Abdominal wall defects in infants. Survival and implications for adult life

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.

Cisapride Use in Pediatric Patients With Intestinal Failure and Its Impact on Progression of Enteral Nutrition

OBJECTIVE

Gastrointestinal dysmotility is common in patients with pediatric intestinal failure (PIF), leading to delays in advancement of enteral nutrition (EN). Few studies have been published regarding the safety and efficacy of cisapride for improvement of enteral tolerance and ability to wean parenteral nutrition. Our objective was to describe a single center experience on the use of cisapride in patients with PIF.

METHODS

Retrospective chart review of patients was performed. Demographic, intestinal anatomy, and outcome data were collected. Percentage of EN before initiation of cisapride, progression of EN at 3 and 6 months, and ability to wean parenteral nutrition after initiation of cisapride were calculated.

RESULTS

Prokinetics were used in 61 of 106 patients (56.6%); 29 of 60 patients (48.3%) failed to progress EN on other prokinetics and started on cisapride. Before cisapride the progress of EN plateaued for a mean of 42.3 (standard deviation [SD] 60.2) days. The rate of feed progression was 0.14% (SD 0.19)/day pre-cisapride and 0.69%/day (SD 0.31) after cisapride initiation (P < 0.001). Percentage of EN improved significantly from baseline to 3 months postinitiation (23.9% vs 79.4%, respectively; P < 0.001). Electrocardiogram was performed on initiation of cisapride and after every dose change. Medication was discontinued in 2 of 29 (6.8%).

CONCLUSION

This retrospective study suggests that cisapride may be beneficial in PIF patients who fail to progress EN on first line prokinetics. The most significant period of improvement occurs within 3 months of cisapride initiation. Cardiac side effects in our cohort were lower than previously reported; however, cardiac monitoring is still recommended.

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

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

The influence of prematurity on neonatal surgical morbidity and mortality

BACKGROUND

As survival rates amongst premature infants have improved, prematurity remains a leading contributor to neonatal surgical morbidity and mortality. This study aims to better assess the influence of prematurity on surgical outcomes.

METHODS

The NSQIP-Pediatric database was used to compare outcomes between preterm and term infants undergoing surgical repair of select congenital anomalies from 2012 to 2017. Prematurity was categorized as extremely preterm (EP) (<29 weeks), very preterm (VP) (29-32 weeks), moderate to late preterm (MLP) (33-36 weeks), and term (≥37 weeks). Significance was determined using Chi-square tests, Fisher exact tests and adjusted logistic regression analysis.

RESULTS

4852 infants were identified with 45 (0.9%) EP, 211 (4.3%) VP, 1492 (30.8%) MLP, and 3104 (64.0%) term. Compared to term, preterm infants have increased odds of surgical morbidity (EP Odds Ratio (OR) 3.2 95% Confidence Interval (CI) 1.6-6.4, VP OR 1.2 95%CI 0.9-1.7, and MLP OR 1.2 95%CI 1.0-1.4). 30-day mortality decreased as neonatal age increased from 22.2% EP to 2.9% term (p < 0.001). Premature populations had higher rates of sepsis, pneumonia, bleeding requiring transfusion and 30-day mortality.

CONCLUSIONS

Prematurity increases morbidity and mortality amongst neonates undergoing surgery. Risk-adjustment for prematurity is needed and premature infants may have unique quality improvement targets.

LEVEL OF EVIDENCE

Level III.

Gastroesophageal Reflux Disease and Foregut Dysmotility in Children with Intestinal Failure

Gastrointestinal dysmotility is a common problem in a subgroup of children with intestinal failure (IF), including short bowel syndrome (SBS) and pediatric intestinal pseudo-obstruction (PIPO). It contributes significantly to the increased morbidity and decreased quality of life in this patient population. Impaired gastrointestinal (GI) motility in IF arises from either loss of GI function due to the primary disorder (e.g., neuropathic or myopathic disorder in the PIPO syndrome) and/or a critical reduction in gut mass. Abnormalities of the anatomy, enteric hormone secretion and neural supply in IF can result in rapid transit, ineffective antegrade peristalsis, delayed gastric emptying or gastroesophageal reflux. Understanding the underlying pathophysiologic mechanism(s) of the enteric dysmotility in IF helps us to plan an appropriate diagnostic workup and apply individually tailored nutritional and pharmacological management, which might ultimately lead to an overall improvement in the quality of life and increase in enteral tolerance. In this review, we have focused on the pathogenesis of GI dysmotility in children with IF, as well as the management and treatment options.

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.

