Management of giant omphaloceles: A systematic review of methods of staged surgical vs. nonoperative delayed closure

Omphalocele: from diagnosis to growth and development at 2 years of age

OBJECTIVES

To compare the prenatal frame of reference of omphalocele (ie, survival of fetuses) with that after birth (ie, survival of liveborn neonates), and to assess physical growth and neurodevelopment in children with minor or giant omphalocele up to 2 years of age.

DESIGN

We included fetuses and neonates diagnosed in 2000-2012. Physical growth (SD scores, SDS) and mental and motor development at 12 and 24 months were analysed using general linear models, and outcomes were compared with reference norms. Giant omphalocele was defined as defect ≥5 cm, with liver protruding.

RESULTS

We included 145 fetuses and neonates. Of 126 (87%) who were diagnosed prenatally, 50 (40%) were liveborn and 35 (28%) survived at least 2 years. Nineteen (13%) neonates were diagnosed after birth. Of the 69 liveborn neonates, 52 (75%) survived and 42 children (81% of survivors) were followed longitudinally. At 24 months, mean (95% CI) height and weight SDS were significantly below 0 in both minor (height: -0.57 (-1.05 to -0.09); weight: -0.86 (-1.35 to -0.37)) and giant omphalocele (height: -1.32 (-2.10 to -0.54); weight: -1.58 (-2.37 to -0.79)). Mental development was comparable with reference norms in both groups. Motor function delay was found significantly more often in children with giant omphalocele (82%) than in those with minor omphalocele (21%, P=0.002).

CONCLUSIONS

The prenatal and postnatal frames of reference of omphalocele differ considerably; a multidisciplinary approach in parental counselling is recommended. As many children with giant omphalocele had delayed motor development, we recommend close monitoring of these children and early referral to physical therapy.

15q23 Gain in a Neonate with a Giant Omphalocele and Multiple Co-Occurring Anomalies

Background

Omphalocele is a rare congenital abdominal wall defect. It is frequently associated with genetic abnormality and other congenital anomalies, although isolated omphalocele cases do exist. Data have shown that omphalocele with co-occurring genetic abnormality has worse prognosis than isolated omphalocele. Chromosomal analysis by a conventional technique such as karyotyping can only detect aneuploidy and large segmental duplication or deletion. Newer techniques such as high-resolution microarray analysis allow for the study of alterations in chromosomal segments that are less than 5 Mb in length; this has led to identification of critical region and genes in the pathogenesis of omphalocele.

Case Presentation

The current study is the initial report of a newborn male with a 15q23 gain and a giant omphalocele. High-resolution chromosomal microarray analysis identified this gain of copy number spanned 676 kb, involving almost the entire NOX5 gene (except for exon 1 of the longer transcript), the entirety of the EWSAT1, GLCE, PAQR5, KIF23, RPLP1, and DRAIC genes and exons 1-3 of the PCAT29 gene.

Conclusion

To date, this is the first report of an associated 15q23 gain in a case with omphalocele. Interestingly, Giancarlo Ghiselli and Steven A Farber have reported that GLCE knockdown impairs abdominal wall closure in zebrafish. We also identified GLCE gene alteration in our case. This highlights the importance of GLCE in abdominal wall development. Further study of the function of GLCE and other genes might lead to a better understanding of the molecular mechanism of omphalocele.

Nonoperative management of giant omphalocele leading to early fascial closure

PURPOSE

We describe our series of giant omphalocele patients treated with a serial taping method for gradual reduction of the abdominal contents and early fascial closure.

METHODS

Between 2010 and 2017 we cared for ten newborns with giant omphaloceles. The average gestational age was 35.5 weeks (range 29-38) and average birthweight was 2.84 kg. Seven infants had other major anomalies, including one with a variant of Pentology of Cantrell. Four had abnormal chromosomes. None had any attempt to primarily close the defect. Omphalocele defects were serially taped at bedside in the NICU with the child awake until the viscera were completely reduced, and the defect could be closed.

RESULTS

Mean time to closure was 13.7 days (median 14 days). Six were closed primarily without a patch. The remaining four infants required Gore-Tex patch (covered by skin) which was later removed and fascia closed in three infants (at 70 days, 75 days, and 11 months of age). Total length of stay was a mean 71.8 days (median 71).

CONCLUSIONS

Serial taping achieves early fascial closure and avoids complications of a staged surgical approach, such as multiple anesthetics, loss of fascial margin integrity, silo dehiscence, and fistula formation. Compression of the viscera is slow enough to avoid abdominal compartment syndrome and the fascia and amnion are left intact leaving the option available to use escharotic agents if required.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level III.

