Morbidity and quality of life in adult patients with a congenital abdominal wall defect: a questionnaire survey

Major surgical conditions of childhood and their lifelong implications: comprehensive review

BACKGROUND

In recent decades, the survival of children with congenital anomalies and paediatric cancer has improved dramatically such that there has been a steady shift towards understanding their lifelong health outcomes. Paediatric surgeons will actively manage such conditions in childhood and adolescence, however, adult surgeons must later care for these 'grown-ups' in adulthood. This article aims to highlight some of those rare disorders encountered by paediatric surgeons requiring long-term follow-up, their management in childhood and their survivorship impact, in order that the adult specialist may be better equipped with skills and knowledge to manage these patients into adulthood.

METHODS

A comprehensive literature review was performed to identify relevant publications. Research studies, review articles and guidelines were sought, focusing on the paediatric management and long-term outcomes of surgical conditions of childhood. The article has been written for adult surgeon readership.

RESULTS

This article describes the aforementioned conditions, their management in childhood and their lifelong implications, including: oesophageal atresia, tracheo-oesophageal fistula, malrotation, short bowel syndrome, duodenal atresia, gastroschisis, exomphalos, choledochal malformations, biliary atresia, Hirschsprung disease, anorectal malformations, congenital diaphragmatic hernia, congenital lung lesions and paediatric cancer.

CONCLUSION

The increasing survivorship of children affected by surgical conditions will translate into a growing population of adults with lifelong conditions and specialist healthcare needs. The importance of transition from childhood to adulthood is becoming realized. It is hoped that this timely review will enthuse the readership to offer care for such vulnerable patients, and to collaborate with paediatric surgeons in providing successful and seamless transitional care.

Trends in prevalence of gastroschisis in Brazil from 2007 to 2020: A national population-based cross-sectional study

BACKGROUND

Gastroschisis is a congenital abnormality of the abdominal wall which worldwide prevalence is increasing with time. Up to now, young maternal age is the main factor associated with gastroschisis. Brazil has a great proportion of adolescent mothers.

OBJECTIVES

To estimate prevalence of gastroschisis in Brazil, explore the effect of very young maternal age, and analyze regional distribution and time trends.

METHODS

Cross-sectional population-based study using data from official national information systems from 2007 to 2020, covering 9,831 gastroschisis cases. Low maternal age was assessed as risk factor through odds ratio. Prevalence time trends by maternal age and geographic area were analyzed using joinpoint regression.

RESULTS

Overall prevalence of gastroschisis in Brazil was 2.47 per 10,000 births. From first to last biennium, there was a 23% relative increase. Last biennium prevalence was higher in the Central-west region and lower in the Northeast. Compared to mothers of 20-34 years old (YO), the odds-ratio for prevalence and 95% confidence intervals for gastroschisis were, as follows: (a) 10-14 YO-4.9 (4.3,5.5); (b) 15-19 YO-3.6 (3.5,3.8); and (c) 35-49 YO-0.3 (95% CI 0.3, 0.4).

CONCLUSIONS

Prevalence of gastroschisis in Brazil relatively increased 23% from 2007 to 2020. This happened in all maternal age groups. Differences between regions may be associated to data quality. Young mothers had a higher prevalence of gastroschisis and still higher for those under 15 YO. Mother age over 34 YO was a protective factor.

Vacuum-assisted staged omphalocele reduction: A preliminary report

INTRODUCTION

Omphalocele represents a rare congenital abdominal wall defect. In giant omphalocele, due to the viscero-abdominal disproportion, gradual reintegration of eviscerated organs is often associated with medical challenges. We report our preliminary experience combining staged gravitational reduction with vacuum (VAC) therapy as a novel approach for treatment of giant omphalocele.

PATIENTS AND METHODS

Retrospective chart review of six patients (five females) born between September 2018 and May 2022 who underwent staged reduction of giant omphalocele in conjunction with VAC therapy was conducted. Treatment was performed at two German third-level Pediatric Surgery Departments. Biometric and periprocedural data were assessed. Main outcome measure was the feasibility of VAC therapy for giant omphalocele. Data are reported as median and interquartile range (Q1-Q3).

