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Baerg J, McAteer J, Miniati D, Somme S, Slidell M. Improving outcomes for uncomplicated gastroschisis: clinical practice guidelines from the American Pediatric Surgical Association Outcomes and Evidence-based Practice Committee. Pediatr Surg Int 2024; 40:246. [PMID: 39222260 DOI: 10.1007/s00383-024-05819-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND The authors sought better outcomes for uncomplicated gastroschisis through development of clinical practice guidelines. METHODS The authors and the American Pediatric Surgical Association Outcomes and Evidenced-based Practice Committee used an iterative process and chose two questions to develop clinical practice guidelines regarding (1) standardized nutrition protocols and (2) postnatal management strategies. An English language search of PubMed, MEDLINE, OVID, SCOPUS, and the Cochrane Library Database identified literature published between January 1, 1970, and December 31, 2019, with snowballing to 2022. The Appraisal of Guideline, Research and Evaluation reporting checklist was followed. RESULTS Thirty-three studies were included with a Level of Evidence that ranged from 2 to 5 and recommendation Grades B-D. Nine evaluated standardized nutrition protocols and 24 examined postnatal management strategies. The adherence to gastroschisis-specific nutrition protocols promotes intestinal feeding and reduces TPN administration. The implementation of a standardized postnatal clinical management protocol is often significantly associated with shorter hospital stays, less mechanical ventilation use, and fewer infections. CONCLUSIONS There is a lack of comparative studies to guide practice changes that improve uncomplicated gastroschisis outcomes. The implementation of gastroschisis-specific feeding and clinical care protocols is recommended. Feeding protocols often significantly reduce TPN administration, although the length of hospital stay may not consistently decrease.
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Affiliation(s)
- Joanne Baerg
- Division of Pediatric Surgery, Presbyterian Healthcare Services, Albuquerque, NM, USA.
| | - Jarod McAteer
- Division of Pediatric Surgery, Providence Sacred Heart Children's Hospital, Spokane, WA, USA
| | - Doug Miniati
- Division of Pediatric Surgery, Kaiser Permanente Northern California, Roseville, CA, USA
| | - Stig Somme
- Division of Pediatric Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Mark Slidell
- Division of Pediatric Surgery, Johns Hopkins Children's Center, Baltimore, MD, USA
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Dhane M, Gervais AS, Joharifard S, Trudeau MO, Barrington KJ, Villeneuve A. Avoidance of routine endotracheal intubation and general anesthesia for primary closure of gastroschisis: a systematic review and meta-analysis. Pediatr Surg Int 2022; 38:801-815. [PMID: 35396604 DOI: 10.1007/s00383-022-05117-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2022] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- Malek Dhane
- Department of Anesthesia, McGill University, 1001 Boulevard Decarie, Montréal, QC, H4A 3J1, Canada.
| | - Anne-Sophie Gervais
- Department of Pediatrics, Northern Ontario School of Medicine, Thunder Bay, ON, Canada
| | - Shahrzad Joharifard
- Division of Pediatric Surgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Maeve O'Neill Trudeau
- Department of Pediatric Surgery, Montréal Children's Hospital, McGill University, Montréal, QC, Canada
| | - Keith J Barrington
- Division of Neonatology, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Andréanne Villeneuve
- Division of Neonatology, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
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Miyata S, Joharifard S, Trudeau MO, Villeneuve A, Yang J, Bouchard S. Tu-be or not tu-be? Is routine endotracheal intubation necessary for successful bedside reduction and primary closure of gastroschisis? J Pediatr Surg 2022; 57:350-355. [PMID: 34304903 DOI: 10.1016/j.jpedsurg.2021.06.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 06/15/2021] [Accepted: 06/29/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Wide practice variation exists in the management of gastroschisis. Routine endotracheal intubation for bedside closure may lead to longer duration of mechanical ventilation. METHODS The Canadian Association of Pediatric Surgery Network gastroschisis dataset was queried for all patients undergoing attempted bedside reduction and closure. Patients with evidence of intestinal necrosis or perforation were excluded. A propensity score analysis was used to compare the rate of successful primary repair and post-operative outcomes between intubated and non-intubated patients. RESULTS In propensity score matched analysis, the successful primary repair rate did not reach statistical significance between patients who were intubated for attempted bedside closure and those who were not intubated (Odds Ratio: 2.18, 95% Confidence Interval: 0.79, 6.03). Intubated patients experienced 3.02 more ventilator days than patients who were not intubated at the time of initial attempted closure. Other post-operative parameters were similar between both groups. CONCLUSIONS It is reasonable to attempt primary bedside gastroschisis closure without intubation in otherwise healthy infants.
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Affiliation(s)
- Shin Miyata
- Department of Surgery, University Hospital Center Sainte-Justine, 3175 Chemin de la Côte Ste-Catherine, Montréal, Québec, H3T 1C5, Canada; Division of Pediatric Surgery, SSM Health Cardinal Glennon Children's Hospital, 1465 S. Grand Boulevard, St. Louis, MO, 63104, USA.
| | - Shahrzad Joharifard
- Department of Surgery, University Hospital Center Sainte-Justine, 3175 Chemin de la Côte Ste-Catherine, Montréal, Québec, H3T 1C5, Canada; Division of Pediatric General Surgery, Department of Surgery, BC Children's Hospital, 4500 Oak St, Vancouver, BC, V6H 3N1 Canada
| | - Maeve O'Neill Trudeau
- Department of Surgery, University Hospital Center Sainte-Justine, 3175 Chemin de la Côte Ste-Catherine, Montréal, Québec, H3T 1C5, Canada
| | - Andréanne Villeneuve
- Division of Neonatology, CHU Sainte-Justine, Montreal, QC Canada, 3175 Chemin de la Côte Ste-Catherine, Montréal, Québec, H3T 1C5, Canada
| | - Junmin Yang
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario
| | - Sarah Bouchard
- Department of Surgery, University Hospital Center Sainte-Justine, 3175 Chemin de la Côte Ste-Catherine, Montréal, Québec, H3T 1C5, Canada
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Escarcega-Fujigaki P, Hernandez-Peredo-Rezk G, Wright NJ, Del Carmen Cardenas-Paniagua A, Velez-Blanco H, Gutierrez-Canencia C, Saavedra-Velez L, Venegas-Espinoza B, Diaz-Luna JL, Castro-Ramirez M. Gastroschisis: A Successful, Prospectively Evaluated Treatment Model in a Middle-Income Country. World J Surg 2021; 46:322-329. [PMID: 34674002 DOI: 10.1007/s00268-021-06357-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2021] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Pastor Escarcega-Fujigaki
- Department of Pediatric Surgery, Centro de Alta Especialidad Dr. Rafael Lucio, Av Adolfo Ruiz Rortines 2903, col. Unidad Magisterial, Xalapa, Veracruz, Mexico.
| | - Guillermo Hernandez-Peredo-Rezk
- Department of Pediatric Surgery, Centro de Alta Especialidad Dr. Rafael Lucio, Av Adolfo Ruiz Rortines 2903, col. Unidad Magisterial, Xalapa, Veracruz, Mexico
| | - Naomi J Wright
- King's Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, King's College London, London, UK
| | | | - Haydee Velez-Blanco
- Department of Neonatology, Centro de Alta Especialidad Dr. Rafael Lucio, Xalapa, Veracruz, Mexico
| | | | - Lorenzo Saavedra-Velez
- Department of Neonatology, Centro de Alta Especialidad Dr. Rafael Lucio, Xalapa, Veracruz, Mexico
| | | | - Jose Luis Diaz-Luna
- Department of Medical Pediatrics, Centro de Alta Especialidad Dr. Rafael Lucio, Xalapa, Veracruz, Mexico
| | - Miguel Castro-Ramirez
- Department of Anesthesiology, Centro de Alta Especialidad Dr. Rafael Lucio, Xalapa, Veracruz, Mexico
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Abdominal Wall Defects-Current Treatments. CHILDREN-BASEL 2021; 8:children8020170. [PMID: 33672248 PMCID: PMC7926339 DOI: 10.3390/children8020170] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 02/13/2021] [Accepted: 02/15/2021] [Indexed: 01/29/2023]
Abstract
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.
