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

The Prognostic Impact of Defect Size Based on Body Surface Area in Omphaloceles

INTRODUCTION

This study addresses the existing gaps in understanding the cases with omphalocele by investigating the potential prognostic impact of the ratio between omphalocele diameter-and -body surface area (BSA), particularly in premature and low birth weight neonates.

MATERIAL AND METHODS

Data retrieved from the hospital files of 25 patients with omphalocele related to their gestational histories, demographics, anthropometric data, comorbidities, defect diameters, and prognoses were retrospectively analyzed. BSA was calculated using the Haycock Formula. Binary logistic regression analysis performed identified mortality-associated factors.

RESULTS

Most (84 %) of the patients with omphalocele, required mechanical ventilation, and the median hospital stay was 19 days. There was no significant correlation between defect diameter or defect diameter-to-BSA ratio and hospital stay. Mortality rate in these patients was 24 %, with a significantly higher mean (±SD) defect diameter-to-BSA ratio in non-survivors compared to survivors (467.9 ± 54.8 vs. 283.1 ± 24.8; p = 0.002). Logistic regression analysis identified the defect diameter-to-BSA ratio as a significant predictor of mortality (p = 0.023, Exp(B) = 1.038, 95 % CI: 1.005-1.072). Other variables, including defect size, cardiac anomalies, and solid organ presence in the sac, were not significant predictors.

CONCLUSION

This study underscores the superior prognostic value of the defect diameter-to-BSA ratio for omphalocele patients, surpassing conventional markers such as defect diameter, cardiac anomalies, and the presence of solid organs in the sac.

Combined negative pressure wound therapy with new wound dressings to repair a ruptured giant omphalocele in a neonate: a case report and literature review

BACKGROUND

Current treatment of giant omphalocele in newborns is not standardized. The main treatments include one-time repair and staged surgery using synthetic and biologic mesh, or silos. However, surgery can lead to various postoperative complications. Recently, negative pressure wound therapy (NPWT) has been recommended as an effective method for giant omphalocele. We adopted NPWT and some new wound dressings for a case of ruptured giant omphalocele. Vaseline gauze (VG), followed by silver-containing sodium carboxymethylcellulose dressing(CMC-Ag)was used to control infection. NPWT was mainly performed to promote granulation and accelerated healing. Recombinant human basic fibroblast growth factor (Rh-bFGF) was used to heal the wound. No studies have conducted NPWT and new wound dressings healing the wound of ruptured giant omphalocele. Therefore, we present our management experience in this case.

CASE PRESENTATION

The patient was a baby boy aged 2 days, weighing 2930 g. He was diagnosed with a giant omphalocele with a partial intestine exposed. Two hours after admission, the baby underwent a silo placement. The herniation of the bowel was gradually reduced into the abdominal cavity. At the age of 13 days, the stitches at the bottom of the silo fell off, and the liver was exposed with the defect size about 8 cm x 10 cm. The hole failed to be repaired by surgery. We used VG and CMC-Ag patched on the defect hole. After creating a moist and fresh environment, NPWT was then applied mainly to extract excess fluid and promote granulation. CMC-Ag was performed for 19 days when the wound showed no exudate or infection. NPWT was stopped at the age of 47 days when the granulation tissue was fully formed with the defect size reduced to 4.5 cm x 3.5 cm. After halting the NPWT, the wound was managed with Rh-bFGF and VG. At the age of 2 months, the wound was reduced to 1 cm x 1 cm with satisfactory epithelialization.

CONCLUSIONS

NPWT is a safe and effective alternative therapy for the repair of giant omphalocele. CMC-Ag can help control wound infection and manage exudate and Rh-bFGF promotes wound healing. NPWT combined with new wound dressings can effectively manage ruptured giant omphalocele.

CLINICAL TRIAL NUMBER

Not applicable.

Surgical management of a massive omphalocele in a newborn: A case report study

INTRODUCTION AND IMPORTANCE

Omphalocele is a rare congenital defect in the abdominal wall, affecting about 1 in 5000 to 10,000 newborns. It occurs when abdominal organs protrude through an opening at the base of the umbilical cord. Treating massive omphaloceles is highly challenging, requiring innovative and staged surgical methods to avoid complications like increased intra-abdominal pressure and potential organ damage.

CASE PRESENTATION

A female newborn with a 12.5 cm omphalocele was delivered emergently via cesarean section due to fetal distress. The exposed organs, including parts of the intestines and liver, were covered by a thin membrane. To minimize complications, a staged approach was opted for: first, a silo was placed to gradually reduce the herniated organs, followed by closure of the abdominal wall with absorbable sutures and biologic mesh.

CLINICAL DISCUSSION

Omphalocele in newborns is a serious congenital defect where abdominal organs protrude through the umbilical cord, covered by a membrane. It requires urgent medical care to prevent complications like respiratory distress and infections. Treatment typically involves a team of pediatric surgeons and staged surgeries to repair the defect and ensure the infant's long-term health.

CONCLUSION

The successful staged surgical method of silo reduction and biologic mesh for this massive omphalocele highlights the need for personalized surgical planning and multidisciplinary care. Six months later, the patient is thriving, showing no signs of recurrence or complications.

Long-Term Assessment of Aesthetic Results in Omphalocele Repair with POSAS Scale

INTRODUCTION

Omphalocele (OM) is a congenital defect of the abdominal wall. The main goal of the surgical management is the survival of the neonate. However, the residual scar following the surgery can be extremely burdensome and negatively impact the quality of life (QoL) of these patients. The aim of this study is to assess the cosmetic results of the surgical treatment, the level of satisfaction of patients and surgeons, and the influence of the scar on the QoL of the patient.