RESULTS

Gestational age was 37 (37-38) weeks, and birth weight was 2700 (2500-3000) g. VAC dressing was changed every 3 (3-4) days until abdominal fascia closure at the age of 9 (3-13) days. Time to first/full oral feeds was 3 (1-5)/20 (12-24) days with a hospital stay of 22 (17-30) days. Follow-up was 8 (5-22) months and complications were of minor extent (none: n = 2; Clavien-Dindo I: n = 3; Clavien-Dindo II: n = 1), comprising a delayed neo-umbilical cord rest separation (n = 2) and/or concomitant neo-umbilical site infection (n = 2) with no repeat surgery.

CONCLUSION

In neonates with giant omphalocele, VAC constitutes a promising and technically feasible enhancement of the staged gravitational reduction method. This study shows evidence that VAC may accelerate restoration of the abdominal wall integrity in giant omphalocele, thus minimizing associated comorbidities inherent to a prolonged hospitalization.

Incidence of surgical procedures for gastrointestinal complications after abdominal wall closure in patients with gastroschisis and omphalocele

PURPOSE

This study aims to define the extent of additional surgical procedures after abdominal wall closure (AWC) in patients with gastroschisis (GS) and omphalocele (OC) with special focus on gastrointestinal related operations.

METHODS

A retrospective chart review was performed including all operations in GS and OC patients in the first year after AWC (2010-2019). The risk for surgery was calculated using the one-year cumulative incidence (CI).

RESULTS

33 GS patients (18 simple GS, 15 complex) and 24 OC patients (12 without (= OCL), 12 OC patients with liver protrusion (= OCL +)) were eligible for analysis. 43 secondary operations (23 in GS, 20 in OC patients) occurred after a median time of 84 days (16-824) in GS and 114.5 days (12-4368) in OC. Patients with complex versus simple GS had a significantly higher risk of undergoing a secondary operation (one-year CI 64.3% vs. 24.4%; p = 0.05). 86.5% of surgical procedures in complex GS and 36.3% in OCL + were related to gastrointestinal complications. Complex GS had a significantly higher risk for GI-related surgery than simple GS. Bowel obstruction was a risk factor for surgery in complex GS (one-year CI 35.7%).

CONCLUSION

Complex GS and OCL + patients had the highest risk of undergoing secondary operations, especially those with gastrointestinal complications.

Gastro-intestinal function and quality of life are favorable in adolescent and adult gastroschisis patients

BACKGROUND AND AIMS

Studies on long-term sequelae of gastroschisis are scarce. The limited data suggest increased abdominal complaints in young children. To provide proper counseling for both parents and patients, more information on long-term outcome is needed. This study aims to evaluate long-term outcome regarding GI function, gastroesophageal reflux (GER), health-related quality of life (HRQoL) and cosmetic satisfaction.

METHODS

An observational longitudinal cohort study was performed. All patients (N = 43) born between 1982 and 2008 with gastroschisis that were admitted to the University Medical Centre Utrecht, Wilhelmina Children's Hospital were invited to fill in a survey. Data of included patients were compared to validated Dutch reference standards.

RESULTS

Fourteen patients responded to the survey. The median follow-up was 18 years. Abdominal pain on weekly basis was present in two patients (14%) and feeding difficulties were present in one patient. Presence of a complication during gastroschisis treatment led to more GI symptoms (80% versus 22%). One patient experienced moderate complaints of regurgitation or dyspepsia. Although the overall HRQoL was lower in teenage gastroschisis patients as compared to healthy controls (73/100 versus 83/100, respectively), we found no relevant difference in overall HRQoL in the other age groups. Seven patients (50%) were satisfied with the cosmetic result of the scar.

CONCLUSIONS

GI function and HRQoL in gastroschisis patients seem similar to healthy controls at adolescent and adult age. Complications during gastroschisis treatment led to an increase of abdominal complaints later in life. The surgical technique had no significant effect on the cosmetic results.

Early Life Incidence of Gastrointestinal and Respiratory Infections in Children With Gastroschisis: A Cohort Study

OBJECTIVES

Survival in infants with gastroschisis is increasing although little is known about early childhood morbidity. In the context of a hypothesized link between the gastrointestinal (GI) tract and immune function, this study explores rates of GI and respiratory infections in children with gastroschisis.

