Small-bowel continuity: a crucial factor in determining survival in gastroschisis

Gastroschisis with intestinal atresia leads to longer hospitalization and poor feeding outcomes

OBJECTIVE

Compare in-hospital outcomes in gastroschisis with intestinal atresia versus simple gastroschisis (GS) using a national database.

STUDY DESIGN

The Children's Hospitals Neonatal Database identified infants with gastroschisis from 2010 to 2016.

RESULTS

2078 patients with gastroschisis were included: 183 (8.8%) with co-existing intestinal atresia, 1713 (82.4%) with simple gastroschisis, the remainder with complex gastroschisis without atresia. Length of hospitalization was longer for those with atresia, and yielded higher rates of mortality, medical NEC, and intestinal perforation. They began enteral feedings later, were less likely to initiate feeds orally, and reached full feedings later. They were less likely to be receiving any maternal breast milk or breastfeeding at discharge and more likely than simple gastroschisis to be discharged with a feeding tube.

CONCLUSION

A large multicenter cohort showed gastroschisis with atresia results in worse outcomes and complications, including necrotizing enterocolitis, feeding delays, and enteral feeding tube dependence.

Outcomes of infants with abdominal wall defects over 18years

BACKGROUND/PURPOSE

Infants with abdominal wall defects (AWD) are at risk of poor outcomes including prolonged hospitalization, infections and mortality. Our objective was to describe and compare the outcomes of infants admitted with gastroschisis and omphalocele over 18years.

METHODS

Population-based study of clinical data and outcomes of live-born infants with AWD admitted to all tertiary-level neonatal intensive care units in New South Wales and Australian Capital Territory from 1992 to 2009.

RESULT

There were 502 infants with AWD - 336 gastroschisis, 166 omphalocele. Infants with gastroschisis required a longer duration of total parenteral nutrition (19 vs 4days, p<0.05), longer hospitalization (28 vs 15days, p<0.05) and had a higher rate of systemic infection [23.5% vs 13.3%, OR 1.77 (1.15-2.74), p<0.05] compared to infants with omphalocele. Overall, omphalocele infants had higher mortality rate compared to gastroschisis infants [OR 2.77 (1.53, 5.04), p<0.05]. Gastroschisis mortality rates increased from epoch 1 to epoch 3 (4.2% to 8.8%).

CONCLUSION

Compared to infants with omphalocele, infants with gastroschisis required significantly longer hospitalization and parenteral nutrition with higher rates of infection. Infants with omphalocele had higher overall mortality rates. However, there has been an increase in the gastroschisis mortality rates but the cause for this is unclear.

Total Parenteral Nutrition-Induced Cholestasis: Prevention and Management

When cholestasis occurs in patients receiving total parenteral nutrition, it is the result of many pathogenic pathways converging on the hepatic acinus. The result may be a temporary rise in liver function tests. The resulting fibrosis, portal hypertension, and jaundice are hallmarks of type 3 intestinal-associated liver disease to which children are more susceptible than adults. The key to prevention is in identifying high-risk scenarios, meticulous monitoring, and personalized prescription of parenteral nutrition solutions combined with an active approach in reducing the impact of inflammatory events when they occur by prompt use of antibiotics and line locks.

Gastroschisis-related complications requiring further surgical interventions

PURPOSE

The aim of this study was to determine the incidence of gastroschisis-related complications (GRCs) after closure of the abdominal wall defect, with a focus on frequency, type and timing of required surgical interventions, and to identify the impact of these on further outcome.

METHODS

All gastroschisis patients treated from 1975 to 2008 in a tertiary-level center were retrospectively reviewed. Surgical procedures for GRCs following abdominal wall closure of simple gastroschisis [SG (intact continuous bowel)] and complex gastroschisis [CG (additional gastrointestinal malformations)] were compared, and outcomes were determined.

RESULTS

One hundred and eight patients were identified with a median follow-up of 15.0 years (range 4-37). Ninety-four (87%) had SG, and 14 (13%) CG. Surgical interventions for GRCs were performed in 28 (26%) patients with 16 requiring multiple operations. Overall, 60 surgical procedures were performed. Bowel obstruction (n = 34) was the most common GRC, followed by anastomotic stricture (n = 8) and ischemic bowel (n = 3). The median interval between gastroschisis closure and secondary surgery for GRCs was 62.5 days (range 1 day-15 years). Surgical interventions were significantly more frequent in CG compared with SG [12/14 (86%) vs. 16/94 (17%); P < 0.0001]. The overall survival rate was 90%. Significantly, more patients required parenteral nutrition for more than 28 days [9/28 (32%) vs. 13/80 (16 %); P = 0.0468], longer median time to achieve full enteral feedings (87 vs. 33 days; P < 0.0001) and longer median hospital stay (117 vs. 54 days; P < 0.0001) compared with those not requiring additional surgery.

