Fetal omphalocele and gastroschisis: a review of 24 cases

Fetal omphalocele and gastroschisis are congenital defects of the abdominal wall that require prompt surgical management at the time of delivery. To evaluate the role of prenatal sonography in identifying factors that influence prognosis, 24 cases of abdominal-wall defect (16 omphalocele, eight gastroschisis) were reviewed. Sonograms were evaluated for location of umbilical cord insertion, contents of the ventral defect, presence or absence of a covering membrane, fetal ascites, bowel-wall thickening, and coexisting anomalies. Sonographic differentiation between omphalocele and gastroschisis was possible in 18 (75%) of 24 cases. Eighteen patients had congenital defects in addition to the abdominal-wall defect. Associated abnormalities were present in 14 (88%) of 16 fetuses with omphalocele and four (50%) of eight with gastroschisis. Overall survival rate was 50%, excluding six terminated pregnancies. Survival rate was 33% for neonates with omphalocele and 83% for those with gastroschisis. The better prognosis for neonates with gastroschisis appears to reflect the lower frequency of associated congenital anomalies.

Omphalocele and gastroschisis. Trends in survival across two decades

During the decade from July 1970 through June 1980, 57 patients with omphalocele and 64 with gastroschisis were treated at the Childrens Hospital of Los Angeles. Among the patients with omphalocele, the mortality was not significantly different between those with an abdominal wall defect smaller than 4 cm (5 of 24 patients) and those with a larger defect (6 of 33 patients); between those with a birth weight of less than 2,500 g (3 of 13 patients) and those with a higher birth weight (8 of 44 patients); between patients who had part of their liver in the omphalocele sac (6 of 29 patients) and those who did not (5 of 28 patients); and between patients who had primary fascial closure of the abdominal wall defect (3 of 24 patients) and those who had staged closure (4 of 25 patients). The overall mortality of 19 percent (11 of 57 patients) is not significantly different from that seen in patients treated during the preceding decade, 1960 through 1970 (23 percent, 5 of 22 patients), in our institution. Major chromosomal and other associated anomalies adversely affected the survival rate in these patients. In contrast, the overall survival rate of gastroschisis patients has markedly increased over the past two decades (91 percent in 1975 to 1980). In these patients, the difference in survival between those who had primary fascial closure (73 percent) and those who had staged closure by skin flaps or silon chimney (81 percent) was not statistically significant. Prematurity, bowel complications, and candida septicemia associated with the use of total parenteral nutrition contributed to the mortality.

Epidemiological study of gastroschisis and omphalocele in Spain

We report an epidemiological study of gastroschisis and omphalocele performed through the Spanish Collaborative Study of Congenital Malformations. Among 264,502 live births analyzed from April 1976 to September 1981, 12 gastroschisis and 40 omphaloceles were identified. The overall incidence of gastroschisis was 0.4 per 10,000 live births and 1.5 for omphalocele. The incidence of gastroschisis showed a significant secular trend with a mean annual increase of 0.38 per 10,000 livebirths. The mean maternal age was 21.42, which is significantly lower than the control group (p less than 0.01). Among isolated omphaloceles the maternal ages showed a U-shape distribution. Maternal vaginal bleeding, gestational age, and birth weight were significantly different between gastroschisis and omphaloceles and the controls. Mortality within the first 3 days of life was significantly higher in gastroschisis, syndromic omphaloceles, and those associated with other malformations when compared to controls. No significant consanguinity or familial cases were observed for either gastroschisis or omphaloceles.

A plea for conservative treatment of large, unruptured omphaloceles

Forty-six babies with an unruptured omphalocele were admitted over a 10-year period. The conservative treatment consisted of the application of mercurochrome or an antibiotic powder, while the primary surgical treatment consisted of either full-layer closure or silastic sac insertion. Liver containing omphaloceles were considered large. Of the 25 babies without associated life-threatening congenital anomalies, all 9 with a small omphalocele survived, irrespective of the method of treatment. Sixteen babies had a large omphalocele of which all 8 conservatively treated babies survived against only 4 of the 7 who underwent surgery. The remaining baby, weighting 960 g, died prior to treatment, due to respiratory distress. Eighteen of the 21 babies with associated life-threatening congenital anomalies died, irrespective the extent of the defect. Although the conservative treatment of the large defects did not result in an improved survival rate, therapy-related complications did not occur. From this study it appears that large unruptured omphaloceles should be treated conservatively. Babies not doing well with a small omphalocele or a large one treated conservatively, will have one or more major associated anomalies, necessitating urgent diagnosis and treatment.