MATERIALS AND METHODS

We conducted an observational retrospective cross-sectional study collecting all data regarding patients born with OM, operated at our Centre between 1998 and 2021. The cosmetic results of the surgical repair were evaluated using the validated Patient and Observer Scar Assessment Scale (POSAS). The assessment of the quality of life determined by the presence of the scar was conducted using PedQL 4.0. At last, the patients were visited by two paediatric surgeons and a medical student, which then scored the cosmetic result of the scar. Statistical analysis was conducted with Spearman linear correlation and Mann-Whitney test. A P-value below 0.05 was considered statistically significant.

RESULTS

In our study, we included a total of 19 patients, with a mean of 12 years of age at the time of the evaluation. The parameters with the major influence on the patient's general opinion of the scar were stiffness, thickness, and irregularity. We discovered significant differences in median values of all scores between the giant OM group and the nongiant OM group, in favour of the latter. Finally, we found a low grade of concordance between PedsQL filled by parents and patients.

CONCLUSION

The POSAS scale is a valid, feasible, and reliable tool for the assessment of the aesthetic outcome of surgical procedures. The original size of the defect is the most important factor acting on the result. However, it is crucial that any decision on plastic surgery to improve the looks of the scar must be postponed to the adult age of the patient.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Clinical characteristics and outcome of omphalocele and gastroschisis: a 20-year multicenter regional experience

Omphalocele and gastroschisis are the most common types of abdominal wall defects. Comprehensive local experience helps parents to make decisions on the pregnancy and foresee the disease journey. A retrospective review of abdominal wall defect patients in all three pediatric surgical centers in Hong Kong between January 2003 and February 2023 was conducted. All patients consecutively diagnosed with omphalocele and gastroschisis were included, excluding other forms. Data of demographics and short- and long-term outcome parameters were collected. A total of 99 cases were reviewed and 85 patients met the inclusion criteria. Diagnoses include omphalocele major (n = 49, 57.6%), omphalocele minor (n = 22, 25.9%) and gastroschisis (n = 14, 16.5%), with mean gestational age 37 weeks (SD 2.2) and birth weight 2.7 kg (SD 0.6). Omphalocele is most commonly associated with cardiovascular (n = 28, 39.4%) and chromosomal defects (n = 11, 15.5%). Surgical procedures including primary repair (n = 38, 53.5%), staged closure (n = 30, 42.3%) with average 8.6 days (SD 4.7) of silo reduction, and conservative management (n = 3, 4.2%) were performed. The mortality rate was 14.1% (n = 10) and the complication rate was 36.6% (n = 26). The majority of patients had normal intellectual development (92.5%) and growth (79.2%) on the latest follow-up. For gastroschisis, one patient (7.1%) had intestinal atresia. Surgical procedures included primary repair (n = 9, 64.3%) and staged closure (n = 5, 35.7%) with average 8 days (SD 3.5) of silo reduction. Complication rate was 21.4% (n = 3), with one mortality (7.1%). All patients had normal intellectual development and growth. The mean follow-up time of this series is 76.9 months (SD 62.9). Most abdominal wall defects in our series were managed surgically with a good overall survival rate and long-term outcome. This information is essential during antenatal and postnatal counseling for parents.

Ruptured giant omphalocele with congenital short small intestine: a case report

We herein present a case of a ruptured giant omphalocele with congenital short small intestine. Vacuum-sealing drainage and carboxymethylcellulose silver dressing promoted wound healing after repair, avoided abdominal compartment syndrome, and reduced the risks of multiple procedures. We review the perioperative management of omphaloceles in congenital short small intestines.

Use of a new vertical traction device for early traction-assisted staged closure of congenital abdominal wall defects: a prospective series of 16 patients

PURPOSE

Abdominal wall closure in patients with giant omphalocele (GOC) and complicated gastroschisis (GS) remains to be a surgical challenge. To facilitate an early complete abdominal wall closure, we investigated the combination of a staged closure technique with continuous traction to the abdominal wall using a newly designed vertical traction device for newborns.

METHODS

Four tertiary pediatric surgery departments participated in the study between 04/2022 and 11/2023. In case primary organ reduction and abdominal wall closure were not amenable, patients underwent a traction-assisted abdominal wall closure applying fasciotens®Pediatric. Outcome parameters were time to closure, surgical complications, infections, and hernia formation.

RESULTS

Ten patients with GOC and 6 patients with GS were included. Complete fascial closure was achieved after a median time of 7 days (range 4-22) in GOC and 5 days (range 4-11) in GS. There were two cases of tear-outs of traction sutures and one skin suture line dehiscence after fascial closure. No surgical site infection or signs of abdominal compartment syndrome were seen. No ventral or umbilical hernia occurred after a median follow-up of 12 months (range 4-22).

CONCLUSION

Traction-assisted staged closure using fasciotens®Pediatric enabled an early tension-less fascial closure in GOC and GS in the newborn period.

A case series of successfully managing exomphalos major with awake graduated compression dressing and early enteral feeding

INTRODUCTION

Exomphalos anomaly is defined as the herniation of abdominal viscera into the base of the umbilical cord, with only a membranous sac covering these contents. It has an incidence of approximately 1 in 4000-6000 births. Management of exomphalos major (EM) remains controversial and limited, with very few studies to guide decision-making.