METHODS

We conducted a population-based retrospective cohort study using data from the Health Improvement Network, a large database of UK primary care medical records. We identified children born from 1990 to 2013, and extracted follow-up data to their fifth birthday. We calculate incidence rates (IR) of GI and respiratory tract infections, overall and stratified by age, sex, socioeconomic status, and gestational age at birth, and compared these between children with and without gastroschisis by calculating adjusted incidence rate ratios (aIRR).

RESULTS

Children with gastroschisis had a 65% higher IR of GI infection compared to children without (aIRR 1.65, 95% confidence interval [CI] 1.37-1.99, P < 0.001). Children with gastroschisis had a 27% higher IR of all respiratory tract infections (aIRR 1.27, 95% CI 1.12-1.44, P < 0.001) and more than 2-fold increase in lower respiratory tract infections compared to children without the condition (aIRR 2.15, 95% CI 1.69-2.74, P < 0.001).

CONCLUSIONS

Children born with gastroschisis have a significantly higher incidence of GI and respiratory tract infections compared to children without gastroschisis. This association requires further investigations but could be related to the neonatal care they receive such as delayed enteral feeding or frequent antibiotic courses altering the gut microbiome and developing immune system.

The Management of an Ectopic Ovary in an Adolescent Patient with Gastroschisis

BACKGROUND

Gastroschisis is an abdominal wall defect through which the bowel herniates into the amniotic cavity. Surgical correction of gastroschisis is performed during infancy. Gynecologic concerns have not been described in this population as either an associated anomaly or complication of surgical repair.

CASE

A 15-year-old nulliparous female patient presented with abdominal pain with a history of gastroschisis requiring 4 surgeries in infancy. Computed tomography scan showed an ovary located in the right upper quadrant, which was concerning for torsion. She was taken for a laparotomy with right oophorectomy after conservative management had failed.

SUMMARY AND CONCLUSION

Long-term gynecologic outcomes of patients with gastroschisis are not well documented. Because gastroschisis patients are known to have abdominal pain later in life, this case shows that the differential diagnosis should include etiologies beyond the gastrointestinal tract.

Understanding gastroschisis and its clinical management: where are we?

Gastroschisis is the commonest developmental defect of the anterior abdominal wall in both developed and developing countries. The past 30 years have seen transformational improvements in outcome due to advances in neonatal intensive care and enhanced integration between the disciplines of maternal fetal medicine, neonatology and pediatric surgery. A review of gastroschisis, which emphasizes its epidemiology, multidisciplinary care strategies and contemporary outcomes is timely. Areas covered: This review discusses the current state of knowledge related to prevalence and causation, and postulated embryopathologic mechanisms contributing to the development of gastroschisis. Using relevant, current literature with an emphasis on high level evidence where it exists, we review modern techniques of prenatal diagnosis, pre and postnatal risk stratification, preferred timing and method of delivery, options for abdominal wall closure, nutritional management, and short and long term clinical and neurodevelopmental follow-up. Expert commentary: This section explores controversies in contemporary management which contribute to practice and cost variation and discusses the benefits of novel nutritional therapies and care standardization that target unnecessary practice variation and improve overall cost-effectiveness of gastroschisis care. The commentary concludes with a review of fertile areas of gastroschisis research, which represent opportunities for knowledge synthesis and further outcome improvement.

High mortality among children with gastroschisis after the neonatal period: A long-term follow-up study

BACKGROUND

During the last decades neonatal outcomes for children born with gastroschisis have improved significantly. Survival rates >90% have been reported. Early prenatal diagnosis and increased survival enforce the need for valid data for long-term outcome in the pre- and postnatal counseling of parents with a child with gastroschisis.

METHODS

Long-term follow-up on all newborns with gastroschisis at Odense University Hospital (OUH) from January 1 1997-December 31 2009. Follow-up included neonatal chart review for neonatal background factors, including whether a GORE^®DUALMESH was used for staged closure, electronic questionnaires, interview and laboratory investigations. Cases were divided into complex and simple cases according to the definition by Molik et al. (2001). Survival status was determined by the national personal identification number registry. Because of the consistency of the registration, survival status was obtained from all children participating in the study.