CONCLUSION

GRCs requiring surgical interventions were more common in patients with CG, which were associated with delay in achieving full enteral feedings and prolonged hospital stay.

Gastroschisis--what should be told to parents?

Gastroschisis is a common congenital abdominal wall defect. It is almost always diagnosed prenatally thanks to routine maternal serum screening and ultrasound screening programs. In the majority of cases, the condition is isolated (i.e. not associated with chromosomal or other anatomical anomalies). Prenatal diagnosis allows for planning the timing, mode and location of delivery. Controversies persist concerning the optimal antenatal monitoring strategy. Compelling evidence supports elective delivery at 37  weeks' gestation in a tertiary pediatric center. Cesarean section should be reserved for routine obstetrical indications. Prognosis of infants with gastroschisis is primarily determined by the degree of bowel injury, which is difficult to assess antenatally. Prenatal counseling usually addresses gastroschisis issues. However, parental concerns are mainly focused on long-term postnatal outcomes including gastrointestinal function and neurodevelopment. Although infants born with gastroschisis often endure a difficult neonatal course, they experience few long-term complications. This manuscript, which is structured around common parental questions and concerns, reviews the evidence pertaining to the antenatal, neonatal and long-term implications of a fetal gastroschisis diagnosis and is aimed at helping healthcare professionals counsel expecting parents.

Outcomes of early versus late intestinal operations in patients with gastroschisis and intestinal atresia: results from a prospective national database

BACKGROUND

Gastroschisis may be complicated by intestinal atresia, necrosis, and/or perforation. In the absence of an urgent indication, intestinal procedures are often delayed to allow for bowel recovery. This practice has not been evaluated.

METHODS

We queried a prospective Canadian database of all patients with gastroschisis born between 2005 and 2011. Patients with intestinal atresia who underwent an intestinal operation during the first 21 days of life (EARLY GROUP) were compared with those who underwent operations later (LATE GROUP).

RESULTS

Of 629 gastroschisis patients, 78 (12.4%) had intestinal complications; 27 patients (4.3%) had intestinal operations for atresia without necrosis or perforation - 14 EARLY and 13 LATE. Baseline clinical parameters were similar between the two groups. There was a decreased incidence of the following complications in the EARLY group but none reached statistical significance: post-operative bowel obstruction (28.6% vs. 61.5%, p = 0.1); line sepsis (14.3% vs. 30.8 %, p = 0.4); and wound infection (14.3% vs. 46.1%, p = 0.1). Earlier tolerance of enteral feeding in the EARLY group was manifested by younger age at first enteral feeding (14.8 + 2.6 vs. 44.7 + 7.4 days, p = 0.002) and higher tolerance of enteral feeding at 28 days of life [less patients exclusively on TPN (28.6% vs. 61.5%, p = 0.06), and more patients on more than 50 cc kg(-1)day(-1) of enteral feeding (42.9% vs. 7.7%, p = 0.08)].

CONCLUSIONS

Early intestinal operations in patients with gastroschisis and intestinal atresia are not associated with increased complications, and allow patients to receive and tolerate enteral feeding earlier.

Cholestasis and growth in neonates with gastroschisis

PURPOSE

The aim of this study was to determine the incidence of cholestasis and the correlation between cholestasis and weight-for-age z scores in parenteral nutrition-dependent neonates with gastroschisis.

METHODS

A single-center retrospective review of 59 infants born with gastroschisis from January 2000 to June 2007 was conducted. Demographic and clinical data were collected and analyzed. Subjects were divided into cholestatic and noncholestatic groups. Statistical analyses included the Student t test, Wilcoxon rank sum test, Fisher exact test, and a general linear model.

RESULTS

Fifty-nine neonates with gastroschisis were identified, and 16 (28%) of 58 patients developed cholestasis. Younger gestational age and cholestasis were found to be independently associated with weight-for-age z score in 30 of 58 patients with available long-term follow-up data.

CONCLUSIONS

Parenteral nutrition-dependent neonates with gastroschisis remain at considerable risk for the development of cholestasis. Both gestational age and cholestasis were found to be independent risk factors, predisposing these neonates to poor postnatal growth.

Bowel-defect disproportion in gastroschisis: does the need to extend the fascial defect predict outcome?

BACKGROUND/PURPOSE

Validated outcome prediction for gastroschisis (GS) permits early risk stratification. The aim of our study was to determine whether the need for GS defect extension: (a) correlates with bowel injury severity at birth, and (b) predicts outcome.