METHOD

This is a case series of four neonates with EM treated at a tertiary paediatric referral centre between 2018 and 2021 with a gradual compression dressing technique.

RESULTS

Four neonates were diagnosed with EM. The average gestational age was 38 + 5 (range 38 + 2 - 39 + 2), and the average birth weight was 3.1 kg (range 2.56 - 3.49 kg). The defect size ranged between 5 and 7 cm. All patients were commenced on gradual compression dressing between days 1 and 3 of life. Dressings were applied at the bedside in the general neonatal ward. The average time taken to reach full feeds was 1 week; only one patient required parenteral nutrition. Three underwent surgical repair at two and 16 weeks of age; one had delayed repair at the age of 1 year because of the COVID-19 pandemic. None required patch repair. None required prolonged ventilation after repair.

CONCLUSION

This case series describes a successful compression dressing technique that reduces sac content without the need for general anaesthetic or respiratory compromise, whereby simultaneous enteral feeding is tolerated.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Magnetic resonance imaging of fetal abdominal pathology: a complementary tool to prenatal ultrasound

Fetal magnetic resonance imaging (MRI) is increasingly being used worldwide as a complementary tool to prenatal ultrasound (US) for multiple fetal pathologies. The aim of this article is to describe and illustrate how MRI can help US to evaluate fetal abdominal anomalies, based on cases performed in a tertiary public university hospital. Prenatal US, fetal MRI and postnatal imaging of these cases will be shown side-by-side to describe and illustrate the added value of fetal MRI in the different organs/systems and its impact on clinical management.

Abdominal wall defect repair with component separation technique for giant omphalocele with previous relaxing incisions on the abdominal skin

BACKGROUND

The repair of large abdominal wall defects that cannot be closed primarily is quite challenging. The component separation technique (CST) is a surgical approach using autologous tissue to close large abdominal wall defects. The CST requires extensive dissection between the abdominal skin and the anterior sheath of the rectus abdominis muscle. Subsequently, incisions are made at both sides of the external oblique aponeurosis, releasing the external oblique muscle from the internal oblique muscle, and then the right and left rectus abdominis muscles are brought together in the midline for defect closure. However, impairment of blood flow in the abdominal wall skin and necrotic changes are recognized as potential complications.

CASE PRESENTATION

The CST was performed in a 4-year-old boy with a large ventral hernia who had undergone skin closure with abdominal wall relaxing incisions for the primary treatment of giant omphalocele in the neonatal period. Given his history of incisions on the abdominal wall, he was speculated to be at high risk for postoperative skin ischemia. Dissection was therefore kept to a minimum to preserve the blood supply from the superior and inferior epigastric arteries and perforating branches of those arteries through the rectus abdominis muscle. In addition, care was taken to adjust the muscle relaxant dosage while monitoring the intravesical pressure, ensuring that it did not exceed 20 mmHg to avoid impaired circulation in the abdominal wall caused by abdominal compartment syndrome. He was discharged 23 days after the surgery without any complications, and neither recurrence of the ventral hernia nor bowel obstruction was observed in 4 years.

CONCLUSIONS

A giant omphalocele with primary skin closure was treated by applying the CST. The procedure can be performed safely while preserving the blood flow to the abdominal wall, even in patients with a history of relaxing incisions on the abdominal skin. The CST is expected to be effective for repairing the large abdominal wall defects seen in giant omphalocele when primary closure is not possible.

Delayed Surgical Management of an Unusual Classic Bladder Exstrophy Variant

Anterior abdominal wall defects are rare anomalies that can affect multiple organ systems including gastrointestinal, genitourinary, musculoskeletal, and the neurospinal axis. The highly varied, complex anatomy in this patient population creates a challenging reconstruction scenario that merits careful surgical planning. We present an unusual female variant with an anorectal malformation as well as musculoskeletal and genital abnormalities consistent with classic bladder exstrophy in which the urinary bladder, sphincter, and urethra were largely uninvolved.

Evaluation and Management of Noncardiac Comorbidities in Children With Congenital Heart Disease

Outcomes for patients with neonatal heart disease are affected by numerous noncardiac and genetic factors. These can include neonatal concerns, such as prematurity and low birth weight, and congenital anomalies, such as airway, pulmonary, gastrointestinal, and genitourinary anomalies, and genetic syndromes. This section will serve as a summary of these issues and how they may affect the evaluation and management of a neonate with heart disease. These noncardiac factors are heavily influenced by conditions common to neonatologists, making a strong argument for multidisciplinary care with neonatologists, cardiologists, surgeons, anesthesiologists, and cardiovascular intensivists. Through this section and this project, we aim to facilitate a comprehensive approach to the care of neonates with congenital heart disease.

Giant omphalocele associated pulmonary hypertension: A retrospective study

BACKGROUND

Omphalocele is a common congenital defect of the abdominal wall, management of giant omphalocele (GO) is particularly for pediatric surgeons and neonatologists worldwide. The current study aimed to review and summarize the clinical features and prognosis in neonates with GO complicated with pulmonary hypertension (PH), which is associated with increased mortality, while in hospital.

MATERIALS AND METHODS

Medical records of infants with GO between July 2015 and June 2020 were retrospectively analyzed. The patients enrolled were divided into PH and non-PH groups based on the presence or absence of PH, and patients with PH were divided into death and survival groups based on survival status. Clinical characteristics and outcomes were compared between groups, respectively. The risk factors for PH were analyzed by binary logistic regression.