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Abstract
The importance of defining and implementing a culture of safety in pediatric surgery is being increasingly seen as essential to decreasing complications and improving outcomes. The concept of a safety culture is a universal one, but the elements of such a culture are different for every disease and anomaly treated. In this paper, I will review these elements as they pertain to the treatment of abdominal wall defects starting from fetal evaluation to post-discharge care.
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Affiliation(s)
- Sherif Emil
- Department of Pediatric Surgery, The Montreal Children's Hospital, McGill University Health Centre, Room B04.2028, 1001 Decarie Boulevard, Montreal, QC H4A 3J1, Canada.
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7
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Zalles-Vidal C, Peñarrieta-Daher A, Bracho-Blanchet E, Ibarra-Rios D, Dávila-Perez R, Villegas-Silva R, Nieto-Zermeño J. A Gastroschisis bundle: effects of a quality improvement protocol on morbidity and mortality. J Pediatr Surg 2018; 53:2117-2122. [PMID: 30318281 DOI: 10.1016/j.jpedsurg.2018.06.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 05/09/2018] [Accepted: 06/10/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Gastroschisis incidence is rising. Survival in developed countries is over 95%. However, in underdeveloped countries, mortality is higher than 15% often due to sepsis. The aim of this study was to evaluate the effect on morbidity and mortality of a Quality Improvement Protocol for out-born gastroschisis patients. METHODS The protocol consisted in facilitating transport, primary or staged reduction at the bedside and sutureless closure, without anesthesia, PICC lines and early feeding. Data was prospectively collected for the Protocol Group (PG) treated between June 2014 through March 2016 and compared to the last consecutive patients Historical Group (HG). Primary outcome was mortality. SECONDARY OUTCOMES need for and duration of mechanical ventilation (MV), time to first feed (TFF) after closure, parenteral nutrition (TPN), length of stay (LOS) and sepsis. Data were analyzed using χ2 and Mann-Whitney U tests. RESULTS 92 patients were included (46 HG and 46 PG). Demographic data were homogeneous. Mortality decreased from 22% to 2% (p = 0.007). Mechanical ventilation use decreased from 100% to 57% (p = <0.001), ventilator days from 14 to 3 median days (p = <0.0001), TPN days: 27 to 21 median days (p = 0.026), sepsis decreased from 70% to 37% (p = 0.003) and anesthesia from a 100% to 15% (p = <0.001), respectively. No difference was found in NPO or LOS. CONCLUSION A major improvement in the morbidity and mortality rates was achieved, with outcomes comparable to those reported in developed countries. It was suitable for all patients with gastroschisis. We believe this protocol can be implemented in other centers to reduce morbidity and mortality. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Cristian Zalles-Vidal
- Department of Pediatric Surgey, Hospital Infantil de México Federico Gomez, Mexico City, Mexico.
| | | | - Eduardo Bracho-Blanchet
- Department of Pediatric Surgey, Hospital Infantil de México Federico Gomez, Mexico City, Mexico
| | - Daniel Ibarra-Rios
- Department of Neonatology, Hospital Infantil de México Federico Gomez, Mexico City, Mexico
| | - Roberto Dávila-Perez
- Department of Pediatric Surgey, Hospital Infantil de México Federico Gomez, Mexico City, Mexico
| | - Raul Villegas-Silva
- Department of Neonatology, Hospital Infantil de México Federico Gomez, Mexico City, Mexico
| | - Jaime Nieto-Zermeño
- Department of Pediatric Surgey, Hospital Infantil de México Federico Gomez, Mexico City, Mexico
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8
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Abstract
The expected outcome of gastroschisis has evolved from an almost certain death of the child prior to the use of parenteral nutrition to almost certain survival. The primary goal of the surgical intervention is return of eviscerated contents into the abdominal cavity. The optimal surgical technique is dependent on the status of the intestine and the accommodation of abdominal domain. In this review, the various surgical techniques for management are discussed as they have evolved. Ironically, a minimalist surgical intervention originally practiced due to the poor expected outcome is now being adopted as a minimalist surgical approach for abdominal wall closure associated with an expected excellent outcome.
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Affiliation(s)
- Mikael Petrosyan
- Children's National Health System, George Washington University Medical Center, United States
| | - Anthony D Sandler
- Children's National Health System, George Washington University Medical Center, United States.
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9
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Omphalocele and Gastroschisis. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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10
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Pet GE, Stark RA, Meehan JJ, Javid PJ. Outcomes of bedside sutureless umbilical closure without endotracheal intubation for gastroschisis repair in surgical infants. Am J Surg 2017; 213:958-962. [DOI: 10.1016/j.amjsurg.2017.03.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 01/24/2017] [Accepted: 03/16/2017] [Indexed: 11/25/2022]
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Abstract
Neonatal surgery is recognized as an independent discipline in general surgery, requiring the expertise of pediatric surgeons to optimize outcomes in infants with surgical conditions. Survival following neonatal surgery has improved dramatically in the past 60 years. Improvements in pediatric surgical outcomes are in part attributable to improved understanding of neonatal physiology, specialized pediatric anesthesia, neonatal critical care including sophisticated cardiopulmonary support, utilization of parenteral nutrition and adjustments in fluid management, refinement of surgical technique, and advances in surgical technology including minimally invasive options. Nevertheless, short and long-term complications following neonatal surgery continue to have profound and sometimes lasting effects on individual patients, families, and society.
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Affiliation(s)
- Mauricio A Escobar
- Pediatric Surgery, Mary Bridge Children׳s Hospital, PO Box 5299, MS: 311-W3-SUR, 311 South, Tacoma, Washington 98415-0299.
