Staged repair of giant omphalocele in the neonatal period

Giant omphalocele: A novel approach for primary repair in the neonatal period using botulinum toxin

INTRODUCTION

Giant omphalocele (GO) is a complex condition for which many surgical treatments have been developed; however, no consensus on its treatment has been reached. The benefits and efficacy of botulinum toxin A (BTA) in the repair of large abdominal wall defects in adults has been proven, and its reported use in children has recently grown. The goal of this study is to describe a novel technique for primary repair of GO using BTA during the neonatal period and report our initial experience.

METHODS

patients were followed from August 2020 to July 2022. BTA was applied to the lateral abdominal wall in the first days of life followed by surgical repair of the abdominal defect.

RESULTS

while awaiting surgery, patients had minimal manipulation, without requiring mechanical ventilation, were on full enteral feeding, and in contact with their parents. The midline was approximated without tension and without the need for additional techniques or the use of a prosthesis. Patients were discharged with repaired defects.

CONCLUSION

this approach represents a middle ground between staged and the nonoperative delayed repairs. It does not require aggressive interventions early in life, allowing maintenance of mother-child bonding and discharge of the patient with a repaired defect without the need for additional techniques or the use of a prosthesis. We believe that this technique should be considered as a new possible asset when managing this complex condition.

Using acellular porcine dermal matrix (XCM Biologic® Tissue Matrix) to repair a giant omphalocele: A case report

RATIONALE

An omphalocele is an abdominal wall birth defect, and a giant omphalocele (GO) is defined as an omphalocele having a diameter >5 cm or containing a herniated liver. GOs are usually treated in stages and in this case, during the silo reduction, dehiscence occurred at the suture site of the axis ring and skin edge, which was repaired using synthetic absorbable mesh.

PATIENT CONCERNS

A girl infant was born at 36 weeks with a GO of 8 cm diameter, and herniated multiple organs such as the small bowel, cecum, appendix, and the entire liver. Even after the staged repair technique for the GO silo, wound dehiscence between the ring of the silo and the edge of the skin occurred and gradual reduction failed.

DIAGNOSIS

A GO of 8 cm diameter, which was found during prenatal ultrasonography.

INTERVENTIONS

Revision was performed to repair the defect. The small bowel and liver were still prolapsed, and there were severe adhesions. After adhesiolysis, the muscle layer of the abdominal wall was repaired using the tissue matrix, but the skin could not be repaired. After the second operation, the defect wound was dressed as sterilely as possible.

OUTCOMES

The abdominal wall defect was repaired completely; there were no residual complications.

LESSONS

Repair of GOs using an acellular porcine dermal matrix can be considered a viable treatment option.

Ductus venosus reversed flow in omphalocele: Could it be a prognostic factor for long-term neurological impairment?

Omphalocele (exomphalos) represents one of the most frequent congenital abdominal wall defects. It presents as a defect of inconstant size and is located on the midline, at the base of the umbilical cord, the skin, fascia, and abdominal muscles being absent at this level. Omphaloceles are classified as liver-containing or non-liver-containing, the latter containing primarily bowel loops. We present the case of a 37-year-old pregnant woman with an early diagnosis of liver-containing omphalocele associating ductus venosus reversed flow, with the aim to highlight the importance of the first-trimester morphology scan and to develop a pilot study regarding the neurological development of infants after surgical repair of giant omphaloceles. The particularity of this case consists of a fetus with a positive diagnosis of a giant liver-containing omphalocele but with a small abdominal wall defect during the first-trimester morphology scan at 13 weeks and 3 days of gestation which associated ductus venosus reversed flow, presenting a normal karyotype postabortum. With a small defect, we can speculate the risk of strangling besides the mechanical traction exercised on the ductus venosus generating fetal distress, specifically fetal hypoxia at an early gestational age. In conclusion, the main issue, in this case, was if the fetal omphalocele and ductus venosus reversed flow indicated fetal hypoxia, what was the obstruction effect on the oxygenated blood pathway caused by the abdominal defect, and which were the long-term effects on infants with this complex pathology with an unknown outcome.

Vacuum-assisted staged omphalocele reduction: A preliminary report

INTRODUCTION

Omphalocele represents a rare congenital abdominal wall defect. In giant omphalocele, due to the viscero-abdominal disproportion, gradual reintegration of eviscerated organs is often associated with medical challenges. We report our preliminary experience combining staged gravitational reduction with vacuum (VAC) therapy as a novel approach for treatment of giant omphalocele.

PATIENTS AND METHODS

Retrospective chart review of six patients (five females) born between September 2018 and May 2022 who underwent staged reduction of giant omphalocele in conjunction with VAC therapy was conducted. Treatment was performed at two German third-level Pediatric Surgery Departments. Biometric and periprocedural data were assessed. Main outcome measure was the feasibility of VAC therapy for giant omphalocele. Data are reported as median and interquartile range (Q1-Q3).

RESULTS

Gestational age was 37 (37-38) weeks, and birth weight was 2700 (2500-3000) g. VAC dressing was changed every 3 (3-4) days until abdominal fascia closure at the age of 9 (3-13) days. Time to first/full oral feeds was 3 (1-5)/20 (12-24) days with a hospital stay of 22 (17-30) days. Follow-up was 8 (5-22) months and complications were of minor extent (none: n = 2; Clavien-Dindo I: n = 3; Clavien-Dindo II: n = 1), comprising a delayed neo-umbilical cord rest separation (n = 2) and/or concomitant neo-umbilical site infection (n = 2) with no repeat surgery.