RESULTS

In total, 67 neonates were identified as having GO and 24 (35.8%) were complicated with PH. Infants with PH were associated with intubation within 24 h after birth (p = 0.038), pulmonary dysplasia (p = 0.020), presence of patent ductus arteriosus (PDA; p = 0.028), a staged operation (p = 0.002), longer mechanical ventilation days (p < 0.001), oxygen requirement days (p < 0.001), parenteral nutrition (PN) days (p < 0.001), length of neonatal intensive care unit (NICU) or hospital stay (p = 0.001 and 0.002, respectively), and mortality (p = 0.001). The results of multivariable logistic regression analysis revealed that a staged operation was independently associated with PH. In addition, PH patients with lower birth weight, higher peak of pulmonary arterial systolic pressure, and refractory to pulmonary vasodilators (PVD) had increased mortality.

CONCLUSION

Pulmonary hypertension is a serious complication and significantly increases the mortality and morbidities in infants with a GO. In addition, early and serial assessment of PH by echocardiography should be a routine screening scheme, especially in the neonatal omphalocele population who required a staged surgical repair. Clinicians should be aware that infants with PH who had low weight, severe and refractory PH have a higher risk of death.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TYPE OF STUDY

Retrospective Study Level of Evidence: Level IV.

[Conservative treatment of giant omphaloceles with dissodic 2% aqueous eosin: a case serie]

La fermeture chirurgicale primaire dans le traitement de l´omphalocèle géante est émaillée des complications. Le traitement conservateur est une option adaptée aux pays à faible revenu où la chirurgie te la réanimation néonatales sont pourvoyeuses d´une grande mortalité. Ceci est une étude prospective menée aux cliniques universitaires de Lubumbashi, incluant les patients reçus entre janvier et avril 2020 et qui ont bénéficié d´un traitement conservateur à l´éosine aqueuse disodique selon un protocole défini. Trois patientes ont été inclues dans notre série. L´âge moyen était de 24 heures (1 - 48), toutes nées à terme (38 - 39 SA), et par voie basse, sans aucun diagnostic anténatal posé. La moyenne du poids de naissance était de 2.800 grammes (2.400 - 3.000). Le diamètre moyen du sac était de 13,7 cm (11 - 15 cm), le sac contenant le foie dans tous les cas. Le délai moyen de nutrition entérale était de 4,3 jours (4 - 5 jours), celui de granulation était de 31,7 jours (30 - 33 jours) et celui d´épithélialisation était de 71,7 jours (60 - 90 jours). Aucun décès n´a été déploré. Ces résultats préliminaires encouragent l´utilisation de l´éosine aqueuse disodique dans le traitement conservateur des omphalocèles géantes non rompues.

Abdominal Wall Defects

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.

Exomphalos major: Conservative management using Manuka honey dressings and an outreach surgical nursing team

INTRODUCTION

Controversy exists over the best dressing for conservative management of exomphalos major. Here we describe our experience of using Manuka Honey.

METHODS

Our regimen involved covering the sac with Manuka honey (Advancis Medical™) wrapped with gauze and crepe bandage. Initially, dressings were changed 3 times a week and then twice weekly until full epithelialisation. Babies went home after reaching full feeds, with our outreach nurses continuing dressings in clinic until the parents were trained to do them alone. Only patients needing management of co-morbidities were transferred to our unit. Patients would be reviewed by video consultation. Data was prospectively collected.

RESULTS

From 2011-2019, 24 consecutive patients (11:13 M:F; median gestation 37 weeks, birth weight 3.1 kg) with exomphalos major were managed with honey dressings. Fourteen babies had significant associated anomalies of which 10 died of problems unrelated to the exomphalos. Time to full feeds 6 (2-58) days; time to discharge 21(7-66) days if no associated anomalies; time to epithelialisation 73 (27-199) days. Dressings were well tolerated. Definitive closure occurred at 17(11-38) months and was uneventful. No patient required fundoplication and all patients were orally fed. Only one patient developed a clinically significant infection.

CONCLUSION

This is the largest report of using Manuka honey for the management of exomphalos major. Benefits include early feeding, early discharge and a 'normalisation' of the neonatal period. Key to our success was the surgical outreach service supporting parents doing the dressings, first at the local hospital and then at home.

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

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

Management of giant omphalocele with a simple and efficient nonsurgical silo

INTRODUCTION

Giant omphaloceles can be a challenge for pediatric surgeons and neonatologists worldwide. It is a rare and low-frequency congenital anomaly with no standardized management schemes or treatment protocols. Over the past few decades, we have developed a simple and efficient staged management for giant omphaloceles that allows definitive closure in the neonatal period, the results of which we outline in this report.

MATERIAL AND METHODS

With IRB approval, a retrospective and multicentric cohort study was carried out between 1994 and 2019 with patients with giant omphalocele defined as an abdominal wall defect greater than 5 cm in diameter and/or that contains more than 50% of the liver within the sac. We included all patients managed with the nonsurgical silo technique. Data on demographics, gestational age, associated malformations, amnion reduction and inversion time, anatomic closure, requirement of a mesh, intra- and post-silo complications, mortality and follow-up were collected. The technique consists of the construction of a silo with an adhesive hydrocolloid dressing (DuodermⓇ) to achieve an omphalocele staged-reduction until complete abdominal reintegration of the liver and bowel preservation of the amnion sac. This also enables the simulation of abdominal closure before definitive surgical closure, being managed in the neonatal intensive care unit (NICU).

