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Zvizdic Z, Becirovic N, Milisic E, Jonuzi A, Terzic S, Vranic S. Epidemiologic and clinical characteristics of selected congenital anomalies at the largest Bosnian pediatric surgery tertiary center. Medicine (Baltimore) 2022; 101:e32148. [PMID: 36482591 PMCID: PMC9726290 DOI: 10.1097/md.0000000000032148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Congenital anomalies (CA) are any abnormality present at birth, either structural or functional, that may potentially affect an infant's health, development, and/or survival. There is a paucity of studies on clinical characteristics and outcomes of CA in Bosnia and Herzegovina, mainly due to the lack of a nationwide congenital malformations monitoring system. A 5-year hospital-based study was conducted to determine the prevalence at birth and clinical characteristics of selected major CA in Sarajevo Canton, Bosnia and Herzegovina. Ninety-one CA were observed from 2012 to 2016 (the overall prevalence was 39.6 cases/10,000 live births). The mean age of neonates at diagnosis was 3 days. The gastrointestinal tract was the most commonly affected system (76.9%), with esophageal atresia (EA) being the most frequent (17.6% of all CA). Major CA were more prevalent among preterm infants than term infants (P = .001), particularly in males (61.5% vs. 38.5%; P = .028; M:F ratio was 1.59). Multiple CA were seen in 37.4% of neonates. The overall mortality rate of neonates was 11%, and the median length of hospital stay was 19.8 days. Our study revealed the distribution and clinical patterns of common major CA in the largest tertiary care facility in Bosnia and Herzegovina. It also confirmed a relatively high mortality rate, which requires further efforts to improve the quality of neonatal care in the country.
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Affiliation(s)
- Zlatan Zvizdic
- Clinic of Pediatric Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Naida Becirovic
- Department of Surgery, General Hospital “Prim. Dr Abdulah Nakas,” Sarajevo, Bosnia and Herzegovina
| | - Emir Milisic
- Clinic of Pediatric Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Asmir Jonuzi
- Clinic of Pediatric Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Sabina Terzic
- Pediatric Clinic, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Semir Vranic
- College of Medicine, QU Health, Qatar University, Doha, Qatar
- * Correspondence: Semir Vranic, College of Medicine, QU Health, Qatar University, Doha 2713, Qatar (e-mail: )
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The Canadian Consortium for Research in Pediatric Surgery: Roadmap for Creation and Implementation of a National Subspecialty Research Consortium. J Am Coll Surg 2022; 235:952-961. [PMID: 36102499 PMCID: PMC9653101 DOI: 10.1097/xcs.0000000000000396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Clinical practice should be driven by high-quality research that produces evidence to inform best practices. Generation of such evidence is often challenging, particularly for smaller specialties, such as pediatric surgery, that treat many patients with rare diseases. Multi-institutional collaboration is seen as a major strategy to address these challenges. We have recently created the Canadian Consortium for Research in Pediatric Surgery, a national consortium that includes all major pediatric surgical services across Canada. The mission of the Consortium is to improve pediatric surgical care through high-quality collaborative research. In this article, we describe the rationale and methodology for creation of the Canadian Consortium for Research in Pediatric Surgery, demonstrate its achievements to date, and share a number of foundational concepts that are integral to its success. Our aim is to provide a model for creation of such consortia, ultimately leading to improvements in the quality of clinical research and patient care.
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Al Maawali A, Skarsgard ED. The medical and surgical management of gastroschisis. Early Hum Dev 2021; 162:105459. [PMID: 34511287 DOI: 10.1016/j.earlhumdev.2021.105459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Gastroschisis (GS) is a full-thickness abdominal wall defect in which fetal intestine herniates alongside the umbilical cord into the intrauterine cavity, resulting in an intestinal injury of variable severity. An increased prevalence of gastroschisis has been observed across several continents and is a focus of epidemiologic study. Prenatal diagnosis of GS is common and allows for delivery planning and treatment in neonatal intensive care units (NICUs) by collaborative interdisciplinary teams (neonatology, neonatal nursing and pediatric surgery). Postnatal treatment focuses on closure of the defect, optimized nutrition, complication avoidance and a timely transition to enteral feeding. Babies born with complex GS are more vulnerable to complications, have longer and more resource intensive hospital stays and benefit from standardized care pathways provided by teams with expertise in managing infants with intestinal failure. This article will review the current state of knowledge related to the medical and surgical management and outcomes of gastroschisis with a special focus on the role of the neonatologist in supporting integrated team-based care.
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Affiliation(s)
| | - Erik D Skarsgard
- Department of Surgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.
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Abstract
The 2 most common congenital abdominal wall defects are gastroschisis and omphalocele. Both are usually diagnosed prenatally with fetal ultrasonography, and affected patients are treated at a center with access to high-risk obstetric services, neonatology, and pediatric surgery. The main distinguishing features between the 2 are that gastroschisis has no sac and the defect is to the right of the umbilicus, whereas an omphalocele typically has a sac and the defect is at the umbilicus. In addition, patients with an omphalocele have a high prevalence of associated anomalies, whereas those with gastroschisis have a higher likelihood of abnormalities related to the gastrointestinal tract, with the most common being intestinal atresia. As such, the prognosis in patients with omphalocele is primarily affected by the severity and number of other anomalies and the prognosis for gastroschisis is correlated with the amount and function of the bowel. Because of these distinctions, these defects have different management strategies and outcomes. The goal of surgical treatment for both conditions consists of reduction of the abdominal viscera and closure of the abdominal wall defect; primary closure or a variety of staged approaches can be used without injury to the intra-abdominal contents through direct injury or increased intra-abdominal pressure, or abdominal compartment syndrome. Overall, the long-term outcome is generally good. The ability to stratify patients, particularly those with gastroschisis, based on risk factors for higher morbidity would potentially improve counseling and outcomes.
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Affiliation(s)
- Bethany J Slater
- Division of Pediatric Surgery, University of Chicago Medicine, Chicago, IL
| | - Ashwin Pimpalwar
- Division of Pediatric Surgery, Children's Hospital, University of Missouri, Columbia, MO
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Management of Gastroschisis: Results From the NETS2G Study, a Joint British, Irish, and Canadian Prospective Cohort Study of 1268 Infants. Ann Surg 2021; 273:1207-1214. [PMID: 33201118 DOI: 10.1097/sla.0000000000004217] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE In infants with gastroschisis, outcomes were compared between those where operative reduction and fascial closure were attempted ≤24 hours of age (PC), and those who underwent planned closure of their defect >24 hours of age following reduction with a pre-formed silo (SR). SUMMARY OF BACKGROUND DATA Inadequate evidence exists to determine how best to treat infants with gastroschisis. METHODS A secondary analysis was conducted of data collected 2006-2008 using the British Association of Pediatric Surgeons Congenital Anomalies Surveillance System, and 2005-2016 using the Canadian Pediatric Surgery Network.28-day outcomes were compared between infants undergoing PC and SR. Primary outcome was number of gastrointestinal complications. Interactions were investigated between infant characteristics and treatment to determine whether intervention effect varied in sub-groups of infants. RESULTS Data from 341 British and Irish infants (27%) and 927 Canadian infants (73%) were used. 671 infants (42%) underwent PC and 597 (37%) underwent SR. The effect of SR on outcome varied according to the presence/absence of intestinal perforation, intestinal matting and intestinal necrosis. In infants without these features, SR was associated with fewer gastrointestinal complications [aIRR 0.25 (95% CI 0.09-0.67, P = 0.006)], more operations [aIRR 1.40 (95% CI 1.22-1.60, P < 0.001)], more days PN [aIRR 1.08 (95% CI 1.03-1.13, P < 0.001)], and a higher infection risk [aOR 2.06 (95% CI 1.10-3.87, P = 0.025)]. In infants with these features, SR was associated with a greater number of operations [aIRR 1.30 (95% CI 1.17-1.45, P < 0.001)], and more days PN [aIRR 1.06 (95% CI 1.02-1.10, P = 0.003)]. CONCLUSIONS In infants without intestinal perforation, matting, or necrosis, the benefits of SR outweigh its drawbacks. In infants with these features, the opposite is true. Treatment choice should be based upon these features.
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The association of perinatal and clinical factors with outcomes in infants with gastroschisis-a retrospective multicenter study in Finland. Eur J Pediatr 2021; 180:1875-1883. [PMID: 33532890 PMCID: PMC7853702 DOI: 10.1007/s00431-021-03964-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/18/2021] [Accepted: 01/22/2021] [Indexed: 01/27/2023]
Abstract
The aim of the present study was to assess the prognostic factors for the outcome of gastroschisis in Finland. A retrospective multicenter study of gastroschisis patients born between 1993 and 2015 in four Finnish university hospitals was undertaken, collecting perinatal, surgical, and clinical data of neonates for uni- and multifactorial modeling analysis. The aim of the present study was to identify risk factors for mortality and the composite adverse outcome (death and/or short bowel syndrome or hospital stay > 60 days). Of the 154 infants with gastroschisis, the overall survival rate was 90.9%. In Cox regression analysis, independent risk factors for mortality included liver herniation, pulmonary hypoplasia, relaparotomy for perforation or necrosis, abdominal compartment syndrome, and central line sepsis. Furthermore, a logistic regression analysis identified central line sepsis, abdominal compartment syndrome, complex gastroschisis, and a younger gestational age as independent predictors of the composite adverse outcome.Conclusion: The risk of death is increased in newborns with gastroschisis who have liver herniation, pulmonary hypoplasia, abdominal compartment syndrome, relaparotomy for perforation or necrosis, or central line-associated sepsis. Special care should be taken to minimize the risk of central line sepsis in the clinical setting. What is known: • Gastroschisis is a relatively rare congenital anomaly of the abdominal wall and its incidence is increasing. • Complex gastroschisis has been reported to increase risk of mortality and complications. What is new: • Central line sepsis was found to be independently associated with mortality in gastroschisis patients. • Liver herniation was also significantly associated with mortality.