RESULTS

A total of 71 infants (7 complex and 64 simple) were included. Overall seven out of the 71 children (9.9%, median age: 52days (25-75% percentile 0-978days) had died at the time of follow-up. Three died during the neonatal period and four died after the neonatal period. Parenteral nutrition (PN) induced liver failure and suspected adhesive small bowel obstruction were the causes of deaths after the neonatal period. Overall mortality was high in the "complex" group compared to the simple group (3/7 (42.9%) vs 4/64 (6.3%), p = 0.04). Forty (62.5%) of the surviving children consented to participate in the follow-up. A total of 12 children had had suspected adhesive small bowel obstruction. Prevalence of small bowel obstruction was not related to the number of operations needed for neonatal closure of the defect. Staged closure was done in 5/12 (41.7%) who developed small bowel obstruction vs 11/35 (31.43%) without small bowel obstruction, p=0.518. A GORE^®DUALMESH was used in 16 children (22.5%). Of these 2 were complex and 14 were simple cases. Prevalence of recurrent abdominal pain was 22.5% (9/40) among children with gastroschisis compared to 12% in a study on Danish school children, p=0.068. Gastrointestinal symptoms had led to hospital admission after primary discharge in significantly more children with gastroschisis 16 (40.0%) than children younger than 16years old in the general Danish population 129.419/1.081.542 (12.0%), p=0.000. Fecal calprotectin level was above the reference level (>50mg/kg) in 6/16 (37.5%) children >8years old with gastroschisis compared to 1/7 (14.3%) healthy children. (Fisher's exact=0.366). Only 8/38 (21.1%) children with gastroschisis reported to have an umbilicus.

CONCLUSION

Mortality among children with gastroschisis is still significant with the highest risk among complicated cases. The majority of the deaths is potentially preventable as PN-related causes and suspected adhesive small bowel obstruction counted for five of seven deaths. Neither categorization upon method of abdominal wall closure nor categorization into simple and complex cases can predict the risk of adhesive small bowel obstruction. With improved administration of PN and timely information and attention to the risk of the small bowel obstruction there is good possibility that the associated mortality could decrease. Type of study and level of evidence: Prognosis study, level II.

Quality of life in patients with gastroschisis is comparable with the general population: A questionnaire survey

AIM

To evaluate long-term quality of life and somatic growth of patients with gastroschisis and compare them with the general population.

METHODS

We performed a questionnaire survey of the quality of life of our patients treated between 2004-2012.

RESULTS

A questionnaire was sent to our 56 patients with gastroschisis, 38 mothers of patients (68%) responded to the questionnaire. 33 of 38 mothers claim that the quality of life of their child is very good, 4 of them responded that it is good. 1 mother confessed that the quality of life was very poor. Anthropometric data show comparable results with the standard population except for patients of 1 year of age who still have lower weight (P<0.001) and body height in the 5th percentile and patients of 3 years of age who are also significantly thinner. 13% of patients in our study group have gastrointestinal problems. 9 patients (24%) attend follow-up at the neurological center (Attention Deficit Hyperactivity Disorder n=6, mental retardation n=1, dysarthria n=2), however, overall intellectual abilities are within normal range. 7 patients underwent surgery for umbilical (n=3) or inguinal hernia (n=4), 2 patients were operated on for undescended testicles, 3 patients were operated on for an adhesive ileus. 92% of mothers are very satisfied with the cosmetic result of the scar.

CONCLUSION

The study has shown that the majority of patients after operation of gastroschisis have a very good quality of life without limitation in comparison with the general population. The presented anthropometric data confirm that the development of patients with gastroschisis is favourable.

Complications in neonatal surgery

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.

The Surgical Correction of Congenital Deformities: The Treatment of Diaphragmatic Hernia, Esophageal Atresia and Small Bowel Atresia

BACKGROUND

More than half of all congenital deformities can be detected in utero. The initial surgical correction is of paramount importance for the achievement of good long-term results with low surgical morbidity and mortality.

METHODS

Selective literature review and expert opinion.