RESULTS

Forty patients, 21 of whom were female, were managed with this technique. The average weight was 2900 gs (890-3900), and the median gestational age was 38 weeks (28-40). In total, 37.5% of cases had an associated comorbidity. The average silo reduction time was 7.3 days (0-35), the average time of amnion inversion was 5 days (2-9), and the average time to closure was 14.6 days (6-38). Anatomical closure was achieved in 95% of cases. In 4 patients, an absorbable mesh was used to reinforce the anatomical closure, and in 2 patients (5%), a mesh (DualmeshⓇ) was required to achieve an abdominal closure. There was no mortality associated with this nonsurgical silo technique. The average follow-up time was 60 (6 - 288) months.

CONCLUSION

The staged silo management of giant omphalocele in this series is safe and effective and reduces the time to closure and potential morbidity and mortality compared with traditional surgical or medical management.

Abdominal wall defects

Abdominal wall defects are common congenital anomalies with the most frequent being gastroschisis and omphalocele. Though both are the result of errors during embryologic development of the fetal abdominal wall, gastroschisis and omphalocele represent unique disorders that have different clinical sequelae. Gastroschisis is generally a solitary anomaly with postnatal outcomes related to the underlying integrity of the prolapsed bowel. In contrast, omphalocele is frequently associated with other structural anomalies or genetic syndromes that contribute more to postnatal outcomes than the omphalocele defect itself. Despite their embryological differences, both gastroschisis and omphalocele represent anomalies of fetal development that benefit from multidisciplinary and translational approaches to care, both pre- and postnatally. While definitive management of abdominal wall defects currently remains in the postnatal realm, advancements in prenatal diagnostics and therapies may one day change that. This review focuses on recent advancements, novel techniques, and current controversies related to the prenatal diagnosis and management of gastroschisis and omphalocele.

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

INTRODUCTION

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVELS OF EVIDENCE

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

Complex ventral hernia repair in a child: An association of botulinum toxin, progressive pneumoperitoneum and negative pressure therapy. A case report on an arising surgical technique

•

Giant omphalocele establish a therapeutic challenge to the surgeon - mainly because of the increased visceroabdominal disproportion and underlying malformations - and the best approach is still debatable worldwide.

•

This is the second report on the literature and states the management of a child born with giant omphalocele that developed a very complex ventral hernia secondary to an unsuccessful attempt of closing the primary defect.

•

It seems that the use of botulinum toxin agents in the abdominal wall is safe and effective in children with giant omphaloceles and it eliminates the use of a mesh even in more difficult cases.

•

This technique seems safe and effective and it should be encouraged and best evaluated.

•

It is time to start defining better criteria to categorize giant omphalocele in order to choose the best management for each patient.

Introduction

The purpose of this manuscript is to report the management of a child born with giant omphalocele (GO) that developed a complex ventral hernia secondary to an unsuccessful attempt of closing the primary defect.

Presentation of case

The patient underwent a one-step surgery to correct a ventral hernia associated with a largely prolapsed enteroatmospheric fistula (EAF) along with an ileostomy. It was managed by a pre-operative association of botulinum toxin agent (BTA) application with preoperative progressive pneumoperitoneum (PPP) and trans-operative negative pressure wound therapy (NPWT) dressing with staged abdominal closure. The patient needed 4 reoperations due to enteric fistulas. Nine days after the first surgery, it was possible to completely close the abdominal wall without mesh substitution. No signs of hernia in 9 months of follow-up.

Discussion

This is the second report in the literature and it reinforces the safety and effectiveness of the BTA injection associated with PPP in children.

Conclusion

The use of BTA in association with PPP should be encouraged and best investigated in patients with GO. The fistulas were not attributed to the negative pressure. Maybe it is time to start defining better criteria to categorize GO in order to choose the best management for each patient.

Complex abdominal wall reconstruction after oncologic resection in a sequalae of giant omphalocele: A case report

INTRODUCTION

Trauma injuries and oncologic resection are common aetiologies of complex abdominal wall defect. Reconstruction of abdominal wall is an everlasting question for general, paediatric and reconstructive surgeons. The plethora of techniques, bioprosthetic and engineered tissues offer countless possibilities.

PRESENTATION OF CASE

The patient was a 28 years old woman, with past history of untreated giant liver omphalocele, admitted for a suspicious hepatic tumefaction without specific clinical signs. The thoraco abdominopelvic CT scan revealed lung metastasis and a bilobed left hepatic tumour. Pre-operative cytologic findings of mild differentiated hepatocellular carcinoma differed from the post-operative findings of hepatoblastoma. The full-thickness abdominal wall defect after a radical resection was reconstructed with a combined acellular dermal matrix, NPWT and skin graft solution. A total epithelization was obtained after 8 weeks follow-up.

DISCUSSION

Hepatoblastoma in adult is rare, with no consensus. A radical resection in context of giant untreated omphalocele is an unusual challenge for the surgical team. The pre-operative evaluation, the defect classification and the general conditions of the patient are paramount steps for an appropriate reconstruction. Primary or delayed reconstruction with myocutaneous flap as gold standard, depends on the oncologic management and anticipated post-operative complications. Acellular dermal matrix used for a bridged fascial repair directly on viscera and covered by NPWT, favourited a healthy granulation tissue. The full-thickness defect was then reconstructed with an ADM, NPWT and skin graft instead of an association with the myocutaneous flap. The patient follow-up was emphasized in the hepatoblastoma, but the complications of this reconstruction strategy are unknown. A total epithelization was obtained, the abdominal bulge or hernia is the first complication under surveillance.

