortality. Mortality in SSA was compared with published benchmark mortality in HICs using χ2 analysis. Generalised linear mixed models were used to identify patient-level and hospital-level factors affecting mortality. A p<0.05 was deemed significant. RESULTS 1407 children from 51 hospitals in 19 countries across SSA were studied: 111 with gastroschisis, 188 anorectal malformation, 225 intussusception, 250 appendicitis and 633 inguinal hernia. Mortality was significantly higher in SSA compared with HICs for all conditions: gastroschisis (75.5% vs 2.0%), anorectal malformation (11.2% vs 2.9%), intussusception (9.4% vs 0.2%), appendicitis (0.4% vs 0.0%) and inguinal hernia (0.2% vs 0.0%), respectively. Mortality was 41.9% (112/267) among neonates, 5.0% (20/403) in infants and 1.0% (7/720) in children. Paediatric surgical condition, higher American Society of Anesthesiologists score at primary intervention, and needing/receiving a blood transfusion were significantly associated with mortality on multivariable analysis. CONCLUSION Mortality from common paediatric surgical conditions is unacceptably high in SSA compared with HICs, particularly for neonates. Interventions to reduce mortality should focus on improving resuscitation and timely transfer at the district level, and preoperative resuscitation and perioperative care at paediatric surgical centres.
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A retrospective review of gastroschisis epidemiology and referral patterns in northern Ghana. Pediatr Surg Int 2021; 37:1069-1078. [PMID: 34059928 DOI: 10.1007/s00383-021-04898-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To describe the epidemiology and referral patterns of gastroschisis patients in northern Ghana. METHODS A hospital-based retrospective review was undertaken at Tamale Teaching Hospital (TTH) Neonatal Intensive Care Unit (NICU) between 2014 and 2019. Data from gastroschisis patients were compared to patients with other surgical diagnoses. Descriptive and inferential statistics were performed with SAS. Referral flow maps were made with ArcGIS. RESULTS From a total of 360 neonates admitted with surgical conditions, 12 (3%) were diagnosed with gastroschisis. Around 91% (n = 10) of gastroschisis patients were referred from other hospitals, traveling 4 h, on average. Referral patterns showed gastroschisis patients were admitted from three regions, whereas patients with other surgical diagnoses were admitted from eight regions. Only 6% (12/201) of expected gastroschisis cases were reported during the 6-year period in all regions. All gastroschisis deaths occurred within the first week of life. CONCLUSIONS Improving access to surgical care and reducing neonatal mortality related to gastroschisis in northern Ghana is critical. This study provides a baseline to inform future gastroschisis interventions at TTH. Priority areas may include special management of low birth weight newborns, better referral systems, empowerment of community health workers, and increasing access to timely, affordable, and safe neonatal transport.
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Bethell GS, Long AM, Knight M, Hall NJ. One-year Outcomes of Congenital Duodenal Obstruction: A Population-based Study. J Pediatr Gastroenterol Nutr 2021; 72:239-243. [PMID: 32826802 DOI: 10.1097/mpg.0000000000002921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Congenital duodenal obstruction (CDO) occurs in 1.2 per 10,000 live births and is frequently associated with other anomalies, most commonly cardiac. The aim of this study was to report important outcomes to 1 year following surgical repair. METHODS This was a prospective population-based study using the British Association of Paediatric Surgeons Congenital Anomaly Surveillance System. Cases were identified at specialist pediatric surgical centres in the United Kingdom during a 12-month period starting in March 2016. Outcomes were recorded at 1 year following surgical repair. RESULTS There were 100 infants with possible follow-up at 1 year and follow-up was achieved in 80 of these (80%) of whom 76 were alive at 1 year. The remainder had been discharged home, although one remained on parenteral nutrition. Five (6.1%) infants underwent repeat surgery for reasons related to CDO and overall 23 (23%) experienced at least 1 central venous catheter-related complication within 1 year. Overall mortality either before repair or within 1 year following surgical repair was 8.4% (95% CI 2.5%-14.4%), no deaths were related to CDO. CONCLUSIONS One year outcomes for CDO are generally very good with poor outcomes typically related to comorbidities. These data are useful for national benchmarking and parental counselling.
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Affiliation(s)
- George S Bethell
- University Surgery Unit, Faculty of Medicine, University of Southampton, Southampton
| | - Anna-May Long
- National Perinatal Epidemiology Unit, Oxford
- Department of Paediatric Surgery, Cambridge University Hospitals, Cambridge, UK
| | | | - Nigel J Hall
- University Surgery Unit, Faculty of Medicine, University of Southampton, Southampton
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Perry DC, Arch B, Appelbe D, Francis P, Spowart C, Knight M. A protocol for a nationwide multicentre, prospective surveillance cohort and nested-consented cohort to determine the incidence and clinical outcomes of slipped capital femoral epiphysis. Bone Jt Open 2020; 1:35-40. [PMID: 33215105 PMCID: PMC7659633 DOI: 10.1302/2633-1462.13.bjo-2020-0002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Aims Slipped capital femoral epiphysis (SCFE) is one of the most common hip diseases of adolescence that can cause marked disability, yet there is little robust evidence to guide treatment. Fundamental aspects of the disease, such as frequency, are unknown and consequently the desire of clinicians to undertake robust intervention studies is somewhat prohibited by a lack of fundamental knowledge. Methods The study is an anonymized nationwide comprehensive cohort study with nested consented within the mechanism of the British Orthopaedic Surgery Surveillance (BOSS) Study. All relevant hospitals treating SCFE in England, Scotland, and Wales will contribute anonymized case details. Potential missing cases will be cross-checked against two independent external sources of data (the national administrative data and independent trainee data). Patients will be invited to enrich the data collected by supplementing anonymized case data with patient-reported outcome measures. In line with recommendations of the IDEAL Collaboration, the study will primarily seek to determine incidence, describe case mix and variations in surgical interventions, and explore the relationships between baseline factors (patients and types of interventions) and two-year outcomes. Discussion This is the first disease to be investigated using the BOSS Study infrastructure. It provides a robust method to determine the disease frequency, and a large unbiased sample of cases from which treatment strategies can be investigated. It may form the basis for definitive robust intervention studies or, where these are demonstrated not to be feasible, this may be the most robust cohort study.
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Affiliation(s)
- Daniel C Perry
- University of Liverpool, Institute of Translational Medicine, Alder Hey Hospital, Liverpool, UK
| | - Barbara Arch
- University of Liverpool, Institute of Translational Medicine, Alder Hey Hospital, Liverpool, UK
| | - Duncan Appelbe
- NDORMS, University of Oxford, Kadoorie Centre, John Radcliffe Hospital, Oxford, UK
| | - Priya Francis
- University of Liverpool, Institute of Translational Medicine, Alder Hey Hospital, Liverpool, UK
| | - Catherine Spowart
- University of Liverpool, Institute of Translational Medicine, Alder Hey Hospital, Liverpool, UK
| | - Marian Knight
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Perry DC, Arch B, Appelbe D, Francis P, Spowart C, Knight M. The BOSS Study. Determining the incidence and clinical outcomes of uncommon conditions and events in orthopaedic surgery. Bone Jt Open 2020; 1:41-46. [PMID: 33215106 PMCID: PMC7659705 DOI: 10.1302/2633-1462.13.bjo-2020-0008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Introduction There is widespread variation in the management of rare orthopaedic disease, in a large part owing to uncertainty. No individual surgeon or hospital is typically equipped to amass sufficient numbers of cases to draw robust conclusions from the information available to them. The programme of research will establish the British Orthopaedic Surgery Surveillance (BOSS) Study; a nationwide reporting structure for rare disease in orthopaedic surgery. Methods The BOSS Study is a series of nationwide observational cohort studies of pre-specified orthopaedic disease. All relevant hospitals treating the disease are invited to contribute anonymised case details. Data will be collected digitally through REDCap, with an additional bespoke software solution used to regularly confirm case ascertainment, prompt follow-up reminders and identify potential missing cases from external sources of information (i.e. national administrative data). With their consent, patients will be invited to enrich the data collected by supplementing anonymised case data with patient reported outcomes. The study will primarily seek to calculate the incidence of the rare diseases under investigation, with 95% confidence intervals. Descriptive statistics will be used to describe the case mix, treatment variations and outcomes. Inferential statistical analysis may be used to analyze associations between presentation factors and outcomes. Types of analyses will be contingent on the disease under investigation. Discussion This study builds upon other national rare disease supporting structures, particularly those in obstetrics and paediatric surgery. It is particularly focused on addressing the evidence base for quality and safety of surgery, and the design is influenced by the specifications of the IDEAL collaboration for the development of surgical research.