Long term complications and outcomes in omphalocele

After a diagnosis of omphalocele during pregnancy, questions regarding long-term prognosis are of primary importance for parents. It is imperative that their questions are answered with substantiated data to promote confident decisions for their children. They frequently express concerns regarding long-term survival, quality of life, need for more operations, feeding issues, motor and cognitive development, cosmesis, and the unique difficulties of giant omphaloceles. The available outcome studies that address these questions are discussed.

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.

Surgery Requiring Detailed Preoperative Simulation and Scar De-epithelialization to Repair Severe Postoperative Scarring from Gastroschisis

We present the case of a patient with severe postoperative scarring from surgical treatment for gastroschisis, with the intestine located immediately under the dermal scar. Although many patients are unsatisfied with the results of scar repair treatment, few reports exist regarding severe or difficult cases involving the surgical repair of postoperative scar contracture. We achieved an excellent result via simulation involving graph paper drawings that were generated using computed tomography images as a reference, followed by dermal scar deepithelialization. The strategy described here may be useful for other cases of severe postoperative scar contracture after primary surgery for gastroschisis.

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.

Surgical Treatment Results In Gastroschisis Based On Preterm Delivery Within The 34th Week Of Gestation By Caesarean Section

was 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 10

The data indicate that in case of gastroschisis, primary closure can be more frequently achieved by section within the 34

Pulmonary complications of abdominal wall defects

The abdominal wall is an integral component of the chest wall. Defects in the ventral abdominal wall alter respiratory mechanics and can impair diaphragm function. Congenital abdominal wall defects also are associated with abnormalities in lung growth and development that lead to pulmonary hypoplasia, pulmonary hypertension, and alterations in thoracic cage formation. Although infants with ventral abdominal wall defects can experience life-threatening pulmonary complications, older children typically experience a more benign respiratory course. Studies of lung and chest wall function in older children and adolescents with congenital abdominal wall defects are few; such investigations could provide strategies for improved respiratory performance, avoidance of respiratory morbidity, and enhanced exercise ability for these children.

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.

A case of choledocholithiasis and intestinal malrotation in an adolescent with repaired gastroschisis

Most infants with repaired gastroschisis develop normally and remain in good health. About 10% of patients with gastroschisis have other malformations. We report a case of choledocholithiasis and intestinal malrotation in an adolescent with repaired gastroschisis. A 17-year-old girl presented with fever, jaundice, and abdominal pain. She had undergone an operation to repair gastroschisis at birth. Physical examination revealed icteric sclera, a tight abdominal wall, and a longitudinal surgical scar at the midline. An abdominal computed tomography scan revealed a round calcifying lesion near the pancreas and a midline-positioned liver and gallbladder. Absence of the retroperitoneal duodenum and the anterior and left-sided position of the superior mesenteric vein compared with the superior mesenteric artery were observed. Results of abarium examination revealed intestinal malrotation. Endoscopic retrograde cholangiopancreatography revealed diffuse dilatation of the biliary trees and a malpositioned gallbladder. A single stone was removed by using a basket. The clinical symptoms improved after the patient underwent endoscopic retrograde cholangiopancreatography.

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.

Prenatal coverage of experimental gastroschisis with a collagen scaffold to protect the bowel

BACKGROUND/PURPOSE

In fetuses with gastroschisis, toxic products in the amniotic fluid and constriction at the defect of the abdominal wall are considered causative of damage to the eviscerated bowel. The aim of this study was to cover the eviscerated bowel in gastroschisis with a collagen scaffold to protect the bowel and induce cell growth into the scaffold, which could lead to skin or abdominal wall formation replacing the scaffold.

METHODS

In 12 fetal lambs gastroschisis was surgically created at 79 days gestation. A dual-layer type I collagen scaffold was sutured into the skin of the abdominal wall around the defect covering the eviscerated bowel. Lambs were examined after caesarean section at 140 days' gestation.

RESULTS

Survival was 67%. In 7 of 8 surviving lambs the bowel was found to be covered after birth. One scaffold had ruptured. The bowel was found repositioned in the abdominal cavity in 5 lambs. In 2 lambs it was still partially outside. Only minor adherence of bowel loops and no fibrous peel formation were seen. Connective tissue and skin tissue replaced the scaffold.

CONCLUSIONS

Prenatal coverage of the bowel in experimental gastroschisis with a collagen scaffold is feasible in fetal lambs, significantly diminished damage to the bowel wall, and skin and connective tissue replaced the scaffold. This technique may be promising in the care of fetuses with this congenital anomaly.