CONCLUSION

Delayed reconstruction after an oncologic large abdominal wall resection has the advantage to manage post-operative complications and prepare alternative solutions. Acellular dermal matrix was not first designed for skin tissue regeneration, some authors as us experimented the conclusion that this matrix could be used for permanent abdominal wall reconstruction.

Omphalocele-What should we tell the prospective parents?

An omphalocele is a congenital defect in the abdominal wall characterized by absent abdominal muscles, fascia, and skin. The characteristic ultrasound appearance includes a midline defect with herniation of abdominal contents into the base of the umbilical cord. Other anatomic abnormalities are seen in approximately 50% of cases, most notably cardiac defects (19%-32%). Approximately, 50% of cases are associated with genetic and multiple malformation syndromes including trisomy 13/18, pentalogy of Cantrell and Beckwith-Wiedemann syndrome. Therefore, a thorough evaluation is recommended, including detailed anatomic survey, fetal echocardiogram, genetic counseling, and prenatal diagnostic testing. Overall prognosis depends on the size of the omphalocele, genetic studies, and associated anomalies. Early prenatal diagnosis remains important in order to provide parental counseling and assist in pregnancy management. Delivery should occur at a tertiary care center. Timing and mode of delivery should be based on standard obstetric indications with cesarean delivery reserved for large omphalocele (>5 cm) or those that involve the fetal liver. Neonatal management involves either primary or staged reduction, both of which can be associated with a prolonged neonatal hospitalization.

Mortality in neonates with giant omphalocele subjected to a surgical technique in Barranquilla, Colombia from 1994 to 2019

No studies of the efficacy and safety of surgical techniques for the primary closure of giant omphalocele have been performed in Colombia. To determine the mortality rate and factors associated with mortality in neonates with giant omphalocele subjected to the surgical technique of early closure with a surgical silo described by Abello in Barranquilla, Colombia from 1994 to 2019. Retrospective cohort study of 30 neonates diagnosed with giant omphalocele and subjected to early closure of the defect. Medical history data were collected, information bias was controlled for, and descriptive statistical analysis was performed using Fisher’s exact test and the Mann–Whitney U test in SPSS 25.0. Of the patients in the cohort, 36.7% presented technique-related complications, 56.7% developed sepsis, 23.3% had low birth weight, 26.7% were preterm births, 43.3% had other malformations, 26.7% had congenital heart defects, and 13.3% presented pulmonary hypertension. The mean hospital stay was 26 days. The mortality rate was 16.7%; it was significantly higher among patients with other malformations, congenital heart defects, pentalogy of Cantrell and pulmonary hypertension. The Abello technique for the treatment of giant omphalocele showed a high neonatal survival rate and a low rate of procedure-related complications. The main factors associated with the death of neonatal patients were the presence of other malformations, congenital heart defect, pentalogy of Cantrell and pulmonary hypertension.

Long-term hospital admissions and surgical treatment of children with congenital abdominal wall defects: a population-based study

Congenital abdominal wall defects, namely, gastroschisis and omphalocele, are rare congenital malformations with significant morbidity. The long-term burden of these anomalies to families and health care providers has not previously been assessed. We aimed to determine the need for hospital admissions and the requirement for surgery after initial admission at birth. For our analyses, we identified all infants with either gastroschisis (n=178) or omphalocele (n=150) born between Jan 1, 1998, and Dec 31, 2014, in the Register of Congenital Malformations. The data on all hospital admissions and operations performed were acquired from the Finnish Hospital Discharge Register between Jan 1, 1998, and Dec 31, 2015, and compared to data on the whole Finnish pediatric population (0.9 million) live born 1993-2008. Patients with gastroschisis and particularly those with omphalocele required hospital admissions 1.8 to 5.7 times more than the general pediatric population (p<0.0001). Surgical interventions were more common among omphalocele than gastroschisis patients (p=0.013). At the mean follow-up of 8.9 (range 1.0-18.0) years, 29% (51/178) of gastroschisis and 30% (45/150) of omphalocele patients required further abdominal surgery after discharge from the neonatal admission.Conclusion: Patients with gastroschisis and especially those with omphalocele, are significantly more likely than the general pediatric population to require hospital care. Nevertheless, almost half of the patients can be treated without further surgery, and redo abdominal surgery is only required in a third of these children. What is Known: • Gastroschisis and omphalocele are congenital malformations with significant morbidity • There are no reports on the long-term need for hospital admissions and surgery in these children What is New: • Patients with abdominal wall defects are significantly more likely than the general pediatric population to require hospital care • Almost half of the patients can be treated without further surgery, and abdominal redo operations are only required in a third of these children.

Treatment of Ruptured Giant Omphalocele and Gastroschisis with Liver Herniation using a Wound Retractor as a Novel Approach

Ruptured giant omphaloceles (GO) and gastroschisis with total liver herniation are rare cases of exceptionally large abdominal wall defects. Many of these children have lethal outcome. The surgical and postsurgical management are complex. We report on two cases treated with staged surgical repair using a wound retractor as a silo. With this technique, the liver and intestines could be reduced into the abdomen with secondary closure of the abdominal cavity within the first 1 to 2 weeks of life.

Successful abdominal wall closure following collagen-based artificial dermis induced epithelialization for giant omphalocele: A case report

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A giant omphalocele (GO) is related to higher rates of morbidity and mortality.

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No consensus exists on optimal GO management, which may be surgically challenging.

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We report the successful GO management of a neonate with numerous complications.

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We applied a collagen-based artificial dermis for epithelization as a new treatment.