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Affiliation(s)
- Daniel C Perry
- University of Liverpool; Institute of Translational Medicine, Alder Hey Hospital, Liverpool, University of Oxford, Kadoorie Centre, John Radcliffe Hospital, Oxford, UK
| | - Barbara Arch
- University of Liverpool; Institute of Translational Medicine, Alder Hey Hospital, Eaton Road, Liverpool
| | - Duncan Appelbe
- NDORMS, University of Oxford, Kadoorie Centre, John Radcliffe Hospital, Oxford, Oxfordshire, UK OX3 9DU
| | - Priya Francis
- University of Liverpool; Institute of Translational Medicine, Alder Hey Hospital, Eaton Road, Liverpool
| | - Catherine Spowart
- University of Liverpool, Institute of Translational Medicine, Alder Hey Hospital, Liverpool, UK
| | - Marian Knight
- Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK OX3 7LF
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Oluwafemi OO, Benjamin RH, Navarro Sanchez ML, Scheuerle AE, Schaaf CP, Mitchell LE, Langlois PH, Canfield MA, Swartz MD, Scott DA, Northrup H, Ray JW, McLean SD, Ludorf KL, Chen H, Lupo PJ, Agopian AJ. Birth defects that co-occur with non-syndromic gastroschisis and omphalocele. Am J Med Genet A 2020; 182:2581-2593. [PMID: 32885608 DOI: 10.1002/ajmg.a.61830] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/22/2020] [Accepted: 07/30/2020] [Indexed: 01/24/2023]
Abstract
Gastroschisis and omphalocele are the two most common abdominal wall birth defects, and epidemiologic characteristics and frequency of occurrence as part of a syndromic condition suggest distinct etiologies between the two defects. We assessed complex patterns of defect co-occurrence with these defects separately using the Texas Birth Defects Registry. We used co-occurring defect analysis (CODA) to compute adjusted observed-to-expected (O/E) ratios for all observed birth defect patterns. There were 2,998 non-syndromic (i.e., no documented syndrome diagnosis identified) cases with gastroschisis and 789 (26%) of these had additional co-occurring defects. There were 720 non-syndromic cases with omphalocele, and 404 (56%) had additional co-occurring defects. Among the top 30 adjusted O/E ratios for gastroschisis, most of the co-occurring defects were related to the gastrointestinal system, though cardiovascular and kidney anomalies were also present. Several of the top 30 combinations co-occurring with omphalocele appeared suggestive of OEIS (omphalocele, exstrophy of cloaca, imperforate anus, spinal defects) complex. After the exclusion of additional cases with features suggestive of OEIS in a post-hoc sensitivity analysis, the top combinations involving defects associated with OEIS (e.g., spina bifida) were no longer present. The remaining top combinations involving omphalocele included cardiovascular, gastrointestinal, and urogenital defects. In summary, we identified complex patterns of defects that co-occurred more frequently than expected with gastroschisis and omphalocele using a novel software platform. Better understanding differences in the patterns between gastroschisis and omphalocele could lead to additional etiologic insights.
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Affiliation(s)
- Omobola O Oluwafemi
- Department of Epidemiology, Human Genetics and Environmental Sciences, UTHealth School of Public Health, Houston, Texas, USA
| | - Renata H Benjamin
- Department of Epidemiology, Human Genetics and Environmental Sciences, UTHealth School of Public Health, Houston, Texas, USA
| | - Maria Luisa Navarro Sanchez
- Department of Epidemiology, Human Genetics and Environmental Sciences, UTHealth School of Public Health, Houston, Texas, USA
| | - Angela E Scheuerle
- Department of Pediatrics, Division of Genetics and Metabolism, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Christian P Schaaf
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA.,Jan and Dan Duncan Neurological Research Institute, Texas Children's Hospital, Houston, Texas, USA.,Heidelberg University, Institute of Human Genetics, Heidelberg, Germany
| | - Laura E Mitchell
- Department of Epidemiology, Human Genetics and Environmental Sciences, UTHealth School of Public Health, Houston, Texas, USA
| | - Peter H Langlois
- Birth Defects Epidemiology and Surveillance Branch, Texas Department of State Health Services, Austin, Texas, USA
| | - Mark A Canfield
- Birth Defects Epidemiology and Surveillance Branch, Texas Department of State Health Services, Austin, Texas, USA
| | - Michael D Swartz
- Department of Biostatistics and Data Science, UTHealth School of Public Health, Houston, Texas, USA
| | - Daryl A Scott
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA.,Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston, Texas, USA
| | - Hope Northrup
- Department of Pediatrics, Division of Medical Genetics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Joseph W Ray
- Department of Pediatrics, Division of Medical Genetics and Metabolism, University of Texas Medical Branch, Galveston, Texas, USA
| | - Scott D McLean
- Clinical Genetics Section, Children's Hospital of San Antonio, San Antonio, Texas, USA
| | - Katherine L Ludorf
- Department of Epidemiology, Human Genetics and Environmental Sciences, UTHealth School of Public Health, Houston, Texas, USA
| | - Han Chen
- Department of Epidemiology, Human Genetics and Environmental Sciences, UTHealth School of Public Health, Houston, Texas, USA.,Center for Precision Health, UTHealth School of Public Health and UTHealth School of Biomedical Informatics, Houston, Texas, USA
| | - Philip J Lupo
- Department of Pediatrics, Section of Hematology-Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - A J Agopian
- Department of Epidemiology, Human Genetics and Environmental Sciences, UTHealth School of Public Health, Houston, Texas, USA
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Kim NE, Vervoot D, Hammouri A, Riboni C, Salem H, Grimes C, Wright NJ. Cost-effectiveness of neonatal surgery for congenital anomalies in low-income and middle-income countries: a systematic review protocol. BMJ Paediatr Open 2020; 4:e000755. [PMID: 32923695 PMCID: PMC7462241 DOI: 10.1136/bmjpo-2020-000755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/21/2020] [Accepted: 07/26/2020] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Congenital anomalies are the fifth leading cause of death in children under 5 years old globally (591 000 deaths reported in 2016). Over 95% of deaths occur in low-income and middle-income countries (LMICs). It is estimated that two-thirds of the congenital anomaly health burden could be averted through surgical intervention and that such interventions can be cost-effective. This systematic review aims to evaluate current evidence regarding the cost-effectiveness of neonatal surgery for congenital anomalies in LMICs. METHODS AND ANALYSIS A systematic literature review will be conducted in PubMed, MEDLINE, Embase, Cochrane Library, Scielo, Google Scholar, African Journals OnLine and Regional WHO's African Index Medicus databases for articles on the cost-effectiveness of neonatal surgery for congenital anomalies in LMICs. The following search strings will be used: (1) congenital anomalies; (2) LMICs; and (3) cost-effectiveness of surgical interventions. Articles will be uploaded to Covidence software, duplicates removed and the remaining articles screened by two independent reviewers. Cost information for interventions or procedures will be extracted by country and condition. Outcome measurements by reported unit and cost-effectiveness ratios will be extracted. Methodological quality of each article will be assessed using the Drummond checklist for economic evaluations. The Agency for Healthcare Research and Quality's Effective Health Care Program guidance will be followed to assess the grade of the studies. ETHICS AND DISSEMINATION No ethical approval is required for conducting the systematic review. There will be no direct collection of data from individuals. The finalised article will be published in a scientific journal for dissemination. The protocol has been registered with PROSPERO (International Prospective Register of Systematic Reviews). CONCLUSION Congenital anomalies form a large component of the global health burden that is amenable to surgical intervention. This study will systematically review the current literature on the cost-effectiveness of neonatal surgery for congenital anomalies in LMICs. PROSPERO REGISTRATION NUMBER CRD42020172971.