Assessment of early pulmonary function abnormalities in giant omphalocele survivors

PURPOSE

Infants with giant omphalocele (GO) are at increased risk for persistent respiratory insufficiency, yet information regarding the systematic assessment of their lung function is limited. We performed a group of pulmonary function tests (PFTs) including spirometry, fractional lung volume measurements, assessment of bronchodilator responsiveness, and passive respiratory mechanics in GO survivors during infancy and early childhood to evaluate the nature and degree of pulmonary dysfunction.

MATERIAL AND METHODS

Between July 2004 and June 2008, 30 consecutive GO survivors were enrolled in our interdisciplinary follow-up program. Forty-seven percent (14/30) underwent PFT during follow-up evaluation using the raised volume rapid thoracic compression technique to measure forced expiratory flows and bronchodilator responsiveness, body plethysmography to calculate lung volumes, and the single breath occlusion technique to measure passive mechanics of the respiratory system.

RESULTS

The mean age at PFT assessment was 19.3 ± 19.7 months (range, 1.0-58). Mean forced vital capacity and mean forced expiratory volume in the first 0.5 second were significantly reduced compared with published normative values (P = .03 and P < .01, respectively). Total lung capacity was significantly reduced (P < .001), whereas functional residual capacity, residual volume, and residual volume to total lung capacity ratio were within the normative range (P = .21, P = .34, and P = .48, respectively). Among the 46% who demonstrated significant bronchodilator responsiveness, there were greater increases in the mean percentage changes in flow at 25% to 75% (P = .01), flow at 75% (P < .001), and flow at 85% (P < .001) compared with those participants that did not respond. Specific compliance was reduced, whereas specific conductance increased, compared with published normal results.

CONCLUSIONS

Abnormalities of pulmonary function in GO survivors include lung volume restriction without airway obstruction, an increased likelihood of airway hyperresponsivness, and reduced respiratory system specific compliance. Early recognition of pulmonary functional impairment in GO survivors could help to develop targeted treatment strategies to reduce the risk of subsequent pulmonary morbidity.

Delayed management of giant omphalocele using silver sulfadiazine cream: an 18-year experience

BACKGROUND/PURPOSE

To assess the value of topical silver sulfadiazine (SSD) cream in the treatment of babies with a giant omphalocele.

METHODS

From 1991 to 2008 inclusive, 20 infants with giant omphalocele (defined as >10 cm diameter) were treated with SSD, leaving a large ventral hernia to be repaired at a later date.

RESULTS

There were 12 boys and 8 girls. Thirteen had prenatal ultrasound diagnosis at a mean gestational age of 23 weeks. The mean gestational age at delivery was 37 weeks, and mean birth weight was 2.5 kg. Nineteen had other anomalies and/or medical problems, 18 of them multiple. The most common was pulmonary hypoplasia (70%). Mechanical ventilation and/or oxygen treatment was required in 15 (75%) for a mean of 10 weeks. SSD was used as primary sac treatment in 5 and secondary treatment in 15 (after Silon pouch 11, Op-site 3, povidone-iodine 1). Six omphalocele sacs were ruptured within the first 5 days of life. SSD was used for a mean of 6 months at a cost of $1 per day. Complications included 2 instances of staphylococcal sepsis and 1 jejunal perforation inside a Silon pouch. Six (30%) died from pulmonary hypoplasia at a mean age of 18 weeks. There were 14 (70%) survivors who went home after a mean of 14 weeks. Of the 14 survivors, 12 had ventral hernias repaired (18 operations with 2 recurrences), and 2 remain with their original ventral hernia.

CONCLUSIONS

Initial topical coverage with SSD is associated with excellent outcomes for infants with giant omphalocele who cannot undergo immediate closure.

Medical management of motility disorders in patients with intestinal failure: a focus on necrotizing enterocolitis, gastroschisis, and intestinal atresia

BACKGROUND

Intestinal failure (IF) is the dependence upon parenteral nutrition to maintain minimal energy requirements for growth and development. It may occur secondary to a loss of bowel length, disorders of motility, or both. Short bowel syndrome (SBS) is a malabsorptive state resulting from surgical resection, congenital defect, or diseases associated with loss of absorptive surface area. A particularly vexing problem is associated with whole bowel and/or segmental intestinal dysmotility. Motility disorders within the context of SBS and IF may relate to rapid intestinal transit secondary to loss of intestinal length, dysmotility associated with loss or poor antegrade peristalsis, or gastroparesis. Therapy may be classified into medical (prokinetic and antidiarrheal agents) and surgical to deal with the overdistended poorly motile bowel.