CONCLUSION

In neonates with giant omphalocele, VAC constitutes a promising and technically feasible enhancement of the staged gravitational reduction method. This study shows evidence that VAC may accelerate restoration of the abdominal wall integrity in giant omphalocele, thus minimizing associated comorbidities inherent to a prolonged hospitalization.

Refractory CSF leakage following untethering surgery performed 10 months after birth for enlarging terminal myelocystocele associated with OEIS complex

Background:

Terminal myelocystocele (TMC) is an occult spinal dysraphism characterized by cystic dilatation of the terminal spinal cord in the shape of a trumpet (myelocystocele) filled with cerebrospinal fluid (CSF), which herniates into the extraspinal subcutaneous region. The extraspinal CSF-filled portion of the TMC, consisting of the myelocystocele and the surrounding subarachnoid space, may progressively enlarge, leading to neurological deterioration, and early untethering surgery is recommended.

Case Description:

We report a case of a patient with TMC associated with OEIS complex consisting of omphalocele (O), exstrophy of the cloaca (E), imperforate anus (I), and spinal deformity (S). The untethering surgery for TMC had to be deferred until 10 months after birth because of the delayed healing of the giant omphalocele and the respiration instability due to hypoplastic thorax and increased intra-abdominal pressure. The TMC, predominantly the surrounding subarachnoid space, enlarged during the waiting period, resulting in the expansion of the caudal part of the dural sac. Although untethering surgery for the TMC was uneventfully performed with conventional duraplasty, postoperative CSF leakage occurred, and it took three surgical interventions to repair it. External CSF drainage, reduction of the size of the caudal part of the dural sac and use of gluteus muscle flaps and collagen matrix worked together for the CSF leakage.

Conclusion:

Preoperative enlargement of the TMC, together with the surrounding subarachnoid space, can cause the refractory CSF leakage after untethering surgery because the expanded dural sac possibly increases its own tensile strength and impedes healing of the duraplasty. Early untethering surgery is recommended after recovery from the life-threatening conditions associated with OEIS complex.

The incidence of abdominal surgical site infections after abdominal birth defects surgery in infants: A systematic review with meta-analysis

BACKGROUND

Surgical site infections (SSI) are a frequent and significant problem understudied in infants operated for abdominal birth defects. Different forms of SSIs exist, namely wound infection, wound dehiscence, anastomotic leakage, post-operative peritonitis and fistula development. These complications can extend hospital stay, surge medical costs and increase mortality. If the incidence was known, it would provide context for clinical decision making and aid future research. Therefore, this review aims to aggregate the available literature on the incidence of different SSIs forms in infants who needed surgery for abdominal birth defects.

METHOD

The electronic databases Pubmed, EMBASE, and Cochrane library were searched in February 2020. Studies describing infectious complications in infants (under three years of age) were considered eligible. Primary outcome was the incidence of SSIs in infants. SSIs were categorized in wound infection, wound dehiscence, anastomotic leakage, postoperative peritonitis, and fistula development. Secondary outcome was the incidence of different forms of SSIs depending on the type of birth defect. Meta-analysis was performed pooling reported incidences in total and per birth defect separately.

RESULTS

154 studies, representing 11,786 patients were included. The overall pooled percentage of wound infections after abdominal birth defect surgery was 6% (95%-CI:0.05-0.07) ranging from 1% (95% CI:0.00-0.05) for choledochal cyst surgery to 10% (95%-CI:0.06-0.15) after gastroschisis surgery. Wound dehiscence occurred in 4% (95%-CI:0.03-0.07) of the infants, ranging from 1% (95%-CI:0.00-0.03) after surgery for duodenal obstruction to 6% (95%-CI:0.04-0.08) after surgery for gastroschisis. Anastomotic leakage had an overall pooled percentage of 3% (95%-CI:0.02-0.05), ranging from 1% (95%-CI:0.00-0.04) after surgery for duodenal obstruction to 14% (95% CI:0.06-0.27) after colon atresia surgery. Postoperative peritonitis and fistula development could not be specified per birth defect and had an overall pooled percentage of 3% (95%-CI:0.01-0.09) and 2% (95%-CI:0.01-0.04).

CONCLUSIONS

This review has systematically shown that SSIs are common after correction for abdominal birth defects and that the distribution of SSI differs between birth defects.

Modified sequential sac ligation and staged closure technique for the management of giant omphalocele

PURPOSE

This study aimed to describe sac ligation and sequential closure for the management of giant omphalocele (GO) and analyze its outcomes.

METHODS

The medical records of 13 neonates with GO treated at a tertiary general hospital between July 2012 and April 2020 were reviewed. Sac ligation and progressive external compression were performed on most cases immediately after birth. Staged closure with or without a prosthetic patch was conducted after a period of sac suspension.

RESULTS

Sac ligation-traction-compression was performed on 12 cases, of which 10 underwent staged closure, one with delayed closure. One patient with coexistent esophageal atresia was deemed ineligible for surgery. Among those who had undergone staged closure, 9 survived; however, one neonate who complicated with bilateral diaphragmatic eventration and severe ventilator-associated pneumonia died from multiple-organ failure. Pentalogy of Cantrell was excluded. One patient in whom primary closure was performed after birth died aged 29 h. Pneumonia was the most common infection among patients (5/13), with three having ventilator-associated pneumonia. The median durations of mechanical ventilation and hospital stay were 22.2 days (range, 1-151) and 44.2 days (range, 2-152), respectively, and 25.6 days and 46.4 days, respectively, among patients with staged closure. Among five infants who required oxygen support for more than 28 days, four had pulmonary hypoplasia.

