Primary fascial closure versus staged closure with silo in patients with gastroschisis: a meta-analysis

The outcomes of treatment between primary closure and staged closure in gastroschisis in the pre and post era of the bedside wound retractor silo placement technique

PURPOSE

This study aimed to compare the treatment outcomes of the closure methods between pre and post-eras of bedside wound retractor silo placement technique (BSC).

METHODS

This retrospective cohort study included infants diagnosed with gastroschisis from 2006-2013, pre-BSC era, and from 2014-2021, BSC era. Infants who had fetal anomalies did not survive before receiving treatment and were treated with the delayed closure method were excluded. Pretreatment covariates were adjusted using propensity score in the multivariable logistic regression.

RESULTS

From 170 patients, 5 were excluded. 111 patients underwent primary closure (PC), 54 patients were staged closure (SC). Successful early enteral feeding was achieved in 70(42%) of patients. Among these patients, 52.2% were in the PC group, and 22.2% in the SC group. PC had a significantly higher rate of successful early enteral feeding compared to SC in the pre-BSC era (OR 21.98, 95%CI 2.59-186.51, p-value 0.005). The BSC era, there was no significant difference between the groups (OR 2.04, 95%CI 0.41-1.20, p-value 0.386). There were no differences in complications between PC and SC.

CONCLUSIONS

SC was not inferior in terms of achieving early feeding compared with PC. BSC is an acceptable procedure when a PC was not appropriate and accessible.

Predictors of outcomes in infants with gastroschisis treated with a preformed silo

PURPOSE

To describe the outcomes of infants with gastroschisis treated with a preformed silo (PFS) and determine whether routinely measured early physiological parameters, sepsis (blood culture positive), gastroschisis complexity or location of birth influenced the length of stay (LOS) and duration of parenteral nutrition (PN).

METHODS

Infants cared for in a tertiary surgical neonatal intensive care unit during a 10-year period were identified.

RESULTS

Seventy-seven infants were assessed [median gestational age 36 + 6 (IQR 35 + 3 to 38 + 0)] weeks. All survived; 82% were inborn. The median LOS was 37 (IQR 28-76.5) days and duration of PN was 28 (IQR 21-53) days. In the first 72 h, the worst median lactate, base excess and 'toe-core' gap were 4.2 (IQR 3.0-5.8) mmol/l, -7.0 (IQR - 5.55 to - 9.35), 3.4 (IQR 3.0-4.2) °C respectively. There were no significant correlations between early physiological parameters or place of birth and LOS or PN days, but sepsis (n = 18 infants) and complex gastroschisis (n = 13 infants) were associated with an increased LOS and PN duration (both p < 0.001).

CONCLUSIONS

Survival was 100% in infants with gastroschisis who were managed with PFS, sepsis and gastroschisis complexity were associated with a longer hospital stay and duration of parenteral nutrition. Level of Evidence (I-V): IV.

Evaluation of the Management of Gastroschisis in Aristide Le Dantec University Hospital Center in Dakar: A Cross Sectional Study

INTRODUCTION

The management of gastroschisis remains problematic in low- and middle-income countries with high perioperative mortality. The objective of this work was to make an initial assessment of our management of gastroschisis.

MATERIALS AND METHODS

This was a monocentric and cross-sectional study including all newborns with gastroschisis between January 2017 and December 2021 in the Pediatric Surgery and Anesthesia Resuscitation Department of the Aristide Le Dantec University Hospital Center from Dakar. The socio-demographic, diagnostic, therapeutic and evolutionary parameters were studied.

RESULTS

Eighteen cases of gastroschisis (11 males and 7 females). The mothers' mean age were 23.1 ± 5.7 years old. Only one antenatal diagnosis was made. The mean gestation age were 36.5 ± 1.5 weeks. On admission, the mean age was 16.8 ± 6.3 h and the mean weight 2244 ± 260.3 g. Gastroschisis was complex in four patients. Primary bowel reintegration was performed in 8 cases (44.4%) and progressive reintegration using an Applied Alexis retractor in 9 newborns (55.6%). Main complications were respiratory distress (28.3%) and sepsis (22.2%). The mean duration of return of oral feeding was 5.1 ± 1.9 days. Mortality was 94.4% (17/18).

CONCLUSION

Reducing gastroschisis-related mortality in our low-income countries remains a major challenge.

Special Populations-Surgical Infants

Congenital gastrointestinal disorders and other surgical diagnoses share many common problems: increased nutritional requirements to prevent catabolism, enhance wound healing, and provide optimal growth; impaired motility and altered intestinal flora leading to feeding intolerance requiring long-term parenteral nutrition; gastroesophageal reflux and poor feeding mechanics requiring tube feedings and support; growth failure; poor barrier function and risk of infection; and other long-term sequelae. Consequently, the surgical "at-risk" infant requires specialized nutritional support to meet their increased requirements to ensure adequate growth and meet the increased demands from critical illness.

Gastroschisis in Sub-Saharan Africa: a scoping review of the prevalence, management practices, and associated outcomes

Gastroschisis is a congenital defect of the anterior abdominal wall characterized by a periumbilical abdominal wall defect with associated bowel protrusion. Limitations in the diagnosis and management of gastroschisis in Sub-Saharan African countries contribute to the high mortality rate. Few studies have been published despite its significant contribution to neonatal mortality in Sub-Saharan Africa. This review study explores the prevalence of gastroschisis, likewise the management and clinical outcomes. Full-text articles reporting the prevalence, management, and associated outcomes of gastroschisis in Sub-Saharan Africa were included. Data were extracted from databases such as PubMed, Google Scholar, and Ajol following a systematic search. The study was reported following the PRISMA-ScR guideline. A total of ten articles which included studies conducted from 1999 to 2022 fulfilled the criteria. The prevalence of gastroschisis varied widely, ranging from 0.026 to 1.75 with an overall mortality rate of 62.48%. Young maternal age is strongly associated with the incidence of gastroschisis. The study showed a slight male preponderance with a M: F ratio of 1.12:1. Staged closure with silos is the preferred method of management, it is explicitly linked to improved clinical outcomes. The prevalence rate and associated mortality of gastroschisis remain alarmingly high in most of the studies. There is a need for advanced diagnostic and management practices as well as increased awareness of gastroschisis to reduce mortality and improve survival outcomes.

Factors Associated with Hospital Readmission One Year Post-Discharge in Infants with Gastroschisis

INTRODUCTION

Gastroschisis is the most common congenital abdominal wall defect with a rising prevalence. Infants with gastroschisis are at risk for multiple complications, leading to a potential increased risk for hospital readmission after discharge. We aimed to find the frequency and factors associated with an increased risk of readmission.

METHODS

A retrospective analysis of infants born with gastroschisis between 2013 and 2019 who received initial surgical intervention and follow-up care in the Children's Wisconsin health system was performed. The primary outcome was the frequency of hospital readmission within 1 year of discharge. We also compared maternal and infant clinical and demographic variables between those readmitted for reasons related to gastroschisis, and those readmitted for other reasons or not readmitted.