METHODS

We performed a systematic review of the literature pertaining to IF, SBS, and dysmotility in the pediatric population with gastroschisis, necrotizing enterocolitis, and intestinal atresia. In addition to the available treatment options, we have provided a review of the literature and a summary of the available evidence.

CONCLUSION

Despite relatively poor level of evidence regarding the application of promotility and antidiarrheal medications in patients with SBS and IF, these agents continue to be used. Herein, we provide a review of the physiology and pathophysiology of intestinal motility/dysmotility and available strategies for the use of promotility and antidiarrheal agents in patients with IF/SBS.

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.

Prospective, interdisciplinary follow-up of children with prenatally diagnosed giant omphalocele: short-term neurodevelopmental outcome

PURPOSE

The objective of this study is to determine the short-term neurodevelopmental outcome in infants with giant omphalocele (GO).

MATERIALS AND METHODS

Between January 2002 and December 2007, 31 consecutive infants with GO received prenatal and postnatal care at our institution. Overall survival was 81% (25/31). Twenty (80%) of the survivors were enrolled in a prospective interdisciplinary follow-up program. Fifteen were at least 6 months of age and received detailed neurodevelopmental evaluation using the Bayley Scales of Infant Development II (BSID-II [before 2006, n = 3]) or BSID-III (after 2006, n = 12). Scores were grouped as average, mildly delayed, and severely delayed by SD intervals (115-85, 71-84, <70). Scores were considered mixed if cognitive or language skills were in different ranges.

RESULTS

Median age at evaluation was 12 months (range, 6-26 months). Average, mildly delayed, and severely delayed scores for cognitive and language skills were found in 6 (40%), 2 (13%), and 6 (40%), respectively. One child had mixed scores (severely delayed for cognitive and mildly delayed for language skills). Motor scores were normal, mildly delayed, and severely delayed in 6 (40%), 2 (13%), and 7 (47%), respectively. The neuromuscular examination was abnormal in 8 patients (62%). Five (33%) scored within the average range, whereas 6 (40%) demonstrated severe delays for cognitive, language, and motor outcome. Of the 6 children with severe delays, 2 (13% of total) have autism, 4 required tracheostomy, and 1 was diagnosed with Williams syndrome.

CONCLUSIONS

The presence of GO is associated with deficits in developmental achievements in most of the affected infants ranging from mild to profound delays. These findings underscore the importance of early and standardized neurodevelopmental evaluation throughout childhood for all survivors with GO. Larger studies are warranted for risk factor stratification.

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.

Successful vaginal delivery following laparoscopic abdominal wall reconstruction in an adult survivor of an omphalocele without prior surgical repair: report of a case

We report the case of a successful vaginal delivery following laparoscopic abdominal wall reconstruction in an adult survivor of an omphalocele without prior surgical repair. Untreated omphaloceles are rare in adulthood. A 30-year-old female patient presented with a large anterior abdominal wall defect due to an untreated omphalocele, who expressed a desire to have a baby in the near future. A laparoscopic herniorrhaphy was performed with a double-layered expanded polytetrafluoroethylene (ePTFE, Gore-Tex) mesh. The patient delivered a full-term healthy baby vaginally 2 years after surgical repair of the omphalocele.

Growth and neurodevelopment at 16 to 24 months of age for infants born with gastroschisis

OBJECTIVE

To examine growth, neurodevelopment and morbidity in infants with gastroschisis.

STUDY DESIGN

We enrolled all infants with gastroschisis treated at the North Carolina Children's Hospital from March 2003 through June 2005. Neonatal data were collected. Medical history, growth and neurodevelopment were assessed at 16 to 24 months.

RESULT

Of 24 infants, 17 completed follow-up. Weight and length were below the 10th percentile for five and six infants, respectively. Three infants scored less than 85 on the Bayley Scales of Infant Development, second edition. Small for gestational age (SGA) infants were smaller and had lower neurodevelopmental scores. Fourteen experienced continued bowel dysfunction; nine were rehospitalized.

CONCLUSION

One-third of infants with gastroschisis experience growth delay. Infants who are SGA are at higher risk, suggesting that postnatal growth may be influenced by fetal phenomena, and may not be modifiable. Neurodevelopment is not delayed. Continued bowel dysfunction is common.

Traction-compression-closure for exomphalos major

PURPOSE

We present our experience with traction-compression-closure (TCC) for exomphalos major (EM) to achieve a safe and embryologically correct midline supraumbilical aesthetic closure with preservation of the umbilicus.