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Martins BMR, Abreu I, Méio MDB, Moreira MEL. Gastroschisis in the neonatal period: A prospective case-series in a Brazilian referral center. J Pediatr Surg 2020; 55:1546-1551. [PMID: 32467036 DOI: 10.1016/j.jpedsurg.2020.04.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 04/19/2020] [Accepted: 04/20/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND/PURPOSE Gastroschisis is increasing in incidence and has low mortality and high morbidity. We describe the clinical and surgical characteristics of gastroschisis patients in a Brazilian referral center. METHODS Single-center prospective case series of gastroschisis patients. The following two groups were formed depending on the intestinal characteristics: simple and complex patients. RESULTS In total, 79 patients were enrolled, 89% of whom were classified as simple and 11% as complex. The baseline characteristics were similar between the groups, with the exception of the illness severity score. The complex group had a significantly smaller defect size, more reoperations and worse clinical outcomes than the simple group, with the initiation of feeding taking 1.5 times longer, the duration of total parenteral nutrition taking twice as long, and the length of hospitalization being 2.5 times longer; the complex group also included all the deaths that occurred. Overall, the survival rate was 96%. Patients who underwent the sutureless technique had significantly fewer wound infections and a decreased duration of mechanical ventilation than sutured patients. CONCLUSIONS This study provides a comprehensive picture of gastroschisis during the neonatal period in a Brazilian referral center, emphasizing the significantly higher risk for morbidity and mortality among complex patients than among simple patients and the few advantages of the sutureless technique over the sutured technique in terms of closing the defect. TYPE OF STUDY Prognostic. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Bianca M R Martins
- Department of Surgery, Surgical NICU, Instituto Fernandes Figueira - Fundação Oswaldo Cruz, FIOCRUZ, Rio de Janeiro, Brazil.
| | - Isabel Abreu
- Department of Surgery, Surgical NICU, Instituto Fernandes Figueira - Fundação Oswaldo Cruz, FIOCRUZ, Rio de Janeiro, Brazil
| | - Maria Dalva B Méio
- Clinical Research Unit, Instituto Fernandes Figueira - Fundação Oswaldo Cruz, FIOCRUZ, Rio de Janeiro, Brazil
| | - Maria Elisabeth L Moreira
- Clinical Research Unit, Instituto Fernandes Figueira - Fundação Oswaldo Cruz, FIOCRUZ, Rio de Janeiro, Brazil
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Hall NJ, Drewett M, Burge DM, Eaton S. Growth pattern of infants with gastroschisis in the neonatal period. Clin Nutr ESPEN 2019; 32:82-87. [PMID: 31221296 DOI: 10.1016/j.clnesp.2019.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 04/25/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND/AIM Early postnatal growth patterns may have significant long term health effects. Although preterm infants on parenteral nutrition (PN) exhibit poor growth, growth pattern of term or near-term infants requiring PN is not well reported. We aimed to investigate this in infants born with gastroschisis. METHODS Retrospective review of all infants with gastroschisis requiring PN treated at a single centre over a 4 year period. Growth and clinical data were retrieved, and weight SDS scores for corrected gestational age calculated. Weight SDS (mean ± SD) were compared at clinically relevant timepoints and multi-level regression used to model growth trends over time. MAIN RESULTS During the study period 61 infants with gastroschisis were treated; all were included. Infants were small for gestational age at birth for weight (SDS score -0.87 ± 0.85). Weight SDS decreased significantly during the first 10 days of age (mean decrease 0.81 ± 0.56; p < 0.0001) and between birth and discharge (mean decrease 0.81 ± 0.56; p < 0.0001). Despite tolerating full enteral feeds, weight SDS velocity was negative around the time of transition from parenteral to enteral feed. There was evidence of 'catch up' growth between 3 and 6 months of age. CONCLUSION Despite nutritional support with PN, infants with gastroschisis demonstrate significant growth failure during the newborn period. Further efforts are required to understand the underlying mechanisms, improve nutritional support and to evaluate the long term consequences of postnatal growth failure in this population.
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Affiliation(s)
- Nigel J Hall
- University Surgery Unit, Faculty of Medicine, University of Southampton, Southampton, UK; Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK.
| | - Melanie Drewett
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
| | - David M Burge
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
| | - Simon Eaton
- Developmental Biology and Cancer Programme, UCL Great Ormond Street Institute of Child Health, London, UK
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Abstract
Currently, the most important determinant of gastroschisis outcomes in high resource settings is whether the condition is associated with intestinal complications, such as atresia, necrosis, perforation, or volvulus. This form of the anomaly, known as complex gastroschisis, accounts for most of the mortality and a disproportionate burden of the morbidity from gastroschisis. There is some disagreement about what constitutes complex gastroschisis, and little consensus on the type and timing of surgical interventions. This article establishes a clear definition of complex gastroschisis. Surgical approaches to treatment of the diverse presentations of complex gastroschisis will be described and the timing of such interventions will be discussed. Contemporary outcomes of complex gastroschisis will be reviewed. Finally, a non-congenital intestinal complications that may arise in gastroschisis patients will be discussed.
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Affiliation(s)
- Sherif Emil
- Department of Pediatric Surgery; The Montreal Children's Hospital, McGill University Health Centre, Room B04.2028, 1001 Decarie Boulevard, Montreal, QC, Canada H4A 3J1.
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Abstract
The expected outcome of gastroschisis has evolved from an almost certain death of the child prior to the use of parenteral nutrition to almost certain survival. The primary goal of the surgical intervention is return of eviscerated contents into the abdominal cavity. The optimal surgical technique is dependent on the status of the intestine and the accommodation of abdominal domain. In this review, the various surgical techniques for management are discussed as they have evolved. Ironically, a minimalist surgical intervention originally practiced due to the poor expected outcome is now being adopted as a minimalist surgical approach for abdominal wall closure associated with an expected excellent outcome.
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Affiliation(s)
- Mikael Petrosyan
- Children's National Health System, George Washington University Medical Center, United States
| | - Anthony D Sandler
- Children's National Health System, George Washington University Medical Center, United States.
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Trends in incidence and outcomes of gastroschisis in the United States: analysis of the national inpatient sample 2010-2014. Pediatr Surg Int 2018; 34:919-929. [PMID: 30056479 DOI: 10.1007/s00383-018-4308-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/23/2018] [Indexed: 12/26/2022]
Abstract
PURPOSE Gastroschisis is a severe congenital anomaly associated with a significant morbidity and mortality. There are limited temporal trend data on incidence, mortality, length of stay, and hospital cost of gastroschisis. Our aim was to study these temporal trends using the National Inpatient Sample (NIS). METHODS We identified all neonatal admissions with a diagnosis of gastroschisis within the NIS from 2010 through 2014. We limited admission age to ≤ 28 days and excluded all those transferred to other hospitals. We estimated gastroschisis incidence, mortality, length of hospital stay, and cost of hospitalization. For continuous variables, trends were analyzed using survey regression. Cochrane-Armitage trend test was used to analyze trends for categorical variables. P < 0.05 was considered as significant. RESULTS The incidence of gastroschisis increased from 4.5 to 4.9/10,000 live births from 2010 through 2014 (P = 0.01). Overall mortality was 3.5%, median length of stay was 35 days (95% CI 26-55 days), and median cost of hospitalization was $75,859 (95% CI $50,231-$122,000). After adjusting for covariates, there was no statistically significant change in mortality (OR = 1.13; 95% CI 0.87-1.48), LOS (β = - 2.1 ± 3.5; 95% CI - 9.0 to 4.8) and hospital cost (β = - 2.137 ± 10.813; 95% CI - 23,331 to 19,056) with each calendar year increase on multivariate logistic regression analysis. CONCLUSION The incidence of neonates with gastroschisis increased between 2010 and 2014. Incidence was highest in the West. No difference in mortality and resource utilization was observed.
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Mansfield SA, Ryshen G, Dail J, Gossard M, McClead R, Aldrink JH. Use of quality improvement (QI) methodology to decrease length of stay (LOS) for newborns with uncomplicated gastroschisis. J Pediatr Surg 2018; 53:1578-1583. [PMID: 29291893 DOI: 10.1016/j.jpedsurg.2017.11.061] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 10/26/2017] [Accepted: 11/30/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE Gastroschisis is a congenital defect of the abdominal wall leading to considerable morbidity and long hospitalizations. The purpose of this study was to use quality improvement methodology to standardize care in the management of gastroschisis that may contribute to length of stay (LOS). METHODS A gastroschisis quality improvement team established a best-practice protocol in order to decrease LOS in infants with uncomplicated gastroschisis. The specific aim was to decrease median LOS from a baseline of 34days. We used statistical process control charts including rational subgroup analysis to monitor LOS. RESULTS From December 2008 to December 2016, 119 patients with uncomplicated gastroschisis were evaluated. Retrospective data were obtained on 25 patients prior to protocol implementation. Ninety-four patients with uncomplicated gastroschisis comprised the prospective process stage. The median LOS for this retrospective cohort was 34days (IQR: 30.5-50.5), while the median LOS for the prospective cohort following implementation of the protocol decreased to 29days (IQR: 23-43). CONCLUSIONS With the use of quality improvement methodology, including standardization of care and a change in surgical approach, the median LOS for newborns with uncomplicated gastroschisis at our institution decreased from 34days to 29days. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Sara A Mansfield
- Department of General Surgery, The Ohio State University College of Medicine, Columbus, OH
| | - Gregory Ryshen
- Quality Improvement Services, Nationwide Children's Hospital, Columbus, OH
| | - James Dail
- Quality Improvement Services, Nationwide Children's Hospital, Columbus, OH
| | - Mary Gossard
- Division of Neonatology, Nationwide Children's Hospital, Columbus, OH
| | - Richard McClead
- Department of Pediatrics, Division of Neonatology, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Jennifer H Aldrink
- Department of Surgery, Division of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH.