RESULTS

Forty of 90 (44%) infants born with gastroschisis were readmitted within 1-year of the initial discharge date, with 33 (37%) of the 90 infants being readmitted due to reasons directly related to gastroschisis. The presence of a feeding tube (p < 0.0001), a central line at discharge (p = 0.007), complex gastroschisis (p = 0.045), conjugated hyperbilirubinemia (p = 0.035), and the number of operations during the initial hospitalization (p = 0.044) were associated with readmission. Maternal race/ethnicity was the only maternal variable associated with readmission, with Black race being less likely to be readmitted (p = 0.003). Those who were readmitted were also more likely to be seen in outpatient clinics and utilize emergency healthcare resources. There was no statistically significant difference in readmission based on socioeconomic factors (all p > 0.084).

CONCLUSION

Infants with gastroschisis have a high hospital readmission rate, which is associated with a variety of risk factors including complex gastroschisis, multiple operations, and the presence of a feeding tube or central line at discharge. Improved awareness of these risk factors may help stratify patients in need of increased parental counseling and additional follow-up.

Therapeutic Hypothermia Treatment for an Infant with Hypoxic-Ischemic Encephalopathy and Gastroschisis: A Case Report

Gastroschisis is a congenital, typically isolated, full-thickness abdominal wall defect in which the abdominal contents, usually only the small intestine, remain outside the abdominal cavity. It is commonly detected on fetal ultrasonography, and has generally excellent survival and outcomes, though these can be decreased in cases of complicated gastroschisis. We present the case of a female infant with a prenatal diagnosis of gastroschisis who required a prolonged and complex resuscitation after delivery. In addition to her gastroschisis, she presented with a history and physical examination consistent with severe hypoxic-ischemic encephalopathy and was treated with therapeutic hypothermia (TH) without further compromise to her bowel. In addition, careful consideration of neuroprotection, fluid status, bowel viability, and hemodynamics were undertaken in her care. She was discharged home on full enteral feeds, with only mild language and gross motor delays at 6 months of age. To our knowledge, there are no reports in the literature of the use of TH in the setting of unrepaired simple gastroschisis.

Gastroschisis for the Gastroenterologist: Updates on Epidemiology, Management, and Outcomes

Gastroschisis is a common congenital abdominal wall defect, likely influenced by environmental factors in utero, with increasing prevalence in the United States. Early detection of gastroschisis in utero has become the standard with improved prenatal care and screening. There are multiple surgical management techniques, though sutureless closure is being used more frequently. Postoperative feeding difficulty is common and requires vigilance for complications, such as necrotizing enterocolitis. Infants with simple gastroschisis are expected to have eventual catch-up growth and normal development, while those with complex gastroschisis have higher morbidity and mortality. Management requires collaboration amongst several perinatal disciplines, including obstetrics, maternal fetal medicine, neonatology, pediatric surgery, and pediatric gastroenterology for optimal care and long-term outcomes.

Predictors of length of stay for simple gastroschisis: analysis of ACS NSQIP-P database

PURPOSE

We aimed to assess predictors of length of stay for simple gastroschisis utilizing the NSQIP-Pediatric Database.

METHODS

The NSQIP-P Participant Use Data File was queried to identify patients with simple gastroschisis. We defined short length of stay (LOS) as patients discharged home ≤ 30 days from birth. We compared patients with short LOS versus prolonged LOS > 30 days. Predictors and outcomes were evaluated.

RESULTS

There were 888 patients with simple gastroschisis identified. Half of patients had LOS ≤ 30 days. Patients with LOS ≤ 30 were younger at repair (median age 1 day vs. 3 days, p = 0.0001), had higher birth weight (median 2.5 kg vs. 2.4 kg, p = 0.0001), and were less premature (37 week vs. 36 weeks, p = 0.0001). However, only gestational age and weight at birth were significant predictors of LOS on multivariate analysis (p = 0.0001). Prolonged LOS patients had more instances of ventilation, oxygen supplementation, sepsis (n = 2/446 or 0.4% vs. n = 9/442 or 2%, p = 0.003), bleeding/transfusion (n = 7/446 or 1.6% vs. n = 43/442 or 9.7%, p = 0.0001), line infections (n = 1/446 or 0.2% vs. n = 12/442, p = 0.001), and reoperations (n = 9/446 or 2% vs. n = 26/442 or 5.9%, p = 0.003).

CONCLUSION

Prematurity and birth weight are significant predictors of length of stay in simple gastroschisis patients. Prenatal counseling should continue to be one of the main factors to improve the outcomes for patients with gastroschisis. Type of study Retrospective cohort study. Level of evidence Level IV.

Improved Mortality of Patients with Gastroschisis: A Historical Literature Review of Advances in Surgery and Critical Care from 1960-2020

The improved survival of gastroschisis patients is a notable pediatric success story. Over the past 60 years, gastroschisis evolved from uniformly fatal to a treatable condition with over 95% survival. We explored the historical effect of four specific clinical innovations—mechanical ventilation, preformed silos, parenteral nutrition, and pulmonary surfactant—that contributed to mortality decline among gastroschisis infants. A literature review was performed to extract mortality rates from six decades of contemporary literature from 1960 to 2020. A total of 2417 publications were screened, and 162 published studies (98,090 patients with gastroschisis) were included. Mortality decreased over time and has largely been <10% since 1993. Mechanical ventilation was introduced in 1965, preformed silo implementation in 1967, parenteral nutrition in 1968, and pulmonary surfactant therapy in 1980. Gastroschisis infants now carry a mortality rate of <5% as a result of these interventions. Other factors, such as timing of delivery, complex gastroschisis, and management in low- and middle-income countries were also explored in relation to gastroschisis mortality. Overall, improved gastroschisis outcomes serve as an illustration of the benefits of clinical advances and multidisciplinary care, leading to a drastic decline in infant mortality among these patients.

Avoidance of routine endotracheal intubation and general anesthesia for primary closure of gastroschisis: a systematic review and meta-analysis

PURPOSE

Over the last few decades, several articles have examined the feasibility of attempting primary reduction and closure of gastroschisis without general anesthesia (GA). We aimed to systematically evaluate the impact of forgoing routine intubation and GA during primary bedside reduction and closure of gastroschisis.

METHODS

The primary outcome was closure success. Secondary outcomes were mortality, time to enteral feeding, and length of hospital stay.

RESULTS

12 studies were included: 5 comparative studies totalling 192 patients and 7 descriptive case studies totalling 56 patients. Primary closure success was statistically equivalent between the two groups, but trended toward improved success with GA/intubation (RR = 0.86, CI 0.70-1.03, p = 0.08). Mortality was equivalent between groups (RR = 1.26, CI 0.26-6.08, p = 0.65). With respect to time to enteral feeds and length of hospital stay, outcomes were either equivalent between the two groups or favored the group that underwent primary closure without intubation and GA.

CONCLUSION

There are few comparative studies examining the impact of performing primary bedside closure of gastroschisis without GA. A meta-analysis of the available data found no statistically significant difference when forgoing intubation and GA. Foregoing GA also did not negatively impact time to enteral feeds, length of hospital stay, or mortality.