CONCLUSIONS

Aside from abdominal wall defects, other major comorbidities and pulmonary hypoplasia influence the prognosis of GO. Sac ligation and staged closure is a effective choice for GO.

TYPE OF STUDY

Retrospective Study Level of Evidence: Level IV.

Combined Staged Surgery and Negative-Pressure Wound Therapy for Closure of a Giant Omphalocele

The management of giant omphaloceles had always been a point of interest for the pediatric surgeons. Many surgical techniques were proposed, but none of them succeeded to become the standard procedure in closing the congenital abdominal defect. We present a case of giant omphalocele in which we used staged surgical closure combined with a prosthetic patch, with negative-pressure therapy and, finally, definitive surgical closure. Even though a major complication occurred during the treatment, we were able to close the defect without any prosthetic material left in place.

Systematic review of mortality associated with neonatal primary staged closure of giant omphalocele

INTRODUCTION

Surgical management of giant omphalocele has evolved at a slow pace, but evidence on the survival of patients who underwent primary staged closure is scattered and atomized.

OBJECTIVE

To analyze the studies about of mortality associated with neonatal primary staged closure of giant omphalocele.

METHODS

Systematic review in three databases using ex-ante search protocol and selection of studies following the phases suggested by PRISMA and MOOSE criteria. Reproducibility and evaluation of methodological quality were guaranteed by using CARE and STROBE.

RESULTS

Seven studies of clinical cases with nine patients, and six cross-sectional studies with 85 individuals were analyzed. These were conducted in the USA mainly, between 1985 and 2018. In the case studies, the death was 11.1% owing to hepatic necrosis and portal system angiomatosis. On the cross-sectional studies, mortality was registered in 18.8% of patients owing to coarctation of the aorta, heart, kidney, intestinal, respiratory or multiple organ failure, an anomaly of venous return, prematurity, ruptured omphalocele, pulmonary hypoplasia, trisomy 13, ARDS, sepsis, and septic shock. The main complication was wound infection with subsequent confection of the silo, found in 5.4% of patients.

CONCLUSION

Only a few studies on staged closure of giant omphalocele were found on a low number of patients. The high survival rate and the low percentage of complications on the 94 analyzed patients suggest the effectiveness and safety of the procedure.

LEVELS OF EVIDENCE

According to the Journal of Pediatric Surgery this research corresponds to type of study level II for retrospective studies, and level IV for case series with no comparison group.

Abdominal Wall Defects-Current Treatments

Gastroschisis and omphalocele reflect the two most common abdominal wall defects in newborns. First postnatal care consists of defect coverage, avoidance of fluid and heat loss, fluid administration and gastric decompression. Definitive treatment is achieved by defect reduction and abdominal wall closure. Different techniques and timings are used depending on type and size of defect, the abdominal domain and comorbidities of the child. The present review aims to provide an overview of current treatments.

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.

Immediate versus staged repair of omphaloceles

Omphalocele is an abdominal wall defect involving the umbilical ring which results in visceral herniation of small and large intestine, liver, spleen and sometimes gonads. The covering of the herniated viscera by a fused membrane consisting of peritoneum, Wharton's jelly and amnion projects viscera from mechanical injury and exposure to chemical irritants in amniotic fluid. Omphalocele is usually diagnosed before birth, is variable in size, and is frequently associated with chromosomal and somatic anomalies, syndromes, and variable degrees of pulmonary hypoplasia which can be lethal. In this article we examine surgical closure options for omphaloceles ranging from early primary fascial repair for small omphaloceles to a staged repair, often facilitated by an amnion preserving silo, which may be necessary for giant omphaloceles that cannot be closed primarily. We also review some of the adjuncts to abdominal wall reconstruction including tissue expansion and mesh. Conservative management (paint and wait) of giant omphaloceles is described elsewhere.

Intestinal malrotation in infants with omphalocele: A systematic review and meta-analysis

PURPOSE

The management of intestinal malrotation in infants with omphalocele varies among surgeons. Herein, we aimed to determine whether infants with omphalocele should be investigated for malrotation.

METHODS

Using a defined search strategy, three investigators identified all studies reporting patients with omphalocele and malrotation. Outcome measures included: 1. incidence of malrotation; 2. correlation with the abdominal size defect in patients with omphalocele; 3. risk of volvulus in those not investigated for malrotation; 4. incidence of adhesive bowel obstruction in those who underwent Ladd's procedure. The meta-analysis was conducted according to PRISMA guidelines and using RevMan 5.3.

RESULTS

Of 111 articles analyzed, 12 (3888 children) reported malrotation in 136 patients (3.5%). Malrotation was equally found in patients with major (15.2%) and minor (13.6%; p = 0.52) omphalocele. A volvulus was more common in children who had Ladd's procedure (8%) than in those who did not (1%; p = 0.03). Adhesive bowel obstruction rate was similar in both groups (5% vs. 3%; p = 0.21).

CONCLUSION

The incidence of malrotation in infants with omphalocele is low but probably underreported, and is not influenced by the size of the defect. At present, there is no evidence in the literature to support investigations to detect malrotation in infants with omphalocele.

TYPE OF STUDY

Therapeutic.

LEVEL OF EVIDENCE

III.

Giant Gastroschisis with Complete Liver Herniation: A Case Report of Two Patients

Introduction

There are no reported survivors of gastroschisis with complete liver herniation. We describe a case report of two patients, one of whom survived.