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Haddock C, Skarsgard ED. Understanding gastroschisis and its clinical management: where are we? Expert Rev Gastroenterol Hepatol 2018; 12:405-415. [PMID: 29419329 DOI: 10.1080/17474124.2018.1438890] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Gastroschisis is the commonest developmental defect of the anterior abdominal wall in both developed and developing countries. The past 30 years have seen transformational improvements in outcome due to advances in neonatal intensive care and enhanced integration between the disciplines of maternal fetal medicine, neonatology and pediatric surgery. A review of gastroschisis, which emphasizes its epidemiology, multidisciplinary care strategies and contemporary outcomes is timely. Areas covered: This review discusses the current state of knowledge related to prevalence and causation, and postulated embryopathologic mechanisms contributing to the development of gastroschisis. Using relevant, current literature with an emphasis on high level evidence where it exists, we review modern techniques of prenatal diagnosis, pre and postnatal risk stratification, preferred timing and method of delivery, options for abdominal wall closure, nutritional management, and short and long term clinical and neurodevelopmental follow-up. Expert commentary: This section explores controversies in contemporary management which contribute to practice and cost variation and discusses the benefits of novel nutritional therapies and care standardization that target unnecessary practice variation and improve overall cost-effectiveness of gastroschisis care. The commentary concludes with a review of fertile areas of gastroschisis research, which represent opportunities for knowledge synthesis and further outcome improvement.
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Affiliation(s)
- Candace Haddock
- a Department of Surgery , British Columbia Children's Hospital , Vancouver , Canada
| | - Erik D Skarsgard
- a Department of Surgery , British Columbia Children's Hospital , Vancouver , Canada
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Sutureless vs Sutured Gastroschisis Closure: A Prospective Randomized Controlled Trial. J Am Coll Surg 2017; 224:1091-1096.e1. [DOI: 10.1016/j.jamcollsurg.2017.02.014] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 02/18/2017] [Accepted: 02/20/2017] [Indexed: 11/23/2022]
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Youssef F, Laberge JM, Puligandla P, Emil S. Determinants of outcomes in patients with simple gastroschisis. J Pediatr Surg 2017; 52:710-714. [PMID: 28188037 DOI: 10.1016/j.jpedsurg.2017.01.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Accepted: 01/23/2017] [Indexed: 11/27/2022]
Abstract
PURPOSE We analyzed the determinants of outcomes in simple gastroschisis (GS) not complicated by intestinal atresia, perforation, or necrosis. METHODS All simple GS patients enrolled in a national prospective registry from 2005 to 2013 were studied. Patients below the median for total parenteral nutrition (TPN) duration (26days) and hospital stay (34days) were compared to those above. Univariate and multivariate logistic and linear regression analyses were employed using maternal, patient, postnatal, and treatment variables. RESULTS Of 700 patients with simple GS, representing 76.8% of all GS patients, 690 (98.6%) survived. TPN was used in 352 (51.6%) and 330 (48.4%) patients for ≤26 and >26days, respectively. Hospital stay for 356 (51.9%) and 330 (48.1%) infants was ≤34 and >34days, respectively. Univariate analysis revealed significant differences in several patient, treatment, and postnatal factors. On multivariate analysis, prenatal sonographic bowel dilation, older age at closure, necrotizing enterocolitis, longer mechanical ventilation, and central-line associated blood stream infection (CLABSI) were independently associated with longer TPN duration and hospital stay, with CLABSI being the strongest predictor. CONCLUSIONS Prenatal bowel dilation is associated with increased morbidity in simple GS. CLABSI is the strongest predictor of outcomes. Bowel matting is not an independent risk factor. LEVEL OF EVIDENCE 2c.
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Affiliation(s)
- Fouad Youssef
- The Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jean-Martin Laberge
- The Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Pramod Puligandla
- The Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sherif Emil
- The Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.
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- The Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
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Briganti V, Luvero D, Gulia C, Piergentili R, Zaami S, Buffone EL, Vallone C, Angioli R, Giorlandino C, Signore F. A novel approach in the treatment of neonatal gastroschisis: a review of the literature and a single-center experience. J Matern Fetal Neonatal Med 2017; 31:1234-1240. [PMID: 28337935 DOI: 10.1080/14767058.2017.1311859] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Gastroschisis is a congenital abdominal wall defect and its management remains an issue. We performed a review of the literature to summarize its evaluation, management and outcome and we describe a new type of surgical reduction performed in our center without anesthesia (GA), immediately after birth, in the delivery room. Between January 2002 and March 2013, we enrolled all live born infants with gastroschisis referred to the third-level Division of Obstetrics and Gynecology "San Camillo" of Rome. Two groups of infants were identified: group 1 in which gastroschis reduction was performed by the traditional technique and group 2 in which reduction was immediately performed after birth in the delivery room without GA. Twelve infants were enrolled in group 1, and seven infants in group 2. Statistical significance was observed between the groups regarding the hospital stay, for the duration of parenteral nutrition and full oral feeds (p = .004). Survival was similar between two groups. The reduction without GA performed immediately after birth in a delivery room encourages the relationship between the mother and her child and appears to be a safe and feasible technique in a selected group of patients with simple gastroschisis defect; for this reason, it could represent a valid alternative to traditional approach.
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Affiliation(s)
- Vito Briganti
- a Department of Pediatric Surgery and Urology , Azienda Ospedaliera San Camillo-Forlanini , Rome , Italy
| | - Daniela Luvero
- b Department of Medicine, Unit of Gynaecology and Obstetrics , Università Campus Bio-Medico di Roma , Rome , Italy
| | - Caterina Gulia
- c Department of Urologic and Gynaecologic Sciences , Policlinico Umberto I, Sapienza - University of Rome , Italy
| | - Roberto Piergentili
- d Institute of Molecular Biology and Pathology, National Research Council , Department of Biology and Biotechnologies , Sapienza - University of Rome , Italy
| | - Simona Zaami
- e Department of Anatomical, Histological Forensic and Orthopaedic Sciences , Sapienza - University of Rome , Italy
| | - Elsa Laura Buffone
- f Department of Neonatal Intensive Care , Azienda Ospedaliera San Camillo-Forlanini , Rome , Italy
| | - Cristina Vallone
- g Department of Gynaecology , Azienda Ospedaliera San Camillo-Forlanini , Rome , Italy
| | - Roberto Angioli
- b Department of Medicine, Unit of Gynaecology and Obstetrics , Università Campus Bio-Medico di Roma , Rome , Italy
| | - Claudio Giorlandino
- h Department of Obstetrics and Gynecology , Altamedica Main Center , Rome , Italy
| | - Fabrizio Signore
- g Department of Gynaecology , Azienda Ospedaliera San Camillo-Forlanini , Rome , Italy
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Abstract
We performed an evidence-based review of the obstetrical management of gastroschisis. Gastroschisis is an abdominal wall defect, which has increased in frequency in recent decades. There is variation of prevalence by ethnicity and several known maternal risk factors. Herniated intestinal loops lacking a covering membrane can be identified with prenatal ultrasonography, and maternal serum α-fetoprotein level is commonly elevated. Because of the increased risk for growth restriction, amniotic fluid abnormalities, and fetal demise, antenatal testing is generally recommended. While many studies have aimed to identify antenatal predictors of neonatal outcome, accurate prognosis remains challenging. Delivery by 37 weeks appears reasonable, with cesarean delivery reserved for obstetric indications. Postnatal surgical management includes primary surgical closure, staged reduction with silo, or sutureless umbilical closure. Overall prognosis is good with low long-term morbidity in the majority of cases, but approximately 15% of cases are very complex with complicated hospital course, extensive intestinal loss, and early childhood death.
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Shetty S, Kennea N, Desai P, Giuliani S, Richards J. Length of stay and cost analysis of neonates undergoing surgery at a tertiary neonatal unit in England. Ann R Coll Surg Engl 2016; 98:56-60. [PMID: 26688402 DOI: 10.1308/rcsann.2016.0034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction There is a lack of knowledge on the average length of stay (LOS) in neonatal units after surgical repair of common congenital anomalies. There are few if any publications reporting the activity performed by units undertaking neonatal surgery. Such activity is important for contracting arrangements, commissioning specialist services and counselling parents. The aim of this study was to describe postnatal LOS for infants admitted to a single tertiary referral neonatal unit with congenital malformations requiring surgery. Methods Data on nine conditions were collected prospectively for babies on the neonatal unit over a five-year period (2006-2011). For those transferred back to their local unit following surgery, the local unit was contacted to determine the total LOS. Only those babies who had surgery during their first admission to our unit and who survived to discharge were included in the study. Cost estimates were based on the tariffs agreed for neonatal care between our trust and the London specialised commissioning group in 2011-2012. Results The median LOS for the conditions studied was: gastroschisis 35 days (range: 19-154 days), oesophageal atresia 33 days (range: 9-133 days), congenital diaphragmatic hernia 28 days (range: 7-99 days), intestinal atresia 24 days (range: 6-168 days), Hirschsprung's disease 21 days (range: 15-36 days), sacrococcygeal teratoma 17 days (range: 12-55 days), myelomeningocoele 15.5 days (range: 8-24 days), anorectal malformation 15 days (range: 6-90 days) and exomphalos 12 days (range: 3-228 days). The total neonatal bed day costs for the median LOS ranged from £8,701 (myelomeningocoele) to £23,874 (gastroschisis). The cost of surgery was not included. Conclusions There is wide variation in LOS for the same conditions in a single neonatal unit. This can be explained by different types and severity within the same congenital anomalies, different surgeons and other clinical confounders (eg sepsis, surgical complications, associated anomalies). These data will enable us to give more detailed information to families following prenatal or postnatal diagnosis. They also allow more detailed planning of resource allocation for neonatal admissions.