| | - Michael G Caty
- Section of Pediatric Surgery, Department of Surgery, Yale-New Haven Children׳s Hospital, New Haven, Connecticut
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12
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Cost modeling for management strategies of uncomplicated gastroschisis. J Surg Res 2016; 205:136-41. [DOI: 10.1016/j.jss.2016.06.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 04/14/2016] [Accepted: 06/10/2016] [Indexed: 11/21/2022]
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13
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Youssef F, Gorgy A, Arbash G, Puligandla PS, Baird RJ. Flap versus fascial closure for gastroschisis: a systematic review and meta-analysis. J Pediatr Surg 2016; 51:718-25. [PMID: 26970850 DOI: 10.1016/j.jpedsurg.2016.02.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 02/07/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Flap closure represents an alternative to fascial closure for gastroschisis. We performed a systematic review and meta-analysis of outcomes comparing these techniques. METHODS A registered systematic review ( PROSPERO CRD42015016745) of comparative studies was performed, querying multiple databases without language or date restrictions. Gray literature was sought. Outcomes analyzed included: mortality, ventilation days, feeding parameters, length of stay (LOS), wound infection, resource utilization, and umbilical hernia incidence. Multiple reviewers independently assessed study eligibility and literature quality. Meta-analysis of outcomes was performed where appropriate (Revman 5.2). RESULTS Twelve studies met inclusion criteria, of which three were multi-institutional. Quality assessment revealed unbiased patient selection and exposure, but group comparability was suboptimal in four studies. Overall, 1124 patients were evaluated, of which 350 underwent flap closure (210 immediately; 140 post-silo). Meta-analysis revealed no significant differences in mortality, LOS, or feeding parameters between groups. Flap patients had less wound infections (OR 0.40 [95%CI 0.22-0.74], P=0.003). While flap patients had an increased risk of umbilical hernia, they were less likely to undergo repair (19% vs. 41%; P=0.01). CONCLUSIONS Flap closure has equivalent or superior outcomes to fascial closure for patients with gastroschisis. Given potential advantages of bedside closure and reduced sedation requirements, flap closure may represent the preferred closure strategy.
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Affiliation(s)
- Fouad Youssef
- The Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada, H4A 3J1
| | - Andrew Gorgy
- The Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada, H4A 3J1
| | - Ghaidaa Arbash
- The Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada, H4A 3J1
| | - Pramod S Puligandla
- The Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada, H4A 3J1
| | - Robert J Baird
- The Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada, H4A 3J1.
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Emami CN, Youssef F, Baird RJ, Laberge JM, Skarsgard ED, Puligandla PS. A risk-stratified comparison of fascial versus flap closure techniques on the early outcomes of infants with gastroschisis. J Pediatr Surg 2015; 50:102-6. [PMID: 25598103 DOI: 10.1016/j.jpedsurg.2014.10.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Accepted: 10/06/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND While fascial closure is traditionally used in gastroschisis (GS), flap closure (skin or umbilical cord) has gained popularity. We evaluated early outcomes and complications of the two techniques. METHODS A national, population-based gastroschisis data registry was analyzed from 2005 to 2011. We compared fascial to flap closures and stratified patients into low or high-risk groups using the Gastroschisis Prognostic Score (GPS), a validated marker of post-natal bowel injury. Demographic and outcome data, including length of stay, complications, and markers of resource utilization were analyzed using Fisher's exact and Student's t-tests for categorical and continuous variables, respectively (p<0.05 significant). RESULTS The analyzed dataset included 436 fascial closures (344 [78.8%] low-risk, 92 high-risk) and 129 flap closures (112 [86.7%] low-risk, 17 high-risk; p=0.06). Demographics and birth weight did not differ between groups. In patients with low GPS, flap closure demonstrated significant decreases in resource utilization and failure of closure, without differences in complication rates. Analysis of high-risk patients revealed no statistically significant differences in outcome. CONCLUSION Flap closure was not associated with an increase in patient morbidity and seemed suitable as a definitive closure method for gastroschisis patients irrespective of disease severity. Furthermore, flap closure reduced several markers of resource utilization in patients with low-risk disease.
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Affiliation(s)
- Claudia N Emami
- The Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada, H3H 1P3
| | - Fouad Youssef
- The Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada, H3H 1P3
| | - Robert J Baird
- The Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada, H3H 1P3
| | - Jean-Martin Laberge
- The Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada, H3H 1P3
| | - Erik D Skarsgard
- Division of Pediatric Surgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada, V6J 4K7
| | - Pramod S Puligandla
- The Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada, H3H 1P3.
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Surgical Treatment Results In Gastroschisis Based On Preterm Delivery Within The 34th Week Of Gestation By Caesarean Section. POLISH JOURNAL OF SURGERY 2015; 87:346-56. [DOI: 10.1515/pjs-2015-0068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Indexed: 11/15/2022]
Abstract
Abstractwas to assess the value of the today’s appropriate approach, preterm delivery in the 34th week of gestation by Caesarean section and subsequent surgical intervention at the perinatal center, in daily practice of pediatric surgery with regard to early postoperative and mid-term outcome.Over the time period of 9 years, all consecutive cases diagnosed with gastroschisis at the perinatal center, University Hospital of Magdeburg, were born by Caesarean section within the 34th week of gestation followed by surgical intervention. The registered data were compared with those published by other groups.Overall, there were 19 cases through the investigation period from 01/01/2006 to 12/31/2014. The mean duration of gestation was 237.9 days. The mean birth weight was 2,276 g. In all individuals, a primary closure with no artificial material was achieved. The duration of postoperative artificial respiration was 2.3 days. Oral uptake could be initiated on the 10The data indicate that in case of gastroschisis, primary closure can be more frequently achieved by section within the 34
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Gamba P, Midrio P. Abdominal wall defects: prenatal diagnosis, newborn management, and long-term outcomes. Semin Pediatr Surg 2014; 23:283-90. [PMID: 25459013 DOI: 10.1053/j.sempedsurg.2014.09.009] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Omphalocele and gastroschisis represent the most frequent congenital abdominal wall defects a pediatric surgeon is called to treat. There has been an increased reported incidence in the past 10 years mainly due to the diffuse use of prenatal ultrasound. The early detection of these malformations, and related associated anomalies, allows a multidisciplinary counseling and planning of delivery in a center equipped with high-risk pregnancy assistance, pediatric surgery, and neonatology. At present times, closure of defects, even in multiple stages, is always possible as well as management of most of cardiac-, urinary-, and gastrointestinal-associated malformations. The progress, herein discussed, in the care of newborns with abdominal wall defects assures most of them survive and reach adulthood. Some aspects of transition of medical care will also be considered, including fertility and cosmesis.
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Affiliation(s)
- Piergiorgio Gamba
- Pediatric Surgery, Department of Woman and Child Health, University Hospital, Via Giustiniani 3, Padua 35121, Italy.
| | - Paola Midrio
- Pediatric Surgery, Department of Woman and Child Health, University Hospital, Via Giustiniani 3, Padua 35121, Italy
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Erkrankungen und Therapieformen des unteren Gastrointestinaltrakts. PÄDIATRISCHE GASTROENTEROLOGIE, HEPATOLOGIE UND ERNÄHRUNG 2013. [PMCID: PMC7498818 DOI: 10.1007/978-3-642-24710-1_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Duodenalatresien sind Hemmungsfehlbildungen und können proximal oder distal der Papilla Vateri entstehen, wobei die präpapillären Obstruktionen selten sind. Grundsätzlich kann zwischen einer Membranatresie und einer Defektatresie unterschieden werden. Die Unterscheidung beruht nicht nur auf embryologischen Gesichtspunkten, sondern hat auch eine klinische Bedeutung: Bei der Membranatresie kann die quergestellte, partiell offene oder geschlossene Membran weit in den distalen Duodenalanteil reichen („Windsackphänomen“), was zu diagnostischen und auch intraoperativen Problemen führen kann. Ein Pancreas anulare findet sich bei etwa 20 % aller Patienten mit Duodenalatresie.