Concomitant Hepatectomy and Atrial Thrombectomy under Cardiopulmonary Bypass versus Staged Hepatectomy in the Treatment for Hepatocellular Carcinoma with Large Right Atrial Tumor Thrombi

(1) Background: Hepatocellular carcinoma (HCC) with a large right atrium tumor thrombus (RATT) is a rare and critical presentation. Emergency hepatectomy and thrombectomy under cardiopulmonary bypass (CPB) is life-saving and potentially curative. The aim of this study is to propose an appropriate approach for this condition. (2) Methods: In period A (1998 to 2010, n = 7), hepatectomy and thrombectomy were concomitantly performed, and staged hepatectomy was performed in period B (2011 to 2018, n = 17). (3) Results: The median overall survival time (MOST) in the published studies was 14 months. Moreover, the blood loss, blood transfusion rate, length of ICU stays, and hospital costs were significantly reduced in period B. The MOSTs of patients in period A (n = 6) and period B (n = 17) were 14 vs. 18 months (p = 0.099). The median disease-free survival times (MDFTs) in period A (n = 6) and period B (n = 15) were 8 vs. 14 months (p = 0.073), while the MOSTs in period A and period B were 14 vs. 24 months (p = 0.040). (4) Conclusions: Emergency thrombectomy under CPB and staged hepatectomy 4–6 weeks later may be an appropriate approach for HCC with large RATT. However, the optimal waiting interval requires further investigation.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

The medical and surgical management of gastroschisis

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.

Different strategies, equivalent treatment approaches in terms of mortality in four university hospitals: a retrospective multicenter study of gastroschisis in Finland

PURPOSE

Optimal treatment of gastroschisis is not determined. The aim of the present study was to investigate treatment methods of gastroschisis in four university hospitals in Finland.

METHODS

The data of neonates with gastroschisis born between 1993 and 2015 were collected. The primary outcomes were short and long-term mortality and the length of stay (LOS). Statistical analyses consisted of uni- and multivariate models.

RESULTS

Total of 154 patients were included (range from 31 to 52 in each hospital). There were no statistically significant differences in mortality or LOS between centers. Significant differences were observed between the hospitals in the duration of mechanical ventilation (p = 0.046), time to full enteral nutrition (p = 0.043), delay until full defect closure (p = 0.003), central line sepsis (p = 0.025), abdominal compartment syndrome (p = 0.018), number of abdominal operations during initial hospitalization (p = 0.000) and follow-up (p = 0.000), and ventral hernia at follow-up (p = 0.000). In a Cox multivariate analysis, the treating hospital was not associated with mortality.

CONCLUSION

There were no differences in short or long-term mortality between four university hospitals in Finland. However, some inter-hospital variation in postoperative outcomes was present.

LEVEL OF EVIDENCE

Level III.

Gastroschisis: A Successful, Prospectively Evaluated Treatment Model in a Middle-Income Country

BACKGROUND

This research adopted a care protocol from high-income countries in a level II/III hospital in a middle-income country to decrease morbidity and mortality associated with gastroschisis.

METHODS

We established a multidisciplinary protocol to treat patients with gastroschisis prospectively from November 2012 to November 2018. This included prenatal diagnosis, presence of a neonatologist and pediatric surgeon at birth, and either performing primary closure on the patients with an Apgar score of 8/9, mild serositis, and no breathing difficulty or placing a preformed silo, when unable to fulfill these criteria, under sedation and analgesia (no intubation) in the operating room or at the patients' bedside. The subsequent management took place in the neonatal intensive care unit. The data were analyzed through the Mann-Whitney and Student's t-distribution for the two independent samples; the categorical variables were analyzed through a chi-square distribution or Fisher's exact test.

RESULTS

In total, 55 patients were included in the study: 33 patients (60%) were managed with a preformed silo, whereas 22 patients (40%) underwent primary closure. Prenatal diagnosis (P = 0.02), birth at the main hospital (P = 0.02), and the presence of a pediatric surgeon at birth (P = 0.04) were associated with successful primary closure. The primary closure group had fewer fasting days (P < 0.001) and a shorter neonatal intensive care unit length of stay (P = 0.025). The survival rate was 92.7% (51 patients).

CONCLUSION

The treatment model modified to fit the means of our hospital proved successful.

Management of Gastroschisis: Results From the NETS2G Study, a Joint British, Irish, and Canadian Prospective Cohort Study of 1268 Infants

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.

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

BACKGROUND

Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality.

METHODS

We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung's disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis.

FINDINGS

We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung's disease) from 264 hospitals (89 in high-income countries, 166 in middle-income countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36-39) and median bodyweight at presentation was 2·8 kg (2·3-3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in low-income countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88-4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59-2·79], p<0·0001), sepsis at presentation (1·20 [1·04-1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4-5 vs ASA 1-2, 1·82 [1·40-2·35], p<0·0001; ASA 3 vs ASA 1-2, 1·58, [1·30-1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02-1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41-2·71], p=0·0001; parenteral nutrition 1·35, [1·05-1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47-0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50-0·86], p=0·0024) or percutaneous central line (0·69 [0·48-1·00], p=0·049) were associated with lower mortality.

INTERPRETATION

Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between low-income, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030.

FUNDING

Wellcome Trust.

Risk factors for perioperative hypothermia and infectious outcomes in gastroschisis patients

INTRODUCTION

Prior data suggest that infants with gastroschisis are at high risk for hypothermia and infectious complications (ICs). This study evaluated the associations between perioperative hypothermia (PH) and ICs in gastroschisis using a multi-institutional cohort.

METHODS

Retrospective review of infants with gastroschisis who underwent abdominal closure from 2013-2017 was performed at 7 children's hospitals. Any-IC and surgical site infection (SSI) were stratified against the presence or absence of PH, and perioperative characteristics associated with PH and SSI were determined using multivariable logistic regression.

RESULTS

Of 256 gastroschisis neonates, 42% developed PH, with 18% classified as mild hypothermia (35.5-35.9 °C), 10.5% as moderate (35.0-35.4 °C), and 13% severe (<35 °C). There were 82 (32%) ICs with 50 (19.5%) being SSIs. No associations between PH and any-IC (p = 0.7) or SSI (p = 0.98) were found. Pulmonary comorbidities (odds ratio (OR)=3.76, 95%CI:1.42-10, p = 0.008) and primary closure (OR=0.21, 95%CI:0.12-0.39, p<0.001) were associated with PH, while silo placement (OR=2.62, 95%CI:1.1-6.3, p = 0.03) and prosthetic patch (OR=3.42, 95%CI:1.4-8.3, p = 0.007) were associated with SSI on multivariable logistic regression.

CONCLUSIONS

Primary abdominal closure and pulmonary comorbidities are associated with PH in gastroschisis, however PH was not associated with increased risk of ICs. Independent risk factors for SSI include silo placement and prosthetic patch closure.