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Affiliation(s)
- Na Eun Kim
- Department of General Surgery, Boston Medical Center, Boston, Massachusetts, USA
- King's College London, London, UK
| | - Dominique Vervoot
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ahmad Hammouri
- Department of Internal Medicine, Bethlehem Arab Society for Rehabilitation, Bethlehem, Palestine, State of
| | | | | | - Caris Grimes
- King's College London, London, UK
- Department of Surgery, Medway NHS Foundation Trust, Gillingham, Kent, UK
| | - Naomi Jane Wright
- King’s Centre for Global Health and Health Partnerships, King’s College London, London, UK
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Goley SM, Sakula-Barry S, Adofo-Ansong N, Isaaya Ntawunga L, Tekyiwa Botchway M, Kelly AH, Wright N. Investigating the use of ultrasonography for the antenatal diagnosis of structural congenital anomalies in low-income and middle-income countries: a systematic review. BMJ Paediatr Open 2020; 4:e000684. [PMID: 32864479 PMCID: PMC7443309 DOI: 10.1136/bmjpo-2020-000684] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 06/17/2020] [Accepted: 06/22/2020] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Congenital anomalies are the fifth leading cause of under-5 mortality globally. The greatest burden is faced by those in low/middle-income countries (LMICs), where over 95% of deaths occur. Many of these deaths may be preventable through antenatal diagnosis and early intervention. This systematic literature review investigates the use of antenatal ultrasound to diagnose congenital anomalies and improve the health outcomes of infants in LMICs. METHODS A systematic literature review was conducted using three search strings: (1) structural congenital anomalies; (2) LMICs; and (3) antenatal diagnosis. The search was conducted on the following databases: Medline, Embase, PubMed and the Cochrane Library. Title, abstract and full-text screening was undertaken in duplicate by two reviewers independently. Consensus among the wider authorship was sought for discrepancies. The primary analysis focused on the availability and effectiveness of antenatal ultrasound for diagnosing structural congenital anomalies. Secondary outcomes included neonatal morbidity and mortality, termination rates, referral rates for further antenatal care and training level of the ultrasonographer. Relevant policy data were sought. RESULTS The search produced 4062 articles; 97 were included in the review. The median percentage of women receiving an antenatal ultrasound examination was 50.0% in African studies and 90.7% in Asian studies (range 6.8%-98.8%). Median detection rates were: 16.7% Africa, 34.3% South America, 34.7% Asia and 47.3% Europe (range 0%-100%). The training level of the ultrasound provider may affect detection rates. Four articles compared morbidity and mortality outcomes, with inconclusive results. Significant variations in termination rates were found (0%-98.3%). No articles addressed referral rates. CONCLUSION Antenatal detection of congenital anomalies remains highly variable across LMICs and is particularly low in sub-Saharan Africa. Further research is required to investigate the role of antenatal diagnosis for improving survival from congenital anomalies in LMICs. PROSPERO REGISTRATION NUMBER CRD42019105620.
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Affiliation(s)
| | | | - Nana Adofo-Ansong
- Department of Paediatrics, Mafikeng Provincial Hospital, Mafikeng, South Africa
| | | | - Maame Tekyiwa Botchway
- Department of Paediatric Surgery, University of the Witwatersrand, Johannesburg-Braamfontein, Gauteng, South Africa
| | - Ann Horton Kelly
- Department of Global Health & Social Medicine, King’s College London, London, UK
| | - Naomi Wright
- King’s Centre for Global Health and Health Partnerships, King’s College London, London, UK
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Martins BMR, Abreu I, Méio MDB, Moreira MEL. Gastroschisis in the neonatal period: A prospective case-series in a Brazilian referral center. J Pediatr Surg 2020; 55:1546-1551. [PMID: 32467036 DOI: 10.1016/j.jpedsurg.2020.04.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 04/19/2020] [Accepted: 04/20/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND/PURPOSE Gastroschisis is increasing in incidence and has low mortality and high morbidity. We describe the clinical and surgical characteristics of gastroschisis patients in a Brazilian referral center. METHODS Single-center prospective case series of gastroschisis patients. The following two groups were formed depending on the intestinal characteristics: simple and complex patients. RESULTS In total, 79 patients were enrolled, 89% of whom were classified as simple and 11% as complex. The baseline characteristics were similar between the groups, with the exception of the illness severity score. The complex group had a significantly smaller defect size, more reoperations and worse clinical outcomes than the simple group, with the initiation of feeding taking 1.5 times longer, the duration of total parenteral nutrition taking twice as long, and the length of hospitalization being 2.5 times longer; the complex group also included all the deaths that occurred. Overall, the survival rate was 96%. Patients who underwent the sutureless technique had significantly fewer wound infections and a decreased duration of mechanical ventilation than sutured patients. CONCLUSIONS This study provides a comprehensive picture of gastroschisis during the neonatal period in a Brazilian referral center, emphasizing the significantly higher risk for morbidity and mortality among complex patients than among simple patients and the few advantages of the sutureless technique over the sutured technique in terms of closing the defect. TYPE OF STUDY Prognostic. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Bianca M R Martins
- Department of Surgery, Surgical NICU, Instituto Fernandes Figueira - Fundação Oswaldo Cruz, FIOCRUZ, Rio de Janeiro, Brazil.
| | - Isabel Abreu
- Department of Surgery, Surgical NICU, Instituto Fernandes Figueira - Fundação Oswaldo Cruz, FIOCRUZ, Rio de Janeiro, Brazil
| | - Maria Dalva B Méio
- Clinical Research Unit, Instituto Fernandes Figueira - Fundação Oswaldo Cruz, FIOCRUZ, Rio de Janeiro, Brazil
| | - Maria Elisabeth L Moreira
- Clinical Research Unit, Instituto Fernandes Figueira - Fundação Oswaldo Cruz, FIOCRUZ, Rio de Janeiro, Brazil
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Nitzsche K, Fitze G, Rüdiger M, Birdir C. Prenatal Prediction of Outcome by Fetal Gastroschisis in a Tertiary Referral Center. Diagnostics (Basel) 2020; 10:diagnostics10080540. [PMID: 32751744 PMCID: PMC7460378 DOI: 10.3390/diagnostics10080540] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/29/2020] [Accepted: 07/30/2020] [Indexed: 01/02/2023] Open
Abstract
The aim of this study was to find a prenatal parameter to be able to predict possible prenatal complications or postnatal surgical options, thus allowing the fetal medicine specialist, together with pediatric surgeons and neonatologists, to improve the counseling of the parents and to determine the timing of delivery and therapy. This was a retrospective analysis of prenatal diagnosis and outcome of fetuses with 34 cases of gastroschisis between the years 2007 and 2017. A total of 34 fetuses with gastroschisis were examined and 33 outcomes registered: 22 cases of simple gastroschisis (66.7%) and 11 cases of complex gastroschisis (33.3%). A cut-off value of 18 mm for intraabdominal bowel dilatation (IABD) showed a positive predictive value (PPV) of 100% for predicting simple gastroschisis. IABD gives the best prediction for simple versus complex gastroschisis (cut-off of 18 mm). Extra-abdominal bowel dilatation (EABD) cut-off values of 10 mm and 18 mm showed low sensitivity and specificity to predict complex gastroschisis.
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Affiliation(s)
- Katharina Nitzsche
- Department of Obstetrics and Gynecology, University Clinic of Carl Gustav Carus Dresden, Technische Universität Dresden, 01307 Dresden, Germany;
| | - Guido Fitze
- Department of Pediatric Surgery, University Clinic of Carl Gustav Carus Dresden, Technische Universität Dresden, 01307 Dresden, Germany;
| | - Mario Rüdiger
- Department of Pediatrics, University Clinic of Carl Gustav Carus Dresden, Technische Universität Dresden, 01307 Dresden, Germany;
| | - Cahit Birdir
- Department of Obstetrics and Gynecology, University Clinic of Carl Gustav Carus Dresden, Technische Universität Dresden, 01307 Dresden, Germany;
- Correspondence:
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Arivoli M, Biswas A, Burroughs N, Wilson P, Salzman C, Kakembo N, Mugaga J, Ssekitoleko RT, Saterbak A, Fitzgerald TN. Multidisciplinary Development of a Low-Cost Gastroschisis Silo for Use in Sub-Saharan Africa. J Surg Res 2020; 255:565-574. [PMID: 32645490 DOI: 10.1016/j.jss.2020.05.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 04/01/2020] [Accepted: 05/03/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND Gastroschisis silos are often unavailable in sub-Saharan Africa (SSA), contributing to high mortality. We describe a collaboration between engineers and surgeons in the United States and Uganda to develop a silo from locally available materials. METHODS Design criteria included the following: < $5 cost, 5 ± 0.25 cm opening diameter, deformability of the opening construct, ≥ 500 mL volume, ≥ 30 N tensile strength, no statistical difference in the leakage rate between the low-cost silo and preformed silo, ease of manufacturing, and reusability. Pugh scoring matrices were used to assess designs. Materials considered included the following: urine collection bags, intravenous bags, or zipper storage bags for the silo and female condom rings or O-rings for the silo opening construct. Silos were assembled with clothing irons and sewn with thread. Colleagues in Uganda, Malawi, Tanzania, and Kenya investigated material cost and availability. RESULTS Urine collection bags and female condom rings were chosen as the most accessible materials. Silos were estimated to cost < $1 in SSA. Silos yielded a diameter of 5.01 ± 0.11 cm and a volume of 675 ± 7 mL. The iron + sewn seal, sewn seal, and ironed seal on the silos yielded tensile strengths of 31.1 ± 5.3 N, 30.1 ± 2.9 N, and 14.7 ± 2.4 N, respectively, compared with the seal of the current standard-of-care silo of 41.8 ± 6.1 N. The low-cost silos had comparable leakage rates along the opening and along the seal with the spring-loaded preformed silo. The silos were easily constructed by biomedical engineering students within 15 min. All silos were able to be sterilized by submersion. CONCLUSIONS A low-cost gastroschisis silo was constructed from materials locally available in SSA. Further in vivo and clinical studies are needed to determine if mortality can be improved with this design.