Obstetric management of the fetus with omphalocele or gastroschisis: a review and report of one hundred twelve cases

The prenatal diagnosis of an abdominal wall defect in the fetus has led some obstetricians to recommend delivery by cesarean section in order to avoid trauma to the defect and reduce the risk of dystocia. A review was made of the obstetric management of 112 infants with abdominal wall defects who were admitted to a neonatal surgical unit. Cesarean section was performed in 16%, but no cesarean sections were performed because of the prenatal diagnosis, which was made in only four cases. The mortality rate for infants with omphalocele was 29%, and that for infants with gastroschisis was 13.5%. Visceral injury from the delivery process was suggested in one case. Decisions about obstetric management were made in the absence of the knowledge of the anomaly, and vaginal delivery did not appear to adversely affect outcome. It remains to be seen whether more accurate prenatal diagnosis will identify subgroups of infants who would benefit by cesarean section. Until that time, elective cesarean section does not seem to be justified.

Management of spontaneous umbilical hernia disruption in the cirrhotic patient

Umbilical hernia is a common finding in cirrhotic patients with ascites. Spontaneous disruption of the hernia and attendant discharge of ascitic fluid is an unusual and rarely reported complication in these patients and is associated with an overall mortality rate of nearly 30%. During the 5-year period 1977-1982, nine patients with hepatic cirrhosis and ascites were treated for spontaneous rupture of an umbilical hernia. Ascites was attributed to alcoholic cirrhosis in all cases and was present for an average of 21 months prior to rupture. In two cases, failed peritoneovenous shunts resulted in reaccumulation of massive ascites. Initial management included sterile occlusive dressings, fluid repletion, and intravenous antibiotic administration. Hernia repair was performed an average of 4.2 days after rupture. General anesthesia was used in eight cases and local anesthesia in one case. In one instance, the hernia became incarcerated and required urgent repair. Postoperative complications, including wound infection and colonic dilatation, occurred separately in two patients (22%). One patient died of hepatic failure 28 days after operation, for an overall mortality rate of 11%. Surviving patients have been followed for an average of 8 months, and most have done well. Spontaneous rupture of umbilical hernia in patients with ascites occurs uncommonly. Operative management is indicated uniformly and can be conducted safely when the patient's condition has stabilized. The prognosis is favorable for patients with good hepatic reserve.

Gastroschisis and omphalocele

The experience of 73 consecutive infants with gastroschisis and omphalocele is reported. The overall survival rate was 80 percent; however, since 1973 the survival rate for ruptured and intact omphaloceles has been 87 percent and 93 percent for gastroschisis. This remarkable reduction in mortality has been attributed primarily to the advent of total parenteral hyperalimentation, but mortality has also decreased due to the use of pediatric respirators which overcome the effects of increased intraabdominal pressure, and the creation of the neonatal intensive care unit where monitoring of these often fragile infants and the presence of specialty personnel assist in their care.

Exomphalos: management problems in the tropics

Twenty-six neonates presenting to Ahmadu Bello University Hospital, Zaria, with omphalocele were reviewed. Most sacs were heavily contaminated and some babies were hypothermic on admission. Treatment in most cases followed the standard textbook practice of attempting primary closure. In the absence of mechanical respiratory support, deaths (42.3%) were usually caused by respiratory failure and septicaemia. It is suggested that in the tropics, because of our limitations, conservative management should probably be the rule rather than the exception. Primary fascia or skin closure should only be cautiously carried out for the small defects. For babies with ruptured omphalocele a surgical glove may be substituted for silastic sheet coverage.

Aspects on the treatment of omphalocele and gastroschisis. Twenty years' clinical experience

Sixty-one patients with abdominal wall defects (omphalocele 37; gastroschisis 24) were treated during a twenty-year period according to different therapeutical principles. An analysis showed that good results were obtained by means of primary radical closure, large lesions included. The silo-technique appeared to be less successful. The use of central vessels for infusion probably contributed to a negative outcome, while total parenteral nutrition (in peripheral veins) and postoperative assisted ventilation had positive effects. With the exception of the antenatal type of gastroschisis, our experience indicates that the vast majority of cases with omphalocele or gastroschisis can be successfully treated by means of radical primary repair.

Omphalocele: a prognostic classification

A classification for infants born with an omphalocele is proposed that is based on the recognition of four syndromes and two common associated anomalies. The recognition of these syndromes and anomalies in our newborns with an omphalocele provided a better estimate of expected mortality and morbidity than the size of the omphalocele, preoperative rupture, delay in treatment, or low birth weight. This classification should aid the physician in determining priorities regarding the timing and type of treatment for the omphalocele itself.

Congenital defects of the abdominal wall

We reviewed a 22 year experience with 138 newborn infants with congenital evisceration through defects of the abdominal wall. Omphalocele is a large defect which always has a sac, in which the rectus muscles insert laterally on the costal margins and which usually has associated anomalies. Cord hernia is a small defect which always has a sac, in which the rectus muscles insert at the xiphoid and which commonly has associated anomalies. Gastroschisis is a small defect which never has a sac, in which the rectus muscles insert at the xiphoid and has few associated anomalies, though prematurity is frequent. We hypothesize that gastroschisis develops because the umbilical coelom fails to form, which forces the elongating midgut to rupture into the amniotic cavity. This differs from the embryogenesis of omphalocele, which is failure of closure of a primary body fold, and from that of cord hernia, which is failure of the midgut to return from the umbilical coelom. The number of infants in this series who survived after surgical repair of an omphalocele was 31 of 51 patients; of a cord hernia, 22 of 28 patients, and of gastroschisis, 40 of 59 patients. Factors contributing to mortality were associated anomalies, low birthweight and surgical closure under excessive tension.