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Choi WW, McBride CA, Bourke C, Borzi P, Choo K, Walker R, Nguyen T, Davies M, Donovan T, Cartwright D, Kimble RM. Long-term review of sutureless ward reduction in neonates with gastroschisis in the neonatal unit. J Pediatr Surg 2012; 47:1516-20. [PMID: 22901910 DOI: 10.1016/j.jpedsurg.2012.01.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Revised: 12/22/2011] [Accepted: 01/09/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND A sutureless ward reduction (SWR) protocol was implemented in the neonatal intensive care unit of a tertiary level hospital in 1999. Although the short-term outcomes associated with SWR have been documented, the long-term outcomes are unknown. METHODS Retrospective data were collected from the medical records of all neonates with gastroschisis from September 1999 to December 2010. Data on their growth and development and the prevalence of any health problems were collected. RESULTS Eighty-eight patients with gastroschisis were managed over an 11 year period. Forty-four of these patients received SWR, with 2 deaths in the neonatal period. In the 42 survivors, 35 patients were reviewed at a median age of 7 years and 10 months (range, 6-134 months; interquartile range, 37-124 months). One patient experienced failure to thrive and developmental delay, and later died of a medical complication. Thirty-two patients (91.4%) developed an umbilical hernia, only 2 of whom required umbilical herniotomy. Four patients (11.4%) developed small bowel obstruction, all within the first year. CONCLUSION Most patients with SWR exhibited normal growth with minimal bowel complications. Despite the high incidence of umbilical hernia, the majority resolved spontaneously and did not require subsequent herniotomy.
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Affiliation(s)
- Wilson W Choi
- School of Medicine, University of Queensland, Herston, Queensland 4006, Australia.
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Baird R, Puligandla P, Skarsgard E, Laberge JM. Infectious complications in the management of gastroschisis. Pediatr Surg Int 2012; 28:399-404. [PMID: 22159577 DOI: 10.1007/s00383-011-3038-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/29/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND/PURPOSE Neonates with gastroschisis make up an increasing proportion of prolonged surgical NICU admissions. While infectious complications are known to increase patient morbidity, it is unclear whether they vary according to abdominal closure method, or can be predicted by initial patient assessment. METHODS A national, prospective, disease-specific database was evaluated for episodes of wound infection (WI) and catheter-related infection (CRI). Antibiotic use and timing, as well as method and location of abdominal closure were studied. The gastroschisis prognostic score (GPS) was calculated and evaluated as a predictor of infectious complications. RESULTS Of 395 patients, 48 (12.6%) had a documented abdominal WI, and 59 patients (14.9%) had at least one episode of CRI-most commonly coagulase negative staphylococcus. Most abdominal closures took place within 6 h of admission (194 = 51.3%), while 132 (34.9%) were delayed greater than 24 h. The WI rate was greater in the delayed group (21.2 vs. 8.2%, p = 0.0006). The GPS was found to predict development of an infectious complication (WI + CRI, p = 0.04). CONCLUSION Infectious complications remain an important consideration in the management of gastroschisis. GPS correlates with the development of infectious complications. Prophylaxis for skin flora and early closure, when feasible, may reduce WI rates.
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Affiliation(s)
- Robert Baird
- Division of Pediatric Surgery, McGill University Health Center, The Montreal Children's Hospital, McGill University, 2300 Tupper Street, Montreal, QC, H3H 1P3, Canada.
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Bradnock TJ, Marven S, Owen A, Johnson P, Kurinczuk JJ, Spark P, Draper ES, Knight M. Gastroschisis: one year outcomes from national cohort study. BMJ 2011; 343:d6749. [PMID: 22089731 PMCID: PMC3216470 DOI: 10.1136/bmj.d6749] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe one year outcomes for a national cohort of infants with gastroschisis. DESIGN Population based cohort study of all liveborn infants with gastroschisis born in the United Kingdom and Ireland from October 2006 to March 2008. SETTING All 28 paediatric surgical centres in the UK and Ireland. PARTICIPANTS 301 infants (77%) from an original cohort of 393. MAIN OUTCOME MEASURES Duration of parenteral nutrition and stay in hospital; time to establish full enteral feeding; rates of intestinal failure, liver disease associated with intestinal failure, unplanned reoperation; case fatality. RESULTS Compared with infants with simple gastroschisis (intact, uncompromised, continuous bowel), those with complex gastroschisis (bowel perforation, necrosis, or atresia) took longer to reach full enteral feeding (median difference 21 days, 95% confidence interval 9 to 39 days); required a longer duration of parenteral nutrition (median difference 25 days, 9 to 46 days) and a longer stay in hospital (median difference 57 days, 29 to 95 days); were more likely to develop intestinal failure (81% (25 infants) v 41% (102); relative risk 1.96, 1.56 to 2.46) and liver disease associated with intestinal failure (23% (7) v 4% (11); 5.13, 2.15 to 12.3); and were more likely to require unplanned reoperation (42% (13) v 10% (24); 4.39, 2.50 to 7.70). Compared with infants managed with primary fascial closure, those managed with preformed silos took longer to reach full enteral feeding (median difference 5 days, 1 to 9) and had an increased risk of intestinal failure (52% (50) v 32% (38); 1.61, 1.17 to 2.24). Event rates for the other outcomes were low, and there were no other significant differences between these management groups. Twelve infants died (4%). CONCLUSIONS This nationally representative study provides a benchmark against which individual centres can measure outcome and performance. Stratifying neonates with gastroschisis into simple and complex groups reliably predicts outcome at one year. There is sufficient clinical equipoise concerning the initial management strategy to embark on a multicentre randomised controlled trial comparing primary fascial closure with preformed silos in infants suitable at presentation for either treatment to determine the optimal initial management strategy and define algorithms of care.
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Affiliation(s)
- Timothy J Bradnock
- Department of Paediatric Surgery, Royal Hospital for Sick Children, Glasgow, Scotland, UK
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21
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Christison-Lagay ER, Kelleher CM, Langer JC. Neonatal abdominal wall defects. Semin Fetal Neonatal Med 2011; 16:164-72. [PMID: 21474399 DOI: 10.1016/j.siny.2011.02.003] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Gastroschisis and omphalocele are the two most common congenital abdominal wall defects. Both are frequently detected prenatally due to routine maternal serum screening and fetal ultrasound. Prenatal diagnosis may influence timing, mode and location of delivery. Prognosis for gastroschisis is primarily determined by the degree of bowel injury, whereas prognosis for omphalocele is related to the number and severity of associated anomalies. The surgical management of both conditions consists of closure of the abdominal wall defect, while minimizing the risk of injury to the abdominal viscera either through direct trauma or due to increased intra-abdominal pressure. Options include primary closure or a variety of staged approaches. Long-term outcome is favorable in most cases; however, significant associated anomalies (in the case of omphalocele) or intestinal dysfunction (in the case of gastroschisis) may result in morbidity and mortality.
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Abstract
A large number of published studies have shown that the use of diverse regional anaesthetic techniques is associated with high-quality pain relief following the different types of surgery and painful procedures that are commonly performed in neonatal patients. Apart from pain, few studies have examined other outcomes in this setting. Some data suggest a benefit with regional anaesthesia. In a retrospective study, Bosenberg et al. found that the use of epidural analgesia in neonatal patients undergoing tracheo-oesophageal fistula repair resulted in a reduced need for postoperative mechanical ventilation. Furthermore, epidural analgesia was found to be associated with a significant and beneficial modification of the neuroendocrine surgical stress response after major abdominal surgery in infants when compared to postoperative morphine infusions. The use of local anaesthetics in association with neonatal circumcision has also shown a benefit as neonates not treated with eutectic mixture of lidocaine and prilocaine (EMLA) or a penile block had an exaggerated pain response to later vaccinations as compared with neonates treated with a local anaesthetic technique. Finally, safety data generated from large, prospective studies and audits clearly show that the use of paediatric regional anaesthetic techniques is associated with adequate safety also in neonatal patients. In conclusion, a large variety of local and regional anaesthetic techniques can be safely used in neonatal patients. The use of such techniques must obviously be associated with sufficient knowledge about the various techniques, as well as adherence to adequate dosage guidelines and other safety precautions. However, if these prerequisites are met, regional anaesthesia may offer great advantages to our smallest and most vulnerable patients.