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Affiliation(s)
- S Shetty
- St George's University Hospitals NHS Foundation Trust , UK
| | - N Kennea
- St George's University Hospitals NHS Foundation Trust , UK
| | - P Desai
- St George's University Hospitals NHS Foundation Trust , UK
| | - S Giuliani
- St George's University Hospitals NHS Foundation Trust , UK
| | - J Richards
- St George's University Hospitals NHS Foundation Trust , UK
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Bassil KL, Yang J, Arbour L, Moineddin R, Brindle ME, Hazell E, Skarsgard ED. Spatial variability of gastroschisis in Canada, 2006-2011: An exploratory analysis. Canadian Journal of Public Health 2016; 107:e62-e67. [PMID: 27348112 DOI: 10.17269/cjph.107.5084] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 01/21/2016] [Accepted: 08/30/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Gastroschisis is a serious birth defect of the abdominal wall that is associated with mortality and significant morbidity. Our understanding of the factors causing this defect is limited. The objective of this paper is to describe the geographic variation in incidence of gastroschisis and characterize the spatial pattern of all gastroschisis cases in Canada between 2006 and 2011. Specifically, we aimed to ascertain the differences in spatial patterns between geographic regions and identify significant clusters and their location. METHODS The study population included 641 gastroschisis cases from the Canadian Pediatric Surgery Network (CAPSNet) database, a population-based dataset of all gastroschisis cases in Canada. Cases were geocoded based on maternal residence. Using Statistics Canada live-birth data as a denominator, the total prevalence of gastroschisis was calculated at the provincial/territorial levels. Random effects logistic models were used to estimate the rates of gastroschisis in each census division. These rates were then mapped using ArcGIS. Cluster detection was performed using Local Indicators of Spatial Association (LISA). RESULTS There is significant spatial heterogeneity of the rate of gastroschisis across Canada at both the provincial/territorial and census-division level. The Yukon, Northwest Territories and Prince Edward Island have higher overall rates of gastroschisis relative to other provinces/territories. Several census divisions in Alberta, Manitoba, Saskatchewan, Ontario, Northwest Territories and British Columbia demonstrated case "clusters", i.e., focally higher rates in discrete areas relative to surrounding areas. CONCLUSIONS There is clear evidence of spatial variation in the rates of gastroschisis across Canada. Future research should explore the role of area-based variables in these patterns to improve our understanding of the etiology of gastroschisis.
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Affiliation(s)
| | - Junmin Yang
- Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, ON, Canada
| | - Laura Arbour
- Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada.,Division of Medical Sciences, University of Victoria, Victoria, BC, Canada
| | - Rahim Moineddin
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Mary E Brindle
- Departments of Surgery and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Emily Hazell
- Department of Geography, Ryerson University, Toronto, ON, Canada
| | - Erik D Skarsgard
- Department of Surgery, University of British Columbia, Vancouver, BC, Canada.
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Youssef F, Cheong LHA, Emil S. Gastroschisis outcomes in North America: a comparison of Canada and the United States. J Pediatr Surg 2016; 51:891-5. [PMID: 27004440 DOI: 10.1016/j.jpedsurg.2016.02.046] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 02/26/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Care of infants with gastroschisis is centralized in Canada and noncentralized in the United States. We conducted an outcomes comparison between the two countries and analyzed the determinants of such outcomes. METHODS Inpatient mortality and hospital stay of gastroschisis patients from the Canadian Pediatric Surgery Network prospective clinical database for the period 2005-2013 were compared with those from the US Kids Inpatient Database for the period 2003-2012. Potential outcome determinants were analyzed using univariate and multivariate analyses. RESULTS A comparison was made between 695 Canadian patients and 5216 American patients. Complex gastroschisis was found in 16.0% and 13.7% of patients in Canada and the US, respectively; P=0.11. Canada had less premature births, more normal birth weight (BW) infants, less cesarean section deliveries, and more inborn patients compared to the US. For simple gastroschisis, Canadian mortality was lower (1.4% vs. 3.4%; P=.008) and hospital stay was longer (45±38 vs. 41±32days; P=.04). US mortality correlated strongly with low BW (P=.002) and marginally with cesarean section delivery (P=.08). A longer Canadian hospital stay was associated with lower gestational age (P=0.01) and western region (P=0.04), while a longer American hospital stay was associated with medium neonatal intensive care unit gastroschisis volume (P=.03), low socioeconomic status (P=.06), low BW (P=0.06), and public insurance (P=0.07). Outcomes for complex gastroschisis did not differ between Canada and the US. CONCLUSIONS Mortality for simple gastroschisis is higher in the US than in Canada, whereas no outcome differences exist for complex gastroschisis. Outcome determinants are different between the 2 countries.
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Affiliation(s)
- Fouad Youssef
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Li Hsia Alicia Cheong
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Sherif Emil
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada.
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Abstract
PURPOSE OF REVIEW The diagnosis and treatment of gastroschisis spans the perinatal disciplines of maternal fetal medicine, neonatology, and pediatric surgery. Since gastroschisis is one of the commonest and costliest structural birth defects treated in neonatal ICUs, a comprehensive review of its epidemiology, prenatal diagnosis, postnatal treatment, and short and long-term outcomes is both timely and relevant. RECENT FINDINGS The incidence of gastroschisis has increased dramatically over the past 20 years, leading to a renewed interest in causation. The widespread availability of maternal screening and ultrasound results in very high rates of prenatal diagnosis, which enables evaluation of the optimal timing and mode of delivery. The preferred method of surgical closure continues to be an issue of debate among pediatric surgeons, whereas postsurgical treatment seeks to expedite the initiation and progression of enteral feeding and minimize complications. A small subset of babies with complex gastroschisis leading to intestinal failure benefit from the knowledge and expertise of dedicated interdisciplinary teams, which seek to bring novel therapies and improved clinical outcomes. SUMMARY The opportunities to increase the knowledge of causation, and identify best practices leading to improved outcomes, drive the ongoing need for collaborative clinical research in gastroschisis.
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22
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Nutritional management and postoperative prognosis of newborns submitted to primary surgical repair of gastroschisis. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2016. [DOI: 10.1016/j.jpedp.2016.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Miranda da Silva Alves F, Miranda ME, de Aguiar MJB, Bouzada Viana MCF. Nutritional management and postoperative prognosis of newborns submitted to primary surgical repair of gastroschisis. J Pediatr (Rio J) 2016; 92:268-75. [PMID: 26844392 DOI: 10.1016/j.jped.2015.07.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 07/15/2015] [Accepted: 07/17/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Gastroschisis is a defect of the abdominal wall, resulting in congenital evisceration and requiring neonatal intensive care, early surgical correction, and parenteral nutrition. This study evaluated newborns with gastroschisis, seeking to associate nutritional characteristics with time of hospital stay. METHODS This was a retrospective cohort study of 49 newborns undergoing primary repair of gastroschisis between January 1995 and December 2010. The newborns' characteristics were described with emphasis on nutritional aspects, correlating them with length of hospital stay. RESULTS The characteristics that influenced length of hospital stay were: (1) newborn small for gestational age (SGA); (2) use of antibiotics; (3) day of life when enteral feeding was started; (4) day of life when full diet was reached. SGA infants had longer length of hospital stay (24.2%) than other newborns. The length of hospital stay was increased by 2.1% for each additional day taken to introduce enteral feeding. However, slower onset of full enteral feeding acted as a protective factor, decreasing length of stay by 3.6%. The volume of waste drained by the stomach catheter in the 24h prior the start of enteral feeding was not associated with the timing of diet introduction or length of hospital stay. CONCLUSION Early start of enteral feeding and small, gradual increase of volume can shorten the use of parenteral nutrition. This management strategy contributes to reduce the incidence of infection and length of hospital stay of newborns with gastroschisis.
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Affiliation(s)
- Flavia Miranda da Silva Alves
- Department of Pediatrics, School of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil; Department of Surgery, School of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil.
| | - Marcelo Eller Miranda
- Department of Surgery, School of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Marcos José Burle de Aguiar
- Department of Pediatrics, School of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
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Allin B, Aveyard N, Campion-Smith T, Floyd E, Kimpton J, Swarbrick K, Williams E, Knight M. What Evidence Underlies Clinical Practice in Paediatric Surgery? A Systematic Review Assessing Choice of Study Design. PLoS One 2016; 11:e0150864. [PMID: 26959824 PMCID: PMC4784961 DOI: 10.1371/journal.pone.0150864] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 02/19/2016] [Indexed: 11/18/2022] Open
Abstract
Objective Identify every paediatric surgical article published in 1998 and every paediatric surgical article published in 2013, and determine which study designs were used and whether they were appropriate for robustly assessing interventions in surgical conditions. Methods A systematic review was conducted according to a pre-specified protocol (CRD42014007629), using EMBASE and Medline. Non-English language studies were excluded. Studies were included if meeting population criteria and either condition or intervention criteria. Population: Children under the age of 18, or adults who underwent intervention for a condition managed by paediatric surgeons when they were under 18 years of age. Condition: One managed by general paediatric surgeons. Intervention: Used for treatment of a condition managed by general paediatric surgeons. Main Outcome Measure Studies were classified according to whether the IDEAL collaboration recommended their design for assessing surgical interventions or not. Change in proportions between 1998 and 2013 was calculated. Results 1581 paediatric surgical articles were published in 1998, and 3453 in 2013. The most commonly used design, accounting for 45% of studies in 1998 and 46.8% in 2013, was the retrospective case series. Only 1.8% of studies were RCTs in 1998, and 1.9% in 2013. Overall, in 1998, 9.8% of studies used a recommended design. In 2013, 11.9% used a recommended design (proportion increase 2.3%, 95% confidence interval 0.5% increase to 4% increase, p = 0.017). Conclusions and Relevance A low proportion of published paediatric surgical manuscripts utilise a design that is recommended for assessing surgical interventions. RCTs represent fewer than 1 in 50 studies. In 2013, 88.1% of studies used a less robust design, suggesting the need for a new way of approaching paediatric surgical research.
