Caring for the newborn with an omphalocele

Enhancing Omphalocele Care: Navigating Complications and Innovative Treatment Approaches

Congenital abdominal wall abnormalities in infants present an interesting and difficult management problem for surgeons. Congenital malformations of the ventral abdominal wall can be diagnosed by their distinctive anatomical presentations. Among them, omphalocele, gastroschisis and umbilical cord hernias are the most frequently observed clinically detected abdominal wall anomalies. Omphalocele refers to the herniation of abdominal contents through a defect in the abdominal wall at the umbilicus with or without the presence of a sac. This article gives an insight into the embryology, risk factors, treatment, investigations and complications of omphalocele, a common congenital abdominal wall defect. There is minimal proof that environmental factors contribute to the development of omphalocele. However, there is a considerable amount of evidence which points to the importance of genetic or familial risk factors. Newborns and infants with prenatal diagnoses are the most frequently presenting patients with omphalocele to paediatric surgeons. This article describes the problems and the steps of management for handling each circumstance, as well as any further complications. Omphalocele and gastroschisis are frequently described together in many research papers. However, it's crucial to consider that they are two different conditions which vary in anatomy, pathology and associated conditions which account for the difference in their treatments and noticeably varied outcomes. Additionally, there is evidence that each has a different set of factors associated with risk for occurrence. There are no known etiologic causes that cause these abnormalities to develop. The size of the baby, the extent of the lesion, and any other disorders all affect how individuals with these congenital abdominal wall anomalies are treated.

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

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

Mortality in neonates with giant omphalocele subjected to a surgical technique in Barranquilla, Colombia from 1994 to 2019

No studies of the efficacy and safety of surgical techniques for the primary closure of giant omphalocele have been performed in Colombia. To determine the mortality rate and factors associated with mortality in neonates with giant omphalocele subjected to the surgical technique of early closure with a surgical silo described by Abello in Barranquilla, Colombia from 1994 to 2019. Retrospective cohort study of 30 neonates diagnosed with giant omphalocele and subjected to early closure of the defect. Medical history data were collected, information bias was controlled for, and descriptive statistical analysis was performed using Fisher’s exact test and the Mann–Whitney U test in SPSS 25.0. Of the patients in the cohort, 36.7% presented technique-related complications, 56.7% developed sepsis, 23.3% had low birth weight, 26.7% were preterm births, 43.3% had other malformations, 26.7% had congenital heart defects, and 13.3% presented pulmonary hypertension. The mean hospital stay was 26 days. The mortality rate was 16.7%; it was significantly higher among patients with other malformations, congenital heart defects, pentalogy of Cantrell and pulmonary hypertension. The Abello technique for the treatment of giant omphalocele showed a high neonatal survival rate and a low rate of procedure-related complications. The main factors associated with the death of neonatal patients were the presence of other malformations, congenital heart defect, pentalogy of Cantrell and pulmonary hypertension.

Successful abdominal wall closure following collagen-based artificial dermis induced epithelialization for giant omphalocele: A case report

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A giant omphalocele (GO) is related to higher rates of morbidity and mortality.

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No consensus exists on optimal GO management, which may be surgically challenging.

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We report the successful GO management of a neonate with numerous complications.

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We applied a collagen-based artificial dermis for epithelization as a new treatment.

Introduction

A giant omphalocele (GO) with marked viscero-abdominal disproportion is associated with surgical difficulty and higher morbidity and mortality rates. Despite various treatment strategies, no consensus exists on optimal GO management. We report the clinical course of a neonate with a GO who was successfully treated with abdominal-wall closure through the novel application of collagen-based artificial dermis (CAD) for epithelization.

Presentation of case

A female neonate (estimated gestational age, 38 weeks; birthweight, 3.047 kg) with a GO where most viscera, including the liver, were completely herniated. G-band analysis showed no chromosomal abnormality and normal karyotype. Conventional silo formation was attempted, but incomplete silo was formed due to adhesion between the portal vein and fascia, and repatriation of the herniated viscera had not progressed. A new silo was formed using biomaterial, but it was infected and removed. Abdominal wall epithelialization using NPWT was attempted again but was interrupted by the occurrence of jejunal perforation. After incising the epithelialized part of the abdominal wall and repairing the perforated jejunum, the GO was covered and fixed using CAD. Epithelialization progressed well, and she was discharged on day 328.

Discussion

In this case, the major therapeutic challenges (including formation of an incomplete silo, silo infection, and jejunal perforation) were overcome with conventional treatment except for epithelialization of the abdominal wall, which was achieved by using CAD.

Conclusion

The treatment with CAD for epithelialization can be considered in cases where it is extremely difficult to return the viscera in conventional management.