Case #1

The patient was born with gastroschisis and herniation of the entire liver. Along with silo placement, the abdominal fascia was attached to an external traction system for growth. Complete closure was achieved at 5 months. Due to pulmonary hypoplasia, high-frequency ventilation was required. The patient is doing well, on a home ventilator wean, at 20 months.

Case #2

The patient was born prematurely with gastroschisis, total liver herniation, and a defect extending to the pericardium. A silo was attached to the fascia to provide growth of the abdominal cavity. The patient developed respiratory failure, diffuse anasarca, and renal failure. She died at 38 days of life.

Discussion

We report the first survivor of gastroschisis with complete liver herniation, contrasting it with a death of a similar case. The associated pulmonary hypoplasia may require long-term ventilation, the inflammatory response can lead to anasarca, and renal injury can occur from acute-on-chronic compartment syndrome.

Conclusion

External fascial traction systems can help induce growth of the abdominal wall, allowing closure of the challenging abdomen. While critical care management is complex, survival is possible.

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.

Component Separation Technique for Repair of Massive Abdominal Wall Defects at a Pediatric Hospital

BACKGROUND

Massive defects of the abdominal wall are commonly repaired with the component separation technique (CST) when insufficient tissue exists to close the defect primarily. Although the utility of CST has been documented in cases of large ventral hernias in adults, its application to congenital and acquired defects in pediatric patients has been largely unreported. This study is a retrospective case series discussing the success of CST at a large pediatric hospital.

METHODS

Seven patients with massive abdominal wall defects, including ventral hernia and omphalocele, repaired with CST at a pediatric hospital were identified as candidates. Patient records were reviewed for relevant history, cause of ventral hernia, surgical repair using CST with or without tissue expansion (TE), use of mesh, postoperative complications, and length of follow-up.

RESULTS

Seven patients, 4 with omphalocele and 3 with acquired ventral hernia, were successfully treated with CST. Median patient age at the time of CST was 7 years (range, 3-19 years) with a mean defect diameter of 10.1 cm (range, 5-12 cm). Four patients underwent TE before component separation. Recurrent ventral hernia required reoperation with CST in 2 cases. Mean follow-up was 2 years and 9 months (range, 13 months-6 years).

CONCLUSIONS

Component separation technique is a valuable method for abdominal wall reconstruction in pediatric patients with low risk of serious complication. This technique can be augmented with TE and mesh placement to address lack of available soft tissue or other operative challenges.

Staged closure of a giant omphalocele with amnion preservation, modified technique

Closure of a giant omphalocele can be challenging. Preservation of the amnion in staged closure is not commonly practiced. Here, we describe 2 cases of giant omphalocele treated with a modified amnion preservation, staged closure technique. This paper demonstrates the feasibility and safety of this technique, and the versatility of amnion to adapt to an escharization strategy if closure is not achievable.

The risk of midgut volvulus in patients with abdominal wall defects: A multi-institutional study

BACKGROUND

The management of malrotation in patients with congenital abdominal wall defects has varied among surgeons. We were interested in investigating the risk of midgut volvulus in patients with gastroschisis and omphalocele to help determine if these patients may benefit from undergoing a Ladd procedure.

METHODS

A retrospective chart review was performed for all patients managed at three institutions born between 1/1/2000 and 12/31/2008 with a diagnosis of gastroschisis or omphalocele. Patient charts were reviewed through 12/31/2012 for occurrence of midgut volvulus or need for second laparotomy.

RESULTS

Of the 414 patients identified with abdominal wall defects, 299 patients (72%) had gastroschisis, and 115 patients (28%) had omphalocele. The mean gestational age at birth was 36.1±2.3weeks, and the mean birth weight was 2.57±0.7kg. There were a total of 8 (1.9%) cases of midgut volvulus: 3 (1.0%) patients with gastroschisis compared to 5 patients (4.4%) with omphalocele (p=0.04).

CONCLUSIONS

Patients with omphalocele have a greater risk of developing midgut volvulus, and a Ladd procedure should be considered during definitive repair to mitigate these risks.

LEVEL OF EVIDENCE

III; retrospective comparative study.

[Umbilicus in children]

The umbilicus is our first scar. It is the last remain of our life in utero. Besides the umbilical hernia, a common pathology during the first three years of life that rarely requires surgery, there are some rare congenital abnormalities such as gastroschisis and omphalocele, which occur in about 1-5/10,000 births. Gastroschisis is a birth defect of the anterior abdominal wall, through which the fetal intestines freely protrude and are not covered by any membranes. During the 13th week prenatal ultrasound, the umbilical cord can be seen to be properly attached while the intestines float freely in the amniotic fluid. This defect is most common in young women who smoke and/or use cocaine and is not typically associated with genetic disorders. Omphalocele is an average coelosomy, in which a visceral hernia protrudes into the base of the umbilical cord. Omphalocele is typically diagnosed during the prenatal phase, and occurs most commonly in older mothers. It is frequently associated with genetic and morphologic abnormalities, therefore a karyotype should automatically be performed. For these two pathologies, the surgical problem lies in managing, during the reintegration, the conflict container/content responsible to lower vena cava syndrome and disorders ventilatory. Deciding on the technique will depend on the clinical form, and on the tolerance to reinsertion. The success of the surgery is directly linked to the postoperative emergence care for the pre-, per- and postnatal phases. The umbilical cord is preserved in the case of a gastroschisis. A primary or secondary umbilicoplasty will be performed for an omphalocele closure. The umbilicoplasty aims to create an umbilicus in a good position by giving it a shape, ideally oval, but also and especially an umbilication. The primary or secondary umbilicoplasty remains a challenge in a growing abdomen (change in position, deformation, loss of intussusception with growth). Many techniques are described: cutaneous flaps randomly placed, excision and skin plasty, resection and controlled wound healing. The choice of technique is a matter of practice but must be done in a rational way, depending on the scar condition when secondary reconstruction, and with minimal scarring, for primary reconstruction. To avoid morphological changes associated with growth, secondary umbilicoplasty should be proposed after the age of five.