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Affiliation(s)
- Benjamin Allin
- National Perinatal Epidemiology Unit, Oxford, United Kingdom
- Department of Paediatric Surgery, Oxford Children’s Hospital, Oxford, United Kingdom
- * E-mail:
| | | | | | - Eleanor Floyd
- Royal Berkshire Hospital NHS Trust, Reading, United Kingdom
| | - James Kimpton
- University of Oxford Medical School, Oxford, United Kingdom
| | - Kate Swarbrick
- Royal Berkshire Hospital NHS Trust, Reading, United Kingdom
- Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Emma Williams
- Royal Berkshire Hospital NHS Trust, Reading, United Kingdom
- Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Marian Knight
- National Perinatal Epidemiology Unit, Oxford, United Kingdom
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Outcomes in infants with prenatally diagnosed gastroschisis and planned preterm delivery. Pediatr Surg Int 2015; 31:1047-53. [PMID: 26399421 DOI: 10.1007/s00383-015-3795-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND The timing and mode of delivery of pregnancies with prenatally diagnosed gastroschisis remains controversial. AIM To evaluate the outcome of patients with gastroschisis managed during two time periods: 2006-2009 and 2010-2014, with planned elective cesarean delivery at 37 versus 35 gestational weeks (gw). A secondary aim was to analyze the outcome in relation to the gestational age at birth. MATERIAL AND METHODS Retrospective review of all cases with gastroschisis managed at our institution between 2006 and 2014. RESULTS Fifty-two patients were identified, 24 during the initial period, and 28 during the second. There were a significantly higher number of emergency cesarean deliveries in the first period. There were no differences between groups with regard to the use of preformed silo, need of parenteral nutrition or length of hospital stay. When analyzing the outcome in relation to the gw the patients actually were born, we observed that patients delivered between 35 and 36.9 gw were primary closed in 88.5% of cases, with shorter time on mechanical ventilation, parenteral nutrition and hospital stay. CONCLUSION Planned caesarian section at 35 completed gestational weeks for fetuses with prenatally diagnosed gastroschisis is safe. We observe the best outcome for patients born between 35 and 36.9 gw.
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Shariff F, Peters PA, Arbour L, Greenwood M, Skarsgard E, Brindle M. Maternal and community predictors of gastroschisis and congenital diaphragmatic hernia in Canada. Pediatr Surg Int 2015; 31:1055-60. [PMID: 26410083 DOI: 10.1007/s00383-015-3797-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE The incidence of gastroschisis (GS) has increased globally. Maternal age and smoking are risk factors and aboriginal communities may be more commonly affected. Factors leading to this increased incidence are otherwise unclear. We investigate maternal sociodemography, air pollution and personal risk factors comparing mothers of infants with GS with a control group of infants with diaphragmatic hernia (CDH) in a large population-based analysis. METHODS Data were collected from a national, disease-specific pediatric surgical database (May 2006-June 2013). Maternal community sociodemographic information was derived from the Canadian 2006 Census. Univariate and multivariable analyses were performed examining maternal factors related to diagnosis of GS. RESULTS GS infants come from poorer, less educated communities with more unemployment, less pollution, fewer immigrants, and more aboriginal peoples than infants with CDH. Teen maternal age, smoking, and illicit drug use, are associated with GS. CONCLUSION Mothers of infants with GS are younger, more likely to smoke and come from socially disadvantaged communities with higher proportions of aboriginal peoples but lower levels of air pollution compared to mothers of CDH infants. Identification of maternal risks provides direction for prenatal screening and public health interventions.
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Affiliation(s)
| | | | - Laura Arbour
- University of British Columbia, Vancouver, BC, Canada
| | - Margo Greenwood
- University of Northern British Columbia, Prince George, BC, Canada
| | | | - Mary Brindle
- University of Calgary, 2888 Shaganappi Trail NW, Calgary, AB, T3B 6A8, Canada.
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Al-Kaff A, MacDonald SC, Kent N, Burrows J, Skarsgard ED, Hutcheon JA. Delivery planning for pregnancies with gastroschisis: findings from a prospective national registry. Am J Obstet Gynecol 2015; 213:557.e1-8. [PMID: 26116872 DOI: 10.1016/j.ajog.2015.06.048] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 05/13/2015] [Accepted: 06/17/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the influence of planned mode and planned timing of delivery on neonatal outcomes in infants with gastroschisis. STUDY DESIGN Data from the Canadian Pediatric Surgery Network cohort were used to identify 519 fetuses with isolated gastroschisis who were delivered at all tertiary-level perinatal centers in Canada from 2005-2013 (n = 16). Neonatal outcomes (including length of stay, duration of total parenteral nutrition, and a composite of perinatal death or prolonged exclusive total parenteral nutrition) were compared according to the 32-week gestation planned mode and timing of delivery with the use of the multivariable quantile and logistic regression. RESULTS Planned induction of labor was not associated with decreased length of stay (adjusted median difference, -2.6 days; 95% confidence interval [CI], -9.9 to 4.8), total parenteral nutrition duration (adjusted median difference, -0.2 days; 95% CI, -6.4 to 6.0), or risk of the composite adverse outcome (relative risk, 1.7; 95% CI, 0.1-3.2) compared with planned vaginal delivery after spontaneous onset of labor. Planned delivery at 36-37 weeks' gestation was not associated with decreased length of stay (adjusted median difference, 5.9 days; 95% CI, -5.7 to 17.5), total parenteral nutrition duration (adjusted median difference, 3.2 days; 95% CI, -7.9 to 14.3), or risk of composite outcome (relative risk, 2.3; 95% CI, 0.8-5.4) compared with planned delivery at ≥38 weeks' gestation. CONCLUSION Infants with gastroschisis who were delivered after planned induction or planned delivery at 36-37 weeks' gestation did not have significantly better neonatal outcomes than planned vaginal delivery after spontaneous onset of labor and planned delivery at ≥38 weeks' gestation.
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Beaumier CK, Beres AL, Puligandla PS, Skarsgard ED. Clinical characteristics and outcomes of patients with right congenital diaphragmatic hernia: A population-based study. J Pediatr Surg 2015; 50:731-3. [PMID: 25783377 DOI: 10.1016/j.jpedsurg.2015.02.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 02/13/2015] [Indexed: 10/24/2022]
Abstract
PURPOSE The purpose of this study was to compare RCDH to LCDH from the perspective of prenatal diagnosis, illness severity, treatment, and outcome. METHODS A retrospective study of all cases of CDH registered in the Canadian Pediatric Surgery Network (CAPSNet) database from 2005 to 2013 was conducted. Side of defect comparisons were made by prenatal diagnostic features, birth demographic data, intensity of medical treatment, timing and type of surgery, and outcomes. Outcomes prediction with logistic regression modeling using side of defect as an exploratory covariate was performed. RESULTS The study cohort included 498 patients, of which 84 (17%) cases had RCDH. Prenatal diagnosis was more commonly made for LCDH. No difference existed in perinatal risk factors (GA, illness severity (SNAP-II) score, associated anomalies), preoperative treatment intensity (use of vasodilators, inotropes), timing of surgery, ventilation days, need for ECMO, LOS, and overall survival. Significant differences between RCDH and LCDH were detected for patch repair rate (48.2% vs. 30.6%; p=0.036) and recurrence (4.1% vs. 0.6%; p=0.038). Stepwise regression modeling identified side of hernia as independently predictive of need for patch. CONCLUSIONS Overall, little difference exists between RCDH and LCDH in terms of prognostic factors and outcomes.
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Affiliation(s)
- Catherine K Beaumier
- Division of Pediatric Surgery, Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Alana L Beres
- Department of Pediatric Surgery, McGill University, Montreal, Canada
| | | | - Erik D Skarsgard
- Division of Pediatric Surgery, Department of Surgery, University of British Columbia, Vancouver, Canada.
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Youssef F, Laberge JM, Baird RJ. The correlation between the time spent in utero and the severity of bowel matting in newborns with gastroschisis. J Pediatr Surg 2015; 50:755-9. [PMID: 25783374 DOI: 10.1016/j.jpedsurg.2015.02.030] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 02/13/2015] [Indexed: 01/26/2023]
Abstract
BACKGROUND Optimal timing of delivery in fetuses with gastroschisis (GS) is unknown. Some favor early induced delivery to prevent bowel injury. This study evaluates the correlation between bowel injury and the gestational age at birth using the Gastroschisis Prognostic Score (GPS). METHODS A national database was analyzed from 2005 to 2013. Patients were pooled based on their gestational age at birth. The mean GPS and % of patients with severe bowel matting were tabulated for each week in utero. Regression modeling was used to evaluate the relationship between the dependent (severe matting and GPS) and independent (gestational age) variables and the R(2) coefficient of determination was derived to evaluate model strength. Additional factors influencing the timing of delivery were evaluated. RESULTS Of 780 cases, 88 were excluded because of missing data. A linear relationship is seen between increasing gestational age and decreasing bowel matting (R(2)=0.66) and GPS (R(2)=0.72). For every week in utero, the % of patients with severe matting decreases by 3.6%. CONCLUSION Early induced delivery simply to protect the bowel from ongoing in utero damage appears unfounded and should be reserved for evidence of closing gastroschisis or traditional obstetrical/fetal indications.
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Affiliation(s)
- Fouad Youssef
- The Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Jean Martin Laberge
- The Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Robert J Baird
- The Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada.