Outcomes in the giant omphalocele population: A single center comprehensive experience

BACKGROUND/PURPOSE

Morbidity and mortality in the giant omphalocele population is complicated by large abdominal wall defects, physiologic aberrancies, and congenital anomalies. We hypothesized different anomalies and treatment types would affect outcomes.

METHODS

A 2009-2018 retrospective chart review of giant omphaloceles was performed. Exclusions included cloacal exstrophy, transfer after 3 weeks, surgery prior to transfer, conjoined twins, or not yet achieving fascial closure. Thirty-five patients met criteria and mortality and operative morbidity categorized them into favorable (n = 20) or unfavorable (n = 15) outcomes. Odds ratios analyzed potential predictors. Survivors were stratified into staged (n = 11), delayed (n = 8), and primary closure (n = 6) for subgroup analysis.

RESULTS

Unfavorable outcomes were associated with other major congenital anomalies, sac rupture, and major cardiac anomalies, but had significantly lower odds with increasing gestational age (p = 0.03) and birth weight (p < 0.001). In survivors, the primary group was younger at repair (p < 0.001) and had shorter length of stay (hospital p = 0.02, neonatal intensive care unit p = 0.005). There was no significant difference for sepsis, ventilator days, return to the operating room, or ventral hernia.

CONCLUSIONS

Predictions of overall outcomes in the giant omphalocele population require analysis of multiple variables. Our findings demonstrated increased odds of unfavorable outcomes in major cardiac anomalies, pulmonary hypertension, genetic diagnosis, other major anomalies, polyhydramnios, postnatal sac rupture, increasing omphalocele sac diameter, lower O/E TLV, lower gestational age at birth, lower birth weight, and repair other than primary. In those surviving to repair, surgical outcomes analyses demonstrated an earlier age of repair and a shorter length of stay for those patients able to be closed primarily; however further research is necessary to determine overall superiority between operative treatment types.

LEVEL OF EVIDENCE

Level III.

Major abdominal wall defects in the low- and middle-income setting: current status and priorities

Major congenital abdominal wall defects (gastroschisis and omphalocele) may account for up to 21% of emergency neonatal interventions in low- and middle-income countries. In many low- and middle-income countries, the reported mortality of these malformations is 30-100%, while in high-income countries, mortality in infants with major abdominal wall reaches less than 5%. This review highlights the challenges faced in the management of newborns with major congenital abdominal wall defects in the resource-limited setting. Current high-income country best practice is assessed and opportunities for appropriate priority setting and collaborations to improve outcomes are discussed.

Impact of Breast Milk, Respiratory Insufficiency, and Gastroesophageal Reflux Disease on Enteral Feeding in Infants With Omphalocele

OBJECTIVES

The aim of this study was to document the process of achieving full enteral feeding in infants with omphalocele and to identify factors that affect feeding success.

METHODS

After institutional review board approval (study no. 5100169), 123 infants with omphalocele, born between 1993 and 2011 were reviewed. Mortalities were excluded. All survivors had complete follow-up. Variables suspected to impact enteral feeding in infants with non-giant versus giant omphalocele were compared. Independent t test, Mann-Whitney, and χ test were used. Regression evaluated for variable independence.

RESULTS

Of 123 infants with omphalocele, 97 (79%) survived, 62/97 (64%) had non-giant, and 35/97 (36%) giant omphalocele. For survivors, the mean gestational age was 37 ± 4 weeks with median follow-up of 4.4 years (range: 1.4-7.4 years). The median time to full feeds was 4 days (range: 0-85 days) for non-giant versus 8 days (range: 1-96 days) for giant, a significant difference (P < 0.01). Breast milk significantly decreased time to full feeds independent of omphalocele size. Giant omphalocele infants had a significantly higher incidence of respiratory insufficiency at birth (P < 0.01) and sac rupture (P = 0.02), but fewer chromosomal anomalies (P = 0.04). Respiratory insufficiency at birth (P < 0.01) and gastroesophageal reflux disease (P < 0.01) independently delayed feeding in omphalocele infants.

CONCLUSIONS

Infants with non-giant omphalocele can achieve full enteral feeds within the first week of life, but giant omphalocele infants require significantly more time. Breast milk independently promotes feeding success whereas gastroesophageal reflux disease and respiratory insufficiency at birth independently delay feeding in infants with omphalocele.

Long term complications and outcomes in omphalocele

After a diagnosis of omphalocele during pregnancy, questions regarding long-term prognosis are of primary importance for parents. It is imperative that their questions are answered with substantiated data to promote confident decisions for their children. They frequently express concerns regarding long-term survival, quality of life, need for more operations, feeding issues, motor and cognitive development, cosmesis, and the unique difficulties of giant omphaloceles. The available outcome studies that address these questions are discussed.