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

PURPOSE

Despite the numerous methods of closure for giant omphaloceles, uncertainty persists regarding the most effective option. Our purpose was to review the literature to clarify the current methods being used and to determine superiority of either staged surgical procedures or nonoperative delayed closure in order to recommend a standard of care for the management of the giant omphalocele.

METHODS

Our initial database search resulted in 378 articles. After de-duplification and review, we requested 32 articles relevant to our topic that partially met our inclusion criteria. We found that 14 articles met our criteria; these 14 studies were included in our analysis. 10 studies met the inclusion criteria for nonoperative delayed closure, and 4 studies met the inclusion criteria for staged surgical management.

RESULTS

Numerous methods for managing giant omphaloceles have been described. Many studies use topical therapy secondarily to failed surgical management. Primary nonoperative delayed management had a cumulative mortality of 21.8% vs. 23.4% in the staged surgical group. Time to initiation of full enteric feedings was lower in the nonoperative delayed group at 14.6days vs 23.5days.

CONCLUSION

Despite advances in medical and surgical therapies, giant omphaloceles are still associated with a high mortality rate and numerous morbidities. In our analysis, we found that nonoperative delayed management with silver therapy was associated with lower mortality and shorter duration to full enteric feeding. We recommend that nonoperative delayed management be utilized as the primary therapy for the newborn with a giant omphalocele.

Umbilical hernia following gastroschisis closure: a common event?

PURPOSE

To assess incidence and natural history of umbilical hernia following sutured and sutureless gastroschisis closure.

METHODS

With audit approval, we undertook a retrospective clinical record review of all gastroschisis closures in our institution (2007-2013). Patient demographics, gastroschisis closure method and umbilical hernia occurrence were recorded. Data, presented as median (range), underwent appropriate statistical analysis.

RESULTS

Fifty-three patients were identified, gestation 36 weeks (31-38), birth weight 2.39 kg (1-3.52) and 23 (43 %) were male. Fourteen patients (26 %) underwent sutureless closure: 12 primary, 2 staged; and 39 (74 %) sutured closure: 19 primary, 20 staged. Sutured closure was interrupted sutures in 24 patients, 11 pursestring and 4 not specified. Fifty patients were followed-up over 53 months (10-101) and 22 (44 %) developed umbilical hernias. There was a significantly greater hernia incidence following sutureless closure (p = 0.0002). In sutured closure, pursestring technique had the highest hernia rate (64 %). Seven patients underwent operative hernia closure; three secondary to another procedure. Seven patients had their hernias resolve. One patient was lost to follow-up and seven remain under observation with no reported complications.

CONCLUSIONS

There is a significant umbilical hernia incidence following sutureless and pursestring sutured gastroschisis closure. This has not led to complications and the majority have not undergone repair.

The risk of volvulus in abdominal wall defects

BACKGROUND

Congenital abdominal wall defects are associated with abnormal intestinal rotation and fixation. A Ladd's procedure is not routinely performed in these patients; it is believed intestinal fixation is provided by adhesions that develop post-repair of the defects. However, patients with omphalocele may not have adequately protective postoperative adhesions because of difference in the inflammatory state of the bowel wall and in repair strategy. The aim of this study is to describe the occurrence of midgut volvulus in patients with gastroschisis or omphalocele.

METHODS

A retrospective chart review was performed for all patients managed in a single institution born between 1/1/2000 and 12/31/2008 with a diagnosis of gastroschisis or omphalocele. Patient charts were reviewed through 12/31/2012 for occurrence of midgut volvulus or need for second laparotomy.

RESULTS

Of the 206 patients identified with abdominal wall defects, 142 patients (69%) had gastroschisis and 64 patients (31%) had omphalocele. Patients' follow up ranged from 4 years to 13 years. The median gestational age was 36 weeks (26-41 weeks) and the median birth weight was 2.42 kg (0.8-4.87 kg). None of the patients with gastroschisis developed midgut volvulus, however two patients (3%) with omphalocele developed midgut volvulus.

CONCLUSIONS

No patients with gastroschisis developed midgut volvulus. Therefore, the current practice of not routinely performing a Ladd's procedure is a safe approach during surgical repair of gastroschisis. The two cases of volvulus in patients with omphalocele may be related to less bowel fixation. It is necessary to examine current practice in regards to the need for assessing the risk of volvulus during omphalocele closure and counseling of these patients. This assessment may be achieved via routine examination of the width of the small bowel mesenteric base, whenever feasible; however, the sample size is relatively small to draw any definitive conclusions.

Abdominal wall defects: prenatal diagnosis, newborn management, and long-term outcomes

Omphalocele and gastroschisis represent the most frequent congenital abdominal wall defects a pediatric surgeon is called to treat. There has been an increased reported incidence in the past 10 years mainly due to the diffuse use of prenatal ultrasound. The early detection of these malformations, and related associated anomalies, allows a multidisciplinary counseling and planning of delivery in a center equipped with high-risk pregnancy assistance, pediatric surgery, and neonatology. At present times, closure of defects, even in multiple stages, is always possible as well as management of most of cardiac-, urinary-, and gastrointestinal-associated malformations. The progress, herein discussed, in the care of newborns with abdominal wall defects assures most of them survive and reach adulthood. Some aspects of transition of medical care will also be considered, including fertility and cosmesis.