Intragastric pressure measurement: a guide for reduction and closure of the silastic chimney in omphalocele and gastroschisis

In newborn infants with omphalocele or gastroschisis, traditional criteria for reduction of the herniated viscera either primarily or after application of a Silastic chimney have been the baby's color, respiratory rate, and lower extremity turgor. These are not always accurate or immediately apparent. In order to define more objective guidelines for reduction, measurements of intragastric pressure through a gastrostomy tube using a water manometer were carried out. The validity of this pressure measurement was demonstrated in five puppies where intra-abdominal pressure correlated well with inferior vena cava pressure and intragastric pressure measured through a gastrostomy tube (R = .98 and .99, respectively). Over a 3.5-yr period, 25 newborn infants with omphalocele (9) or gastroschisis (16) were treated. Ten underwent primary closure, and 15 were treated by placement of a Silastic chimney with serial reduction and closure. Manual reductions were performed once or twice daily to a maximum intragastric pressure of 20 cm water. Greater pressures demonstrated cardiovascular and respiratory comprise both experimentally and clinically. The mean time required for removal of the Silastic chimney was 4.7 days. There were no infections related to the chimney. There were 2 early and 5 late deaths, a 28% mortality rate. The remaining patients are alive and well. Intragastric pressure measurement in patients with omphalocele or gastroschisis provides objective criteria for safe primary closure and Silastic chimney reduction, shortens the time of reduction, and reduces the number of associated circulatory, respiratory, and septic complications.

Congenital defects of the abdominal wall. A review of the experience in New Mexico

Omphalocele, umbilical cord hernia, and gastroschisis are surgically correctable defects of the abdominal wall. Each of these defects has a distinct embryologic basis that results in a characteristic clinical picture. Twenty-five infants with congenital defects of the abdominal wall were treated at the University of New Mexico Hospital in the past four years. Six infants had omphalocele, one had umbilical cord hernia, and 18 had gastroschisis. Survival among infants who underwent a corrective operation was as follows: omphalocele, 50%; umbilical cord hernia, 100%; and gastroschisis, 82%. Long-term survival for the entire group was 72% (18/25). Gastroschisis, which had a lower incidence of major associated anomalies, had a better prognosis than omphalocele. The mortality of congenital abdominal wall defects was related to presence of severe associated anomalies and to poor clinical condition on admission. Prompt and informed initial care may increase the chance of survival.

Omphalocele: treatment options

The charts of 62 infants born with an omphalocele were reviewed to determine both the timing and type of treatment that yielded the most satisfactory result. Infants born with an omphalocele can be divided into prognostic groups based on physical examination and simple roentgenograms. No single treatment method is applicable to or optimal for all types of omphalocele. Treatment options can be selected based on the presence or absence of conditions requiring emergency operation, the presence of complicating anomalies, and the size of the omphalocele. Although urgent evaluation of all infants born with an omphalocele is essential, emergency operation should be avoided in selected cases.

Prognostic factors in omphalocele and gastroschisis

Size of the abdominal wall defect, viscera exposed or herniated, birth weight, associated medical conditions and congenital anomalies, mode and complications of treatment, and the use of total parenteral alimentation was reviewed in 79 cases of omphalocele and 44 cases of gastroschisis treated in the past 10 yr. Sixty-seven percent of infants with omphalocele and 73% of those with gastroschisis survived. In omphalocele, the most important factors affecting mortality were the presence of other associated abnormalities and low birth weight. The size of the abdominal wall defect, the viscera herniated, and the mode of treatment did not appear to affect mortality. In gastroschisis, the size of the abdominal defect, birth weight, viscera exposed or herniated, and associated anomalies were not significant factors affecting mortality. Mortality was usually secondary to intestinal or wound complications. Statistical analysis could not prove that primary repair resulted in greater survival than the use of a silon pouch, but analysis of complications clearly indicates that the former method is preferable and that silon pouch should be reserved for cases in which primary repair is not possible.

Giant exomphalos--conservative or operative treatment?

The rate of survival for infants with intact giant exomphatos has much improved during the last 20 years; this is partly due to better respiratory and nutritional support. The use of a staged operative closure using a sialon prosthesis has been advocated for 12 years, but our data do not show this to be superior to nonoperative management.

[Exomphalos. A review of 23 cases (author's transl)]

The omphalocele is very often combined with congenital malformations and is primarely to be looked at as a medical and surgical disease. The radiological examination possibly can help to decrease the rate of mortality by disclosing the malformations. These very often consist of malformations, complicating ileus and Bochdalek's hernia. We present 23 cases with omphalocele with special regard to the congenital malformations, complications postoperatively and the causes of death.