Management of gastroschisis with concomitant jejuno-ileal atresia

Gastroschisis-related complications requiring further surgical interventions

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Gastroschisis--what should be told to parents?

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Catheter enterostomy and patch repair of the abdominal wall for gastroschisis with intestinal atresia: report of a case

A male infant, weighing 2177 g, was born with the entire intestine protruding through a defect on the right side of the navel. Intestinal atresia, approximately 70 cm from the Treitz ligament, was also confirmed. Primary anastomosis and abdominal wall repair were impossible because of the intestinal dilation and thick peel, as well as the small abdominal cavity. Thus, we initially performed catheter enterostomy with a 14-F balloon catheter and patch repair of the abdominal wall, to enable the baby to be fed. Secondary anastomosis and abdominal wall repair was safely performed when the baby was 106 days old. The combination of catheter enterostomy and patch repair of the abdominal wall does not require dissection of the intestine and it can be safely performed in low-birth-weight babies. It also enables feeding and weight gain, and the overlying skin prevents contamination of the artificial sheet. We recommend this combination for neonates with both gastroschisis and intestinal atresia.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Contemporary postnatal surgical management strategies for congenital abdominal wall defects

Early definitive closure of abdominal wall defects is possible in most cases. Staged reduction does offer distinct advantages, and mortality and morbidity may be better. Risk stratification may produce outcome and tailor management of difficult cases in the form of a clinical pathway. Stem cell technology may, in the future, offer the ideal allogenic prosthesis in complex cases.

Factors determining outcome in gastroschisis: clinical experience over 18 years

Although the survival in gastroschisis has improved to more than 85%, serious morbidity with consequent long hospital stay is still very common. Alternative strategies such as planned early delivery and amniotic fluid exchange are being explored. In order to evaluate these approaches, adequate risk stratification of patients with gastroschisis is required. The aim of this study was to identify the risk factors associated with increased morbidity and mortality. A retrospective analysis of all patients with gastroschisis treated at our institution between 1988 and 2005 was conducted. Patients' data were collected from the files and compared for statistical significance with three outcome measures: (1) complicated post-operative course; (2) time to full enteral feeding (TFE); (3) length of hospital stay (LOS). SPSS was used for statistical analysis. Fifty-nine newborns with gastroschisis were admitted during the study period. Antenatal diagnosis was made in 40 cases (68%). Associated malformations (other than intestinal anomalies) were present in eight patients. One patient with trisomy 13 was excluded from the analysis. Ten patients (17%) had compromised bowel (atresia, severe ischaemia or a combination). Primary repair was successful in 47 (81%) and in 11 patients a silo was applied. Overall survival was 54/58 children (93%), four patients died. Complications associated with closure occurred in eight patients. Post-operative course was uncomplicated in 45 patients and complicated in 13. The RR for patients with compromised bowel to have a complicated post-operative course is 9 (95% CI 2-39) and the RR to die is 20 (95% CI 2-222) for these patients. Risk stratification of patients with gastroschisis appears possible based on the presence of compromised bowel before closure.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Management of intestinal atresia in patients with gastroschisis

BACKGROUND/PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Gastroschisis: a plea for risk categorization

BACKGROUND

The incidence of gastroschisis has increased in the past decade. A differing clinical course between "complex" (those with atresias, perforation, or stenosis) and "simple" cases has prompted a review of risk assessment factors.

METHODS

A retrospective chart review was conducted of 103 infants with gastroschisis over 5 years (1992 to 1997).

RESULTS

Of 103 infants, 52 were girls and 51 were boys. Seventy-one infants (69%) had a simple defect, and 32 (31%) were complex. The simple group had an average estimated gestational age of 37.5 weeks (range, 26 to 40), and a birth weight of 3.0 kg (range, 1.7 to 3.8). A total of 71% underwent primary repair, whereas 29% required a silo. Mechanical ventilation averaged 6.8 days (range, 1 to 19). Enteral feedings were initiated at 15 days (range, 3 to 27) with full enteral intake achieved by 22.4 days (range, 5 to 40). Three infants required home parenteral nutrition. The average length of stay (LOS) was 26.4 days (range, 10 to 57). Complications occurred in 26 infants (36%), including intravenous catheter sepsis (n = 15), pneumatosis (n = 2), pneumonia (n = 1), bowel obstruction (n = 7), wound infection (n = 5), and SVC thrombosis (n = 1). Survival rate was 100%. Thirty-two infants had complex defects; 27 patients had atresias, stenosis, or perforations; and 3 had volvulus. The average estimated gestational age was 34 weeks (range, 26 to 38), and birth weight was 2.0 kg (range, 0.9 to 4.0). Primary repair was performed in 65% and silo placement in 35%. Mechanical ventilation was required for 22.3 days (range, 2 to 14). Enteral feedings were initiated at 22.5 days (range, 6 to 56) with full feedings achieved at 50 days (range, 21 to 113). Fourteen infants required home total parenteral nutrition (TPN). The LOS was 85.4 days (range, 24 to 270). A total of 47 complications occurred in the complex group including catheter sepsis (n = 15), short bowel syndrome (n = 7), pneumatosis (n = 3), bowel obstruction (n = 4), pneumonia (n = 2), superior vena cava thrombosis (n = 1), enterocutaneous fistula (n = 1), and 9 deaths (28% mortality rate).

CONCLUSIONS

These data indicate gastroschisis can be divided into low-risk (simple) and high-risk (complex) categories. These 2 groups have significant differences in clinical behavior, postsurgical complications, LOS, and mortality rate (0 v 28%). Although the overall survival rate was 91% (94 of 103), parents, referring physicians, and insurers must be made aware of the impact of risk categorization on the estimated cost, LOS, and outcomes.

The contemporary outcome of gastroschisis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Intestinal atresia with gastroschisis: a selective approach to management

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Prenatal diagnosis of complicated abdominal wall defects

The accurate prenatal diagnosis of anterior abdominal wall defects is important because it affects patient management and prognosis. The pathophysiology of each defect leads to key characteristics that make it possible to differentiate one entity from another. Among these features are the location of the defect in relation to cord insertion, the size and contents of the defect, and the associated anomalies. This article reviews the underlying defects, the characteristic ultrasound findings, the associated anomalies, and the prognosis of simple and complicated abdominal wall defects. The basic features of simple abdominal wall defects (i.e., omphalocele and gastroschisis) were used as the initial points of assessment. A comparison of the different features of these abnormalities and how they differ from one another resulted in the development of criteria that facilitated the understanding of the different ultrasound manifestations of these anomalies.