Medicated Manuka honey in conservative management of exomphalos major

PURPOSE

The aim of this study was to assess the effectiveness of Manuka honey ointment and dressings in the conservative management of exomphalos major (EM).

METHODS

A retrospective review of five patients with EM who underwent non-operative management with Manuka honey ointments and dressings was carried out to assess the time to complete epithelialisation, time to full feeds, hospital stay, adverse effects, complications and outcome.

RESULTS

The skin epithelialisation over the EM sac was achieved in a median of 63 days (48-119). The median time to full enteral feed was 13 days (3-29). The median hospital stay was 66 days (21-121). No adverse effects were noted related to Manuka honey. Three patients had pulmonary hypoplasia requiring prolonged hospitalization; one of those died with respiratory complications at home after achieving complete epithelialisation. The follow-up was a median 16 months (6-22). Two patients did not require repair of the ventral hernia. One patient had ventral hernia repair at 16 months with excellent cosmesis. The remaining patient is awaiting repair.

CONCLUSION

This is the first description of the use of medicated Manuka honey ointment and impregnated dressings in the conservative management of EM. This treatment is safe, efficacious and promotes wound healing with favorable outcome.

Non-operative management of giant omphalocele with topical povidone-iodine and powdered antibiotic combination: early experience from a tertiary centre

PURPOSE

The aim of the study was to evaluate topical povidone-iodine and topical powdered antibiotic combination (Polymyxin, Bacitracin and Neomycin) in initial non-operative management with delayed closure of the defect of giant omphaloceles.

METHODS

A prospective study was conducted between July 2010 and June 2013 including all neonates with giant omphalocele without signs of intestinal obstruction. All cases were managed by daily application of povidone-iodine (5% solution) followed by spraying topical powdered antibiotic combination to promote eschar formation and eventual epithelialisation. Record was made of sex, associated anomalies, length of stay, and thyroid function tests.

RESULTS

Twenty-four neonates with giant omphaloceles were treated with topical povidone-iodine and topical powdered antibiotic combination. No sac ruptures were observed in our series. All patients had a normal thyroid function test at presentation and after 10 days of initiation of treatment. Six patients have undergone delayed repair.

CONCLUSION

Topical povidone-iodine and powdered antibiotic combination promotes more rapid escharification and epithelialisation of the omphalocele than povidone-iodine alone. We also hypothesise that combination minimises the chances of hypothyroidism associated with use of povidone-iodine alone.

Omphalocele, gastroschisis: epidemiology, survival, and mortality in Imam Khomeini hospital, Ahvaz-Iran

Gastroschisis and omphalocele are the most common malformation of the anterior abdominal wall.The aim of the study was to determine the abdominal wall defect frequencies, survival, and mortalities in Ahvaz, Khuzestan province of Iran.Materiał and methods. All cases born with omphalocele or gastroschisis whom born in Imam Khomeini hospital, were included in this study. Duration of study was 3 years from April 2005. All patients treated at Imam Khomeini hospital in Ahwaz, Iran.Results. Among 15321 consecutive births, 42 patients had abdominal wall deformity. Overall incidence was 27.41 per 10,000 live births. Of all cases, 18 (42.9%) of cases were male and 24 (57.1%) were female. Of all cases, 21.7% of patients with omphalocele and 10% patients with gastroschisis had other anomalies. Of all cases, 71.8% of patients with omphalocele and 60% with gastroschisis underwent surgery. The type of anomaly (omphalocele and gastroschisis) had correlation with post operation prognosis significantly (p<0.001). Of 66.7% of patients under went surgery, 46.4% with mesh and 53.6% without mesh performed. 80% of patients with omphalocele and 20% with gastroschisis were lived.

CONCLUSIONS

In our study, mortality was significantly higher in cases with gastroschisis than cases with omphalocele.

Advances in surgery for abdominal wall defects: gastroschisis and omphalocele

Abdominal wall defects (AWDs) are a common congenital surgical problem in fetuses and neonates. The incidence of these defects has steadily increased over the past few decades due to rising numbers of gastroschisis. Most of these anomalies are diagnosed prenatally and then managed at a center with available pediatric surgical, neonatology, and high-risk obstetric support. Omphaloceles and gastroschisis are distinct anomalies that have different management and outcomes. There have been a number of recent advances in the care of patients with AWDs, both in the fetus and the newborn, which will be discussed in this article.

An 18 years' review of exomphalos highlighting the association with malrotation

INTRODUCTION

This was a retrospective 18 years' review of infants with exomphalos with particular attention to its association with malrotation.

MATERIALS AND METHODS

We reviewed all exomphalos cases presenting to our neonatal surgery unit, from October 1991 to September 2009. Data were presented as median and range values. Categorical data were analyzed using Fisher's exact tests and P value of ≤0.05 was considered as significant.

RESULTS

Forty-two infants with exomphalos (E. major 23, E. minor 19) were treated during this period. The incidence of surgically confirmed malrotation was 45% in E. major and 31% in E. minor.

CONCLUSION

The association of malrotation in exomphalos major and exomphalos minor infants is alarmingly high and supports the need to actively exclude this abnormality, either operatively or radiologically.