[Tissue expansion in management of giant omphalocele parietal sequelae]

OBJECTIVE

According to major difficulty for the giant omphalocele management in the visceral reintegration and the parietal closure, many teams use currently conservative treatment by topical application. These techniques are suppliers of a covered eventration and a scar sequela requiring a complementary treatment. We report the place of the tissue expansion as complementary treatment.

PATIENTS AND METHODS

Two patients with a giant omphalocele benefited from a protocol of cutaneous expansion for the correction of their abdominal scar±of their residual eventration.

RESULTS

An eventration closure was possible thanks to this protocol. The skin expansion allowed the complete excision of the abdominal scar and the defect cover. An additional skin graft was necessary in the first case.

CONCLUSION

The cutaneous expansion in the parietal sequela management of the giant omphaloceles seems to be an interesting alternative. This technique should be realized remotely and except any septic context.

Silver-impregnated hydrofiber dressing followed by delayed surgical closure for management of infants born with giant omphaloceles

OBJECTIVE

We successfully employed silver-impregnated hydrofiber dressing for management of giant omphaloceles (GO) followed by delayed surgical closure.

STUDY DESIGN

Between 2005 and 2008, eight consecutive GO infants were cared for at Driscoll Children's Hospital. Four patients had additional congenital anomalies including Beckwith-Wiedemann (n = 1), tetralogy of Fallot (n = 1), pulmonary hypoplasia (n = 1), and ruptured omphalocele (n=1). Infants underwent amnion epithelization using a silver-impregnated hydrofiber dressing over the course of several months followed by delayed surgical closure. Mean ± SD of parameters including maternal age, gestational age, infant weight, size of GO, preoperative intubation, preoperative hospitalization, time to epithelization, days to surgical closure, postoperative hospitalization, postoperative intubation and months of follow-up were studied.

RESULTS

Five patients underwent successful closure, 2 were lost to follow-up and 1 was lost because of withdrawal of support. The maternal age, gestation age and weight of infant were 28 ± 5.3 years, 34 ± 4 weeks and 2.5 ± 0.62 kg, respectively. The GO size was 11 cm in length and 11 cm in width, respectively. Preoperative hospitalization days were 78 ± 74 days. Preoperative intubation was 3.5 ± 3.1 days with 2 neonates requiring tracheostomy and home ventilation owing to additional congenital abnormalities. Time to epithelization was 2.9 ± 0.9 months. Days to surgical closure and postoperative hospitalization were 331 ± 119 days and 5 ± 3.4 days, respectively. Average follow-up was 37 ± 27 months. No treatment associated morbidities are noted.

CONCLUSIONS

Silver-impregnated hydrofiber mediated epithelization of GO followed by delayed surgical closure is safe for management of infants.

Three-dimensional ultrasound of massive macroglossia in a fetus with Beckwith-Wiedemann syndrome

We present the prenatal ultrasound findings of massive macroglossia in a fetus with prenatally diagnosed Beckwith-Wiedemann syndrome. Three-dimensional surface mode ultrasound was utilized for enhanced visualization of the macroglossia.

Breastfeeding success in infants with giant omphalocele

Infants born with a giant omphalocele often require multiple surgeries requiring a lengthy hospital stay. These vulnerable infants may experience a long period of being NPO (nothing by mouth), followed by slowly advancing to enteral feeds. Human milk is the ideal method of nutrition for all infants and should be used to initiate enteral feeds in infants recovering from omphalocele closure surgeries. Human milk provides immunological, nutritional, and developmental benefits for high-risk infants and may play a critical role in preventing associated morbidities often associated with infants born with giant omphalocele. Because of the stress of hospitalization, mother-infant dyads should be targeted to receive extensive lactation support, which can help ensure maintenance of milk supply and successful transition to breastfeeding once the infant is healthy enough to do so. Two case studies are presented as exemplars, demonstrating that the provision of human milk for even the most vulnerable infants can be achieved.

Emergency treatment of a ruptured huge omphalocele by simple suture of its membrane

BACKGROUND

The rupture of a huge omphalocele is an emergency that threatens the newborn baby's life. It constitutes a therapeutical concern in the absence of prosthesis especially in developing countries.

METHODS

We are reporting herein the case of a newborn baby that we managed in emergency successfully thanks to a simple treatment.

RESULTS

It was a huge omphalocele, ruptured during delivery, in a male newborn baby. We conducted a simple and conservative surgical treatment without prosthesis, which consisted of reconstruction of the omphalocele's membrane by closing it with absorbable suture materials. The suture of the omphalocele's membrane was followed by treatment with the Grob's method. This treatment saved the newborn baby's life. The total skinning was obtained after 3 months.