METHODS

A national dataset was used to study GS babies born between 2005 and 2010. The primary outcome was days of parenteral nutrition (PN). Outcomes were analyzed according to the need for fascial extension to facilitate closure or silo placement as follows: Group 1, no extension; Group 2A, extension <2 cm; Group 2B, extension >2 cm. Univariate and where appropriate, multivariate analyses were used.

RESULTS

Of 507 cases, 402 had complete defect extension data: Group 1, 297 (73%); Group 2A, 67 (17%); Group 2B, 42 (10%). Group 2B patients had higher rates of atresia, perforation and severe matting (P = 0.001) and required more days on PN compared to Group 1 (63.0 ± 100.4 vs. 39.7 ± 44.5 days: CI 1.2-45.1; P = 0.03). Multivariate analysis revealed that the presence of atresia (P = 0.01) and surgical site (P = 0.001) or bloodstream (P = 0.001) infections were predictive of prolonged PN; however, the need for fascial extension was not.

CONCLUSIONS

GS newborns who require fascial extension are more likely to have complicated GS and are at greater risk for adverse outcome, although it is not an independent predictor of the latter.

Gastroschisis with intestinal atresia--predictive value of antenatal diagnosis and outcome of postnatal treatment

PURPOSE

The purpose of this study is to evaluate (1) the predictive value of fetal bowel dilatation (FBD) for intestinal atresia in gastroschisis and (2) the postnatal management and outcome of this condition.

METHODS

A retrospective review of all gastroschisis cases diagnosed in our fetal medicine unit between 1992 and 2010 and treated postnatally in our center was performed.

RESULTS

One hundred thirty cases had full postnatal data available. Intestinal atresia was found at surgery in 14 neonates (jejunum, n = 6; ileum, n = 3; ascending colon, n = 3; multiple, n = 2). Polyhydramnios and FBD were more likely in the atresia group compared with infants with no atresia (P = .0003 and P = .005, respectively). Fetal bowel dilatation had 99% negative predictive value (95% confidence interval, 0.9-0.99) and 17% positive predictive value (95% confidence interval, 0.1-0.3) for atresia. Treatment of intestinal atresia included primary anastomosis (n = 5), delayed anastomosis (n = 2), and stoma formation followed by anastomosis (n = 7). Infants with atresia had longer duration of parenteral nutrition, higher incidence of sepsis, and cholestasis compared with infants with no atresia (P = .0003). However, the presence of atresia did not increase mortality.

CONCLUSIONS

Polyhydramnios and FBD are associated with atresia. Absence of FBD in gastroschisis excludes intestinal atresia. In our experience, atresia is associated with a longer duration of parenteral nutrition but does not influence mortality. These findings may be relevant for antenatal counseling.

Neonatal abdominal wall defects

Gastroschisis and omphalocele are the two most common congenital abdominal wall defects. Both are frequently detected prenatally due to routine maternal serum screening and fetal ultrasound. Prenatal diagnosis may influence timing, mode and location of delivery. Prognosis for gastroschisis is primarily determined by the degree of bowel injury, whereas prognosis for omphalocele is related to the number and severity of associated anomalies. The surgical management of both conditions consists of closure of the abdominal wall defect, while minimizing the risk of injury to the abdominal viscera either through direct trauma or due to increased intra-abdominal pressure. Options include primary closure or a variety of staged approaches. Long-term outcome is favorable in most cases; however, significant associated anomalies (in the case of omphalocele) or intestinal dysfunction (in the case of gastroschisis) may result in morbidity and mortality.

Intestinal atresia in association with gastroschisis: a 26-year review

PURPOSE

We reviewed our experience with gastroschisis (GS) complicated by intestinal atresia over the last 26 years. Our aim was to determine the effect of different management strategies employed and the morbidity associated with this condition in our unit.

METHODS

A retrospective casenote review was carried out. Data regarding the operative management of the GS and atresia was recorded. Primary outcome measures included time to commence and establish full enteral feeds, duration of parenteral nutrition, complications and outcome.

RESULTS

Of 179 neonates with GS, 23 also had intestinal atresia. 13 underwent primary closure of the defect, 5 had patch closure and 5 had a silo placed. 4 atresias were 'missed' at first operation. The 19 recognised atresias were managed either by stoma formation, primary anastomosis or deferred management with subsequent primary anastomosis. There was wide variation in the outcomes of patients in each group.

CONCLUSION

Differences in outcome between the management strategies are likely to reflect an inherent variability in patient condition, site of atresia, and bowel suitability for anastomosis at first surgery, rather than the mode of surgical management. Individual management plans should be tailored to the clinical condition of each patient.