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Leadbeater K, Kumar R, Feltrin R. Ward reduction of gastroschisis: risk stratification helps optimise the outcome. Pediatr Surg Int 2010; 26:1001-5. [PMID: 20658297 DOI: 10.1007/s00383-010-2659-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Categorization of gastroschisis into low risk (simple) and high risk (complex) has been reported as an important determinant of outcome. The role of risk categorization in choosing the optimal surgical approach is unreported. This study aims to investigate the role of risk categorization in decision making for ward reduction of gastroschisis. METHODS Data on a cohort of 52 consecutive neonates with gastroschisis between 2000 and 2009 were reviewed. A clinical pathway based on risk categorization was implemented in 2004, and children with simple gastroschisis underwent ward reduction and those with complex gastroschisis underwent surgical closure. Thirty-three neonates since 2004 were analysed and compared to the 19 born prior to 2004. RESULTS Of the 33 children with gastroschisis in the study group, 23 were assessed as simple and underwent ward reduction with 96% survival. Ten had complex gastroschisis and underwent varying surgical procedures. Only six out of ten children (60%) with complex gastroschisis survived in spite of multiple surgical attempts. CONCLUSIONS Risk stratification of gastroschisis at birth helps in choosing optimal surgical management. Ward reduction can be successfully and safely performed in all children with simple gastroschisis. Those with complex gastroschisis require conventional surgical treatment.
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Affiliation(s)
- Kate Leadbeater
- Department of Paediatric Surgery, John Hunter Children's Hospital, Locked Bag 1, Hunter Region Mail Centre, Newcastle, NSW 2310, Australia
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24
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Abstract
Gastroschisis (GS) continues to increase in frequency, with several studies now reported an incidence of between 4 and 5 per 10,000 live births. The main risk factor would seem to be young maternal age, and it is in this group that the greatest increase has occurred. Whilst various geographical regions confer a higher risk, the impact of several other putative risk factors, including smoking and illicit drug use, may be less important than when first identified in early epidemiological studies. Over 90% of cases of GS will now be diagnosed on antenatal ultrasound, but its value in determining the need for early delivery remains unclear. There would appear no clear evidence for either routine early delivery or elective caesarean section for infants with antenatally diagnosed GS. Delivery at a centre with paediatric surgical facilities reduces the risk of subsequent morbidity and should represent the standard of care. The relative roles of primary closure, staged closure and ward reduction, with or without general anaesthesia, appear less clear with considerable variation between centres in both the use of these techniques and subsequent surgical outcomes. Survival rates continue to improve, with rates well in excess of 90% now routine. The limited long-term developmental data available would suggest that normal or near-normal outcomes may be expected although there remains a need for further studies.
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Owen A, Marven S, Johnson P, Kurinczuk J, Spark P, Draper ES, Brocklehurst P, Knight M. Gastroschisis: a national cohort study to describe contemporary surgical strategies and outcomes. J Pediatr Surg 2010; 45:1808-16. [PMID: 20850625 DOI: 10.1016/j.jpedsurg.2010.01.036] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Revised: 01/20/2010] [Accepted: 01/28/2010] [Indexed: 11/16/2022]
Abstract
BACKGROUND Information on adoption of newer surgical strategies for gastroschisis and their outcomes is largely limited to hospital-based studies. The aim of this study was to use a new UK national surveillance system to identify cases and thus to describe the contemporary surgical management and outcomes of gastroschisis. METHODS We conducted a national cohort study using the British Association of Paediatric Surgeons Congenital Anomalies Surveillance System to identify cases between October 2006 and March 2008. RESULTS All 28 surgical units in the United Kingdom and Ireland participated (100%). Data were received for 95% of notified cases of gastroschisis (n = 393). Three hundred thirty-six infants (85.5%) had simple gastroschisis; 45 infants (11.5%) had complex gastroschisis. For 12 infants (3.0%), the type of gastroschisis could not be categorized. Operative primary closure (n = 170, or 51%) and staged closure after a preformed silo (n = 120, or 36%) were the most commonly used intended techniques for simple gastroschisis. Outcomes for infants with complex gastroschisis were significantly poorer than for simple cases, although all deaths occurred in the simple group. CONCLUSIONS This study provides a comprehensive picture of current UK practice in the surgical management of gastroschisis. Further follow-up data will help to elucidate additional prognostic factors and guide future research.
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Affiliation(s)
- Anthony Owen
- Paediatric Surgical Unit, Sheffield Children's Hospital NHS Foundation Trust, S10 2TH Sheffield, UK
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26
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Houben C, Davenport M, Ade-Ajayi N, Flack N, Patel S. Closing gastroschisis: diagnosis, management, and outcomes. J Pediatr Surg 2009; 44:343-7. [PMID: 19231531 DOI: 10.1016/j.jpedsurg.2008.10.084] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2008] [Accepted: 10/23/2008] [Indexed: 12/16/2022]
Abstract
PURPOSE Gastroschisis (GS) is defined as a full-thickness abdominal wall defect (usually right-sided) with intestinal prolapse and occasionally other viscera. The defect itself may close around the viscera causing exit or entry level intestinal atresia and ischaemia or midgut infarction, previously described as closed GS. We now report the largest series of infants born with various stages of closing GS describing features, management, and outcome. METHODS The study used a single-centre retrospective review of infants with GS and evidence of defect closure at birth. RESULTS Nine infants (6 girls) with a median of 35 (range, 32-36) weeks of gestation fulfilled criteria for closing GS from a series of 146 (6%) infants born from August 1994 to December 2007. Delivery had been expedited in 6 based on increasing intraabdominal bowel dilatation and suspicion of closing GS on serial antenatal ultrasound. At delivery, 5 had compromised but viable bowel and required intestinal surgery. Three fetuses, all with midgut necrosis, had antenatal scans typical of GS with no additional features. After a variety of surgical procedures, 7 patients are now fully enterally fed, one is parenteral nutrition-dependent. One died of end-stage liver failure secondary to short bowel syndrome. The length of follow-up was 6 (range, 0.5-11) years. CONCLUSIONS Of infants with GS, 6% present with closing abdominal ring. Close antenatal monitoring may prevent severe bowel loss in some cases. After multiple surgical interventions, most have a favorable outcome.
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Affiliation(s)
- Chris Houben
- Department of Paediatric Surgery, King's College Hospital, London, United Kingdom.
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27
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Marven S, Owen A. Contemporary postnatal surgical management strategies for congenital abdominal wall defects. Semin Pediatr Surg 2008; 17:222-35. [PMID: 19019291 DOI: 10.1053/j.sempedsurg.2008.07.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Sean Marven
- Sheffield Children's Hospital NHS Foundation Trust, Western Bank, United Kingdom.