What is the main factor in predicting the morbidity and mortality in patients with gastroschisis: delivery time, delivery mode, closure method, or the type of gastroschisis (simple or complex)?

Background/aim

There are numerous debates in the management of gastroschisis (GS). The current study aimed to evaluate perinatal outcomes and surgical and clinical characteristics among GS patients based on their type of GS, abdominal wall closure method, and delivery timing.

Materials and methods

This study was a retrospective analysis of prospectively collected data of 29 fetuses with GS that were prenatally diagnosed, delivered, and managed between June 2015 and December 2019 at the Obstetrics and Pediatric Surgery Clinics of Kanuni Sultan Süleyman Training and Research Hospital.

Results

Twenty-three of the patients had simple GS, and six of them had complex GS. The reoperation requirement, number of operations, duration of mechanical ventilation, time to initiate feeding, time to full enteral feeding, total parenteral nutrition (TPN) duration, TPN-associated cholestasis, wound infection, sepsis, and necrotizing enterocolitis were significantly lower in the simple GS group than in the complex GS group. The mean hospital length of stay was 3.5 times longer in the complex GS group (121.50 ± 24.42 days) than in the simple GS group (33.91 ± 4.13 days, p = 0.009). There were no cases of death in the simple GS group. However, two deaths occurred in the complex GS group.

Conclusion

This study indicated that simple GS, compared with complex GS, was associated with improved neonatal outcomes. We suggest that the main factor affecting the patients’ outcomes is whether the patient is a simple or complex GS rather than the abdominal wall closure method.

The association between fluid restriction and hyponatremia in newborns with gastroschisis

INTRODUCTION

Newborns with gastroschisis require appropriate fluid resuscitation but are also at risk for hyponatremia that may lead to adverse outcomes. The etiology of hyponatremia in gastroschisis has not been defined.

METHODS

Over a 24-month period, all newborns with gastroschisis in a free-standing pediatric hospital had sodium levels measured from serum, urine, gastric output, and the bowel bag around the eviscerated contents for the first 48 h of life. Total fluid intake and output were measured. Maintenance fluids were standardized at 120 mL/kg/day. Hyponatremia was defined as a serum sodium <132 mEq/L. A logistic regression model was created to determine independent predictors of hyponatremia.

RESULTS

28 infants were studied, and 14 patients underwent primary closure. While serum sodium was normal in all patients at birth, 9 (32%) infants developed hyponatremia at a median of 17.4 h of life. On univariate analysis, hyponatremic babies had a greater net positive fluid balance (74.9 vs 114.7 mL/kg, p = 0.001) primarily due to a decrease in total fluid output (p = 0.05). On multivariable regression, a 10 mL/kg increase in overall fluid balance was associated with an increased risk of developing hyponatremia (OR 1.84 [1.23, 3.45], p = 0.016). No differences in the sodium content of urine, gastric, or bowel bag fluid were observed, and sodium balance was equivalent between cohorts.

DISCUSSION

Hyponatremia in babies with gastroschisis in the early postnatal period was associated with positive fluid balance and decreased fluid output. Prospective studies to determine the appropriate fluid resuscitation strategy in this population are warranted.

Abdominal Wall Defects-Current Treatments

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

Is fetal magnetic resonance imaging volumetry of eventrated organs in gastroschisis predictive for surgical treatment?

BACKGROUND

Fetal MRI is increasingly used in congenital abdominal wall defects. In gastroschisis, the role of fetal MRI in surgical therapy is poorly understood. Currently, the type of repair is determined primarily by clinical presentation and institutional preference.

OBJECTIVE

To evaluate the feasibility of fetal MRI volumetry in gastroschisis treatment.

MATERIALS AND METHODS

We included 22 cases of gastroschisis in this retrospective single-center study. Routine fetal MRI scans were acquired between Jan. 1, 2006, and July 1, 2018, at gestational ages of 19-34 postmenstrual weeks. Fetal-MRI-based manual segmentation and volumetry were performed utilizing steady-state free precision and T2-weighted sequences. Acquired parameters included intraabdominal volume, eventrated organ volume and total fetal body volume, and we calculated a volume ratio between eventrated organ volume and intraabdominal volume (E/I ratio).

RESULTS

Primary closure was conducted in 13 cases and silo bag treatment with delayed closure in 9 cases. Prenatal MRI volumetry showed a significantly higher E/I ratio in patients with silo bag treatment with delayed closure (mean [M]=0.34; 95% confidence interval [CI] 0.30, 0.40) than in primary closure (M=0.23, 95% CI 0.19, 0.27; P=0.004). We propose a volume ratio cutoff value of 0.27 for predicting silo bag treatment.

CONCLUSION

Fetal MRI predicted silo bag treatment in patients with gastroschisis in 90% of the cases in our cohort and might facilitate prenatal counseling and treatment planning.

Failure of primary closure predicts prolonged length of stay in gastroschisis patients

PURPOSE

Current literature regarding outcomes of gastroschisis closure methods do not highlight differences in patients who successfully undergo primary closure with those who fail and require silo placement. We hypothesize that failure of primary closure has significant effects on clinical outcomes such as length of stay and time to enteral feeding.

METHODS

We conducted a retrospective review between 2009 and 2018 of gastroschisis patients at a tertiary pediatric referral hospital. We compared patients successfully undergoing primary closure to patients who failed an initial primary closure attempt. Bivariate and multivariate linear regression models were used to assess the association of closure method on clinical outcomes.

RESULTS

Sixty-eight neonates were included for analysis, with 44 patients who underwent primary closure and 24 who failed primary closure. On multivariate regression analysis, primary closure patients had shorter estimated time to starting and to full enteral feeds and decreased LOS as compared to those who failed primary closure. Two patients (4.44%) had complications related to primary closure.

CONCLUSION

Patients able to undergo primary closure for gastroschisis were more likely to have a shorter length of stay, shorter time to enteral feeds, and use much fewer medical resources. Initial primary closure is a safe method for most patients.

Gastroschisis: A State-of-the-Art Review

Gastroschisis, the most common type of abdominal wall defect, has seen a steady increase in its prevalence over the past several decades. It is identified, both prenatally and postnatally, by the location of the defect, most often to the right of a normally-inserted umbilical cord. It disproportionately affects young mothers, and appears to be associated with environmental factors. However, the contribution of genetic factors to the overall risk remains unknown. While approximately 10% of infants with gastroschisis have intestinal atresia, extraintestinal anomalies are rare. Prenatal ultrasound scans are useful for early diagnosis and identification of features that predict a high likelihood of associated bowel atresia. The timing and mode of delivery for mothers with fetuses with gastroschisis have been somewhat controversial, but there is no convincing evidence to support routine preterm delivery or elective cesarean section in the absence of obstetric indications. Postnatal surgical management is dictated by the condition of the bowel and the abdominal domain. The surgical options include either primary reduction and closure or staged reduction with placement of a silo followed by delayed closure. The overall prognosis for infants with gastroschisis, in terms of both survival as well as long-term outcomes, is excellent. However, the management and outcomes of a subset of infants with complex gastroschisis, especially those who develop short bowel syndrome (SBS), remains challenging. Future research should be directed towards identification of epidemiological factors contributing to its rising incidence, improvement in the management of SBS, and obstetric/fetal interventions to minimize intestinal damage.