Gastroschisis, atresia, dysmotility: surgical treatment strategies for a distinct clinical entity

PURPOSE

Intestinal atresia (IA) occurs in 10% to 20% of infants born with gastroschisis (GS). We describe a distinct subset of these children with severe dysmotility, without mechanical intestinal obstruction, and with adequate intestinal length for enteral nutrition and propose possible treatment strategies.

METHODS

A total of 177 patients with GS managed at a single institution between 1993 and 2007 were retrospectively reviewed.

RESULTS

Twenty-one (12%) patients had IA. Six (29%) did well, with gradual progression to full diet; 1 died at birth because of complete midgut infarction; 1 died of necrotizing enterocolitis; 4 with short bowel syndrome (SBS) (small bowel length, 30-41 cm) died of liver failure because of total parenteral nutrition (3) or sepsis (1). Nine (43%) were felt to have gastroschisis/atresia/dysmotility, defined as adequate small bowel length for survival as measured at time of laparotomy (mean, 146 cm; range, 66-233 cm), massive intestinal dilatation, and stasis. Of 9 patients with gastroschisis/atresia/dysmotility, 5 (56%) survived. All had surgery to "rescue" their dysfunction intestine, at mean age 128 days (range, 52-271 days): 4 had tapering enteroplasties of mean 37 cm (range, 5-115 cm)-all 4 survived; 3 had diverting stomas created for intestinal decompression, followed by stoma closure-1 survived; 1 nonsurvivor had a Kimura "patch"; 1 nonsurvivor underwent redo anastomosis. Survivors weaned off total parenteral nutrition at mean age 331 days after rescue surgery (range, 42-814 days).

CONCLUSIONS

More than one third of patients with GS/IA appear to have significant intestinal dysmotility without true SBS nor obstruction. Successful treatment of these infants may be achieved with the use of tapering enteroplasty and/or temporary diverting stomas.

Benefit of preformed silos in the management of gastroschisis

Gastroschisis is traditionally managed by primary closure (PC) or delayed closure after surgical silo placement. Bedside insertion of preformed silos (PFS) and delayed closure has become more widespread, although its benefits remain unclear. To identify differences in outcome of infants managed with PFS compared with traditional closure (TC) techniques. Single-centre retrospective review of 53 consecutive neonates admitted between February 2000 and January 2006. Data expressed as median (range). Non-parametric statistical analysis used with P < 0.05 regarded as significant. Forty infants underwent TC and 13 had PFS and delayed closure. Median ventilation time in both groups was 4 days (P = 0.19) however this was achieved with higher mean airway pressures (MAPs) (day 0, 10 (5-16) versus 8 (5-10) cmH(2)O; P = 0.02) and inspired oxygen (40 (21-100) versus 30 (21-60)%; P = 0.03) in TC group. Urine output on day-1 of life was significantly higher in PFS group (1.1 (0.16-3.07) versus 0.45 (0-2.8) ml/kg/h; P = 0.02). Inotrope support was required in 17/40 (43%) of TC versus 0/13 (0%) in PFS (P < 0.01). After exclusion of infants with short bowel syndrome and/or intestinal atresia (n = 9), there was a shorter time to full enteral feeds in the TC group (22 (12-36) versus 27 (17-45); P = 0.07), although there was no difference in the period of parenteral nutrition (PN) (P = 0.1) or overall hospital stay (P = 0.34). No deaths or episodes of necrotizing enterocolitis occurred. The use of PFS for gastroschisis closure is associated with a reduction in pulmonary barotrauma, better tissue perfusion and improved early renal function, consistent with a reduction in abdominal compartment syndrome.

Risk stratification of 4344 patients with gastroschisis into simple and complex categories

BACKGROUND

Gastroschisis is a congenital full-thickness abdominal wall defect characterized by the protrusion of intraabdominal organs outside the abdominal domain that requires surgical management in the early neonatal period. The goal of this study was to validate a previous risk stratification classification of infants born with this defect.

METHODS

A retrospective analysis of a nonoverlapping combination of the databases National Inpatient Sample and Kids' Inpatient Database (1988-2003) was performed. These combined databases contain information from nearly 93 million discharges in the United States. Infants with gastroschisis were identified by an International Classification of Diseases, Ninth Revision procedure code of 54.71 (repair of gastroschisis) and an age at admission of less than 8 days. Infants were divided into simple and complex categories based on the absence or presence of intestinal atresia, stenosis, perforation, necrosis, or volvulus. Variables of sex, race, geographic region, coexisting diagnoses, hospital type and charges adjusted to 2005 dollars, length of stay, inpatient mortality, and complications were collected. Comparison between the 2 groups was performed using Pearson chi2 for categorical outcomes and the Kruskal-Wallis test for non-normally distributed continuous variables.