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Bustorff-Silva JM, Schmidt AFS, Gonçalves A, Marba S, Sbragia L. The female condom as a temporary silo: a simple and inexpensive tool in the initial management of the newborn with gastroschisis. J Matern Fetal Neonatal Med 2008; 21:648-51. [PMID: 18828057 DOI: 10.1080/14767050802178003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The aim of this study is to report the use of a female condom as a non-surgical silon pouch in the early management of newborns with gastroschisis with large visceroabdominal disproportion. METHODS Pre-washed, sterile female condoms without spermicide were used as an early approach to treat gastroschisis in 20 newborns with large defects and in whom staged correction was anticipated. The condom was placed in the neonatal intensive care unit using sterile technique, with no anesthesia, and it was removed only at the time of the surgical procedure for gastroschisis correction. RESULTS There were no complications associated with the use of a female condom as a temporary silo for gastroschisis. It protected the exposed organs and also allowed a careful evaluation of the bowel and a better pre-operative planning without the need for emergency procedures. CONCLUSION The use of a female condom as a silon pouch is a low-cost and simple alternative in the initial management of newborns with gastroschisis in whom primary correction is considered non-feasible.
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Affiliation(s)
- Joaquim M Bustorff-Silva
- Division of Pediatric Surgery, Department of Surgery, School of Medical Sciences, State University of Campinas, Unicamp, Campinas, Brazil.
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Routine use of a SILASTIC spring-loaded silo for infants with gastroschisis: a multicenter randomized controlled trial. J Pediatr Surg 2008; 43:1807-12. [PMID: 18926212 DOI: 10.1016/j.jpedsurg.2008.04.003] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2007] [Revised: 04/02/2008] [Accepted: 04/02/2008] [Indexed: 11/22/2022]
Abstract
BACKGROUND Retrospective studies have suggested that routine use of a preformed silo for infants with gastroschisis may be associated with improved outcomes. We performed a prospective multicenter randomized controlled trial to test this hypothesis. METHODS Eligible infants were randomized to (1) routine bedside placement of a preformed Silastic spring-loaded silo, with gradual reduction and elective abdominal wall closure, or (2) primary closure. RESULTS There were 27 infants in each group. There was no significant difference between groups with respect to age, weight, sex, Apgar scores, prenatal diagnosis, or mode of delivery. The total number of days on the ventilator was lower in the spring-loaded silo group, although it did not reach statistical significance (3.2 vs 5.3, P = .07). There was no significant difference between groups with respect to length of time on total parenteral nutrition, length of stay, or incidence of sepsis and necrotizing enterocolitis. CONCLUSION Routine use of a preformed silo was associated with similar outcomes to primary closure for infants with gastroschisis but with a strong trend toward fewer days on the ventilator. Use of a preformed silo has the advantage of permitting definitive abdominal wall closure in a more elective setting.
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Gelas T, Gorduza D, Devonec S, Gaucherand P, Downham E, Claris O, Dubois R. Scheduled preterm delivery for gastroschisis improves postoperative outcome. Pediatr Surg Int 2008; 24:1023-9. [PMID: 18668252 DOI: 10.1007/s00383-008-2204-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/09/2008] [Indexed: 10/21/2022]
Abstract
There are some evidence to suggest that careful antenatal monitoring, scheduled preterm delivery and immediate abdominal wall closure may reduce gastroschisis morbidity. We hypothesised that the advantages of a scheduled preterm delivery balance possible complications related to prematurity. A retrospective study was performed including all cases of gastroschisis born between 1990 and 2004 (n = 69). Cases were categorised in two groups. Group 1 contained gastroschisis cases born between 1990 and 1997. Group 2 contained cases occurring since 1997, when a new management pathway for gastroschisis was established: weekly evaluation of the foetal gut by ultrasound (>28 weeks), corticosteroids, and delivery by scheduled caesarean section at 35 weeks (before if evidence of bowel compromise was present). The primary endpoints of this study were the initiation of oral feeding and the number of re-operation for intestinal obstruction. There was a significantly faster initiation of oral feeding (P < 0.0001), however, duration of parenteral nutrition (34 vs. 38 days) and hospital discharge (53 vs. 58.5 days) was not reduced. There was no complication due to prematurity in group 2. Postoperative outcome was improved with less need for muscular stretching or prosthetic patch and less re-operation for intestinal obstruction (P < 0.05). Scheduled and elective preterm delivery facilitates surgical procedure and shortens the time to first feeding. A delivery at 35 weeks (preferring vaginal delivery) seems to be a good compromise between risks related to prematurity and complications related to intestinal peel.
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Affiliation(s)
- Thomas Gelas
- Department of Pediatric Surgery, Hôpital Edouard Herriot, Hospices Civils de Lyon, and Université Claude Bernard Lyon 1, Lyon, France.
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Houben CH, Patel S. Gastroschisis closure: a technique for improved cosmetic repair. Pediatr Surg Int 2008; 24:1057-60. [PMID: 18679690 DOI: 10.1007/s00383-008-2215-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/24/2008] [Indexed: 10/21/2022]
Abstract
Gastroschisis closure is performed either primarily or after staged reduction of the prolapsed bowel. A technique for surgical closure of the abdominal wall defect is described which allows for an almost scarless appearance of the abdominal surface with preservation of a midline umbilicus.
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Affiliation(s)
- Christoph Heinrich Houben
- Department of Paediatric Surgery, King's College Hospital, 4th Floor Golden Jubilee Wing (Rm 007) Denmark Hill, London SE5 9RS, UK.
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David AL, Tan A, Curry J. Gastroschisis: sonographic diagnosis, associations, management and outcome. Prenat Diagn 2008; 28:633-44. [DOI: 10.1002/pd.1999] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Skarsgard ED, Claydon J, Bouchard S, Kim PCW, Lee SK, Laberge JM, McMillan D, von Dadelszen P, Yanchar N. Canadian Pediatric Surgical Network: a population-based pediatric surgery network and database for analyzing surgical birth defects. The first 100 cases of gastroschisis. J Pediatr Surg 2008; 43:30-4; discussion 34. [PMID: 18206451 DOI: 10.1016/j.jpedsurg.2007.09.011] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2007] [Accepted: 09/02/2007] [Indexed: 11/17/2022]
Abstract
PURPOSE Outcomes studies for gastroschisis are constrained by small numbers, prolonged accrual, and nonstandardized data collection. The aim of this study is to create a national pediatric surgical network and database for gastroschisis (GS) that tracks cases from diagnosis to hospital discharge. METHODS The 16-center network serves a population of 32 million. Gastroschisis cases are ascertained at prenatal diagnosis. Perinatal data include maternal risk and fetal ultrasound variables, delivery plan and outcome, a postnatal bowel injury score, intended and actual surgical treatment, and neonatal outcomes. Institutional review board-approved data collection conforms to regional privacy legislation. Deidentified data are centralized and accessible for research through the network steering committee. RESULTS To date, 114 cases of pre- and/or postnatal gastroschisis have been uploaded. Of 106 live-born infants (40 [38%] by cesarean delivery), 100 had complete records, and overall survival to discharge was 96%, with a mean survivor length of stay (LOS) of 46 days. Infants treated with attempted urgent closure (61%) had significantly shorter LOS (42 vs 57 days; P = .048) but comparable LOS compared with those treated with silos and delayed closure. Fetal bowel dilation 18 mm or greater did not predict a difference in outcome. CONCLUSION Population-based databases allow rapid case accrual and enable studies that should aid in the identification of optimal perinatal treatment.