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Ross AR, Eaton S, Zani A, Ade-Ajayi N, Pierro A, Hall NJ. The role of preformed silos in the management of infants with gastroschisis: a systematic review and meta-analysis. Pediatr Surg Int 2015; 31:473-83. [PMID: 25758783 DOI: 10.1007/s00383-015-3691-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/03/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND The pre-formed silo (PFS) is increasingly used in the management of gastroschisis, but its benefits remain unclear. We performed a systematic review and meta-analysis of the literature comparing use of a PFS with alternate treatment strategies. METHODS Studies comparing the use of a PFS with alternate strategies were identified and data extracted. The primary outcome measure was length of time on a ventilator. Mean difference (MD) between continuous variables and 95% confidence intervals were calculated. Risk difference and 95% CI were determined for dichotomous data. RESULTS Eighteen studies, including one randomised controlled trial, were included. Treatment strategy and outcome measures reported varied widely. Meta-analysis demonstrated no difference in days of ventilation, but a longer duration of parenteral nutrition (PN) requirement [MD 6.4 days (1.3, 11.5); p = 0.01] in infants who received a PFS. Subgroup analysis of studies reporting routine use of a PFS for all infants demonstrated a significantly shorter duration of ventilation with a PFS [MD 2.2 days (0.5, 3.9); p = 0.01] but no difference in duration of PN requirement. Other outcomes were similar between groups. CONCLUSION The quality of evidence comparing PFS with alternate treatment strategies for gastroschisis is poor. Only routine use of PFS is associated with fewer days on a ventilator compared with other strategies. No strong evidence to support a preference for any strategy was demonstrated. Prospective studies are required to investigate the optimum management of gastroschisis. Standardised outcome measures for this population should be established to allow comparison of studies.
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Affiliation(s)
- Andrew R Ross
- Department of Paediatric Surgery, Great Ormond Street Hospital, London, UK
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Perinatal outcomes and hospital costs in gastroschisis based on gestational age at delivery. Obstet Gynecol 2015; 124:543-550. [PMID: 25162254 DOI: 10.1097/aog.0000000000000427] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the association between gestational age at delivery and perinatal outcomes among gastroschisis-affected pregnancies that result in live birth. METHODS We conducted a retrospective cohort study using a linked maternal-infant database for more than 2.3 million liveborn neonates in Florida from 1998 to 2009. Cases were identified using a combination of International Classification of Diseases, 9th Edition, Clinical Modification, diagnosis and procedure codes indicative of gastroschisis. We restricted our analyses to singleton cases without another major birth defect or medical conditions that would justify early elective delivery. We categorized cases based on gestational age in weeks and compared perinatal outcomes. RESULTS Among 1,005 neonates with gastroschisis, 324 (32.3%) were isolated, singleton cases without an additional indication for early delivery. We observed decreased rates of adverse pregnancy outcomes among those neonates delivered in the early term period (37-38 weeks of gestation) compared with preterm (less than 34 weeks of gestation); specifically, jaundice (18.5% compared with 42.3%, P=.01) and respiratory distress syndrome (5.9% compared with 23.1%, P≤.01). As the gestational age at birth increased, we observed fewer mean number of days spent in the hospital (less than 34 weeks of gestation: 55.9, P<.01; 34-36 weeks of gestation: 51.9, P=.02; 37-38 weeks of gestation: 36.9 [reference]) and lower direct inpatient medical costs (in thousands, U.S. dollars; less than 34 weeks of gestation: 79, P=.01; 34-36 weeks of gestation: 71, P=.04; 37-38 weeks of gestation: 51 [reference]) per infant in the first year of life. CONCLUSION In pregnancies complicated by gastroschisis, and with no other known major indications, birth at early term or later term gestation, when compared with delivery before 37 weeks of gestation, is associated with improved perinatal outcomes and lower medical costs. LEVEL OF EVIDENCE II.
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Abstract
OBJECTIVE To identify perinatal variables associated with adverse outcomes in neonates prenatally diagnosed with gastroschisis. METHODS A retrospective review was conducted of all inborn pregnancies complicated by gastroschisis within the five institutions of the University of California Fetal Consortium from 2007 to 2012. The primary outcome was a composite adverse neonatal outcome comprising death, reoperation, gastrostomy, and necrotizing enterocolitis. Variables collected included antenatal ultrasound findings, maternal smoking or drug use, gestational age at delivery, preterm labor, elective delivery, mode of delivery, and birth weight. Univariate and multivariate analysis was used to assess factors associated with adverse outcomes. We also evaluated the association of preterm delivery with neonatal outcomes such as total parenteral nutrition cholestasis and length of stay. RESULTS There were 191 neonates born with gastroschisis in University of California Fetal Consortium institutions at a mean gestational age of 36 3/7±1.8 weeks. Within the cohort, 27 (14%) had one or more major adverse outcomes, including three deaths (1.6%). Early gestational age at delivery was the only variable identified as a significant predictor of adverse outcomes on both univariate and multivariate analysis (odds ratio 1.4, 95% confidence interval 1.1-1.8 for each earlier week of gestation). Total parenteral nutrition cholestasis was significantly more common in neonates delivered at less than 37 weeks of gestation (38/115 [33%] compared with 11/76 [15%]; P<.001). CONCLUSION In this contemporary cohort, earlier gestational age at delivery is associated with adverse neonatal outcomes in neonates with gastroschisis. Other variables, such as antenatal ultrasound findings and mode of delivery, did not predict adverse neonatal outcomes.
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Skarsgard ED, Meaney C, Bassil K, Brindle M, Arbour L, Moineddin R. Maternal risk factors for gastroschisis in Canada. ACTA ACUST UNITED AC 2015; 103:111-8. [DOI: 10.1002/bdra.23349] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 11/22/2014] [Accepted: 12/02/2014] [Indexed: 11/08/2022]
Affiliation(s)
- Erik D. Skarsgard
- Department of Surgery; University of British Columbia; Vancouver Canada
| | - Christopher Meaney
- Department of Family and Community Medicine; University of Toronto; Toronto Canada
| | - Kate Bassil
- Dalla Lana School of Public Health; University of Toronto; Toronto Canada
| | - Mary Brindle
- Department of Surgery; University of Calgary; Calgary Canada
| | - Laura Arbour
- Department of Medical Genetics; University of British Columbia; Vancouver Canada
| | - Rahim Moineddin
- Department of Family and Community Medicine; University of Toronto; Toronto Canada
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Challenges of improving the evidence base in smaller surgical specialties, as highlighted by a systematic review of gastroschisis management. PLoS One 2015; 10:e0116908. [PMID: 25621838 PMCID: PMC4306505 DOI: 10.1371/journal.pone.0116908] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 12/15/2014] [Indexed: 11/19/2022] Open
Abstract
Objective To identify methods of improving the evidence base in smaller surgical specialties, using a systematic review of gastroschisis management as an example. Background Operative primary fascial closure (OPFC), and silo placement with staged reduction and delayed closure (SR) are the most commonly used methods of gastroschisis closure. Relative merits of each are unclear. Methods A systematic review and meta-analysis was performed comparing outcomes following OPFC and SR in infants with simple gastroschisis. Primary outcomes of interest were mortality, length of hospitalization and time to full enteral feeding. Results 751 unique articles were identified. Eight met the inclusion criteria. None were randomized controlled trials. 488 infants underwent OPFC and 316 underwent SR. Multiple studies were excluded because they included heterogeneous populations and mixed intervention groups. Length of stay was significantly longer in the SR group (mean difference 8.97 days, 95% CI 2.14–15.80 days), as was number of post-operative days to complete enteral feeding (mean difference 7.19 days, 95%CI 2.01–12.36 days). Mortality was not statistically significantly different, although the odds of death were raised in the SR group (OR 1.96, 95%CI 0.71–5.35). Conclusions Despite showing some benefit of OPFC over SR, our results are tempered by the low quality of the available studies, which were small and variably reported. Coordinating research through a National Paediatric Surgical Trials Unit could alleviate many of these problems. A similar national approach could be used in other smaller surgical specialties.
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Emami CN, Youssef F, Baird RJ, Laberge JM, Skarsgard ED, Puligandla PS. A risk-stratified comparison of fascial versus flap closure techniques on the early outcomes of infants with gastroschisis. J Pediatr Surg 2015; 50:102-6. [PMID: 25598103 DOI: 10.1016/j.jpedsurg.2014.10.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Accepted: 10/06/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND While fascial closure is traditionally used in gastroschisis (GS), flap closure (skin or umbilical cord) has gained popularity. We evaluated early outcomes and complications of the two techniques. METHODS A national, population-based gastroschisis data registry was analyzed from 2005 to 2011. We compared fascial to flap closures and stratified patients into low or high-risk groups using the Gastroschisis Prognostic Score (GPS), a validated marker of post-natal bowel injury. Demographic and outcome data, including length of stay, complications, and markers of resource utilization were analyzed using Fisher's exact and Student's t-tests for categorical and continuous variables, respectively (p<0.05 significant). RESULTS The analyzed dataset included 436 fascial closures (344 [78.8%] low-risk, 92 high-risk) and 129 flap closures (112 [86.7%] low-risk, 17 high-risk; p=0.06). Demographics and birth weight did not differ between groups. In patients with low GPS, flap closure demonstrated significant decreases in resource utilization and failure of closure, without differences in complication rates. Analysis of high-risk patients revealed no statistically significant differences in outcome. CONCLUSION Flap closure was not associated with an increase in patient morbidity and seemed suitable as a definitive closure method for gastroschisis patients irrespective of disease severity. Furthermore, flap closure reduced several markers of resource utilization in patients with low-risk disease.
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Affiliation(s)
- Claudia N Emami
- The Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada, H3H 1P3
| | - Fouad Youssef
- The Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada, H3H 1P3
| | - Robert J Baird
- The Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada, H3H 1P3
| | - Jean-Martin Laberge
- The Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada, H3H 1P3
| | - Erik D Skarsgard
- Division of Pediatric Surgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada, V6J 4K7
| | - Pramod S Puligandla
- The Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada, H3H 1P3.