RESULTS

A total of 4344 infants with gastroschisis were identified and divided into simple and complex categories. Simple gastroschisis represented 89.1% (n = 3870) of the group, whereas 10.9% (n = 474) had complex disease. Simple and complex patients differed in coexisting cardiac disease (8.3% vs 11.8%, P = .01), hospital type (78.7% vs 84.1% treated at urban teaching centers, P < .01), median length of stay (28 vs 67 days, P < .01), median inflation-adjusted hospital charges ($90,788 vs $197,871; P < .01), and inpatient mortality (2.9% vs 8.7%, P < .01). Gastrointestinal (14.4% vs 83.5%, P < .01), respiratory (2.6% vs 4.6%, P = .01), and infectious disease complications (24.3% vs 45.4%, P < .01) also differed between the groups.

CONCLUSIONS

These data use the largest data set to date to validate the risk stratification of infants with gastroschisis. This analysis improves the characterization and understanding of clinical subsets of infants in whom this congenital condition is diagnosed.

Development and validation of a risk stratification index to predict death in gastroschisis

BACKGROUND

Gastroschisis is a rare congenital anomaly, the improved surgical management of which has contributed to a survival rate greater than 90%. Development of an accurate risk stratification system to help identify the subset of patients at greatest risk for death may lead to further improvements in outcome.

METHODS

Infants with gastroschisis were identified from 16 years of the National Inpatient Sample database and the Kids' Inpatient Database using the International Classification of Diseases, Ninth Revision, Clinical Modification procedure code 54.71 (repair of gastroschisis) and an age of less than 8 days. Logistic regression analysis determined which coexisting diagnoses were significantly associated with death. Odds ratios from the logistic regression model were simplified and used as weighting factors to create an additive index. The index was validated using the 2003 Kids' Inpatient Database data set.

RESULTS

Intestinal atresia, necrotizing enterocolitis, rare cardiac anomalies, and lung hypoplasia were strongly associated with death and used to create a scoring system with a potential range of 0 to 10. Every point increase on the scale of gastroschisis risk stratification index is associated with a 95% relative increase in the likelihood of death.

CONCLUSION

We have developed a novel index, which is superior to previous classification systems in identifying patients with gastroschisis who are at highest risk for death.

Gastroschisis in the United States 1988-2003: analysis and risk categorization of 4344 patients

OBJECTIVE

Gastroschisis is a rare congenital abdominal wall defect through which intraabdominal organs herniate and it requires surgical management soon after birth. The objectives of this study were to profile patient characteristics of this anomaly utilizing data from two large national databases and to validate previous risk stratification categories of infants born with this condition.

METHODS

An analysis was performed using 13 years of the National Inpatient Sample database (1988-1996, 1998, 1999, 2001, 2002) and 3 years of the Kids' Inpatient Database (1997, 2000, 2003). These combined databases contain information from nearly 93 million discharges in the United States. Infants with gastroschisis were identified by International Classification of Disease-9 procedure code 54.71 (repair of gastroschisis) and an age at admission of <8 days. Variables of gender, race, geographic region, co-existing diagnoses, length of stay, hospital charges adjusted to 2005 dollars, complications and inpatient mortality were collected from the databases. Infants were divided into simple and complex categories based on the absence or presence of intestinal atresia, stenosis, perforation, necrosis or volvulus. Comparisons between groups were performed using Pearson's chi (2) for categorical outcomes and the Kruskal-Wallis test for non-normally distributed continuous variables.

RESULTS

A total of 4344 infants with gastroschisis were identified. These were comprised of 44.0% female infants (n=1910), 46.4% male infants (n=2017) whereas 9.6% were not reported (n=415). Racial analysis showed the largest subset being white in 40.9% of infants (n=1775) with Hispanic infants being the next highest group reported at 17.2% (n=745). Co-existing intestinal anomalies were the most common, affecting 9.9% (n=429) infants, whereas certain cardiac (6.8%, n=294) and pulmonary (1.7%, n=72) conditions were also identified. Simple gastroschisis represented 89.1% (n=3870) of the group whereas 10.9% (n=474) were complex in nature. Simple and complex patients differed in median length of stay (28 vs 67 days, P<0.01), inpatient mortality (2.9 vs 8.7%, P<0.01) and median inflation-adjusted hospital charges (90,788 dollars vs 197,871 dollars, P<0.01).

CONCLUSIONS

These data represent a national analysis of the largest group of infants with gastroschisis to date which further aids the characterization and understanding of this serious congenital condition.