Omphalocele management using goal-oriented classification in African centre with limited resources

In 2000-09, 96 children comprising 57 males and 39 females who were presented between 2 h and 1 week of birth with omphalocele were prospectively managed using goal-oriented classification at the University of Benin Teaching Hospital, Nigeria. All were born through spontaneous vaginal delivery, out of which 9 (9.4%) were preterm. Eighty-two (85.4%) mothers in villages with no supervised antenatal care/delivery and/or prenatal diagnosis presented their babies late. Thirty-three (34.4%) babies in group A, with defect size ≤ 4.5 cm and intact sac, were managed conservatively and had fascial closure after neonatal period, resulting in 32 (97%) survivors. Forty-two (43.8%) babies in group B, with defect size > 4.5 cm and intact sac, were managed conservatively and had fascial closures for 9 months to 5 years, resulting in 40 (95.2%) survivors. Group C comprised of 21 (21.9%) babies with defect of any size/ruptured sac and who had immediate repair, resulting in two (9.5%) survivors owing to lack of facilities (p < 0.0001). Hospital delivery and provision of facilities are advocated.

Review of the evidence on the closure of abdominal wall defects

Infants with congenital abdominal wall defects pose an interesting and challenging management issue for surgeons. We attempt to review the literature to define the current treatment modalities and their application in practice. In gastroschisis, the overall strategies for repair include immediate closure or delayed operative repair. The best level of data for gastroschisis is grade C and appears to support that there is no major difference in survival between immediate closure or delayed repair. In patients with omphalocele, the management techniques are more varied consisting of immediate closure, staged closure or delayed closure after epithelialization. The literature is less clear on when to use one technique over the other, consisting of mostly grade D and E data. In patients with omphalocele, a registry to collect information on patients with larger defects may help determine which of the management strategies is optimal.

Past and current surgical treatment of giant omphalocele: outcome of a questionnaire sent to authors

PURPOSE

Operative treatment of giant omphalocele (OC) is still a challenge for pediatric surgeons. We were interested to ascertain whether published operative techniques for giant OC once advocated by their authors were still being used by these authors and whether the techniques had been modified or even abandoned for other techniques.

METHODS

Relevant studies concerning the treatment of giant OC were identified by an electronic search. Publication date of the articles was from 1967 to 2009. A questionnaire was sent to the first author or coauthor, unless contact details were unavailable. The described surgical techniques were categorized into primary closure, staged closure, and delayed closure.

RESULTS

Almost half of the authors (42%), independent of the initial technique used (primary, staged, or delayed closure), changed or stopped using their technique after the publication of the article. The change was not to one particular proven better technique. Herniation rate was lower in delayed closure (9% delayed vs 18% staged vs 58% primary).

CONCLUSIONS

The results of the questionnaire did not show a generally accepted method of treatment after more than 30 years of innovations in managing patients with a giant OC. There are generally 2 main treatment modalities: staged closure and delayed closure. Because of the lack of large patient numbers and late follow-up, long-term results of the published techniques are needed, and randomized multicenter trials based on these outcomes are recommended. Until then, we remain dependent on expert opinions.

Neonatal care in patients with giant ompholocele: arduous management but favorable outcomes

OBJECTIVES

The objectives of the study were to provide a review of patients with giant omphalocele managed in a single institution (2001-2006), focusing on medical management in the neonatal period, and to evaluate short-term outcomes.

METHODS

Data from 14 neonates with giant ompholocele (abdominal wall defect >5 cm and/or containing liver) and the absence of malformation and chromosomal anomalies during fetal screening were retrospectively reviewed. All were intubated and sedated before surgical treatment. Initial management consisted of progressive reduction of the herniated organs by gentle compression. After sequential reduction, abdominal wall closure was attempted at the skin and fascia level and, when necessary, with a Gore-Tex patch.

RESULTS

Median gestational age was 39 weeks (38-40), and median birth weight was 3100 g (2470-3700). Median age at closure was 6 days (0-20). A central Gore-Tex patch was inserted in 10 cases. Median ventilation length was 26 days (2-78). Full enteral diet was achieved after an average of 33 days (8-82), and median time until discharge from the intensive care unit was 24.5 days (11-85). Nine patients developed sepsis in the postoperative course. In 10 patients, at least 1 associated malformation was diagnosed in the postnatal course, among which cardiac and diaphragmatic defects were the most common. Survival rate was 85.7%.

CONCLUSION

Mortality rate of giant omphalocele without chromosomal anomaly or major malformations is low when treated by gradual reduction of the contents. Parents should be informed of the long hospitalization in the intensive care unit at birth, the potential nonthreatening associated malformations to be diagnosed after birth, and the high risk of sepsis.

A strategy for treatment of giant omphalocele

BACKGROUND

The management of giant omphalocele (GO) presents a major challenge to pediatric surgeons. Current treatment modalities may result in wound infection, fascial separation, and abdominal domain loss. We report a GO infant who required a delayed closure and was managed using sterile incision drape and polypropylene mesh.

METHODS

A 3080 g full-term female infant was born with a GO. The skin was dissected from the fascia circumferentially without opening the amniotic sac and the peritoneum. Subsequently, two polypropylene meshes of 10 x 10 cm in diameter were sutured to each other. Inner surface of the mesh silo was covered with sterile incision drape. This texture was sutured to the fascial margin. Then, the skin was sutured to the mesh and the silo was closed from the side and above. On the 4th day the reduction was started using thick sutures without anesthesia. This procedure was repeated on every 3rd day. When it came closer to the skin margins, constriction was performed using right angle clamps, each time placed 2 cm proximally to the previous sutures in a circular manner. Silo was removed easily and the skin, subcutaneous layers, and fascia were then approximated on the 42nd day.