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Affiliation(s)
| | - Arushi Biswas
- Pratt School of Engineering, Duke University, Durham, North Carolina
| | - Nolan Burroughs
- Pratt School of Engineering, Duke University, Durham, North Carolina
| | - Patrick Wilson
- Pratt School of Engineering, Duke University, Durham, North Carolina
| | - Caroline Salzman
- Pratt School of Engineering, Duke University, Durham, North Carolina
| | - Nasser Kakembo
- Department of Surgery, Makerere University, Kampala, Uganda
| | - Julius Mugaga
- Makerere University College of Health Sciences, Kampala, Uganda; Duke-Makerere University Biomedical Engineering Partnership, Durham, North Carolina and Kampala, Uganda
| | - Robert T Ssekitoleko
- Makerere University College of Health Sciences, Kampala, Uganda; Duke-Makerere University Biomedical Engineering Partnership, Durham, North Carolina and Kampala, Uganda
| | - Ann Saterbak
- Pratt School of Engineering, Duke University, Durham, North Carolina; Duke-Makerere University Biomedical Engineering Partnership, Durham, North Carolina and Kampala, Uganda
| | - Tamara N Fitzgerald
- Department of Surgery, Duke University, Durham, North Carolina; Duke Global Health Institute, Duke University, Durham, North Carolina.
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Hawkins RB, Raymond SL, St. Peter SD, Downard CD, Qureshi FG, Renaud E, Danielson PD, Islam S. Immediate versus silo closure for gastroschisis: Results of a large multicenter study. J Pediatr Surg 2020; 55:1280-1285. [PMID: 31472924 PMCID: PMC7731615 DOI: 10.1016/j.jpedsurg.2019.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 08/07/2019] [Accepted: 08/13/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND/PURPOSE The optimal method to repair gastroschisis defects continues to be debated. The two primary methods are immediate closure (IC) or silo placement (SP). The purpose of this study was to compare outcomes between each approach using a multicenter retrospective analysis. We hypothesized that patients undergoing SP for ≤5 days would have largely equivalent outcomes compared to IC patients. METHODS Gastroschisis patient data were collected over a 7-year period. The cohort was separated into IC and SP groups. The SP group was further stratified based on time to closure (≤5 days, 6-10 days, >10 days). Characteristics and outcomes were compared between groups. Multivariate logistic regression was also performed. RESULTS 566 neonates with gastroschisis were identified including 224 patients in the IC group and 337 patients in the SP group. Among SP patients, 130 were closed within 5 days, 140 in 6-10 days, and 57 in >10 days. There were no significant differences in mortality, sepsis, readmission, or days to full enteral feeds between IC patients and SP patients who had a silo ≤5 days. IC patients had a significantly higher incidence of ventral hernias. Multivariate analysis revealed time to closure as a significant independent predictor of length of stay, ventilator duration, time to full enteral feeds, and TPN duration. CONCLUSIONS Our data show largely equivalent outcomes between patients who undergo immediate closure and those who have silos ≤5 days. We propose that closure within 5 days avoids many of the risks commonly attributed to delay in closure. LEVEL OF EVIDENCE Level II retrospective study.
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Affiliation(s)
- Russell B. Hawkins
- University of Florida College of Medicine, Department of Surgety, Division of Pediatric Surgery, Gainesville, FL, USA
| | - Steven L. Raymond
- University of Florida College of Medicine, Department of Surgety, Division of Pediatric Surgery, Gainesville, FL, USA
| | | | - Cynthia D. Downard
- University of Louisville, Department of Surgery, Division of Pediatric Surgery, Louisville, KY, USA
| | - Faisal G. Qureshi
- University of Texas Southwestern, Department of Surgery, Division of Pediatric Surgery, Dallas, TX, USA
| | - Elizabeth Renaud
- Alpert Medical School of Brown University, Department of Surgery, Division of Pediatric Surgery, Providence, RI, USA
| | | | - Saleem Islam
- University of Florida College of Medicine, Department of Surgery, Division of Pediatric Surgery, Gainesville, FL, USA.
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Wu AJ, Lee DJ, Li F, Tobin NH, Aldrovandi GM, Shew SB, Calkins KL. Impact of Clinical Factors on the Intestinal Microbiome in Infants With Gastroschisis. JPEN J Parenter Enteral Nutr 2020; 45:818-825. [PMID: 32441784 DOI: 10.1002/jpen.1926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 05/04/2020] [Accepted: 05/11/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Infants with gastroschisis require operations and lengthy hospitalizations due to intestinal dysmotility. Dysbiosis may contribute to these problems. Little is known on the microbiome of gastroschisis infants. METHODS The purpose of this study was to investigate the fecal microbiome in gastroschisis infants. Microbiome profiling was performed by sequencing the V4 region of the 16S rRNA gene. The microbiome of gastroschisis infants was compared with the microbiome of healthy controls, and the effects of mode of birth delivery, gestational age, antibiotic duration, and nutrition type on microbial composition and diversity were investigated. RESULTS The microbiome of gastroschisis infants (n = 13) was less diverse (Chao1, P < .001), lacked Bifidobacterium (P = .001), and had increased Staphylococcus (P = .007) compared with controls (n = 83). Mode of delivery (R2 = 0.04, P = .001), antibiotics duration ≥7 days (R2 = 0.03, P = .003), age at sample collection (R2 = 0.03, P = .009), and gestational age (R2 = 0.02, P = .035) explained a small portion of microbiome variation. In gastroschisis infants, Escherichia-Shigella was the predominate genus, and those delivered via cesarean section had different microbial communities, predominantly Staphylococcus and Streptococcus, from those delivered vaginally. Although antibiotic duration contributed to the variation in microbiome composition, there were no significant differences in taxa distribution or α diversity by antibiotic duration or nutrition type. CONCLUSION The microbiome of gastroschisis infants is dysbiotic, and mode of birth delivery, antibiotic duration, and gestational age appear to contribute to microbial variation.