Silo pouch stoma: a rescue procedure for intestinal catastrophe in gastroschisis

Silo pouch formation is a standard procedure to prevent compartment syndrome in gastroschisis. Intestinal complications such as perforation and volvulus can occur and their management can be perplexing. We present three such patients in which we formed a stoma through the silo pouch owing to these complications. Creation of stoma through the silo is a novel, safe temporizing technique to decompress the bowel while delayed reduction continues. Subsequently, when the baby and the bowel improve, the stoma can be closed.

A multicenter, randomized, double-blind, placebo-controlled trial of the prokinetic agent erythromycin in the postoperative recovery of infants with gastroschisis

BACKGROUND/PURPOSE

The recovery of gut function after repair of gastroschisis is frequently prolonged, and these infants are prone to complications associated with parenteral nutrition. This trial was designed to investigate the effect of the prokinetic agent, erythromycin, on the attainment of full enteral feeding in infants after primary repair of uncomplicated gastroschisis.

METHODS

A multicenter, randomized, double-blind, placebo-controlled trial was used to investigate the effect of enteral erythromycin (3 mg/kg/dose 4 times daily) compared with placebo on the attainment of full enteral feeding tolerance after primary repair of uncomplicated gastroschisis. Eleven neonatal surgical units in the United Kingdom participated in the study. The primary end-point was the time taken to achieve continuous enteral feeding at 150 mL/kg/24 hours sustained for 48 hours.

RESULTS

Of 70 eligible infants, 62 were recruited and randomly divided. There were 30 patients in group I (placebo) and 32 in group II (erythromycin). The groups were comparable in terms of mean gestational age, mean birth weight, extent of evisceration, and degree of intestinal peel. There was no statistically significant difference between the 2 groups in the time taken to achieve full enteral feeding (27.2 v 28.7 days; P =.75). Similarly, no significant differences were found in the incidence of catheter-related sepsis, duration of parenteral nutrition, or time to discharge between the 2 groups.

CONCLUSIONS

Enterally administered erythromycin at a dose of 3 mg/kg 4 times daily conferred no advantage in the time taken to achieve full enteral feeding after primary repair of uncomplicated gastroschisis.

Gastroschisis: A sixteen-year review

PURPOSE

The aim of this study was to examine the incidence of gastroschisis in Saskatchewan over a 16-year period and identify risk factors associated with mortality.

METHODS

Information was obtained by retrospective review of all infant charts at the only 2 provincial neonatal intensive care centers from January 1985 through December 2000. Factors recorded were gestational age, birth weight, gender, Apgar score, time to operation, method of closure, time to attain full feedings, presence of sepsis, and length of hospital stay. Live birth data for the province was obtained, and the incidence per 10,000 live births for 3 time intervals was calculated. Analysis was performed with mortality as the dependent variable.

RESULTS

Seventy-one infants were identified. Overall survival rate was 93% (66 of 71). During the 3 time intervals examined, the incidence of gastroschisis per 10,000 live births increased from 1.85 in 1985 to 1990 to 3.66 in 1991 to 1995 to 4.06 in 1996 to 2000. The analysis found that intestinal atresia P =.009, OR = 18.3 (95%CI: 2.457-136) and intestinal necrosis P =.050, OR = 10.33 (95%CI: 1.32-80.68) were significantly associated with mortality.

CONCLUSIONS

The incidence of gastroschisis is increasing. Intestinal atresia and the development of intestinal necrosis were associated with poor outcome. Patients who had these complications all had short bowel, and full feedings could not be established. They required continuation of total parenteral nutrition and experienced episodes of sepsis.

Management of intestinal atresia in patients with gastroschisis

BACKGROUND/PURPOSE

Intestinal atresia occurs in approximately 10% to 20% of children with gastroschisis and may be missed at the initial closure if a thick peel obscures the bowel. Some investigators have identified intestinal atresia as a significant contributor to morbidity and mortality. The authors reviewed their experience with gastroschisis and intestinal atresia in an attempt to answer the following questions. What is the incidence of this association? How often is the intestinal atresia unrecognized as a result of the peel? What is the optimal management for infants with atresia and gastroschisis, and does the atresia affect morbidity or mortality?

METHODS

The hospital charts and medical records of all patients with gastroschisis treated at our institution from 1969 to present were reviewed thoroughly. Parameters analyzed included gestational age (GA), birth weight (BW), antenatal diagnosis, mode of delivery, type of closure, era of repair, presence of other major anomalies, and development of necrotizing enterocolitis. Morbidity and mortality rates were examined. Characteristics of patients with and without atresia were compared. Chi-squared was used for crosstabular analysis. Sample parameters were compared with Student's t test. P values of less than.05 were considered significant.