RESULTS

The postoperative course was uneventful and the infant was well with left inguinal hernia repaired in the 3rd month.

CONCLUSION

The method we used can be performed at bedside and without the application of anesthesia, but should be tried on more patients to determine its effect.

Management of a giant omphalocele with an external skin closure system

BACKGROUND/PURPOSE

The management of neonates with giant omphalocele remains challenging and multiple strategies have been described. We present the case of a 34-week-old neonate with isolated giant omphalocele managed with an external surgical skin closure system as a component of a staged closure strategy.

CASE PRESENTATION

An Inuit boy of 34 weeks gestation was born by urgent Caesarean delivery at an affiliated obstetrical hospital with a giant ruptured omphalocele and loss of abdominal domain. He was transferred to our institution and a silastic silo was fashioned and placed in the operating room. He returned to the operating room several times and was treated by placement of a combined Gore-Tex (WL Gore and Associates, Flagstaff, Ariz)/silastic inlay mesh. An eschar formed over this temporary closure, and we elected to place a dynamic skin closure device to continue gradual bedside reduction. The initial abdominal wall defect was 8.5 cm in transverse diameter and was reduced to 4.5 cm over 3 weeks. Complete closure was subsequently achieved without the need for skin grafting.

DISCUSSION

The use of a dynamic reduction skin closure device has not been documented previously in the pediatric population or in the context of a congenital defect. We describe the use of an external surgical skin closure device in the context of the staged closure of a giant neonatal omphalocele and postulate that such a device may prove useful in the treatment of other congenital tissue defects.

Has the liver and other visceral organs migrated to its normal position in children with giant omphalocele? A follow-up study with ultrasonography

This study evaluates whether, on the long run, in patients born with a giant omphalocele, the liver and other solid organs reach their normal position, shape, and size. Seventeen former patients with a giant omphalocele, treated between 1970 and 2004, were included. Physical examination was supplemented with ultrasonography for ventral hernia and precise description of the liver, spleen, and kidneys. The findings were compared with 17 controls matched for age, gender, and body mass index. We found an abnormal position of the liver, spleen, left kidney, and right kidney in eight, six, five, and four patients, respectively. An unprotected liver was present in all 17 patients and in 11 controls, the difference being statistically significant (p = 0.04). In ten of the 11 patients with an incisional hernia, the liver was located underneath the abdominal defect.

CONCLUSION

In all former patients with a giant omphalocele, an abnormal position of the liver and in the majority of them, an incisional hernia was also found. The liver and sometimes also the spleen and the kidneys do not migrate to their normal position. Exact documentation and good information are important for both the patient and their caretakers in order to avoid liver trauma.

The use of intraabdominal tissue expanders as a primary strategy for closure of giant omphaloceles

BACKGROUND

Giant omphaloceles present a unique challenge to pediatric surgeons because of the difficulty in obtaining timely, tension-free closure of tissues over the defect. Reports of the use of tissue expanders in the subcutaneous space, intramuscular space, or intraabdominal cavity have illustrated the usefulness of this technique to provide biologic closure of abdominal wall defects. However, these reports have focused on use of tissue expanders as a second-line treatment after other options, such as silastic silos or attempted primary closure, have failed.

METHODS

We report 2 cases in which intraabdominal tissue expanders were used as a primary strategy to obtain closure of giant omphalocele defects.

CASE REPORTS

The first patient was a baby boy born at 36 weeks by date who was prenatally diagnosed with a giant omphalocele. An intraabdominal tissue expander was placed at 2 weeks of age. The tissue expander was removed and his abdomen was primarily closed at 8 weeks of age. The second patient was born at 25 weeks gestation as part of a twin gestation with severe intrauterine growth retardation (600 g birth weight). Bedside reduction was not attempted because of severe pulmonary hypertension and significant loss of abdominal domain because of herniated liver and bowel. At 8 months of age, she underwent laparoscopically assisted placement of an intraabdominal tissue expander. At 9 months of age, the tissue expander was removed, all abdominal viscera were reduced, and the defect was closed using only an 8 x 8-cm piece of AlloDerm (LifeCell, Branchburg, NJ). Both children are currently at home and doing well.

CONCLUSIONS

We believe that early use of intraabdominal tissue expanders provides a more expedient method of obtaining closure of the defect in giant omphaloceles.

Exomphalos major: the Northern Ireland experience

PURPOSE

In exomphalos major (EM), closure of the defect in the abdominal wall presents a challenge. The aim of this study is to evaluate a single centre experience of EM.

MATERIALS

A 15-year retrospective case-note review; data presented as median (range).

RESULTS

Fourteen infants (7 female) were born with EM: birth weight 2.9 (1.2-3.8) kg, gestational age 38 (31-39) weeks. One infant died in utero and one within the first hour of life. Severe pulmonary hypoplasia was present in 7/13 (54%), and there was a mortality of 6/13 (46%) live births. Infants were treated non-operatively primarily. Two infants underwent early surgery: one infant, born with a ruptured sac, had a surgical silo constructed on day 1 and closure on day 8, while a second infant had partial closure (skin only) on day 11. Ten infants had application of silver sulphadiazine to the sac 2-3 times per week. Enteral feeds were established soon after birth. They were discharged from hospital to allow granulation. Ventral hernia closure was performed on a subsequent admission.

CONCLUSIONS

Exomphalos major can be successfully treated non-operatively, allowing immediate enteral feeding and early discharge while granulation takes place. In this series, exomphalos major has an incidence of 1 in 26,000, mortality is 46% and severe pulmonary hypoplasia is present in 54% of infants.