RESULTS

Congenital deformities are rare, and no controlled trials have been performed to determine their optimal treatment. In this article, we present the prenatal assessment, treatment, and long-term results of selected types of congenital deformity. Congenital diaphragmatic hernia (CDH) affects one in 3500 live-born infants, while esophageal atresia affects one in 3000 and small-bowel atresia one in 5000 to 10,000. If a congenital deformity is detected and its prognosis can be reliably inferred from a prenatal assessment, the child should be delivered at a specialized center (level 1 perinatal center). The associated survival rates are 60-80% after treatment for CDH and well over 90% after treatment for esophageal or small-bowel atresia. Despite improvements in surgical correction over the years, complications and comorbidities still affect 20-40% of the treated children. These are not limited to surgical complications in the narrow sense, such as recurrence, postoperative adhesions and obstruction, stenoses, strictures, and recurrent fistulae, but also include pulmonary problems (chronic lung disease, obstructive and restrictive pulmonary dysfunction), gastrointestinal problems (dysphagia, gastro-esophageal reflux, impaired intestinal motility), and failure to thrive. Moreover, the affected children can develop emotional and behavioral disturbances. Minimally invasive surgery in experienced hands yields results as good as those of conventional surgery, as long as proper selection criteria are observed.

CONCLUSION

Congenital deformities should be treated in recognized centers with highly experienced interdisciplinary teams. As no randomized trials of surgery for congenital deformities are available, longitudinal studies and registries will be very important in the future.

Management of gastroschisis

PURPOSE OF REVIEW

The diagnosis and treatment of gastroschisis spans the perinatal disciplines of maternal fetal medicine, neonatology, and pediatric surgery. Since gastroschisis is one of the commonest and costliest structural birth defects treated in neonatal ICUs, a comprehensive review of its epidemiology, prenatal diagnosis, postnatal treatment, and short and long-term outcomes is both timely and relevant.

RECENT FINDINGS

The incidence of gastroschisis has increased dramatically over the past 20 years, leading to a renewed interest in causation. The widespread availability of maternal screening and ultrasound results in very high rates of prenatal diagnosis, which enables evaluation of the optimal timing and mode of delivery. The preferred method of surgical closure continues to be an issue of debate among pediatric surgeons, whereas postsurgical treatment seeks to expedite the initiation and progression of enteral feeding and minimize complications. A small subset of babies with complex gastroschisis leading to intestinal failure benefit from the knowledge and expertise of dedicated interdisciplinary teams, which seek to bring novel therapies and improved clinical outcomes.

SUMMARY

The opportunities to increase the knowledge of causation, and identify best practices leading to improved outcomes, drive the ongoing need for collaborative clinical research in gastroschisis.

Management of the Sequelae of Severe Congenital Abdominal Wall Defects

Background

The survival rate of newborns with severe congenital abdominal wall defects has increased. After successfully addressing life-threatening complications, it is necessary to focus on the cosmetic and functional outcomes of the abdominal wall.

Methods

We performed a chart review of five cases treated in our institution.

Results

Five patients, ranging from seven to 18 years of age, underwent the following surgical approaches: simple approximation of the rectus abdominis fascia, the rectus abdominis sheath turnover flap, the placement of submuscular tissue expanders, mesh repair, or a combination of these techniques depending on the characteristics of each individual case.

Conclusions

Patients with severe congenital abdominal wall defects require individualized surgical treatment to address both the aesthetic and functional issues related to the sequelae of their defects.

Assessing quality of life in pediatric gastroschisis patients using the Pediatric Quality of Life Inventory survey: An institutional study

BACKGROUND

The purpose of this study was to quantify quality of life (QOL) outcomes in gastroschisis children using a validated QOL inventory survey.

METHODS

A chart review and prospective survey (2012 Pediatric Quality of Life Inventory™ (PedsQL™)) were performed for gastroschisis patients from 2005 to 2011. Demographics and scores were compared between patents with simple versus complicated gastroschisis and patients with and without bowel resection.