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The association of type of surgical closure on length of stay among infants with gastroschisis born≥34 weeks' gestation. J Pediatr Surg 2014; 49:1220-5. [PMID: 25092080 DOI: 10.1016/j.jpedsurg.2013.12.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Revised: 12/02/2013] [Accepted: 12/26/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND/PURPOSE The optimal surgical approach in infants with gastroschisis (GS) is unknown. The purpose of this study was to estimate the association between staged closure and length of stay (LOS) in infants with GS. DESIGN/METHODS We used the Children's Hospital Neonatal Database to identify surviving infants with GS born ≥34 weeks' gestation referred to participating NICUs. Infants with complex GS, bowel atresia, or referred after 2 days of age were excluded. The primary outcome was LOS; multivariable linear regression was used to quantify the relationship between staged closure and LOS. RESULTS Among 442 eligible infants, staged closure occurred in 68.1% and was associated with an increased median LOS relative to odds ration (OR):primary closure (37 vs. 28 days, p<0.001). This association persisted in the multivariable equation (β=1.35, 95% CI: 1.21, 1.52, p<0.001) after adjusting for the presence of necrotizing enterocolitis, short bowel syndrome, and central-line associated bloodstream infections. CONCLUSIONS In this large, multicenter cohort of infants with GS, staged closure was independently associated with increased LOS. These data can be used to enhance antenatal and pre-operative counseling and also suggest that some infants who receive staged closure may benefit from primary repair.
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Murthy K, Dykes FD, Padula MA, Pallotto EK, Reber KM, Durand DJ, Short BL, Asselin JM, Zaniletti I, Evans JR. The Children's Hospitals Neonatal Database: an overview of patient complexity, outcomes and variation in care. J Perinatol 2014; 34:582-6. [PMID: 24603454 DOI: 10.1038/jp.2014.26] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Revised: 12/10/2013] [Accepted: 01/13/2014] [Indexed: 02/03/2023]
Abstract
The Children's Hospitals Neonatal Consortium is a multicenter collaboration of leaders from 27 regional neonatal intensive care units (NICUs) who partnered with the Children's Hospital Association to develop the Children's Hospitals Neonatal Database (CHND), launched in 2010. The purpose of this report is to provide a first summary of the population of infants cared for in these NICUs, including representative diagnoses and short-term outcomes, as well as to characterize the participating NICUs and institutions. During the first 2 1/2 years of data collection, 40910 infants were eligible. Few were born inside these hospitals (2.8%) and the median gestational age at birth was 36 weeks. Surgical intervention (32%) was common; however, mortality (5.6%) was infrequent. Initial queries into diagnosis-specific inter-center variation in care practices and short-term outcomes, including length of stay, showed striking differences. The CHND provides a contemporary, national benchmark of short-term outcomes for infants with uncommon neonatal illnesses. These data will be valuable in counseling families and for conducting observational studies, clinical trials and collaborative quality improvement initiatives.
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Affiliation(s)
- K Murthy
- Ann & Robert H Lurie Children's Hospital of Chicago, Department of Pediatrics, Feinberg School of Medicine, Northwestern University Chicago, Chicago, IL, USA
| | - F D Dykes
- Children's Healthcare of Atlanta at Egleston and the Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - M A Padula
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - E K Pallotto
- Children's Mercy Hospital and Clinics and the Department of Pediatrics, University of Missouri School of Medicine, Kansas City, MO, USA
| | - K M Reber
- Nationwide Children's Hospital and the Department of Pediatrics, Ohio State University School of Medicine, Columbus, OH, USA
| | - D J Durand
- Department of Pediatrics, Children's Hospital Oakland & Research Center, Oakland, CA, USA
| | - B L Short
- Children's National Medical Center and the Department of Pediatrics, George Washington University School of Medicine, Washington DC, USA
| | - J M Asselin
- Department of Pediatrics, Children's Hospital Oakland & Research Center, Oakland, CA, USA
| | - I Zaniletti
- Children's Hospital Association, Overland Park, KS, USA
| | - J R Evans
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Stanger J, Mohajerani N, Skarsgard ED. Practice variation in gastroschisis: factors influencing closure technique. J Pediatr Surg 2014; 49:720-3. [PMID: 24851755 DOI: 10.1016/j.jpedsurg.2014.02.066] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 02/13/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Little is known about the factors influencing surgical practice variation in newborns with gastroschisis. The purpose of this study was to correlate prognostic variables with the intended and actual abdominal closure technique and assess related outcomes. METHODS GS cases were abstracted from a national database. Variables evaluated included GA, BW, bowel injury severity (GPS), neonatal illness severity (SNAP-II), inborn status, center volume and training status, and admission time. Evaluated outcomes by closure method included duration of TPN, LOS, and complications. Descriptive, univariate and multivariable regression analyses were conducted. RESULTS The cohort consisted of 679 patients. A total of 372 (55%) underwent attempted PR, of which 300 (81%) were successful, while 307 (45%) had a silo placed intentionally. Patients undergoing attempted PR were more likely to be inborn, have daytime admissions, and higher SNAP-II scores. Successful PR was predicted by low risk GPS and high volume center. With the exception of higher rates of SSI in the planned silo group, outcomes in the successful PR and planned silo groups were comparable. CONCLUSION Practice variation related to type of closure is predicted by situational and institutional factors (outborn, nighttime admission, and center volume), while outcome variation is attributable to patient factors rather than practice variation.
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Affiliation(s)
- Jennifer Stanger
- Division of Pediatric Surgery, Department of Surgery, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Noosheen Mohajerani
- Division of Pediatric Surgery, Department of Surgery, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Erik D Skarsgard
- Division of Pediatric Surgery, Department of Surgery, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada.
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Outcomes of early versus late intestinal operations in patients with gastroschisis and intestinal atresia: results from a prospective national database. J Pediatr Surg 2013; 48:2022-6. [PMID: 24094951 DOI: 10.1016/j.jpedsurg.2013.04.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 03/05/2013] [Accepted: 04/09/2013] [Indexed: 11/21/2022]
Abstract
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.
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South AP, Stutey KM, Meinzen-Derr J. Metaanalysis of the prevalence of intrauterine fetal death in gastroschisis. Am J Obstet Gynecol 2013; 209:114.e1-13. [PMID: 23628262 DOI: 10.1016/j.ajog.2013.04.032] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 04/02/2013] [Accepted: 04/24/2013] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of this study was to review the medical literature that has reported the risk for intrauterine fetal death (IUFD) in pregnancies with gastroschisis. STUDY DESIGN We systematically searched the literature to identify all published studies of IUFD and gastroschisis through June 2011 that were archived in MEDLINE, PubMed, or referenced in published manuscripts. The MESH terms gastroschisis or abdominal wall defect were used. RESULTS Fifty-four articles were included in the metaanalysis. There were 3276 pregnancies in the study and a pooled prevalence of IUFD of 4.48 per 100. Those articles that included gestational age of IUFD had a pooled prevalence of IUFD of 1.28 per 100 births at ≥36 weeks' gestation. The prevalence did not appear to increase at >35 weeks' gestation. CONCLUSION The overall incidence of IUFD in gastroschisis is much lower than previously reported. The largest risk of IUFD occurs before routine and elective early delivery would be acceptable. Risk for IUFD should not be the primary indication for routine elective preterm delivery in pregnancies that are affected by gastroschisis.
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Affiliation(s)
- Andrew P South
- Division of Neonatology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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Morris MW, Westmoreland T, Sawaya DE, Blewett CJ. Staged closure with negative pressure wound therapy for gastroschisis with liver herniation: a case report. J Pediatr Surg 2013; 48:E13-5. [PMID: 23701801 DOI: 10.1016/j.jpedsurg.2013.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Revised: 02/22/2013] [Accepted: 03/02/2013] [Indexed: 11/26/2022]
Abstract
Liver herniation with gastroschisis is an uncommon occurrence that is associated with a poor prognosis. This report presents a single case of complex gastroschisis complicated by herniation of the left hepatic lobe. In the subject case, the abdominal wall defect was successfully closed by sequential closure with negative pressure wound therapy after the initial application of a preformed silo. As there are no established standards for the management of gastroschisis with liver herniation, there exists an opportunity for multicenter review to define approaches to optimize clinical outcomes with this complex congenital issue. As a result of the complexity and rarity of this congenital abnormality, reports with a positive prognosis carry clinical relevance.
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Affiliation(s)
- Michael W Morris
- Department of Surgery, University of Mississippi School of Medicine, Jackson, Mississippi, USA.
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Aljahdali A, Mohajerani N, Skarsgard ED. Effect of timing of enteral feeding on outcome in gastroschisis. J Pediatr Surg 2013; 48:971-6. [PMID: 23701769 DOI: 10.1016/j.jpedsurg.2013.02.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 02/03/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Timely initiation of enteral nutrition is pivotal to outcome optimization in gastroschisis (GS). The purpose of our study was to analyze the effect of timing of first feeds on outcome. METHOD GS cases accrued between May 2005 and August 2011 were abstracted from a national database. Risk variables evaluated included GA, illness severity, bowel injury severity, and post-closure days to first feed (DTF). The outcomes analyzed included duration of TPN, LOS, and infectious complications. Descriptive, univariate, and multivariate regression analyses were conducted. RESULTS The study cohort comprised 570 cases (16% with "high risk" bowel injury). Group distribution by DTF was: 0-7 days (12%), 8-14 days (44%), 15-21 days (26%), and >21 days (17%), with a mean DTF of 17 ± 15 days. Mean durations of TPN and LOS were 44 ± 56 and 112 ± 71 days, respectively. DTF subgroups were comparable, except for a greater proportion of "high risk bowel injury" in DTF>21 days. Initiation of feeds between 8 and 21 days was associated with fewer TPN days and reduced LOS. Multivariate analyses revealed that TPN duration, LOS, and infectious complications were independently predicted by DTF. CONCLUSIONS Post-closure DTF predicts outcome in GS, with best outcomes observed when feeds are started 7 days post-closure.