Introduction

A giant omphalocele (GO) with marked viscero-abdominal disproportion is associated with surgical difficulty and higher morbidity and mortality rates. Despite various treatment strategies, no consensus exists on optimal GO management. We report the clinical course of a neonate with a GO who was successfully treated with abdominal-wall closure through the novel application of collagen-based artificial dermis (CAD) for epithelization.

Presentation of case

A female neonate (estimated gestational age, 38 weeks; birthweight, 3.047 kg) with a GO where most viscera, including the liver, were completely herniated. G-band analysis showed no chromosomal abnormality and normal karyotype. Conventional silo formation was attempted, but incomplete silo was formed due to adhesion between the portal vein and fascia, and repatriation of the herniated viscera had not progressed. A new silo was formed using biomaterial, but it was infected and removed. Abdominal wall epithelialization using NPWT was attempted again but was interrupted by the occurrence of jejunal perforation. After incising the epithelialized part of the abdominal wall and repairing the perforated jejunum, the GO was covered and fixed using CAD. Epithelialization progressed well, and she was discharged on day 328.

Discussion

In this case, the major therapeutic challenges (including formation of an incomplete silo, silo infection, and jejunal perforation) were overcome with conventional treatment except for epithelialization of the abdominal wall, which was achieved by using CAD.

Conclusion

The treatment with CAD for epithelialization can be considered in cases where it is extremely difficult to return the viscera in conventional management.

Outcomes in the giant omphalocele population: A single center comprehensive experience

BACKGROUND/PURPOSE

Morbidity and mortality in the giant omphalocele population is complicated by large abdominal wall defects, physiologic aberrancies, and congenital anomalies. We hypothesized different anomalies and treatment types would affect outcomes.

METHODS

A 2009-2018 retrospective chart review of giant omphaloceles was performed. Exclusions included cloacal exstrophy, transfer after 3 weeks, surgery prior to transfer, conjoined twins, or not yet achieving fascial closure. Thirty-five patients met criteria and mortality and operative morbidity categorized them into favorable (n = 20) or unfavorable (n = 15) outcomes. Odds ratios analyzed potential predictors. Survivors were stratified into staged (n = 11), delayed (n = 8), and primary closure (n = 6) for subgroup analysis.

RESULTS

Unfavorable outcomes were associated with other major congenital anomalies, sac rupture, and major cardiac anomalies, but had significantly lower odds with increasing gestational age (p = 0.03) and birth weight (p < 0.001). In survivors, the primary group was younger at repair (p < 0.001) and had shorter length of stay (hospital p = 0.02, neonatal intensive care unit p = 0.005). There was no significant difference for sepsis, ventilator days, return to the operating room, or ventral hernia.

CONCLUSIONS

Predictions of overall outcomes in the giant omphalocele population require analysis of multiple variables. Our findings demonstrated increased odds of unfavorable outcomes in major cardiac anomalies, pulmonary hypertension, genetic diagnosis, other major anomalies, polyhydramnios, postnatal sac rupture, increasing omphalocele sac diameter, lower O/E TLV, lower gestational age at birth, lower birth weight, and repair other than primary. In those surviving to repair, surgical outcomes analyses demonstrated an earlier age of repair and a shorter length of stay for those patients able to be closed primarily; however further research is necessary to determine overall superiority between operative treatment types.

LEVEL OF EVIDENCE

Level III.

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.

Ventral hernia secondary to giant omphalocele in a child: combined approach of botulinum toxin and preoperative progressive pneumoperitoneum

Omphalocele is a congenital abdominal wall defect that occurs approximately 1 in 4000-6000 live births. The abdominal-visceral disproportion, large diameter of the defect, volume of liver in the sac along with high incidence of associated anomalies make the surgical management a real challenge. Currently, there are two strategies for managing giant omphaloceles, staged surgical closure and nonoperative delayed closure. The combined treatment with PPP and BoNT/A injection has recently been described in adults. There is strong evidence on safety and efficacy of the use of BoNT/As in other areas of pediatrics and no recent reports of PPP use in children. Also, there are no data available about the combination of both techniques in pediatric population. The purpose of this manuscript is to report a case of a 7-year-old female child that was referred to our institution with a large ventral hernia secondary to omphalocele. We opted for a combined approach with BoNT/A injection and PPP before the definitive surgery. The surgical result was great with midline closure with no tension and no need for prosthetic substitution or component separation needed. To our knowledge, this is the first case report of BoNT/A injection and PPP for large ventral hernias in children. BoNT/A application was safe and the PPP technique was also proved to be applicable on children. We believe that the combination of BoNT/A and PPP presented to be a safe approach with an excellent result, particularly for not needing abdominal wall prosthetic substitution.

Surgical management of critical congenital malformations in the delivery room

Newborn emergencies that occur in the delivery room are frequently the result of life-threatening congenital anomalies that can result in death or severe disability if not treated in the immediate postnatal period. Prompt recognition and treatment of such disorders are paramount to ensuring the wellbeing of the infant. As congenital anomalies are frequently being diagnosed earlier due to improved prenatal detection, the coordination of planned interventions for life-threatening malformations is also becoming more common. This article serves as a guide for the presentation and initial management of the most common non-cardiac, newborn surgical emergencies.

Management of Giant Omphalocele Leading to Early Fascial Closure

Objective

The aim of the study was to present the clinical outcomes of patients diagnosed with giant omphalocele, treated with early primary closure combined with bandaging and povidone-iodine staining and powder spray antibiotics.