RESULTS

A total of 199 babies had gastroschisis and 25 (12.6%) had intestinal atresia. Intestinal atresia was initially unrecognized in 3 patients. Most patients (80%) underwent primary closure of the abdominal wall. Initial stoma formation and delayed anastomosis was performed in 12 (48%) patients, none of whom required prosthetic material for abdominal wall closure. Initial stomas were avoided in 5 patients who required SILASTIC (Dow Corning, Midland, MI) silos. Skin closure alone was used in 2 babies. The level of the atresia was most commonly jejunoileal (20 of 25, 80%). Mean hospital stay was increased in babies with intestinal atresia, 36.2 versus 63.1 days (P <.001).

CONCLUSIONS

Although patients with intestinal atresia did have feeding delays, an increased incidence of adhesive intestinal obstruction, and prolonged hospitalization, neither chi(2) nor logistic regression analysis showed any correlation with mortality. Intestinal repair at the first operation is sometimes possible and depends on the severity of the peel. Delayed repair of the atresia after a period of bowel decompression and parenteral nutrition is preferred, but in certain situations (colonic atresia, necrotic intestine, complicated atresia) may not be possible. The combination of stomas and prosthetic material can be avoided in almost all patients. A management algorithm for patients with atresia and gastroschisis is discussed.

The contemporary outcome of gastroschisis

BACKGROUND

The aim of this study was to evaluate the contemporary outcome in the management of gastroschisis.

METHODS

A retrospective analysis was conducted of 91 babies admitted over a 7-year period to a single neonatal surgical unit with a diagnosis of gastroschisis.

RESULTS

An antenatal diagnosis was made in 89 (98%) cases. Surgical intervention occurred in 90 babies, at a mean of 5 hours (range, 0.5 to 17) postdelivery. In 72 (80%) cases, primary closure of the abdominal defect was achieved, with a silo fashioned in the remaining 18 (20%). One child died before abdominal closure. The median time to full oral feeding was 30 days (range, 5 to 160 days), and to discharge was 42 days (range, 11 to 183 days). Those children who required a silo, took longer to feed (P =.008) and stayed longer in the hospital (P =.021). The 8 (8.8%) children with an intestinal atresia, required significantly more operative procedures (P =.0001) and took significantly longer to achieve full oral feeding (P =.04), but the presence of an atresia was not an independent risk factor for mortality. There were 7 deaths (7.7%), 3 within the first 7 days. Of the deaths, 5 (71%) were caused by overwhelming sepsis.

CONCLUSIONS

The contemporary mortality rate from gastroschisis is less than 8%, and minimizing septic complications would contribute significantly to reducing this. Strategies designed to improve morbidity must focus on optimizing management of those factors associated with a prolonged recovery, namely intestinal atresia, prematurity, and the use of a silo.

Intestinal atresia with gastroschisis: a selective approach to management

BACKGROUND

The association of bowel atresia with gastroschisis is well recognized, but the ideal management is less certain.

METHODS

The records of 10 infants with gastroschisis and intestinal atresia treated between 1991 and 1997 in a single neonatal surgical unit were reviewed.

RESULTS

Ten infants had midgut atresias: 5 small intestine, 1 jejunum and colon, and 4 colonic. Of the 6 with small bowel atresias, 4 had primary abdominal wall repair with electively delayed primary anastomosis at 21 to 46 days, 1 had decompressing tube jejunostomy at 11 days at the time of secondary abdominal closure, and 1 initial jejunostomy. Of the 4 with colonic atresia alone, 3 had perforation or infarction of the proximal colon at birth, 2 had a primary stoma, and 2, who did not have initial colostomy or anastomosis, required reoperation for increasing abdominal distension at 11 and 23 days. Complications were recorded in 6 patients: 2 had necrotizing enterocolitis after which 1 developed malabsorption, 1 had distal bowel obstruction after delayed primary anastomosis treated with a Bishop-Koop ileostomy at 50 days, 2 had stoma stenosis, and 1 had stoma prolapse. None died, and at 1 year 9 were within the normal range for body weight, and details of 1 are not known.

CONCLUSIONS

At birth, diagnosis of atresia often is uncertain, and the bowel is difficult to repair or exteriorize. For proximal atresias, delayed primary repair is a safe satisfactory approach. At birth, distal atresias are more obvious, often complicated by perforation or infarction, and may benefit from early enterostomy.

Inborn errors of mitochondrial fatty acid oxidation

Inborn errors of the mitochondrial beta-oxidation of long-chain fatty acids represent an evolving field of inherited metabolic disease. Fatty acid oxidation defects demonstrate an abnormal response to the process of fasting adaptation and affect those tissues that utilize fatty acids as an energy source. These tissues include cardiac and skeletal muscle and liver. Muscle directly uses fatty acids as an energy source whilst hepatic metabolism of fatty acids is mostly directed toward the synthesis of ketone bodies for energy utilization by tissues such as brain. The clinical phenotypes of fatty acid oxidation disorders include disease of one or more of these fatty acid-metabolizing tissues. In this review, we provide an overview of the pathway, discuss the disorders that are well established, and describe recent advances in the field. Currently available diagnostic procedures are critically evaluated.