CONCLUSIONS

In case of rupture of huge omphalocele in absence of prosthesis, it is better to suture the membrane, and continue the treatment according to the Grob's method; the residual disembowelment can be repaired later.

Immediate Repair Compared with Delayed Repair of Congenital Omphalocele: Short-Term Neonatal Outcomes in China

This prospective study evaluated the short-term outcomes of 16 neonates undergoing single congenital omphalocele repair. Parents made informed choices for their baby to receive either immediate repair (IR group, n = 8) or repair ≥ 3 h after delivery (control group, n = 8). All babies were delivered by elective caesarian section. Babies in the two groups were matched one-to-one according to their birth weight, bulging volume and gestational age. Short-term outcomes included the incidence of infection and the lengths of stay in the neonatal intensive care unit (NICU) and in the hospital. Compared with the control group, the IR group showed a significantly lower incidence of infection, shorter surgical duration, shorter NICU stay, less time on total parenteral nutrition, less time to total enteral nutrition and shorter length of hospital stay. Immediate repair significantly improved the short-term neonatal outcomes of congenital omphalocele in China.

Nonoperative management of a giant omphalocele using a silver impregnated hydrofiber dressing: a case report

The surgical management of a giant omphalocele is challenging. Many cannot be closed at birth and must initially be managed nonoperatively with a topical agent to facilitate epithelialization. We report the case of a term, 1-day-old female neonate with a giant omphalocele treated initially with a hydrofiber dressing containing silver (Aquacel Ag; ConvaTec Inc, Skillman, NJ) and then with delayed primary closure.

Interpreting neonatal lethal phenotypes in mouse mutants: insights into gene function and human diseases

The mouse represents the model of choice to study the biological function of mammalian genes through mutation of its genome. However, the biggest challenge of mouse geneticists remains the phenotypic analysis of mouse mutants. A survey of mouse mutant databases reveals a surprisingly high number of gene mutations leading to neonatal death. These genetically modified mouse mutants have been instrumental in elucidating gene function and have become important models of congenital human diseases. The main complication when phenotyping mutant mice dying during the neonatal period is the large spectrum of physiological systems whose defects can challenge neonatal survival. Here, we present a comprehensive review of gene mutations leading to neonatal lethality and discuss the impact of these mutations on the major physiological processes critical to mouse newborn survival: parturition, breathing, suckling, and homeostasis. Selected examples of mouse mutants are highlighted to illustrate how the precise identification of the timing and cause of death associated with these physiological processes allows for a more profound understanding of the underlying cellular and molecular defects. This review provides a guide for the analysis of neonatal lethal phenotypes in mutant mice that will be helpful for dissecting out the function of specific genes during mouse development.

The nursing care of the surgical neonate

In the last two decades, advancement in neonatal surgery, anesthesia, and intensive care have improved the outcome not only for neonates with complex surgical conditions but also for those preterm infants with combined medical and surgical issues. Infants with surgical problems may remain in the neonatal care setting for weeks or months, and providing ongoing nursing care can be challenging but rewarding. In this article, the authors outline the immediate preoperative management, stabilization, and subsequent postoperative nursing care of the surgical neonate.

Retrospective case study of team approach to omphalocele orthosis fabrication and implementation

PURPOSE

The purpose of this case report is to describe an interdisciplinary approach to orthotic intervention in a neonate with giant omphalocele.

SUMMARY OF KEY POINTS

An infant with a giant omphalocele was presented to the Neonatal Intensive Care Unit (NICU) for management. An interdisciplinary team including a neonatal surgeon, physical therapists, orthotist, and family collaborated to determine appropriate orthotic intervention. A custom stabilizing orthosis and prone positioning device were fabricated and fit to the infant. The omphalocele was secure and the family felt confident that the omphalocele was protected during physical interaction.

SUMMARY AND RECOMMENDATIONS FOR CLINICAL PRACTICE

In this case, a custom orthosis was shown to be a valuable tool to provide external support for a giant omphalocele and facilitate safe interaction between infant and family. An interdisciplinary approach is recommended to best accommodate the patient's needs.

Delayed three-stage closure of giant omphalocele using pericard patch

The management of giant omphaloceles in a single operative approach is quite difficult. If performed as a single-stage procedure, postoperative complications are encountered, which are usually related to significant changes in intra-abdominal pressures, compromise of interior venous blood return ,and hemodynamic and respiratory instability due to diaphragmatic elevation. We report the case of a giant omphalocele that required a three-stage delayed closure and was managed using bovine pericard patches. The procedure of staged application of pericard patches is described. Delayed staged closure has the advantage of avoiding multiple surgical procedures in the neonatal period and reduces morbidity in the management of giant omphaloceles.