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Affiliation(s)
- Erik D Skarsgard
- Department of Surgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, BC, Canada.
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Jager LC, Heij HA. Factors determining outcome in gastroschisis: clinical experience over 18 years. Pediatr Surg Int 2007; 23:731-6. [PMID: 17576575 DOI: 10.1007/s00383-007-1960-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2007] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- L Cara Jager
- Pediatric Surgical Center of Amsterdam, Emma Children's Hospital AMC and VU University Medical Center, P.O. Box 26600, 1100 DD, Amsterdam, The Netherlands
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35
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Abstract
Gastroschisis is a common congenital abdominal wall defect. Rarely, it is associated with extraabdominal midline congenital anomalies. Oral clefts are the commonest craniofacial congenital midline defects. They can be associated with other midline defects like omphalocele. We believe these are the first 3 case reports of gastroschisis and cleft palate occurring in the same patient.
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Affiliation(s)
- Basem A Khalil
- Department of Paediatric Surgery, Royal Manchester Children's Hospital, Pendlebury, Manchester, UK M27 4HA, UK.
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Abstract
AIM The purpose of this study was to assess the effectiveness of routine staged reduction and closure at the bedside, using preformed silos with no general anesthesia (PSnoGA), compared to emergency operative fascial closure (OFC) under general anesthesia for gastroschisis (GS). METHODS A retrospective matched case-control analysis of neonates with GS was performed between 1990 and 2004 inclusively. Assessment included demographics, method of closure, days on ventilator, days to first enteral feed, days to full oral feeds, days on parenteral nutrition, length of hospital stay, and complications. RESULTS Sixty-five patients with GS were treated in our institution between 1990 and 2004. Thirty-five underwent OFC, 4 had Bianchi ward reduction, and 26 received PSnoGA. Seventeen patients with bowel perforation, atresia, ward reduction, medical complications necessitating ventilation, or any other condition requiring urgent surgical intervention were excluded from the analysis. Patients were well matched for gestation and birth weight. Forty-eight patients (OFC = 27 and PSnoGA = 21) were compared by using Mann-Whitney U test. Median days on ventilator (4 vs 0; P < or = .0001) was significantly reduced, but there was no difference for days to full oral feeds (26 vs 31; P = .26), days on parenteral nutrition (25 vs 30; P = .28), and length of stay (32 vs 36; P = .32), respectively. Complications were similar for both groups. CONCLUSIONS PSnoGA has outcomes statistically similar to OFC, although days on ventilator are significantly reduced. Slow reduction of the bowel avoids abdominal compartment syndrome and closure may be achieved without fascial sutures. PSnoGA is performed at the bedside and aims to avoid general anesthesia, a period of ventilation, and out-of-hours operating, thereby reducing costs. A prospective, multicenter, randomized control trial is needed to evaluate the effectiveness of PSnoGA.
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37
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Cauchi J, Parikh DH, Samuel M, Gornall P. Does gastroschisis reduction require general anesthesia? A comparative analysis. J Pediatr Surg 2006; 41:1294-7. [PMID: 16818066 DOI: 10.1016/j.jpedsurg.2006.03.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Outcome after gastroschisis repair without general anesthesia is controversial, and published conclusions are variable with no comparative studies. AIM The aim of this study was to present a comparative study evaluating outcome after gastroschisis repair with and without general anesthesia. METHODS An ambispective nonrandomized study of a cohort of 51 neonates born with gastroschisis between July 1998 and December 2003 was performed. Twenty-four neonates (group 1) had conventional reduction under general anesthesia, and 27 (group 2) cotside minimal intervention reductions were without general anesthesia. RESULTS Groups were comparable regarding gestational age, birth weight, and quality of eviscerated bowel. Statistical significance (P < .05) was seen between groups 1 and 2 with regard to age at reduction of gastroschisis (5.6 +/- 2.5 vs 3 +/- 1 hours) and time taken for completion of gastroschisis reduction (58.1 +/- 15 vs 49 +/- 14 minutes). No statistical significance (P > .05) was seen with respect to start of feeds (10.4 +/- 3.6 vs 10.9 +/- 4.1 days), duration of total parenteral nutrition (21.5 +/- 7.3 vs 22.4 +/- 6.8 days), and total hospital (stay 29 +/- 10 vs 30 +/- 13 days). Admission to the intensive care unit was required in 92% in group 1 for 1 to 6 days vs 7% in group 2 for 3 to 6 days. There was 1 death in group 1 (4%). Total hospital cost in group 1 was 12,283 pounds sterling +/- 2438 pounds sterling vs 6208 pounds sterling +/- 2120 pounds sterling in group 2 (P = .013). CONCLUSIONS Neonates with gastroschisis, whose bowel was reduced without general anesthesia, have similar outcomes to those whose bowel was reduced under general anesthesia. Both approaches appear to be safe and effective, but reduction without general anesthesia was cost-effective.
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Affiliation(s)
- J Cauchi
- Department of Paediatric Surgery, Birmingham Children's Hospital NHS Trust, Steel House Lane, B4 6NH Birmingham, UK
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38
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Abstract
The acute abdomen in the newborn provides challenging problems from many aspects, not only with regard to diagnosis, resuscitation and treatment, but also now with prenatal management. Most conditions are uncommon and treatment in specialist centres enables concentration of appropriate resources and expertise. Co-morbidity is common, particularly in the preterm or low birth weight infant. A multi-disciplinary team of surgeons, anaesthetists, neonatologists, radiologists, cardiologists, obstetricians, nurses, physiotherapists and other health professionals experienced in dealing with extremely small infants will provide the best outcome. The infant should be resuscitated and, as soon as conditions permit, transferred to a specialist surgical centre with intravenous fluids, gastric tube drainage and circulatory, respiratory and general support as needed. This involves close liaison within healthcare networks and readily available patient transfer facilities. Surgery itself should be carried out in a theatre fully equipped for neonatal surgery. A gentle touch is essential because of the fragility of the tissues, and painstaking care should be taken with blood loss.
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Affiliation(s)
- M N de la Hunt
- Department of Paediatric Surgery, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK.
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39
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Affiliation(s)
- Daniel J Ledbetter
- Department of Surgery, Division of Pediatric Surgery, University of Washington, Children's Hospital and Regional Medical Center, 4800 Sand Point Way NE, P.O. Box 5371/G0035, Seattle, WA 98105-0371, USA.