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Affiliation(s)
- Akram Aljahdali
- Department of Surgery, Division of Pediatric Surgery, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
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Emil S, Canvasser N, Chen T, Friedrich E, Su W. Contemporary 2-year outcomes of complex gastroschisis. J Pediatr Surg 2012; 47:1521-8. [PMID: 22901911 DOI: 10.1016/j.jpedsurg.2011.12.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Revised: 12/20/2011] [Accepted: 12/21/2011] [Indexed: 11/18/2022]
Abstract
PURPOSE Outcomes of gastroschisis are influenced by associated intestinal complications. We present a detailed analysis of complex gastroschisis. METHODS A retrospective study of all patients with gastroschisis treated at 2 university neonatal intensive care units between January 1, 2001, and March 31, 2007, was performed. RESULTS Of 83 patients, 19 (23%) had complex gastroschisis, including atresias (68%), gangrene (37%), closing gastroschisis (32%), perforation (21%), strictures (21%), and volvulus (11%). Prenatal ultrasound did not predict complications. Fifty-three percent underwent primary closure. Duration of mechanical ventilation and total parenteral nutrition (TPN) was 14.4 ± 1.9 days and 90.7 ± 9.0 days, respectively. Enteral feeds started at 35.9 ± 4.6 days. Hospital stay was 104.4 ± 9.6 days. Patients underwent a median of 3 abdominal procedures (range, 2-5) before discharge. Ninety-five percent survived to discharge; 33% and 67% were discharged on TPN and gastrostomy feeds, respectively. Two-year survival was 89%, with 82% on full oral feeding, 12% on a combination of oral and gastrostomy feeding, and 1 patient (who received a liver/bowel transplant) on a combination of enteral and parenteral nutrition. CONCLUSIONS Complex gastroschisis continues to produce significant morbidity. However, most of the patients are TPN free by 2 years of age.
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Affiliation(s)
- Sherif Emil
- Division of Pediatric Surgery, University of California Irvine School of Medicine, Orange, California, USA.
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van Manen M, Bratu I, Narvey M, Rosychuk RJ. Use of paralysis in silo-assisted closure of gastroschisis. J Pediatr 2012; 161:125-8.e1. [PMID: 22284922 DOI: 10.1016/j.jpeds.2011.12.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Revised: 10/14/2011] [Accepted: 12/28/2011] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To examine the association between pre-closure neuromuscular paralysis and time to final surgical closure for infants with gastroschisis undergoing silo reduction. STUDY DESIGN This study was an exploratory review of observational variables obtained from the Canadian Pediatric Surgery Network database. The focus was on the subset of infants with gastroschisis undergoing silo reduction between May 2005 and March 2009. Of the 186 infants, paralysis use could be ascertained for 167 infants (79 received pre-closure paralysis and 88 received none). Groups were compared by using statistical tests, with relationships explored using regression analysis. RESULTS Infants receiving paralysis took longer to achieve closure by an average of 3 days (8 versus 5 days; P < .001) and had greater mean number of ventilation days (12 versus 7 days; P < .001). The relationship between paralysis and days to closure remained after adjusting for other variables. CONCLUSIONS In infants with gastroschisis undergoing silo reduction, use of paralysis was associated with longer time to closure. Pre-closure paralysis should be carefully weighed in this population.
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Affiliation(s)
- Michael van Manen
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Cowan KN, Puligandla PS, Laberge JM, Skarsgard ED, Bouchard S, Yanchar N, Kim P, Lee S, McMillan D, von Dadelszen P. The gastroschisis prognostic score: reliable outcome prediction in gastroschisis. J Pediatr Surg 2012; 47:1111-7. [PMID: 22703779 DOI: 10.1016/j.jpedsurg.2012.03.010] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 03/05/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND/PURPOSE Disease-specific outcome predictors are required for gastroschisis. We derived and validated a gastroschisis prognostic score (GPS) based on bowel appearance after birth. METHODS Visual scoring of bowel matting, necrosis, atresia, and perforation generated a novel gastroschisis bowel injury score recorded in a national database. Reweighting of score components by regression analysis led to assessments of model calibration and goodness of fit. The GPS was validated in subsequent cases. RESULTS Records from 225 infants were used for model derivation. Only intestinal necrosis independently predicted mortality by regression analysis (odds ratio, 11.5; 95% confidence interval, 4.2-31.4). Model recalibration identified that a GPS of 4 or more predicted mortality in 75% of nonsurvivors and 99% of survivors (P = .0001). A GPS of 2 or more demonstrated significantly worse survival outcomes compared with scores of 0 or 1 (length of stay: P = .011, days to first enteral feed: P = .013, days on total parenteral nutrition: P = .006). Model validation with 184 new patients yielded continued high-quality discrimination of outcomes. The GPS demonstrated "near-perfect" interobserver reliability between 2 surgeons (κ ≥ 0.86). CONCLUSIONS The GPS allows the accurate and reliable identification of high-risk groups for mortality and morbidity based on bowel appearance at birth. This information can drive discussions regarding family counseling, resource allocation, and new therapies for these patients.
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Affiliation(s)
- Kyle N Cowan
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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Abstract
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.
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Mills J, Safavi A, Skarsgard ED. Chylothorax after congenital diaphragmatic hernia repair: a population-based study. J Pediatr Surg 2012; 47:842-6. [PMID: 22595558 DOI: 10.1016/j.jpedsurg.2012.01.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2011] [Accepted: 01/26/2012] [Indexed: 02/07/2023]
Abstract
PURPOSE Chylothorax is a recognized complication of congenital diaphragmatic hernia (CDH) repair. Our aims were to describe the frequency and outcomes of chylothorax and to seek predictors of chylothorax occurrence within a population-based CDH cohort. METHODS Records for patients with CDH born between 2006 and 2010 were abstracted from a national database and were compared according to presence/absence of postrepair chylothorax. Univariate, and where appropriate, multivariate analyses were performed for group comparisons and chylothorax outcome prediction. RESULTS Of 243 newborns with CDH surviving to repair, 11 (4.5%) developed a chylothorax. All were managed nonoperatively. Factors predictive of chylothorax outcome on multivariate analysis included need for preoperative transfusion (odds ratio, 13.2; 95% confidence interval, 2.1-83.7; P = .006) and preoperative high-frequency oscillatory ventilation (odds ratio, 7.1; 95% confidence interval, 1.6-31.2; P = .01). Preoperative vasopressor use was significant on univariate analysis only. The groups were comparable for survival, length of stay, and duration of ventilation, but chylothorax patients had prolonged total parenteral nutrition (53 vs 21 days, P = .006) and more central line days (46 vs 24 days, P = .03). CONCLUSIONS Our data suggest that severity of preoperative cardiopulmonary derangement and not anatomical or technical factors predicts chylothorax occurrence after CDH repair.
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Affiliation(s)
- Jessica Mills
- Department of Surgery, BC Children's Hospital and the University of British Columbia, Vancouver, Canada
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Bowel-defect disproportion in gastroschisis: does the need to extend the fascial defect predict outcome? Pediatr Surg Int 2012; 28:495-500. [PMID: 22331201 DOI: 10.1007/s00383-012-3055-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2012] [Indexed: 10/28/2022]
Abstract
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.
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Multi-institutional follow-up of patients with congenital diaphragmatic hernia reveals severe disability and variations in practice. J Pediatr Surg 2012; 47:836-41. [PMID: 22595557 DOI: 10.1016/j.jpedsurg.2012.01.032] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2011] [Accepted: 01/26/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND/PURPOSE Survivors of congenital diaphragmatic hernia (CDH) have a high incidence of morbidity. Variability in follow-up practices between institutions may affect perception of disability and prevent population-based outcome analysis. METHODS A survey of follow-up practices at 16 centers within a population-based CDH network was performed. A descriptive analysis of outcomes (minimum 24 months postdischarge) of CDH survivors from the 2 largest centers was performed. RESULTS The nature of follow-up of CDH survivors was highly variable in 12 of 16 responding centers, ranging from ad hoc, community-based, and pediatrician-sponsored follow-up to a single perinatal center-based multispecialty CDH clinic. Outcomes at 24 to 36 months were reported from the 2 largest centers (n = 44). Among survivors, neurodevelopmental disability was most common (12/44; 27%) followed by gastrointestinal (9; 20.5%), pulmonary (5; 11.4%), musculoskeletal (5; 11.4%), and cardiac (2; 4.5%). Additional surgery was required in 17 patients (38.6%), including recurrent CDH repair in 7 (15.9%). Five patients (11.4%) had hearing loss. Among 41 children with available 24-month data, 32 (78%), 17 (41.5%), and 14 (34.1%) patients had weights below the 50th, 25th, and 3rd percentiles, respectively. CONCLUSION Congenital diaphragmatic hernia survivorship is associated with significant disability. Standardization of follow-up practices is essential to enable population-based outcomes analysis.
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Baird R, Puligandla P, Skarsgard E, Laberge JM. Infectious complications in the management of gastroschisis. Pediatr Surg Int 2012; 28:399-404. [PMID: 22159577 DOI: 10.1007/s00383-011-3038-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/29/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND/PURPOSE Neonates with gastroschisis make up an increasing proportion of prolonged surgical NICU admissions. While infectious complications are known to increase patient morbidity, it is unclear whether they vary according to abdominal closure method, or can be predicted by initial patient assessment. METHODS A national, prospective, disease-specific database was evaluated for episodes of wound infection (WI) and catheter-related infection (CRI). Antibiotic use and timing, as well as method and location of abdominal closure were studied. The gastroschisis prognostic score (GPS) was calculated and evaluated as a predictor of infectious complications. RESULTS Of 395 patients, 48 (12.6%) had a documented abdominal WI, and 59 patients (14.9%) had at least one episode of CRI-most commonly coagulase negative staphylococcus. Most abdominal closures took place within 6 h of admission (194 = 51.3%), while 132 (34.9%) were delayed greater than 24 h. The WI rate was greater in the delayed group (21.2 vs. 8.2%, p = 0.0006). The GPS was found to predict development of an infectious complication (WI + CRI, p = 0.04). CONCLUSION Infectious complications remain an important consideration in the management of gastroschisis. GPS correlates with the development of infectious complications. Prophylaxis for skin flora and early closure, when feasible, may reduce WI rates.
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Affiliation(s)
- Robert Baird
- Division of Pediatric Surgery, McGill University Health Center, The Montreal Children's Hospital, McGill University, 2300 Tupper Street, Montreal, QC, H3H 1P3, Canada.
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