Materials and methods

The study included a total of 22 infants with omphalocele. The omphalocele sacs of the patients were cleaned daily with topical povidone-iodine. A powdered spray antibiotic combination was then applied topically twice a day and the sac was wrapped in a sterile elastic bandage. Following the observation of eschar formation and epithelization, the patients were operated on in the early period and the sac was removed by placing a graft.

Results

Evaluation was made of a total of 14 female and eight male patients with mean duration of conservative monitoring of 11 days and mean total hospital stay of 35. The mean giant omphalocele (GO) defect size of the patients followed-up was 10 cm. Since seven of the patients in the present study died in the 1^st week, conservative and elastic bandages were applied for the GO treatment of 15 patients for 9-14 days. After the conservative follow-up, it was determined that the patients who were applied with a graft at an average of 11 days were hospitalized for an average of 24 days postoperatively.

Conclusion

In conclusion, it is possible to reduce the length of hospital stay with primary closure in the early period by providing faster epithelialization with the combination of povidone-iodine and antibiotic powder together with elastic bandage application in infants with GO.

Omphalocele at school age: What do parents report? A call for long-term follow-up of complex omphalocele patients

OBJECTIVE

Many children with omphalocele experience morbidity in early life, which could affect long-term outcomes. We determined parent-reported outcomes in school-aged children treated for minor or giant omphalocele.

STUDY DESIGN

We sent paper questionnaires to the parents of all children treated for omphalocele in 2000-2012. Giant omphalocele was defined as defect diameter ≥ 5 cm with liver protruding. Motor function (MABC-2 Checklist) was compared with Dutch reference data; cognition (PedsPCF), health status (PedsQL), quality of life (DUX-25) and behavior (Strengths and Difficulties Questionnaire; SDQ) were compared with those of controls (two per child) matched for age, gender and maternal education level. Possible predictors of cognition and behavior were evaluated using linear regression analyses.

RESULTS

Of 54 eligible participants, 31 (57%) returned the questionnaires. MABC-2 Checklist scores were normal for 21/26 (81%) children. Cognition, health status, quality of life and behavior were similar to scores of matched controls. One quarter (26%) of children with omphalocele scored ≤ - 1 standard deviation on the PedsPCF, compared with 9% of matched controls (p = 0.07). Giant omphalocele and presence of multiple congenital anomalies (MCA) were most prominently associated with lower PedsPCF scores (giant omphalocele: β -22.11 (95% CI: -43.65 to -0.57); MCA -23.58 (-40.02 to -7.13)), although not significantly after correction for multiple testing.

CONCLUSIONS

Parent-reported outcomes of children with omphalocele at school age are reassuring. Children with an isolated, minor omphalocele do not need extensive long-term follow-up of daily functioning. Those with a giant omphalocele or MCA might be at risk for delayed cognitive functioning at school age; we recommend long-term follow-up to offer timely intervention.

The validity of the viscero-abdominal disproportion ratio for type of surgical closure in all fetuses with an omphalocele

OBJECTIVE

To determine the predictive value of the fetal omphalocele circumference/abdominal circumference (OC/AC) ratio for type of surgical closure and survival and to describe the trajectory of OC/AC ratio throughout gestation.

METHODS

This cohort study included all live-born infants prenatally diagnosed with an omphalocele in our tertiary centre (2000-2017) with an intention to treat. The OC/AC ratio and liver position were determined using 2D ultrasound at three periods during gestation (11-16, 17-26, and/or 30-38 weeks). Primary outcome was type of closure; secondary outcome was survival. In the secondary analyses, the predictive value of the OC/AC-ratio trend for type of closure and survival was assessed.

RESULTS

Primary closure was performed in 37/63 (59%) infants, and 54/63 (86%) survived. The OC/AC ratio was predictive for type of closure and survival in all periods. Optimal cut-off values for predicting closure decreased throughout gestation from 0.69 (11-16 weeks) to 0.63 (30-38 weeks). Repeated OC/AC-ratio measurements were available in 33 (73%) fetuses. The trend of the OC/AC ratio throughout gestation was not significantly associated with type of closure. All infants without liver herniation underwent primary closure.

CONCLUSION

Type of omphalocele surgical closure and survival can be predicted prenatally on the basis of the OC/AC ratio and liver herniation independent of associated anomalies.

LEARNING OBJECTIVE

The reader will be able to use the OC/AC ratio throughout gestation in all omphalocele cases for prediction of type of closure and survival and thus patient counselling.

Ruptured omphalocele: Diagnosis and management

Omphalocele is an abdominal wall defect which can be classified as small, giant, or ruptured. Ruptured omphaloceles require prompt diagnosis and management to prevent associated morbidity and mortality and represent a challenging surgical condition. This review serves to define the etiology, diagnosis, initial resuscitation, and surgical therapy employed in the treatment of ruptured omphalocele. Resuscitation should focus on maintaining hydration and normothermia. Broad spectrum antibiotics should be initiated. Similar to giant omphaloceles, procedural intervention includes primary closure, silo, synthetic and biologic mesh, negative pressure wound therapy, and topical agents. Despite advances in neonatal care, the prognosis remains guarded and mortality is high.

Paint and wait management of giant omphaloceles

Management of the very large defect or those in patients with severe comorbidities has evolved to the use of methods that result in escharification and eventual skin coverage over the viscera. This treatment strategy employs principles that were described in the early 20th century. This review will describe the history, principles, methods, and outcomes from the so called 'paint and wait' management of omphalocele.