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40
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Logghe HL, Mason GC, Thornton JG, Stringer MD. A randomized controlled trial of elective preterm delivery of fetuses with gastroschisis. J Pediatr Surg 2005; 40:1726-31. [PMID: 16291160 DOI: 10.1016/j.jpedsurg.2005.07.047] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Elective preterm delivery of the fetus with gastroschisis may help to limit injury to the extruded fetal gut and thus promote faster recovery of neonatal gut function and earlier hospital discharge. This hypothesis has not previously been tested in a prospective randomized controlled trial. METHODS Between May 1995 and September 1999, all women referred to a single tertiary center before 34 weeks' gestation with a sonographically diagnosed fetal gastroschisis were invited to participate in a randomized controlled trial. Eligible patients were randomized to elective delivery at 36 weeks or to await the onset of spontaneous labor. The method of delivery was not prescribed by the trial. Primary outcome measures in the neonate were the time taken to tolerate full enteral feeding (150 mL/kg per day) and duration of hospital stay. RESULTS Of 44 eligible women, 42 were randomized, 21 to elective delivery and 21 to await spontaneous labor. There were 20 liveborn infants in each group. Four babies in the elective group and 4 in the spontaneous group delivered before 36 weeks' gestation but were included in the analysis on an intention-to-treat basis. Mean gestational age at delivery was 35.8 weeks in the elective group and 36.7 weeks in the spontaneous group. Primary closure of the gastroschisis was achieved in a similar proportion (80%-85%) of infants in both groups. Two babies in the elective group died from short gut complications. In the survivors, there was a trend in favor of a shorter median time to achieve full enteral feeding (30.5 vs 37.5 days) and a shorter median duration of hospital stay (47.5 vs 53 days) in the elective group, but this was not statistically significant. These findings remained unaltered when the data were reanalyzed after (a) excluding infants with intestinal atresia or (b) excluding infants born before 36 weeks' gestation. CONCLUSIONS Although limited by the small number of patients, this randomized controlled trial demonstrates no significant benefit from elective preterm delivery of fetuses with gastroschisis.
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Affiliation(s)
- Hilde L Logghe
- Feto-maternal Medicine Unit, Leeds Teaching Hospitals NHS Trust, Leeds, LS2 9NS, UK
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41
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Vegunta RK, Wallace LJ, Leonardi MR, Gross TL, Renfroe Y, Marshall JS, Cohen HS, Hocker JR, Macwan KS, Clark SE, Ramiro S, Pearl RH. Perinatal management of gastroschisis: analysis of a newly established clinical pathway. J Pediatr Surg 2005; 40:528-34. [PMID: 15793730 DOI: 10.1016/j.jpedsurg.2004.11.037] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE The authors developed a clinical pathway for optimal management after antenatal diagnosis of gastroschisis. This is the outcomes analysis of our first 30 consecutive patients. METHOD Antenatal counseling was provided for all families with in-utero diagnosis of gastroschisis. Bowel dilatation, thickness, motility, amniotic fluid volume, and fetal development were followed by ultrasonography every 4 weeks. Babies were delivered by cesarean section between 36 and 38 weeks gestation if the lungs were mature or earlier for bowel complications. Gastroschisis repair was scheduled 90 minutes after birth. Primary repair was attempted in all through the abdominal wall defect without an additional incision, resulting in an umbilicus with no abdominal scar. RESULTS Primary repair was achieved in 83%. Babies needed assisted ventilation for 3 days, reached full feeds by 19 days, and were discharged by 24 days (all medians). There were 3 (10%) deaths, all after staged repair. CONCLUSIONS Our new protocol of both scheduled elective cesarean section and early gastroschisis repair resulted in a higher proportion of primary repair, shorter duration of mechanical ventilation, earlier full feeds, and shorter length of stay. There was no increase in mortality or morbidity. The primary-repair babies had no mortality and had excellent cosmesis.
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Affiliation(s)
- Ravindra K Vegunta
- Department of Surgery, University of Illinois College of Medicine, Peoria, IL 61603, USA.
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42
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Abstract
Advances in neonatal care have resulted in the survival of smaller infants with more complicated medical problems. From a surgical standpoint this has required novel approaches to patient care. Surgical care has evolved in many respects. Procedures performed on premature infants range from elective, minor procedures to major, emergent lifesaving interventions. The emergent nature of these surgical interventions has led to controversies in management. Certain conditions require surgical procedures that are commonly performed at the bedside by pediatric surgical specialists. Under other circumstances, the specific details of management are less uniform with wide variability in approach by different practitioners. The rationale in these cases is primarily driven by personal preference with a paucity of supportive data in the published literature to either support or contradict individual opinion. Nevertheless, the role of bedside procedures appears to be expanding. If these procedures are to be undertaken, significant planning is required to ensure a good outcome for the patient. Prospective data are needed determine which patients may benefit from this approach.
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Affiliation(s)
- Milissa McKee
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA.
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43
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Abstract
Outcomes for infants with gastroschisis have paralleled advances made in neonatal intensive care and the use of parenteral nutrition. Mortality rates approaching 100% a half century ago are now closer to 2% to 8%. Further reduction in morbidity has been the focus of many studies during the past decade. Efforts have been made to identify factors associated with the development of gastroschisis and to evaluate the mode, timing, and location of delivery on the outcome of these infants. The effect of the mode and timing of definitive surgical repair has received attention by more recent reports of newer approaches, including the use of a preformed silo to provide coverage for the exposed viscera and allow a gradual reduction into the abdominal cavity.
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Affiliation(s)
- Marc Schlatter
- DeVos Children's Hospital and Department of Surgery, Michigan State University, Grand Rapids, USA.
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44
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Davies MW, Kimble RM, Woodgate PG. Ward reduction without general anaesthesia versus reduction and repair under general anaesthesia for gastroschisis in newborn infants. Cochrane Database Syst Rev 2002; 2002:CD003671. [PMID: 12137704 PMCID: PMC9029839 DOI: 10.1002/14651858.cd003671] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Gastroschisis is a congenital anterior abdominal wall defect with the abdominal contents protruding through the defect. Reduction of the abdominal contents is required within hours after birth as the infant is at risk not only of water and heat loss from the exposed bowel but also of compromised gut circulation with ischaemia and infarction. To avoid the complications of general anaesthetic and mechanical ventilation it has been proposed that the reduction of abdominal contents can be achieved without endotracheal intubation or anaesthesia. OBJECTIVES To determine which approach to the immediate surgical treatment of gastroschisis has the better outcomes: ward reduction without general anaesthetic or reduction and repair of the abdominal wall defect under general anaesthesia. SEARCH STRATEGY Searches were made of MEDLINE from 1966 to March 2002, CINAHL from 1982 to March 2002, and the Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2002). Previous reviews including cross references, abstracts, and conference and symposia proceedings published in Pediatric Research (from 1990 to 1994) were also searched, especially for any unpublished data. SELECTION CRITERIA Randomised, controlled trials (RCT) comparing ward reduction with reduction under general anaesthesia, for neonates with gastroschisis. Outcomes considered were: mortality, duration of total parenteral nutrition, time to full enteral feeds, need for a silo, infection, gastro-intestinal tract perforation, length of bowel lost/resected, need for a general anaesthesia, need for and duration of mechanical ventilation and respiratory support, duration of oxygen therapy, need for further operative procedure after initial reduction, duration of hospital stay, cosmetic outcome, nutritional status, and neurodevelopmental outcome. DATA COLLECTION AND ANALYSIS No studies were found meeting the criteria for inclusion in this review. MAIN RESULTS No studies were found meeting the criteria for inclusion in this review. REVIEWER'S CONCLUSIONS There is no evidence from RCTs to support or refute the practice of ward reduction for the immediate management of gastroschisis. There is an urgent need for RCTs to compare ward reduction versus reduction under general anaesthesia in infants with gastroschisis. Initial trials would best be limited to those infants with uncomplicated gastroschisis (using pre-defined selection criteria excluding infants that are unstable, have gut perforation, necrosis or atresia, have other organs requiring reduction besides bowel, or are considered to need a silo prior to any reduction. Trials should use adequate pain relief and specify a pre-defined time period after which manual reduction is abandoned.
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Affiliation(s)
- M W Davies
- Grantley Stable Neonatal Unit, Royal Women's Hospital, Butterfield St, Herston, Brisbane, Queensland, Australia.
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