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Affiliation(s)
- Allison J Wu
- Department of Pediatrics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA.,Department of Pediatrics, Division of Gastroenterology, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts, USA
| | - David J Lee
- Department of Pediatrics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Fan Li
- Department of Pediatrics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Nicole H Tobin
- Department of Pediatrics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Grace M Aldrovandi
- Department of Pediatrics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Stephen B Shew
- Department of Surgery, Division of Pediatric Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Kara L Calkins
- Department of Pediatrics, Neonatal Research Center of the UCLA of Children's Discovery and Innovation Institute, David Geffen School of Medicine UCLA and UCLA Mattel Children's Hospital, Los Angeles, California, USA
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Lap CCMM, Pistorius LR, Mulder EJH, Aliasi M, Kramer WLM, Bilardo CM, Cohen‐Overbeek TE, Pajkrt E, Tibboel D, Wijnen RMH, Visser GHA, Manten GTR. Ultrasound markers for prediction of complex gastroschisis and adverse outcome: longitudinal prospective nationwide cohort study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:776-785. [PMID: 31613023 PMCID: PMC7318303 DOI: 10.1002/uog.21888] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 09/18/2019] [Accepted: 09/19/2019] [Indexed: 06/02/2023]
Abstract
OBJECTIVES To identify antenatal ultrasound markers that can differentiate between simple and complex gastroschisis and assess their predictive value. METHODS This was a prospective nationwide study of pregnancies with isolated fetal gastroschisis that underwent serial longitudinal ultrasound examination at regular specified intervals between 20 and 37 weeks' gestation. The primary outcome was simple or complex (i.e. involving bowel atresia, volvulus, perforation or necrosis) gastroschisis at birth. Fetal biometry (abdominal circumference and estimated fetal weight), the occurrence of polyhydramnios, intra- and extra-abdominal bowel diameters and the pulsatility index (PI) of the superior mesenteric artery (SMA) were assessed. Linear mixed modeling was used to compare the individual trajectories of cases with simple and those with complex gastroschisis, and logistic regression analysis was used to estimate the strength of association between the ultrasound parameters and outcome. RESULTS Of 104 pregnancies with isolated fetal gastroschisis included, four ended in intrauterine death. Eighty-one (81%) liveborn infants with simple and 19 (19%) with complex gastroschisis were included in the analysis. We found no relationship between fetal biometric variables and complex gastroschisis. The SMA-PI was significantly lower in fetuses with gastroschisis than in healthy controls, but did not differentiate between simple and complex gastroschisis. Both intra- and extra-abdominal bowel diameters were larger in cases with complex, compared to those with simple, gastroschisis (P < 0.001 and P < 0.005, respectively). The presence of intra-abdominal bowel diameter ≥ 97.7th percentile on at least three occasions, not necessarily on successive examinations, was associated with an increased risk of the fetus having complex gastroschisis (relative risk, 1.56 (95% CI, 1.02-2.10); P = 0.006; positive predictive value, 50.0%; negative predictive value, 81.4%). CONCLUSIONS This large prospective longitudinal study found that intra-abdominal bowel dilatation when present repeatedly during fetal development can differentiate between simple and complex gastroschisis; however, the positive predictive value is low, and therefore the clinical usefulness of this marker is limited. © 2019 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- C. C. M. M. Lap
- Department of Obstetrics, Division Woman and BabyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - L. R. Pistorius
- Department of Obstetrics and GynecologyUniversity of StellenboschStellenboschSouth Africa
| | - E. J. H. Mulder
- Department of Obstetrics, Division Woman and BabyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - M. Aliasi
- Department of Obstetrics, Division Woman and BabyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - W. L. M. Kramer
- Department of Pediatric SurgeryUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - C. M. Bilardo
- Department of Obstetrics and GynecologyAmsterdam University Medical Centers, University of Amsterdam, Amsterdam Reproduction and Development Research InstituteAmsterdamThe Netherlands
- Department of Obstetrics and Gynaecology, University Medical Centre GroningenUniversity of GroningenGroningenThe Netherlands
| | - T. E. Cohen‐Overbeek
- Department of Obstetrics and Gynecology, Division of Obstetrics and Prenatal MedicineErasmus MC, Sophia Children's HospitalRotterdamThe Netherlands
| | - E. Pajkrt
- Department of Obstetrics and GynecologyAmsterdam University Medical Centers, University of Amsterdam, Amsterdam Reproduction and Development Research InstituteAmsterdamThe Netherlands
| | - D. Tibboel
- Department of Pediatric Surgery and Intensive Care ChildrenErasmus Medical Center, Sophia Children's HospitalRotterdamThe Netherlands
| | - R. M. H. Wijnen
- Department of Pediatric Surgery and Intensive Care ChildrenErasmus Medical Center, Sophia Children's HospitalRotterdamThe Netherlands
| | - G. H. A. Visser
- Department of Obstetrics, Division Woman and BabyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - G. T. R. Manten
- Department of Obstetrics, Division Woman and BabyUniversity Medical Center UtrechtUtrechtThe Netherlands
- Department of ObstetricsIsala Women and Children's HospitalZwolleThe Netherlands
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Carnaghan H, James CP, Charlesworth PB, Ghionzoli M, Pereira S, Elkhouli M, Baud D, De Coppi P, Ryan G, Shah PS, Davenport M, David AL, Pierro A, Eaton S. Antenatal corticosteroids and outcomes in gastroschisis: A multicenter retrospective cohort study. Prenat Diagn 2020; 40:991-997. [PMID: 32400889 DOI: 10.1002/pd.5727] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 03/08/2020] [Accepted: 04/25/2020] [Indexed: 11/07/2022]
Abstract
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.
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Affiliation(s)
- Helen Carnaghan
- UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital for Children, London, UK
| | | | | | - Marco Ghionzoli
- UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital for Children, London, UK
| | - Susana Pereira
- Departamento de Obstetrícia e Ginecologia, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - Mohamed Elkhouli
- Fetal Medicine Unit, University College London Hospital, London, UK
| | - David Baud
- Fetal Medicine Unit, Mount Sinai Hospital, University of Toronto, Ontario, Canada
- Materno-fetal and Obstetrics Research Unit, Department of Gynaecology and Obstetrics, University Hospital of Lausanne CHUV, Lausanne, Switzerland
| | - Paolo De Coppi
- UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital for Children, London, UK
| | - Greg Ryan
- Fetal Medicine Unit, Mount Sinai Hospital, University of Toronto, Ontario, Canada
| | - Prakesh S Shah
- Division of Neonatology, Mount Sinai Hospital, University of Toronto, Ontario, Canada
| | - Mark Davenport
- Paediatric Surgery Unit, King's College Hospital, London, UK
| | - Anna L David
- Fetal Medicine Unit, University College London Hospital, London, UK
| | - Agostino Pierro
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Simon Eaton
- UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital for Children, London, UK
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Oyinloye AO, Abubakar AM, Wabada S, Oyebanji LO. Challenges and Outcome of Management of Gastroschisis at a Tertiary Institution in North-Eastern Nigeria. Front Surg 2020; 7:8. [PMID: 32195264 PMCID: PMC7064440 DOI: 10.3389/fsurg.2020.00008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 02/17/2020] [Indexed: 01/16/2023] Open
Abstract
Introduction: Gastroschisis is a congenital anterior abdominal wall defect characterized by herniation of abdominal contents through a defect usually located to the right side of the umbilical cord. It occurs in about 1 in 2,000-4,000 live births and is slightly commoner in males. Management has remained challenging in the low and middle-income countries (LMICS), with high mortality rates. This study highlights the clinical presentation, treatment, outcomes, and challenges in the management of gastroschisis at a tertiary healthcare center in a resource-limited setting. Methods: This was a retrospective review of the records of all patients with gastroschisis managed over a period of 30 months (January 2016-June 2018). Data on patients' demographics, age, birth weight, clinical presentation, method of gastroschisis reduction and closure, complications, and outcomes were collated. Statistical analysis was performed using SPSS version 20. A p-value of >0.05 was considered significant. Results: Twenty-four patients with gastroschisis were managed. Of these, 18 patients had data available for analysis. There were 14 males, with a male-female ratio of 3.5:1. The median age at presentation was 11.0 h (range 1-36 h). Ten patients (55.6%) were delivered in a medical facility. One patient had type II jejunal atresia and transverse colonic atresia as associated anomalies. Improvised silos were applied by the bedside in 15 (83.3%) patients, while two patients (11.1%) had primary closure under general anesthesia. One patient died before definitive treatment could be done. Sterile urobags and female condoms were used for constructing improvised silos in 9 (60%) and 6 (40%) patients, respectively. Eight patients who had initial silo application had complete bowel reduction over a median time of 8.0 days (mean 10.0 ± 6.5 days, range 2-23 days). Total parenteral nutrition (TPN) was not available. The average time to commencement of feeding was 8.0 days ± 6.6 (median 6.0 days, range 2-22 days). Full feeding was achieved in five patients (two patients in the primary closure group and three from the silo group) over a mean time of 16.8 days ± 10.4 (median 14.0 days). Sepsis was the commonest complication. Four patients (22.2%) survived. Conclusion: Management of gastroschisis remains challenging in resource-limited regions.