RESULTS

One hundred nineteen patients (>2years of age) were identified. Twenty-eight families participated in the prospective survey with an average patient age of 5.8±2.3years. There were 11 complicated and 17 simple cases. Children with simple gastroschisis had lower rates of reoperation (0.06% versus 90%, p<0.001) and bowel resection (12% and 64%, p=0.004) than complicated patients. Average QOL scores for children with simple and complicated gastroschisis were 81.69/100±19.50 and 78.7/100±20.14 (p=0.70), respectively. Scores were also similar in children with and without bowel resection (74.72/100±19.94 and 83.29/100±19.10, p=0.171). Cronbach's alpha correlation was 0.912 for the overall survey.

DISCUSSION

Despite increased need for reoperation and bowel resection, at >2years of age, PedsQL™ scores were similar between patients with simple and complicated gastroschisis. This study provides preliminary data on QOL outcomes for antenatal counseling of gastroschisis families.

Abdominal wall defects: prenatal diagnosis, newborn management, and long-term outcomes

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.

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.

A systematic review of studies of quality of life in children and adults with selected congenital anomalies

BACKGROUND

Few studies have assessed quality of life (QOL) for children born with major structural congenital anomalies. We aimed to review studies reporting QOL in children and adults born with selected congenital anomalies involving the digestive system.

METHODS

Systematic review methods were applied to literature searches, development of the data extraction protocol, and the review process. We included studies published in English (1990-2010), which used validated instruments to assess QOL in individuals born with congenital diaphragmatic hernia, esophageal atresia, duodenal atresia or abdominal wall defects.

RESULTS

Of 200 papers identified through literature searches, 111 were excluded after applying restrictions and removing duplicates. After scanning 89 abstracts, 32 full-text papers were reviewed (none on duodenal atresia), of which 18 (nine in children or adolescents and nine in adults) were included. Studies measured health-related QOL, but did not assess subjective wellbeing. Instruments used to assess health-related QOL in children varied considerably. In adults most studies used the Short Form 36. Many studies had methodological limitations, such as being from a single institution, retrospective cohorts, and low sample size. The summarized evidence suggests that health-related QOL of these children is affected by associated anomalies and ongoing morbidity resulting in lower physical functioning and general health perception. In adults, health-related QOL is comparable with the general population.

CONCLUSIONS

The reviewed studies considered health status and functioning as a major determinant of QOL. More studies assessing QOL in patients with major congenital anomalies are needed, and those involving children should use age-adjusted, validated instruments to measure both health-related QOL and self-reported subjective wellbeing.

Fetal and neonatal outcome in patients with anterior abdominal wall defects (gastroschisis and omphalocele)

Fetuses with gastroschisis and omphalocele frequently show intrauterine growth restriction (IUGR). The aim of our study was to evaluate the intrauterine course of IUGR and the neonatal outcome in a large patient collective. We retrospectively included all euploid fetuses with gastroschisis and omphalocele between 2001 and 2009 in a single tertiary center. Patients' characteristics, serial ultrasound examinations and neonatal outcomes were evaluated. From 39 fetuses (28 gastroschisis, 11 omphalocele) 61.5% had IUGR <5th percentile and 15.4% had IUGR<10th percentile. The rate of IUGR did not differ significantly between the two groups during pregnancy. Newborns with gastroschisis showed an average weight of 2386 g, and those with omphalocele showed an average weight of 3148 g (P<0.001). Nevertheless, newborns with omphalocele were more frequently eutrophic than those with gastroschisis (88.8% vs. 52.2%, P=0.079). On average, only one surgical intervention was necessary for the definitive repair of the defect (65.5% of the newborns). Children with gastroschisis remained hospitalized nearly twice as long as children with an omphalocele (38 vs. 20 days). IUGR rates during pregnancy did not differ significantly between fetuses with gastroschisis and omphalocele although patients with defects of omphalocele were more frequently eutrophic at birth. Most newborns needed only one operation for definitive surgical treatment. The mean hospitalization time after this intervention was 4 weeks.

Hospital readmission among infants with gastroschisis

OBJECTIVE

Infants with gastroschisis have significant perinatal morbidity including long hospitalizations and feeding intolerance. Two thirds are premature and 20% are growth restricted. Despite these known risk factors for post-natal complications, little is known about readmission for infants with gastroschisis. Our objective was to determine the frequency and indication for hospital readmission after initial discharge among infants with gastroschisis.