Peter SD, Downard CD, Qureshi FG, Renaud E, Danielson PD, Islam S. Immediate versus silo closure for gastroschisis: Results of a large multicenter study

BACKGROUND/PURPOSE

The optimal method to repair gastroschisis defects continues to be debated. The two primary methods are immediate closure (IC) or silo placement (SP). The purpose of this study was to compare outcomes between each approach using a multicenter retrospective analysis. We hypothesized that patients undergoing SP for ≤5 days would have largely equivalent outcomes compared to IC patients.

METHODS

Gastroschisis patient data were collected over a 7-year period. The cohort was separated into IC and SP groups. The SP group was further stratified based on time to closure (≤5 days, 6-10 days, >10 days). Characteristics and outcomes were compared between groups. Multivariate logistic regression was also performed.

RESULTS

566 neonates with gastroschisis were identified including 224 patients in the IC group and 337 patients in the SP group. Among SP patients, 130 were closed within 5 days, 140 in 6-10 days, and 57 in >10 days. There were no significant differences in mortality, sepsis, readmission, or days to full enteral feeds between IC patients and SP patients who had a silo ≤5 days. IC patients had a significantly higher incidence of ventral hernias. Multivariate analysis revealed time to closure as a significant independent predictor of length of stay, ventilator duration, time to full enteral feeds, and TPN duration.

CONCLUSIONS

Our data show largely equivalent outcomes between patients who undergo immediate closure and those who have silos ≤5 days. We propose that closure within 5 days avoids many of the risks commonly attributed to delay in closure.

LEVEL OF EVIDENCE

Level II retrospective study.

Major abdominal wall defects in the low- and middle-income setting: current status and priorities

Major congenital abdominal wall defects (gastroschisis and omphalocele) may account for up to 21% of emergency neonatal interventions in low- and middle-income countries. In many low- and middle-income countries, the reported mortality of these malformations is 30-100%, while in high-income countries, mortality in infants with major abdominal wall reaches less than 5%. This review highlights the challenges faced in the management of newborns with major congenital abdominal wall defects in the resource-limited setting. Current high-income country best practice is assessed and opportunities for appropriate priority setting and collaborations to improve outcomes are discussed.

Variation in hospital costs for gastroschisis closure techniques

BACKGROUND

In newborns with gastroschisis, both primary repair and delayed fascial closure with initial silo placement are considered safe with similar outcomes although cost differences have not been explored.

METHODS

A retrospective review was performed of newborns admitted with gastroschisis at a single center from 2011 to 2016. Demographic, clinical, and cost data during the initial hospitalization were collected. Differences between procedure costs and clinical endpoints were analyzed using multivariable linear regression adjusting for prematurity, complicated gastroschisis, and performance of additional operations.

RESULTS

80 patients with gastroschisis met inclusion criteria. Rates of primary fascial, primary umbilical cord closure, and delayed closure were 14%, 65%, and 21%, respectively. Delayed closure was associated with an increase in total hospital costs by 57% compared to primary repair (p < 0.001). In addition, delayed closure was associated with increased total and NICU LOS (p < 0.05), parenteral nutrition duration (p = 0.02), ventilator days (p < 0.001), time to goal enteral feeds (p = 0.01), and all cost sub-categories except ward room costs (p < 0.01).

CONCLUSION

Delayed fascial closure was associated with significantly greater hospital costs during the index admission.

Challenges and Outcome of Management of Gastroschisis at a Tertiary Institution in North-Eastern Nigeria

Introduction: Gastroschisis is a congenital anterior abdominal wall defect characterized by herniation of abdominal contents through a defect usually located to the right side of the umbilical cord. It occurs in about 1 in 2,000-4,000 live births and is slightly commoner in males. Management has remained challenging in the low and middle-income countries (LMICS), with high mortality rates. This study highlights the clinical presentation, treatment, outcomes, and challenges in the management of gastroschisis at a tertiary healthcare center in a resource-limited setting. Methods: This was a retrospective review of the records of all patients with gastroschisis managed over a period of 30 months (January 2016-June 2018). Data on patients' demographics, age, birth weight, clinical presentation, method of gastroschisis reduction and closure, complications, and outcomes were collated. Statistical analysis was performed using SPSS version 20. A p-value of >0.05 was considered significant. Results: Twenty-four patients with gastroschisis were managed. Of these, 18 patients had data available for analysis. There were 14 males, with a male-female ratio of 3.5:1. The median age at presentation was 11.0 h (range 1-36 h). Ten patients (55.6%) were delivered in a medical facility. One patient had type II jejunal atresia and transverse colonic atresia as associated anomalies. Improvised silos were applied by the bedside in 15 (83.3%) patients, while two patients (11.1%) had primary closure under general anesthesia. One patient died before definitive treatment could be done. Sterile urobags and female condoms were used for constructing improvised silos in 9 (60%) and 6 (40%) patients, respectively. Eight patients who had initial silo application had complete bowel reduction over a median time of 8.0 days (mean 10.0 ± 6.5 days, range 2-23 days). Total parenteral nutrition (TPN) was not available. The average time to commencement of feeding was 8.0 days ± 6.6 (median 6.0 days, range 2-22 days). Full feeding was achieved in five patients (two patients in the primary closure group and three from the silo group) over a mean time of 16.8 days ± 10.4 (median 14.0 days). Sepsis was the commonest complication. Four patients (22.2%) survived. Conclusion: Management of gastroschisis remains challenging in resource-limited regions.

Management and outcomes of gastrointestinal congenital anomalies in low, middle and high income countries: protocol for a multicentre, international, prospective cohort study

INTRODUCTION

Congenital anomalies are the fifth leading cause of death in children <5 years of age globally, contributing an estimated half a million deaths per year. Very limited literature exists from low and middle income countries (LMICs) where most of these deaths occur. The Global PaedSurg Research Collaboration aims to undertake the first multicentre, international, prospective cohort study of a selection of common congenital anomalies comparing management and outcomes between low, middle and high income countries (HICs) globally.

METHODS AND ANALYSIS

The Global PaedSurg Research Collaboration consists of surgeons, paediatricians, anaesthetists and allied healthcare professionals involved in the surgical care of children globally. Collaborators will prospectively collect observational data on consecutive patients presenting for the first time, with one of seven common congenital anomalies (oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation and Hirschsprung's disease).Patient recruitment will be for a minimum of 1 month from October 2018 to April 2019 with a 30-day post-primary intervention follow-up period. Anonymous data will be collected on patient demographics, clinical status, interventions and outcomes using REDCap. Collaborators will complete a survey regarding the resources and facilities for neonatal and paediatric surgery at their centre.The primary outcome is all-cause in-hospital mortality. Secondary outcomes include the occurrence of post-operative complications. Chi-squared analysis will be used to compare mortality between LMICs and HICs. Multilevel, multivariate logistic regression analysis will be undertaken to identify patient-level and hospital-level factors affecting outcomes with adjustment for confounding factors.