Outcome analysis for gastroschisis

BACKGROUND/PURPOSE

Several factors are reportedly associated with an adverse outcome in gastroschisis, including mode of delivery, in utero diagnosis, type of closure, concurrent anomalies, intestinal atresia, and necrotizing enterocolitis (NEC). Since 1969, the authors have treated 185 patients who had gastroschisis. The authors analyzed their database to identify variables associated with increased morbidity and mortality.

METHODS

A retrospective study of all patients with gastroschisis treated at our institution in the last 30 years was performed. The characteristics of survivors and nonsurvivors were compared. A logistic regression analysis was performed, with survival as the dependent variable, and the following parameters as independent variables: in utero diagnosis, mode of delivery, gestational age and birth weight, era of repair, type of closure, presence of other associated anomalies, intestinal atresia, and development of necrotizing enterocolitis. Further logistic regression analysis was performed, with various indicators of morbidity as dependent variables. These included development of sepsis, bowel obstruction, and complications related to the closure or to the silo. No attempt at long-term follow-up was made.

RESULTS

A total of 185 infants with gastroschisis were treated at our institution from 1969 to 1999. Mean gestational age was 36.6 weeks, and the mean birth weight was 2,501 g. A total of 21 infants had intestinal atresia. NEC developed in 8 infants. Six infants had other serious anomalies. The overall survival rate was 91%. Survival improved in last 2 decades (94%). There were no differences in gestational age, birth weight and mode of delivery, method of closure, or presence of intestinal atresia between survivors and nonsurvivors. Only the era of repair (P = .002), presence of necrotizing enterocolitis (P = .044), and presence of other major anomalies (P < .001) correlated with mortality in the logistic regression analysis. Sepsis, bowel obstruction, and closure complications accounted for most of the morbidity. Analysis of these three morbidity factors identified low gestational age (P = .038) and development of necrotizing enterocolitis (P = .020) as independent predictors of sepsis. Closure complications were only associated with lower birth weight (P = .006). No predictors of bowel obstruction were identified.

CONCLUSIONS

Mode of delivery, method of closure, birth weight and gestational age, and the presence of intestinal atresia do not appear to correlate with survival in infants with gastroschisis. Only the presence of another major anomaly, the era of repair, and the development of necrotizing enterocolitis were associated with increased mortality. Degree of prematurity and development of enterocolitis were associated with an increased incidence of septic complications. Low birth weight was a marker for closure complications. Type of delivery (vaginal or cesarean section) had no influence on either morbidity or mortality.

Management of gastroschisis with concomitant jejuno-ileal atresia

BACKGROUND

The incidence of jejuno-ileal atresia in neonates concomitantly found to possess gastroschisis has been reported to be 5% to 25%. Initial treatment for this condition has not been well established.

METHODS

Thirteen newborns with gastroschisis and coexisting jejuno-ileal atresia, were identified and treated at our institution over the past 16 years (1978 through 1996). Patient characteristics at presentation, surgical therapy, and complications at extended follow-up were reviewed.

RESULTS

All neonates were preterm (mean gestational age, 35.2 +/- 2.0 weeks) and of low birth weight (2.1 +/- 0.4 kg). Atresia types II, IIIa, IIIb, and IV were identified at the initial surgical procedure in one, eight, one, and three patients respectively; however, one synchronous small bowel atresia went unrecognized. A primary anastomosis was fashioned in 8 of 13 newborns, the creation of which did not influence length of hospitalization, length of total parenteral nutrition (TPN) requirement, complication rate, or survival; however, reoperation was required in two of eight patients to mediate anastomotic complications. Atresia associated with intestinal gangrene or perforation was treated by primary anastomosis in three of six patients and the remaining three by enterostomy. Primary abdominal wall closure was possible in 10 of 13 patients; a Silon pouch was required in three. All nine survivors (69%) displayed protracted small bowel dysfunction requiring TPN (mean TPN duration of 3.6 +/- 3.0 months; range, 1 to 11). Mortality in four patients was a consequence of severe prematurity, Silon pouch wound sepsis, or TPN-induced cirrhosis.

CONCLUSIONS

When technically feasible, restoration of intestinal continuity by primary anastomosis is a reasonable treatment option in patients with coexisting gastroschisis and jejuno-ileal atresia. Favorable outcome is as much a function of supportive care and parenteral nutrition as the type of surgical repair performed for either the intestinal or the abdominal wall defect.