Early surgical management for giant omphalocele: Results and prognostic factors

OBJECTIVES

Giant omphalocele often represents a major surgical challenge and is reported with high mortality and morbidity rates. The aim of this study was to assess the outcome of neonates with giant omphalocele managed with early operative surgical treatment, and subsequently to identify possible factors that could alter the prognosis.

METHODS

We reviewed the medical records of 29 consecutive newborns with prenatally diagnosed giant omphalocele. In these cases one of two procedures had been performed: either staged closure after silo, or immediate closure with a synthetic patch. The cases were separated into 2 groups: Isolated giant omphalocele (IO group) and giant omphalocele associated with malformation (NIO group).

RESULTS

Infants in the IO group had a lower size of the omphalocele (p<0,001), a shorter hospital stay (95 days [45-915] vs. 41.5 days [10-110] p= 0, 02), and a shorter median ventilation length (10 days [1-33] vs. 27, 5 [6-65] p = 0, 05). In the NIO group, 5 cases displayed a significantly more difficult course than the others. They were compared to the remaining cases for prenatal and anatomic features. Four factors associated with greater morbidity were identified: CONCLUSIONS: Isolated omphalocele, even containing the whole liver, has a very good prognosis with early surgical treatment. Without associated anomalies, 95% of giant omphaloceles can be discharged with a median of 41.5 days in hospital. However, associated anomalies (especially cardiopathies) may burden the prognosis and should be both carefully assessed during pregnancy and taken into account in parental information.

TYPE OF STUDY

Retrospective Study LEVEL OF EVIDENCE: Level I.

Defining normal neonatal abdominal wall musculature with ultrasonography

INTRODUCTION

The development of new surgical approaches for the management of congenital abdominal wall defects may be facilitated by using an animal model. However, because the anatomy of the neonatal abdominal wall has not been described, a suitable model is yet to be identified. We aimed to evaluate and define the neonatal abdominal wall musculature using ultrasound, to be used as a reference to identify an appropriate animal model for the neonatal abdominal wall in the future.

METHODS

Infants with a postconceptual age of less than one month weighing between 2 and 3 kg were eligible. With ethical approval, ultrasonography of three abdominal wall locations bilaterally was performed. The depth of the skin to external oblique and the thickness of the three abdominal wall muscles, external oblique (EO), internal oblique (IO) and transversus abdominis (TA), were measured.

RESULTS

Ten males and seven females were recruited with median postconceptual age of 36 weeks (IQR 36-38), median postnatal age of 8 days (IQR 3-30) and median weight of 2.35kg (IQR 2.26-2.56). The mean depth of EO from skin was 2.06 mm (± 0.44). The mean thicknesses of the muscles were: EO 1.02 mm (± 0.33), IO 1.16 mm (± 0.39) and TA 1.02 mm (± 0.37). There was no statistical difference between the thickness of EO, IO or TA (p= 0.43).

CONCLUSIONS

It is possible to consistently identify and measure the components of the neonatal abdominal wall musculature with ultrasonography. We hope this can aid in developing an appropriate animal model, with the ultimate aim of facilitating innovation in surgical management of neonatal abdominal wall pathology.

LEVELS OF EVIDENCE

Study of Diagnostic test, Level IV.

Dressed for success? Silver impregnated nanocrystalline dressing for initial treatment of giant omphalocele

OBJECTIVE

The purpose of this study was to describe outcomes and resource utilization in patients treated with twice-weekly silver impregnated (SI) nanocrystalline dressings for initial non-operative management of giant omphalocele (GO).

METHODS

A retrospective review of patients with GO treated with SI dressings was undertaken. Clinical parameters, cost, and complications were recorded.

RESULTS

Five patients with GO were treated with SI dressings between 2014 and 2016. Clinical characteristic (mean ± SD) included gestational age 36 ± 4 weeks, birth weight 2.6 ± 0.63 kg, GO size 10.2 ± 4.7 cm, ventilator days 7.5 ± 8.7 d, days in NICU 41 ± 20 d, days to full feeds, 30 ± 15 d, and LOS 62 ± 41 d. The average in-hospital cost of SI dressings was $110 CAD/week. This is comparable to daily silver sulfadiazine dressings ($109CAD/week) which were used historically. All patients were discharged with once- or twice-weekly dressing changes. No ruptures occurred. There was one mortality secondary to pulmonary sepsis.

CONCLUSIONS

For initial non-operative management of GO, twice weekly SI nanocrystalline dressings is safe and effective. Use of SI dressings results in decreased handling of infants, reduced physician and nursing resource utilization, and favourable outcomes.

LEVEL OF EVIDENCE

IV (Retrospective Case Series).