ETHICS AND DISSEMINATION

At the host centre, this study is classified as an audit not requiring ethical approval. All participating collaborators have gained local approval in accordance with their institutional ethical regulations. Collaborators will be encouraged to present the results locally, nationally and internationally. The results will be submitted for open access publication in a peer reviewed journal.

TRIAL REGISTRATION NUMBER

NCT03666767.

A 25-year study of gastroschisis outcomes in a middle-income country

BACKGROUND

Survival of newborns with gastroschisis is significantly higher in high-income versus low and middle-income countries. We reviewed treatment and outcomes of gastroschisis in a middle-income country setting with increasing protocolized management.

METHODS

All newborns with gastroschisis treated during the period 1989-2013 at a single Brazilian academic surgical service were studied retrospectively. Protocolized diagnosis, delivery, nutrition, medical interventions, and surgical interventions were introduced in 2002. Outcomes before and after protocol introduction were studied using univariate and multivariate analysis.

RESULTS

One hundred fifty-six newborns were treated for gastroschisis: 35 (22.4%) and 121 (77.6%) before and after 2002, respectively. When compared to the earlier cohort, patients treated after 2002 had higher rates of prenatal diagnosis (90.9% vs. 60.0%, p < 0.001), delivery at a tertiary center (90.9% vs. 62.9%, p < 0.001), early closure (65.3% vs. 33.3%, p = 0.001), primary repair (55.4% vs. 31.4%, p = 0.013), monitoring of bladder pressure (62.0% vs. 2.9%, p = 0.001), PICC placement (71.1% vs. 25.7%, p < 0.001), early initiation of enteral feeding (54.5% vs. 20.0%, p < 0.001), and lower rates of electrolyte disturbances (53.7% vs. 85.7%, p = 0.001). Mortality decreased from 34.3% before 2002 to 24.8% (p = .27) after 2002 despite an increase in the complex gastroschisis rate from 11.4% to 15.7% during the same period.

CONCLUSIONS

Gastroschisis outcomes in a middle-income country can be gradually improved through targeted interventions and management protocols.

TYPE OF STUDY

Therapeutic.

LEVEL OF EVIDENCE

III.

Developing and implementing an interventional bundle to reduce mortality from gastroschisis in low-resource settings

Background: Gastroschisis is associated with less than 4% mortality in high-income countries and over 90% mortality in many tertiary paediatric surgery centres across sub-Saharan Africa (SSA). The aim of this trial is to develop, implement and prospectively evaluate an interventional bundle to reduce mortality from gastroschisis in seven tertiary paediatric surgery centres across SSA. Methods: A hybrid type-2 effectiveness-implementation, pre-post study design will be utilised. Using current literature an evidence-based, low-technology interventional bundle has been developed. A systematic review, qualitative study and Delphi process will provide further evidence to optimise the interventional bundle and implementation strategy. The interventional bundle has core components, which will remain consistent across all sites, and adaptable components, which will be determined through in-country co-development meetings. Pre- and post-intervention data will be collected on clinical, service delivery and implementation outcomes for 2-years at each site. The primary clinical outcome will be all-cause, in-hospital mortality. Secondary outcomes include the occurrence of a major complication, length of hospital stay and time to full enteral feeds. Service delivery outcomes include time to hospital and primary intervention, and adherence to the pre-hospital and in-hospital protocols.  Implementation outcomes are acceptability, adoption, appropriateness, feasibility, fidelity, coverage, cost and sustainability. Pre- and post-intervention clinical outcomes will be compared using Chi-squared analysis, unpaired t-test and/or Mann-Whitney U test. Time-series analysis will be undertaken using Statistical Process Control to identify significant trends and shifts in outcome overtime. Multivariate logistic regression analysis will be used to identify clinical and implementation factors affecting outcome with adjustment for confounders. Outcome: This will be the first multi-centre interventional study to our knowledge aimed at reducing mortality from gastroschisis in low-resource settings. If successful, detailed evaluation of both the clinical and implementation components of the study will allow sustainability in the study sites and further scale-up. Registration: ClinicalTrials.gov Identifier NCT03724214.

The intestinal fatty acid-binding protein as a marker for intestinal damage in gastroschisis

Background/Purpose

We analyzed the capacity of urinary Intestinal fatty acid-binding protein (I-FABP) to quantify the degree of mucosal injury in neonates with gastroschisis (GS) and to predict the speed of their clinical recovery after surgery.

Methods

In this prospective study, we collected urine during the first 48h after surgery from neonates operated between 2012 and 2015 for GS. Neonates with surgery that did not include gut mucosa served as controls for simple GS and neonates with surgery for intestinal atresia served as control for complex GS patients. The I-FABP levels were analyzed by ELISA.

Results

Urinary I-FABP after the surgery is significantly higher in GS newborns than in control group; I-FABP in complex GS is higher than in simple GS. I-FABP can predict subsequent operation for ileus in patients with complex GS. Both ways of abdominal wall closure (i.e. primary closure and stepwise reconstruction) led to similar levels of I-FABP. None of the static I-FABP values was useful for the outcome prediction. The steep decrease in I-FABP after the surgery is associated with faster recovery, but it cannot predict early start of minimal enteral feeding, full enteral feeding or length of hospitalization.

Conclusion

Urinary I-FABP reflects the mucosal damage in gastroschisis but it has only a limited predictive value for patients’ outcome.

Development of a gastroschisis core outcome set

OBJECTIVE

Outcome reporting heterogeneity impedes identification of gold standard treatments for children born with gastroschisis. Use of core outcome sets (COSs) in research reduces outcome reporting heterogeneity and ensures that studies are relevant to patients. The aim of this study was to develop a gastroschisis COS.

DESIGN AND SETTING

Systematic reviews and stakeholder nomination were used to identify candidate outcomes that were subsequently prioritised by key stakeholders in a three-phase online Delphi process and face-to-face consensus meeting using a 9-point Likert scale. In phases two and three of the Delphi process, participants were shown graphical and numerical representations of their own, and all panels scores for each outcome respectively and asked to review their previous score in light of this information. Outcomes were carried forward to the consensus meeting if prioritised by two or three stakeholder panels in the third phase of the Delphi process. The COS was formed from outcomes where ≥70% of consensus meeting participants scored the outcome 7-9 and <15% of participants scored it 1-3.

RESULTS

71 participants (84%) completed all phases of the Delphi process, during which 87 outcomes were assessed. Eight outcomes, mortality, sepsis, growth, number of operations, severe gastrointestinal complication, time on parenteral nutrition, liver disease and quality of life for the child, met criteria for inclusion in the COS.

CONCLUSIONS

Eight outcomes have been included in the gastroschisis COS as a result of their importance to key stakeholders. Implementing use of the COS will increase the potential for identification of gold standard treatments for the management of children born with gastroschisis.