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Affiliation(s)
- Adewale O Oyinloye
- Division of Pediatric Surgery, Department of Surgery, Federal Medical Center, Yola, Nigeria
| | - Auwal M Abubakar
- Division of Pediatric Surgery, Department of Surgery, Federal Medical Center, Yola, Nigeria
| | - Samuel Wabada
- Division of Pediatric Surgery, Department of Surgery, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria
| | - Lateef O Oyebanji
- Division of Pediatric Surgery, Department of Surgery, Federal Medical Center, Yola, Nigeria
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Reducing Gastroschisis Mortality: A Quality Improvement Initiative at a Ugandan Pediatric Surgery Unit. World J Surg 2020; 44:1395-1399. [DOI: 10.1007/s00268-020-05373-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Abstract
Introduction
With modern treatment, survival of gastroschisis exceeds 90% in high-income countries. Survival in these countries has been largely attributed to prenatal diagnosis, delivery at tertiary facilities with timely resuscitation, timely intervention, parenteral nutrition and intensive care facilities. In sub-Saharan Africa, due to lack of these facilities, mortality rates are still alarmingly high ranging from 75 to 100%. In Uganda the mortality is 98%.
Aim
The aim of this study was to reduce gastroschisis mortality in a feasible, sustainable way using a locally derived gastroschisis care protocol at a referring hospital in Western Uganda.
Methods
Data collection was performed from January to October 2018. Nursing staff were interviewed regarding the survival and management of gastroschisis babies. A locally derived protocol was created with staff input and commitment from all the team members.
Results
Four mothers absconded and 17 babies were cared for using the newly designed protocol. Seven survived and were well at one month post discharge follow-up, reducing the mortality for this condition from 98 to 59%.
Conclusion
A dedicated team with minimal resources can significantly reduce the mortality in gastroschisis by almost 40% using a locally derived protocol.
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40
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Okoro PE, Ngaikedi C. Outcome of management of gastroschisis: comparison of improvised surgical silo and extended right hemicolectomy. ANNALS OF PEDIATRIC SURGERY 2020. [DOI: 10.1186/s43159-019-0012-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Gastroschisis is onea of the major abdominal wall defects encountered commonly in pediatric surgery. Whereas complete reduction and abdominal closure is achieved easily sometimes, a daunting situation arises when the eviscerated bowel loops and other viscera cannot be returned immediately into the abdominal cavity. This situation is a major contributor to the outcome of the treatment of gastroschisis in our region. In our efforts to improve our outcome, we have adopted the technique of extended right hemicolectomy for cases where complete reduction and primary abdominal wall closure is otherwise not possible. This study compared the management outcome of gastroschisis using our improvised silo, and performing an extended right hemicolectomy.
Results
Thirty-nine cases were analyzed. Simple closure could not be achieved in 28 cases. In the absence of standard silos, improvised ones were constructed from the amniotic membrane (3 cases), urine bag (4 cases), and latex gloves (9 cases) giving a total of 16 cases managed with silos. Extended right hemicolectomy was performed in 12 cases.
Conclusions
Given the peculiarities of circumstances in our region regarding human and material resources in the care of gastroschisis patients, an extended right hemicolectomy, to make it possible to close the abdomen primarily in gastroschisis is a more viable option than the use of improvised silo.
Trial registration
This trial was approved by the Ethical Committee of the University of Port Harcourt Teaching Hospital, Nigeria. Reference Number: UPTH/ADM/90/S.II/VOL XI/835. Registered 3 May 2013.
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Wright NJ. Management and outcomes of gastrointestinal congenital anomalies in low, middle and high income countries: protocol for a multicentre, international, prospective cohort study. BMJ Open 2019; 9:e030452. [PMID: 31481373 PMCID: PMC6731898 DOI: 10.1136/bmjopen-2019-030452] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 07/10/2019] [Accepted: 07/11/2019] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Congenital anomalies are the fifth leading cause of death in children <5 years of age globally, contributing an estimated half a million deaths per year. Very limited literature exists from low and middle income countries (LMICs) where most of these deaths occur. The Global PaedSurg Research Collaboration aims to undertake the first multicentre, international, prospective cohort study of a selection of common congenital anomalies comparing management and outcomes between low, middle and high income countries (HICs) globally. METHODS AND ANALYSIS The Global PaedSurg Research Collaboration consists of surgeons, paediatricians, anaesthetists and allied healthcare professionals involved in the surgical care of children globally. Collaborators will prospectively collect observational data on consecutive patients presenting for the first time, with one of seven common congenital anomalies (oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation and Hirschsprung's disease).Patient recruitment will be for a minimum of 1 month from October 2018 to April 2019 with a 30-day post-primary intervention follow-up period. Anonymous data will be collected on patient demographics, clinical status, interventions and outcomes using REDCap. Collaborators will complete a survey regarding the resources and facilities for neonatal and paediatric surgery at their centre.The primary outcome is all-cause in-hospital mortality. Secondary outcomes include the occurrence of post-operative complications. Chi-squared analysis will be used to compare mortality between LMICs and HICs. Multilevel, multivariate logistic regression analysis will be undertaken to identify patient-level and hospital-level factors affecting outcomes with adjustment for confounding factors. ETHICS AND DISSEMINATION At the host centre, this study is classified as an audit not requiring ethical approval. All participating collaborators have gained local approval in accordance with their institutional ethical regulations. Collaborators will be encouraged to present the results locally, nationally and internationally. The results will be submitted for open access publication in a peer reviewed journal. TRIAL REGISTRATION NUMBER NCT03666767.
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Affiliation(s)
- Naomi Jane Wright
- King's Centre for Global Health and Health Partnerships, King's College London, London, UK
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Hall NJ, Drewett M, Burge DM, Eaton S. Growth pattern of infants with gastroschisis in the neonatal period. Clin Nutr ESPEN 2019; 32:82-87. [PMID: 31221296 DOI: 10.1016/j.clnesp.2019.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 04/25/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND/AIM Early postnatal growth patterns may have significant long term health effects. Although preterm infants on parenteral nutrition (PN) exhibit poor growth, growth pattern of term or near-term infants requiring PN is not well reported. We aimed to investigate this in infants born with gastroschisis. METHODS Retrospective review of all infants with gastroschisis requiring PN treated at a single centre over a 4 year period. Growth and clinical data were retrieved, and weight SDS scores for corrected gestational age calculated. Weight SDS (mean ± SD) were compared at clinically relevant timepoints and multi-level regression used to model growth trends over time. MAIN RESULTS During the study period 61 infants with gastroschisis were treated; all were included. Infants were small for gestational age at birth for weight (SDS score -0.87 ± 0.85). Weight SDS decreased significantly during the first 10 days of age (mean decrease 0.81 ± 0.56; p < 0.0001) and between birth and discharge (mean decrease 0.81 ± 0.56; p < 0.0001). Despite tolerating full enteral feeds, weight SDS velocity was negative around the time of transition from parenteral to enteral feed. There was evidence of 'catch up' growth between 3 and 6 months of age. CONCLUSION Despite nutritional support with PN, infants with gastroschisis demonstrate significant growth failure during the newborn period. Further efforts are required to understand the underlying mechanisms, improve nutritional support and to evaluate the long term consequences of postnatal growth failure in this population.
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Affiliation(s)
- Nigel J Hall
- University Surgery Unit, Faculty of Medicine, University of Southampton, Southampton, UK; Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK.
| | - Melanie Drewett
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
| | - David M Burge
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
| | - Simon Eaton
- Developmental Biology and Cancer Programme, UCL Great Ormond Street Institute of Child Health, London, UK
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Wright N, Abantanga F, Amoah M, Appeadu-Mensah W, Bokhary Z, Bvulani B, Davies J, Miti S, Nandi B, Nimako B, Poenaru D, Tabiri S, Yifieyeh A, Ade-Ajayi N, Sevdalis N, Leather A. Developing and implementing an interventional bundle to reduce mortality from gastroschisis in low-resource settings. Wellcome Open Res 2019; 4:46. [PMID: 30984879 PMCID: PMC6456836 DOI: 10.12688/wellcomeopenres.15113.1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2019] [Indexed: 12/14/2022] Open
Abstract
Background: Gastroschisis is associated with less than 4% mortality in high-income countries and over 90% mortality in many tertiary paediatric surgery centres across sub-Saharan Africa (SSA). The aim of this trial is to develop, implement and prospectively evaluate an interventional bundle to reduce mortality from gastroschisis in seven tertiary paediatric surgery centres across SSA. Methods: A hybrid type-2 effectiveness-implementation, pre-post study design will be utilised. Using current literature an evidence-based, low-technology interventional bundle has been developed. A systematic review, qualitative study and Delphi process will provide further evidence to optimise the interventional bundle and implementation strategy. The interventional bundle has core components, which will remain consistent across all sites, and adaptable components, which will be determined through in-country co-development meetings. Pre- and post-intervention data will be collected on clinical, service delivery and implementation outcomes for 2-years at each site. The primary clinical outcome will be all-cause, in-hospital mortality. Secondary outcomes include the occurrence of a major complication, length of hospital stay and time to full enteral feeds. Service delivery outcomes include time to hospital and primary intervention, and adherence to the pre-hospital and in-hospital protocols. Implementation outcomes are acceptability, adoption, appropriateness, feasibility, fidelity, coverage, cost and sustainability. Pre- and post-intervention clinical outcomes will be compared using Chi-squared analysis, unpaired t-test and/or Mann-Whitney U test. Time-series analysis will be undertaken using Statistical Process Control to identify significant trends and shifts in outcome overtime. Multivariate logistic regression analysis will be used to identify clinical and implementation factors affecting outcome with adjustment for confounders. Outcome: This will be the first multi-centre interventional study to our knowledge aimed at reducing mortality from gastroschisis in low-resource settings. If successful, detailed evaluation of both the clinical and implementation components of the study will allow sustainability in the study sites and further scale-up. Registration: ClinicalTrials.gov Identifier NCT03724214.