STUDY DESIGN

Retrospective cohort study. All surviving infants treated for gastroschisis at Cincinnati Children's Hospital Medical Center, born between January 2006 and December 2008 were included. Main outcome measures included the frequency and indication for readmission. Associated neonatal risk factors also were assessed.

RESULT

Fifty-eight patients were analyzed. Twenty-three (40%) subjects were readmitted (five with multiple readmissions); 65% of readmissions occurred in the first year and 70% involved complications directly related to gastroschisis. The most common reasons for readmission were bowel obstruction and abdominal distention/pain. Median time to readmission directly related to gastroschisis was 23 weeks (range 5 to 92). All three infants with home parenteral nutrition were readmitted. Readmission was not associated with gestational age, birth weight or length of initial hospitalization.

CONCLUSION

Readmission after initial hospitalization is common in gastroschisis patients. Parental counseling should include education regarding the possibility of complications requiring readmission. Determinants of readmission require further study.

Review of the evidence on the closure of abdominal wall defects

Infants with congenital abdominal wall defects pose an interesting and challenging management issue for surgeons. We attempt to review the literature to define the current treatment modalities and their application in practice. In gastroschisis, the overall strategies for repair include immediate closure or delayed operative repair. The best level of data for gastroschisis is grade C and appears to support that there is no major difference in survival between immediate closure or delayed repair. In patients with omphalocele, the management techniques are more varied consisting of immediate closure, staged closure or delayed closure after epithelialization. The literature is less clear on when to use one technique over the other, consisting of mostly grade D and E data. In patients with omphalocele, a registry to collect information on patients with larger defects may help determine which of the management strategies is optimal.

Minor and giant omphalocele: long-term outcomes and quality of life

PURPOSE

Long-term outcome and quality of life in omphalocele (OC) studies are mainly focused on cosmetic disorders with the abdominal scar and gastrointestinal disorders. The aim of this study was to compare long-term mortality, morbidity, and quality of life between patients with minor and giant OCs.

METHODS

Records of 89 minor and 22 giant OC children were reviewed. A questionnaire on general health was sent to all patients. A second questionnaire concerning quality of life and functional status; Darthmouth COOP Functional Health Assessment Charts/WONCA (COOP/WONCA) was sent to all patients aged 18 years or older and a peer control group.

RESULTS

Of the surviving patients (69 minor OC, 20 giant OC), 12 were lost to hospital follow-up. The first questionnaire was returned by 64 (83%) of 77 patients. There were no significant differences in gastrointestinal disorders. Cosmetic problems were experienced significantly more in giant OC. The results of the COOP/WONCA charts indicated a good to very good quality of life in both groups comparable to the control group.

CONCLUSIONS

Our study indicates that after a high level of medical intervention perinatally, quality of life is good to very good in both groups and comparable to healthy young adults.

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.

The incidence and morbidity of adhesions after treatment of neonates with gastroschisis and omphalocele: a 30-year review

BACKGROUND/PURPOSE

Adhesive small bowel obstruction (SBO) is a feared complication after correction of abdominal wall defects in neonates. Knowledge of its incidence and potential risk factors in a well-documented group with strict follow-up is needed to guide preventive measures.

METHODS

Records of 170 neonates with abdominal wall defects, 59 gastroschisis (GS) and 111 omphalocele (OC), were reviewed focusing on SBO. Risk of SBO was calculated, and potential risk factors were analyzed. Long-term complaints possibly associated with adhesions were assessed through questionnaire.

RESULTS

One hundred forty-seven neonates were operated on, 12 were treated nonoperatively, and 11 patients died shortly after birth. Defects were primarily closed in 128, 7 neonates needed prosthetic mesh, and 12 had a silastic sac inserted. Twenty-six (18%) neonates had SBO, 14 (25%) of 55 with GS, and 12 (13%) of 92 with OC (P = .06). Of the 26 with SBO, 26 (88%) needed laparotomy. Four patients died because of SBO. Most episodes (85%) were in the first year. Sepsis and fascia dehiscence were predicting risk factors for SBO. Abdominal pain and constipation were frequent long-term complaints not significantly associated with SBO.