Safety and usefulness of plastic closure in infants with gastroschisis: a systematic review and meta-analysis

PURPOSE

Recently, plastic closure of abdominal defect in infants with gastroschisis has been used. Timing of gastroschisis closure can be mainly divided into two groups: primary closure and delayed closure after silo forming. Safety and usefulness of plastic closure in gastroschisis remains unclear. We aimed to evaluate the current evidence for plastic closure in infants with gastroschisis.

METHODS

The analysis was done for primary closure as well as closure after silo. Outcomes were mortality, wound infection, duration of ventilation, time to feeding, and length of hospital stay (LOS). The quality of evidence was summarized using the GRADE approach.

RESULTS

In the "primary" group, there was no significant difference in mortality, time to feeding initiation and LOS. In the "silo" group, wound infection was significantly lower in plastic closure (Odds ratio 0.24, 95%CI 0.09-0.69, p = 0.008). Duration of ventilation, time to feeding initiation and LOS were significantly shorter after plastic closure (Ventilation; mean difference (MD) - 5.76, p = 0.03. Feeding initiation; MD - 9.42, p < 0.0001. LOS; MD - 14.06, p = 0.002). Quality of evidence was very low for all outcomes.

CONCLUSIONS

Current results suggest that plastic closure may be beneficial for infants with gastroschisis requiring silo formation. However, this evidence is suboptimal and further studies are needed.

The association between gestational age at delivery, closure type and perinatal outcomes in neonates with isolated gastroschisis

Objective: The objective of this study was to examine the association between gestational age at delivery and closure type for neonates with gastroschisis. In addition, we compared perinatal outcomes among the cases of gastroschisis based on the following two factors: gestational age at delivery and abdominal wall closure technique.Methods: This was a retrospective cohort study of all fetuses with isolated gastroschisis that were diagnosed prenatally and delivered between September 2000 and January 2017, in a single tertiary care center. Neonates were compared based on the gestational age at the time of delivery: early preterm (less than 35^0/7 weeks), late preterm (35^0/7 - 36^6/7 weeks), and early term (37^0/6 - 38^6/7 weeks), using bivariate and multivariate analyses. The primary outcome was the type of abdominal wall closure: primary surgical closure or delayed closure using spring-loaded silo. Secondary outcomes included length of ventilatory support, length of parenteral nutrition, and length of hospital stay.Results: The analysis included 206 pregnancies complicated by gastroschisis. In univariate analysis, no differences were detected in primary closure rates of gastroschisis among the gestational age at delivery groups (67.4%, at <35 weeks, 70.8% at 35^0/7-36^6/7 weeks, 73.7% at 37^0/6-38^6/7 weeks, p = .865). However, for every additional 100 grams of neonatal live birth weight there was an associated 9% increased odds of primary closure (OR 1.09, 95% CI 1.14-1.19, p = .04). Delivery in the early preterm period compared to the other two groups, was associated with longer duration of ventilation support and longer dependence on the parenteral nutrition. Neonates who underwent primary closure had shorter ventilation support, shorter time to initiation of enteral feeds and to discontinue parenteral nutrition, and shorter length of stay. In multivariate analyses, controlling for gestational age at delivery and presence of bowel atresia, primary closure continued to be associated with the shorter duration of ventilation (by 5 days), earlier initiation of enteral feeds (by 7 days), shorter hospital stay (by 17 days) and lower odds of wound infection (OR = 0.37, 95% CI 0.15-0.97).Conclusions: Our study did not find an association between gestational age at delivery and the rates of primary closure of the abdominal wall defect; however later gestational age at delivery was associated with shorter duration of ventilatory support and parenteral nutrition dependence. In addition, we found that primary closure of gastroschisis, compared with delayed closure technique, was associated with improved neonatal outcomes, including shorter time to initiate enteral feeds and discontinue parenteral nutrition, shorter hospital stay, and lower risk of surgical wound infection. Therefore, postponing delivery of fetuses with gastroschisis until 37 weeks may be considered. Other factors besides the gestational age at delivery should be explored as predictors of primary closure in neonates with gastroschisis.

Closure methods in gastroschisis

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.

Care of infants with gastroschisis in low-resource settings

There is great global disparity in the outcome of infants born with gastroschisis. Mortality approaches 100% in many low income countries. Barriers to better outcomes include lack of antenatal diagnosis, deficient pre-hospital care, ineffective neonatal resuscitation and venous access, limited intensive care facilities, poor access to the operating theatre and safe neonatal anesthesia, and lack of neonatal parenteral nutrition. However, lessons can be learned from the evolution in management of gastroschisis in high-income countries, generic efforts to improve neonatal survival in low- and middle-income countries as well as specific gastroschisis management initiatives in low-resource settings. Micro and meso-level interventions include educational outreach programs, and pre and in hospital management protocols that focus on resuscitation and include the delay or avoidance of early neonatal anesthesia by using a preformed silo or equivalent. Furthermore, multidisciplinary team training, nurse empowerment, and the intentional involvement of mothers in monitoring and care provision may contribute to improving survival. Macro level interventions include the incorporation of ultrasound into World Health Organisation antenatal care guidelines to improve antenatal detection and the establishment of the infrastructure to enable parenteral nutrition provision for neonates in low- and middle-income countries. On a global level, gastroschisis has been suggested as a bellwether condition for evaluating access to and outcomes of neonatal surgical care provision.

Use of quality improvement (QI) methodology to decrease length of stay (LOS) for newborns with uncomplicated gastroschisis

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.

The factors associated with successful early enteral feeding in gastroschisis

BACKGROUND

Gastroschisis is the most common congenital abdominal wall defect. Due to the exposure of midgut to amniotic fluid, the recovery of bowel function is often delayed. This study aimed to identify the factors associated with the successful early enteral feeding in gastroschisis and to develop further guidelines of treatment.

METHODS

A retrospective cohort study of gastroschisis babies from January 2006 to December 2015 was done. Exclusion criteria were incomplete data and death. Successful early enteral feeding was defined when full feeding was achieved within 21 days of life.

RESULTS

One hundred and five gastroschisis patients were divided into a successful early-feeding group (n = 56, 53%) and a non-successful early-feeding group (n = 49, 46%). In multivariable analysis, significant factors for successful feeding clustered by primary treatment were female (RR = 1.38, P value < 0.001), gestational age > 36 weeks (RR = 1.23, P value < 0.001), age at surgery less than 10 h (RR = 1.15, P value < 0.001), postoperative extubation time < 4 days (RR = 1.39, P value < 0.001), and age when feeding started less than 10 days (RR = 35.69, P value < 0.001).

CONCLUSION

Several factors were found to be associated with successful early enteral feeding. The modifiable factors found in this study were surgery within 10 h, early postoperative extubation within 4 days, and feeding started before 10 days of life. These will guide the management of gastroschisis to achieve successful early enteral feeding.

Understanding gastroschisis and its clinical management: where are we?

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.

Variability in outcomes after gastroschisis closure across U.S. children's hospitals

BACKGROUND

In patients undergoing gastroschisis closure, the effects of timing of closure and patient and hospital-level characteristics on length of stay (LOS) and time to enteral autonomy are unknown.