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Affiliation(s)
- Naomi Wright
- King's Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, King's College London, London, SE5 9RJ, UK
| | - Francis Abantanga
- Department of Surgery, Tamale Teaching Hospital, Tamale, P.O. Box TL 16, Ghana
| | - Michael Amoah
- Department of Surgery, Komfo Anokye Teaching Hospital, Kumasi, P.O.Box 1934, Ghana
| | | | - Zaitun Bokhary
- Department of Paediatric Surgery, Muhimbili National Hospital, Dar es Salaam, P.O Box 65000, Tanzania
| | - Bruce Bvulani
- Department of Paediatric Surgery, University Teaching Hospital of Lusaka, Lusaka, 10101, Zambia
| | - Justine Davies
- Global Health and Education Department, University of Birmingham, Birmingham, B15 2TT, UK
| | - Sam Miti
- Department of Paediatrics, Arthur Davison Children's Hospital, Ndola, Zambia
| | - Bip Nandi
- Department of Paediatric Surgery, Kamuzu Central Hospital, Lilongwe, P.O. Box 149, Malawi
| | - Boateng Nimako
- Department of Surgery, Komfo Anokye Teaching Hospital, Kumasi, P.O.Box 1934, Ghana
| | - Dan Poenaru
- McGill University, Montreal, Quebec, H3A 0G4, Canada
| | - Stephen Tabiri
- Department of Surgery, Tamale Teaching Hospital, Tamale, P.O. Box TL 16, Ghana
| | - Abiboye Yifieyeh
- Department of Surgery, Komfo Anokye Teaching Hospital, Kumasi, P.O.Box 1934, Ghana
| | - Niyi Ade-Ajayi
- Department of Paediatric Surgery, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Nick Sevdalis
- Centre for Implementation Science, King's College London, London, SE5 8AF, UK
| | - Andy Leather
- King's Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, King's College London, London, SE5 9RJ, UK
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Narang A, Carlsen V, Long A, Battin M, Upadhyay V, Sadler L, Stone P. Anterior abdominal wall defects managed at a tertiary maternal-fetal medicine service in New Zealand: What counselling advice can we offer parents? Aust N Z J Obstet Gynaecol 2019; 59:805-810. [PMID: 30841012 DOI: 10.1111/ajo.12965] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 01/23/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Anterior abdominal wall defects, including gastroschisis and omphalocoele, are common fetal anomalies. The management remains complicated, and their diagnosis may lead to significant parental distress. Effective parental counselling may impact on parental perceptions of the defect and help guide pregnancy management. AIMS Using contemporary data, we aimed to describe clinical outcomes of patients with gastroschisis or omphalocoele in order to provide information for clinicians to assist in parental counselling. MATERIALS AND METHODS We followed a case-series of patients with anterior abdominal wall defects referred to our regional Maternal Fetal Medicine services from 2011 to 2016. Outcomes of interest antenatally included details of diagnosis, associated anomalies and outcomes of pregnancy and postnatally included the nature of surgical repair, hospital stay and secondary complications until initial discharge. RESULTS Eighty babies with gastroschisis were referred antenatally, and 72 were liveborn. Forty-nine babies with omphalocoele were referred antenatally, and 24 were liveborn. One further neonate with omphalocoele was postnatally diagnosed. Seventy-one neonates with gastroschisis progressed to operation, 30 developed complications post-surgery, and 68 survived until initial discharge. Twenty-two neonates with omphalocoele progressed to surgery, only two developed complications, and 21 survived until initial discharge. Eight of the surviving neonates with omphalocoele had associated structural abnormalities. The median hospital stay was 27 and eight days for gastroschisis and omphalocoele, respectively. CONCLUSION Neonates with gastroschisis can have complex postnatal periods. Omphalocoele is associated with high antenatal mortality, especially in the presence of associated abnormalities; however, surviving neonates may have uneventful postnatal periods.
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Affiliation(s)
- Apoorv Narang
- Faculty of Medical and Health Sciences, Auckland City Hospital, University of Auckland, Auckland, New Zealand
| | - Victoria Carlsen
- Department of Obstetrics and Gynaecology, Waikato Hospital, Hamilton, New Zealand
| | - Audrey Long
- Department of Obstetrics and Gynaecology, National Women's Health, Auckland, New Zealand
| | - Malcolm Battin
- Newborn Services, Auckland City Hospital, Auckland, New Zealand
| | - Vipul Upadhyay
- Department of Paediatric Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Lynn Sadler
- Women's Health, Auckland District Health Board, Auckland, New Zealand
| | - Peter Stone
- Maternal Fetal Medicine, School of Medicine, University of Auckland, Auckland, New Zealand
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Bakalli I, Kola E, Lluka R, Celaj E, Sala D, Gjeta I, Sallabanda S, Klironomi D. Surgical congenital anomalies in Albania: incidence, prenatal diagnosis and outcome. WORLD JOURNAL OF PEDIATRIC SURGERY 2019. [DOI: 10.1136/wjps-2018-000012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
IntroductionSignificant progress has been made in the diagnosis and management of congenital anomalies (CA). In our study, we aimed to evaluate prenatal diagnosis, trend of surgical CA, mortality rate and the factors affecting their prognosis in our country.MethodsWe enrolled in our study all children with CA who underwent surgery from January 2008 to December 2017. We compared prenatal diagnosis, incidence and mortality for two 5-year periods: the first period in 2008–2012 and the second period in 2013–2017.ResultsDuring the study period, a total of 321 cases with CA were presented, with an incidence of 0.69–1.18 per 1000 live births. Intestinal, anal and esophageal atresia remain the most important CAs (23%, 18% and 16%), followed by diaphragmatic hernia and gastroschisis (10% and 7%). Comparing the incidence for the two periods, we did not find statistical differences (p=0.73), but the mortality rate has been reduced from 31.4% during the first period to 24.6% during the second period (p=0.17). Prenatal diagnosis has increased: 28% in the second period compared with 10% in the first period (p<0.001), without significantly affecting the prognosis (p=0.09). Birth of premature babies resulted in a significantly negative predictive factor for the prognosis of these anomalies (p=0.0002).ConclusionIncidence of CA has not changed over the years in our country. Advances in intensive care, surgical techniques and parenteral nutrition made in recent years have significantly increased the survival of neonates born with surgical CA. Birth of premature babies was a significantly negative predictive factor for the prognosis of these anomalies.