Repair of a Giant Omphalocele in an Infant With a Pericardial Implant Crosslinked With Oligourethane

The giant omphalocele (GO) represents a challenge for the pediatric surgeon in its management and wall abdominoplasty. Here, we report the outcome of a case in which a GO in a newborn patient was repaired with an implant derived from decellularized bovine pericardium crosslinked with oligourethane. The implantation time was extended for 6 months. This was then followed up by the retrieval of the implant and the subsequent reconstruction in a second surgical time by the closure of the abdominal wall fascia. A short hospital stay, early integration into the patient's family environment, as well as early onset of the oral route without special care of the implant or reconstructed wall nor food restrictions were observed. The reduced presence of the complications described in the literature after application of surgical meshes suggests that this implant can be an effective and safe alternative method in the treatment of abdominal wall defects such as GO.

Fetal anterior abdominal wall defects: prenatal imaging by magnetic resonance imaging

Abdominal wall defects range from the mild umbilical cord hernia to the highly complex limb-body wall syndrome. The most common defects are gastroschisis and omphalocele, and the rarer ones include the exstrophy complex, pentalogy of Cantrell and limb-body wall syndrome. Although all have a common feature of viscera herniation through a defect in the anterior body wall, their imaging features and, more important, postnatal management, differ widely. Correct diagnosis of each entity is imperative in order to achieve appropriate and accurate prenatal counseling and postnatal management. In this paper, we discuss fetal abdominal wall defects and present diagnostic pearls to aid with diagnosis.

Comparative Cellular Local Response in Abdominal Defect Plastic Surgery with Bovine Pericardium and Bovine Fascia Preserved in Formaldehyde in Experimental Rabbits

In the present paper, we refer to a method of primary closure of congenital defects of the anterior abdominal wall with tensionless viscero-abdominal disproportion. The study group included 10 animals subjected to surgery of the abdominal wall defect closure with bovine pericardium graft preserved in 0.5% formaldehyde, and 5 rabbits of the same breed and weight, in which bovine fascia graft was used as implant, being preserved in 0.5% formaldehyde. The abdominal anterior wall defect was made surgically by excision of the musculo-fascial structures and peritoneum. Bovine pericardium graft and bovine fascia graft were placed and fixed posteriorly to rectus abdominals muscles, having direct contact with the intra-abdominal contents and protected by suturing skin and subcutaneous layer.

The purpose of the study was to perform a comparative postoperative evaluation of local macroscopic and microscopic changes that develop after reconstruction of the major abdominal wall defects experimentally induced in rabbits, using bovine pericardium and bovine fascia grafts preserved in 0.5% formaldehyde.

In cases of major fascial defects of the anterior abdominal wall, bovine pericardium graft has acceptable strength and biocompatibility, having stabilizing properties of the abdominal wall due to the development of the connective tissue layer located between the implant and the subcutaneous layer. Bovine fascia grafts preserved in formaldehyde have an insignificant irritating and inflammatory action on the intestinal loops compared with bovine pericardium, and do not induce the development of a significant abdominal adhesion process, this allowing their use in the abdominal fascial defects closure with placement in direct contact with the abdominal contents.

High Prevalence of Pulmonary Hypertension Complicates the Care of Infants with Omphalocele

BACKGROUND

Omphalocele is one of the most common abdominal wall defects. Many newborn infants born with omphalocele present with significant respiratory distress at birth, requiring mechanical ventilatory support, and have clinical evidence of pulmonary hypertension. Little information exists on the prevalence of and risk factors associated with pulmonary hypertension in this cohort of infants.

OBJECTIVES

To describe the prevalence of and risk factors associated with pulmonary hypertension among infants with omphalocele.

METHODS

This is a multicenter retrospective chart review of demographic data and clinical characteristics of infants with omphalocele admitted to the neonatal intensive care units of Loma Linda University Children's Hospital and Children's Mercy Hospital between 1994 and 2011. Echocardiogram images were reviewed for pulmonary hypertension, and statistical analyses were performed to identify risk factors associated with the presence of pulmonary hypertension.

RESULTS

Pulmonary hypertension was diagnosed in 32/56 (57%) infants with omphalocele. Compared to infants without pulmonary hypertension, infants with pulmonary hypertension were more likely to have a liver-containing defect (16/32 [50%] vs. 5/24 [21%], p = 0.03), require intubation at birth (18/32 [56%] vs. 6/24 [17%], p = 0.03), and die during initial hospitalization (12/32 [38%] vs. 2/24 [8%], p = 0.01).

CONCLUSION

The majority of infants with omphalocele have evidence of pulmonary hypertension which is associated with increased mortality. Echocardiograms to screen for pulmonary hypertension should be obtained at ≥2 days of life in infants with omphalocele, especially in those with liver within the omphalocele sac and/or in those infants who require intubation at birth to screen for pulmonary hypertension.