STUDY DESIGN

Using the Pediatric Health Information System, we compared neonates who underwent early (within 1day of birth) versus delayed (>1day after birth) gastroschisis closure from 2005 to 2013. We evaluated the relationship between time to closure and both LOS and days on total parenteral nutrition (TPN).

RESULTS

Of 4459 neonates with gastroschisis, 43.9% underwent early closure and 56.1% underwent delayed closure. Delayed closure, complicated gastroschisis, government insurance, lower birth weight, older age at closure, and complex chronic conditions were associated with longer LOS and days on TPN (all p<0.05). There was significant inter-hospital variability in both outcomes, after adjusting for patient- and hospital-level characteristics, including hospitals' gastroschisis and neonatal volumes, median age at closure, and percentages of complicated and delayed gastroschisis patients, (p<0.01).

CONCLUSION

Delayed gastroschisis closure is associated with longer LOS and duration of TPN, even after excluding complicated cases. Furthermore, after controlling for hospital volume, rate of complicated gastroschisis, and timing of closure, the persistent inter-hospital variability suggests that practice variability is partially responsible for these differences.

TYPE OF STUDY

Retrospective study.

LEVEL OF EVIDENCE

III.

Gastroschisis. Case report and management in primary care services

Introducción. La gastrosquisis es una enfermedad de baja prevalencia, pero de muy buen pronóstico si se realiza un adecuado manejo inicial. El presente escrito tiene como objetivo realizar una descripción de esta patología, destacando la importancia de su correcto manejo en el primer nivel.Presentación del caso. Neonato a término con hallazgo de gastrosquisis en primer nivel quien fue remitido al servicio de neonatología de una institución de tercer nivel. El infante recibió manejo interdisciplinario y cierre quirúrgico gradual y tuvo evolución favorable tras 3 meses de hospitalización.Discusión. No existe claridad sobre la causa exacta de la gastrosquisis, ya que es una enfermedad multifactorial. Su diagnóstico puede realizarse desde la etapa prenatal mediante la ultrasonografía, un método que posee alta sensibilidad y especificidad para su detección.Conclusión. La gastrosquisis es una enfermedad que para su diagnóstico y tratamiento requiere de personal especializado en primer nivel, lo que garantiza un correcto manejo inicial y evita futuras complicaciones.

Does timing of gastroschisis repair matter? A comparison using the ACS NSQIP pediatric database

BACKGROUND

There is no consensus on optimal timing of gastroschisis repair. The 2012-2014 ACS NSQIP Pediatric Participant Use Data File was used to compare outcomes of primary versus staged gastroschisis repair.

METHODS

Cases were divided into primary repair (0-1day) and staged repair (4-14days). Baseline characteristics and outcomes were compared for primary versus staged closure using Fisher's exact tests for categorical variables and Wilcoxon rank-sum tests for continuous variables. Length of stay was compared after controlling for prematurity.

RESULTS

There were 627 subjects included, with 364 neonates in the primary group and 263 in the staged group. The primary group demonstrated shorter hospital length of stay (LOS) (5.1days; p<0.001) and had less surgical site infections (OR=0.27; p=0.003), but had longer ventilator days (1.9days; p<0.001). Neonates in the primary repair group were less likely to be discharged home versus transferred to another hospital (OR=0.24; p=0.006) and more likely to require nutritional support at discharge (OR=1.74; p=0.034). No significant differences were identified for mortality, readmissions, postoperative LOS, sepsis or other outcomes.

CONCLUSION

Staged repair of gastroschisis has longer LOS attributed to preoperative timing, but less ventilator days. Outcomes for these closure techniques are equivocal and support surgeons performing the closure technique they are most experienced with.

LEVEL OF EVIDENCE

III (Treatment: retrospective comparative study).

A systematic review of the quality of conduct and reporting of systematic reviews and meta-analyses in paediatric surgery

OBJECTIVE

Our objective was to evaluate quality of conduct and reporting of published systematic reviews and meta-analyses in paediatric surgery. We also aimed to identify characteristics predictive of review quality.

BACKGROUND

Systematic reviews summarise evidence by combining sources, but are potentially prone to bias. To counter this, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was published to aid in reporting. Similarly, the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) measurement tool was designed to appraise methodology. The paediatric surgical literature has seen an increasing number of reviews over the past decade, but quality has not been evaluated.

METHODS

Adhering to PRISMA guidelines, we performed a systematic review with a priori design to identify systematic reviews and meta-analyses of interventions in paediatric surgery. From 01/2010 to 06/2016, we searched: MEDLINE, EMBASE, Cochrane, Centre for Reviews and Dissemination, Web of Science, Google Scholar, reference lists and journals. Two reviewers independently selected studies and extracted data. We assessed conduct and reporting using AMSTAR and PRISMA. Scores were calculated as the sum of reported items. We also extracted author, journal and article characteristics, and used them in exploratory analysis to determine which variables predict quality.

RESULTS

112 articles fulfilled eligibility criteria (53 systematic reviews; 59 meta-analyses). Overall, 68% AMSTAR and 56.8% PRISMA items were reported adequately. Poorest scores were identified with regards a priori design, inclusion of structured summaries, including the grey literature, citing excluded articles and evaluating bias. 13 reviews were pre-registered and 6 in PRISMA-endorsing journals. The following predicted quality in univariate analysis:, word count, Cochrane review, journal h-index, impact factor, journal endorses PRISMA, PRISMA adherence suggested in author guidance, article mentions PRISMA, review includes comparison of interventions and review registration. The latter three variables were significant in multivariate regression.

CONCLUSIONS

There are gaps in the conduct and reporting of systematic reviews in paediatric surgery. More endorsement by journals of the PRISMA guideline may improve review quality, and the dissemination of reliable evidence to paediatric clinicians.

Gastroschisis: A Review of Management and Outcomes

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.

Variability of outcome reporting in Hirschsprung's Disease and gastroschisis: a systematic review

Heterogeneity in outcome reporting limits identification of gold-standard treatments for Hirschsprung’s Disease(HD) and gastroschisis. This review aimed to identify which outcomes are currently investigated in HD and gastroschisis research so as to counter this heterogeneity through informing development of a core outcome set(COS). Two systematic reviews were conducted. Studies were eligible for inclusion if they compared surgical interventions for primary treatment of HD in review one, and gastroschisis in review two. Studies available only as abstracts were excluded from analysis of reporting transparency. Thirty-five HD studies were eligible for inclusion in the review, and 74 unique outcomes were investigated. The most commonly investigated was faecal incontinence (32 studies, 91%). Seven of the 28 assessed studies (25%) met all criteria for transparent outcome reporting. Thirty gastroschisis studies were eligible for inclusion in the review, and 62 unique outcomes were investigated. The most commonly investigated was length of stay (24 studies, 80%). None of the assessed studies met all criteria for transparent outcome reporting. This review demonstrates that heterogeneity in outcome reporting and a significant risk of reporting bias exist in HD and gastroschisis research. Development of a COS could counter these problems, and the outcome lists developed from this review could be used in that process.