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Wragg R, Brownlee E, Robb A, Chandran H, Knight M, McCarthy L. The postnatal management of boys in a national cohort of bladder outlet obstruction. J Pediatr Surg 2019; 54:313-317. [PMID: 30528203 DOI: 10.1016/j.jpedsurg.2018.10.087] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 10/30/2018] [Indexed: 12/14/2022]
Abstract
AIM The most common cause of congenital bladder outlet obstruction (BOO) is posterior urethral valves (PUV). Initial treatment requires decompression, but transurethral incision (TUI) or primary diversion is all described. There is no randomized control trial to guide management. This study aims to describe management, circumcision, and UTI rate in a national cohort of PUV boys. METHODS Boys diagnosed with BOO were recruited (via BAPS CASS) over 1 year with ethics committee approval (ref: 12/SC/0416). Data were collected via questionnaire, presented as number (%), analyzed by Mann-Whitney/chi-square/Fisher Exact tests, and p < 0.05 was taken as significant. RESULTS BOO presented in 121 boys during 2014-2015, and 113 were PUV. Catheter placement in 87/121(72%) was more likely to happen in antenatal vs. postnatal vs. late(>1 y) presentations, p < 0.0001. Polyuria occurred in 23/45(51%), 12/48(25%), 0/28(0%), respectively, p < 0.0001. Initial surgical treatment was TUI in 108/121(89%) and vesicostomy in 2. Two ureterostomies were secondary procedures. Circumcision was performed in 52/121(43%) in antenatal presentation vs. postnatal vs. late 27/45(60%), 20/48(42%), 2/28(7%), respectively, p = 0.01. 69 UTIs occurred in 49 patients. Circumcision was associated with an 86% reduced risk of UTI, p < 0.0001. There was a 66% reduction in UTI risk associated with TUI alone, p < 0.01. There was 1 death due to pulmonary hypoplasia and renal failure, and 2 experienced end-stage renal failure (ESRF). CONCLUSION Standard treatment for BOO and PUV in the current UK cohort is urethral catheterization followed by TUI. Supravesical diversion is a rescue therapy. UTIs are common and reduced by circumcision, with 43% being circumcised. Initial mortality rate was 1%, and 1.6% present in ESRF. LEVEL OF EVIDENCE Prognostic study - Level I - Prospective National Cohort Study.
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Affiliation(s)
- Ruth Wragg
- Department of Paediatric Urology, Birmingham Children's Hospital, UK
| | - Ewan Brownlee
- Department of Paediatric Urology, Birmingham Children's Hospital, UK
| | - Andy Robb
- Department of Paediatric Urology, Birmingham Children's Hospital, UK
| | - Harish Chandran
- Department of Paediatric Urology, Birmingham Children's Hospital, UK
| | - Marian Knight
- National Perinatal Epidemiology Unit, University of Oxford, UK
| | - Liam McCarthy
- Department of Paediatric Urology, Birmingham Children's Hospital, UK.
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Wright NJ, Langer M, Norman IC, Akhbari M, Wafford QE, Ade-Ajayi N, Davies J, Poenaru D, Sevdalis N, Leather A. Improving outcomes for neonates with gastroschisis in low-income and middle-income countries: a systematic review protocol. BMJ Paediatr Open 2018; 2:e000392. [PMID: 30687800 PMCID: PMC6326322 DOI: 10.1136/bmjpo-2018-000392] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 11/21/2018] [Accepted: 11/24/2018] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION There is a significant disparity in outcomes for neonates with gastroschisis in high-income countries (HICs) compared with low-income and middle-income countries (LMICs). Many LMICs report mortality rates between 75% and 100% compared with <4% in HICs. AIM To undertake a systematic review identifying postnatal interventions associated with improved outcomes for gastroschisis in LMICs. METHODS AND ANALYSIS Three search strings will be combined: (1) neonates; (2) gastroschisis and other gastrointestinal congenital anomalies requiring similar surgical care; (3) LMICs. Databases to be searched include MEDLINE, EMBASE, Scopus, Web of Science, ProQuest Dissertations and Thesis Global, and the Cochrane Library. Grey literature will be identified through Open-Grey, ClinicalTrials.gov, WHO International Clinical Trials Registry and ISRCTN registry (Springer Nature). Additional studies will be sought from reference lists of included studies. Study screening, selection, data extraction and assessment of methodological quality will be undertaken by two reviewers independently and team consensus sought on discrepancies. The primary outcome of interest is mortality. Secondary outcomes include complications, requirement for ventilation, parenteral nutrition duration and length of hospital stay. Tertiary outcomes include service delivery and implementation outcomes. The methodology of the studies will be appraised. Descriptive statistics and outcomes will be summarised and discussed. ETHICS AND DISSEMINATION Ethical approval is not required since no new data are being collected. Dissemination will be via open access publication in a peer-reviewed medical journal and distribution among global health, global surgery and children's surgical collaborations and international conferences. CONCLUSION This study will systematically review literature focused on postnatal interventions to improve outcomes from gastroschisis in LMICs. Findings can be used to help inform quality improvement projects in low-resource settings for patients with gastroschisis. In the first instance, results will be used to inform a Wellcome Trust-funded multicentre clinical interventional study aimed at improving outcomes for gastroschisis across sub-Saharan Africa. PROSPERO REGISTRATION NUMBER CRD42018095349.
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Affiliation(s)
- Naomi J Wright
- King's Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, King's College London, London, UK
| | | | - Irena Cf Norman
- GKT School of Medical Education, King's College London, London, UK
| | - Melika Akhbari
- GKT School of Medical Education, King's College London, London, UK
| | - Q Eileen Wafford
- Galter Health Sciences Library and Learning Center, Northwestern University, Chicago, Illinois, USA
| | - Niyi Ade-Ajayi
- Paediatric Surgery Department, King's College Hospital, London, UK
| | - Justine Davies
- King's Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, King's College London, London, UK
| | | | - Nick Sevdalis
- Centre for Implementation Science, King's College London, London, UK
| | - Andy Leather
- King's Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, King's College London, London, UK
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Abstract
Selection of outcome determinants and risk stratification are necessary to identify patients at higher risk for morbidity and mortality. This facilitates human and material resource allocation and allows for improved family counseling. While several different factors, including prenatal ultrasonographic bowel features, the timing and mode of delivery, and the features of bowel injury have been investigated in gastroschisis, there is still significant debate as to which of these best predicts outcome. This article reviews the different outcome predictors and risk prognostication schemata currently available in the literature to help guide clinicians caring for infants with gastroschisis.
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Affiliation(s)
- Hussein Wissanji
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Room B04.2318, 1001 Decarie Boulevard, Montreal, Quebec, Canada
| | - Pramod S Puligandla
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Room B04.2318, 1001 Decarie Boulevard, Montreal, Quebec, Canada.
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Wright NJ, Sekabira J, Ade-Ajayi N. Care of infants with gastroschisis in low-resource settings. Semin Pediatr Surg 2018; 27:321-326. [PMID: 30413264 PMCID: PMC7116007 DOI: 10.1053/j.sempedsurg.2018.08.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
There is great global disparity in the outcome of infants born with gastroschisis. Mortality approaches 100% in many low income countries. Barriers to better outcomes include lack of antenatal diagnosis, deficient pre-hospital care, ineffective neonatal resuscitation and venous access, limited intensive care facilities, poor access to the operating theatre and safe neonatal anesthesia, and lack of neonatal parenteral nutrition. However, lessons can be learned from the evolution in management of gastroschisis in high-income countries, generic efforts to improve neonatal survival in low- and middle-income countries as well as specific gastroschisis management initiatives in low-resource settings. Micro and meso-level interventions include educational outreach programs, and pre and in hospital management protocols that focus on resuscitation and include the delay or avoidance of early neonatal anesthesia by using a preformed silo or equivalent. Furthermore, multidisciplinary team training, nurse empowerment, and the intentional involvement of mothers in monitoring and care provision may contribute to improving survival. Macro level interventions include the incorporation of ultrasound into World Health Organisation antenatal care guidelines to improve antenatal detection and the establishment of the infrastructure to enable parenteral nutrition provision for neonates in low- and middle-income countries. On a global level, gastroschisis has been suggested as a bellwether condition for evaluating access to and outcomes of neonatal surgical care provision.
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Affiliation(s)
- Naomi J. Wright
- King’s Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, King’s College London, United Kingdom
| | - John Sekabira
- Paediatric Surgery Department, Mulago University Hospital, Kampala, Uganda
| | - Niyi Ade-Ajayi
- Paediatric Surgery Department, King's College Hospital, Denmark Hill, London SE5 9RS, United Kingdom.
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Fujiogi M, Michihata N, Matsui H, Fushimi K, Yasunaga H, Fujishiro J. Clinical features and practice patterns of gastroschisis: a retrospective analysis using a Japanese national inpatient database. Pediatr Surg Int 2018; 34:727-733. [PMID: 29770842 DOI: 10.1007/s00383-018-4277-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2018] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Michimasa Fujiogi
- Department of Pediatric Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.,Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Nobuaki Michihata
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 112-0002, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Jun Fujishiro
- Department of Pediatric Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
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