CONCLUSIONS

Adhesive SBO is a frequent and serious complication in the first year after treatment of congenital abdominal wall defects. Sepsis and fascial dehiscence are predictive factors.

Progress over 32 years of a survivor of giant exomphalos and outcome of pregnancy

We report the progress of a female survivor of ruptured giant exomphalos over 32 years. Two-stage repair was performed at birth, resulting in a giant ventral hernia, which was repaired at 31 months. She developed gross benign ascites at 24 years, not previously described in association with congenital abdominal wall defects. This was associated with a misleading radiologic finding of a complex ovarian cyst and led to laparotomy. There were dense adhesions. Benign ascites and loculated pelvic fluid were drained, but the ovaries appeared healthy. A further laparotomy was performed for acute abdominal pain 2 years later. She subsequently had a successful pregnancy complicated by urinary retention. The abdomen expanded without difficulty, unlike the only other such case reported in the literature. A healthy baby girl was delivered by cesarean section at 37 weeks' gestation, which was necessary because of a footling breech presentation.

Caring for the newborn with an omphalocele

An omphalocele, a ventral defect of the umbilical ring resulting in herniation of the abdominal viscera, is one of the most common congenital abdominal wall defects seen in the newborn. Omphaloceles occur in 1 in 3000 to 10,000 live births. Associated malformations such as chromosomal, cardiac, or genitourinary abnormalities are common. Postnatal management includes protection of the herniated viscera, maintenance of fluids and electrolytes, prevention of hypothermia, gastric decompression, prevention of sepsis, and maintenance of cardiorespiratory stability. A primary or staged closure approach may be used to repair the defect. Some giant omphaloceles require a skin flap or nonoperative management approach, hoxvever. Immediate postoperative complications, usually related to significant changes in intra-abdominal pressures, include compromise of interior venous blood return and hemodynamic and respiratory instability due to diaphragmaric elevation. Complications occur more frequently with giant defects. Potential short-term complications include necrotizing enterocolitis, prolonged ileus, and respiratory distress. Long-term complications include parenteral nutrition dependence, gastroesophageal reflux, parenteral nutrition-related liver disease, feeding intolerance, and neurodevelopmental delay. Overall, advances in surgical therapies and nursing care have improved outcomes for infants with omphaloceles; survival rates for those with isolated omphaloceles are reported at 75 to 95 percent. Infants with associated anomalies and giant omphaloceles have the poorest outcomes.

Surveillance and outcome of fetuses with gastroschisis

OBJECTIVES

Infants with gastroschisis have a high survival rate. However, the rate (10-15%) of intrauterine fetal death (IUFD) is considerable, and the association with fetal distress is well known. The aim of this study was to describe the outcome of fetuses with a prenatal diagnosis of gastroschisis. The impact of correct prenatal diagnosis, surveillance and signs of complicating risk factors were evaluated.

METHODS

All fetuses with prenatally diagnosed gastroschisis at the National Center for Fetal Medicine from January 1988 to August 2002 were registered and prospectively evaluated with regular ultrasound examinations. From 34-36 completed gestational weeks the fetuses were monitored daily to every second day with cardiotocography (CTG).

RESULTS

Gastroschisis was diagnosed in 64 fetuses at a mean gestational age of 19 + 2 weeks. All had normal karyotype. Associated anomalies were found in four cases (6.3%). Three pregnancies (4.7%) were terminated, all for reasons other than gastroschisis. One fetus (1.6%) died in utero. Thirteen fetuses (22%) had abnormal CTG leading to subsequent Cesarean sections. Mean gestational age at delivery was 36 + 1 weeks. Mean birth weight was 2586 g. Thirteen infants (22%) were small for gestational age (SGA). In 15 cases (25%) meconium-stained amniotic fluid was found; 14 of these had abnormal CTG and/or were SGA. Small bowel atresia was found in four infants (6.7%). Four infants died postnatally at the age of 0-9 months.

CONCLUSIONS

CTG surveillance of fetuses with gastroschisis may improve the outcome through detection of fetal distress thereby reducing the risk of IUFD. Other clinical situations of importance that are associated with gastroschisis are described and discussed.