METHODS

Nineteen neonates with EM were paralyzed and ventilated. The abdominal domain was increased by upward cord traction to assist liver-bowel reduction by gravity and sac ligation, followed by circumferential elastic body binder compression. The supraumbilical abdominal wall anomaly cicatrized spontaneously or was closed surgically as a midline scar, with preservation of the umbilicus.

RESULTS

Over 7 years (1998-2004), 19 patients with EM were treated by TCC, 18 of whom survived. The patients' median gestational age was 36 weeks (range, 24-40 weeks); their median birth weight was 2312 g (range, 890-3000 g). The median time to reduction was 4 days (range, 3-5 days), whereas that to full enteral feeds was 6 days (range, 4-6 days). Mechanical ventilation for 7 days (range, 6-8 days) was not associated with any morbidity, and the time to home discharge was 11 days (range, 8-12 days). Five patients did not require any surgery. There was no episode of sac rupture or infection.

CONCLUSION

Abdominal expansion by vertical cord traction followed by compression reduction (TCC) under muscle relaxation and ventilation is time well spent toward a safe and aesthetic midline abdominal wall closure without tension for EM.

Omphalocele: clinical outcomes in cases with normal karyotypes

OBJECTIVE

This study was undertaken to examine neonatal outcomes in karyotypically normal cases of omphalocele with respect to mode of delivery, presence of associated anomalies, presence of extracorporeal liver, and method of abdominal wall closure.

STUDY DESIGN

We reviewed 36 cases of omphalocele with delivery at University of North Carolina Hospitals between 1988 and 2001. Elective terminations and pregnancies resulting in miscarriage before 20 weeks' gestation were excluded.

RESULTS

Perinatal mortality rate was 19%. Rate of composite neonatal morbidity was 25%. Associated major anomalies were present in 11 (31%) cases and were associated with increased neonatal mortality. Cesarean deliveries were performed in 21 (58%) cases and were not associated with increased primary closure rates or decreased neonatal morbidity and mortality. Extracorporeal liver was present in 27 (75%) cases and was associated with decreased rates of primary closure but did not affect neonatal outcome.

CONCLUSION

In cases of ongoing omphalocele, perinatal mortality rates are low in the absence of associated anomalies or genetic defects. Intracorporeal liver was not associated with increased rates of associated anomalies or was it associated with increased neonatal morbidity or mortality.

Sonographic biometry of liver and spleen size long after closure of abdominal wall defects

Little is known about the fate of the liver and spleen after closure of the abdominal cavity in patients with abdominal wall defects (AWD). Therefore, counselling families for long-term follow-up and in the case of surgery for acute disease, pregnancy or trauma may be difficult. A total of 18 patients ranging in age from 7 to 18 years, with AWD closed at birth, underwent ultrasound evaluation of liver and spleen size by determination of the index of liver size (ILS) and splenic volume (SV). These values were then correlated with some anthropometric parameters such as body mass index (BMI) and weight; correlation was also sought with some clinical features such as type of defect and direct or staged closure. Nearly all subjects exhibited weight above and BMI below the 50th percentile for age. ILS and SV were significantly above normal limits in all cases and no difference was found with regard to the type of defect.

CONCLUSION

In patients having undergone surgery for abdominal wall defects, liver and spleen usually regain their normal shape and position even though size and volume appear to be larger than in normal controls.

Bipedicled skin flaps for reconstruction of the abdominal wall in newborn omphalocele

Despite technical refinements in surgery and advances in postoperative intensive care, abdominal wall closure in giant omphalocele remains a difficult endeavor. In this respect, bipedicled skin flaps obtained with longitudinal incisions along the margins of the rectus abdominis muscle may represent a good alternative solution to achieve a complete, tension-free midline closure. Incisional areas can subsequently be easily covered with split-thickness thigh grafts. Two neonatal cases were treated with this technique with good results. This has enabled avoidance of palliative coverage as well as complex musculo-cutaneous reconstructions at a later age.

Cardiopulmonary performances in young children and adolescents born with large abdominal wall defects

BACKGROUND/PURPOSE

As long as the survival rate of patients with abdominal wall defects (AWD) increases, information about long-term follow-up is becoming necessary. Even though quality of life in these patients, in absence of associated anomalies, appears to be unaffected, respiratory impairment soon after birth has been documented; therefore, participation in sports rarely is addressed.

METHODS

Eighteen patients, ranging in age from 7 to 18 years, operated on at birth for large abdominal wall defects (> 4 cm for gastroschisis; >6 cm for omphalocele) were asked to come for a stress test on a treadmill, with measurements of time of exercise (TE), maximal oxygen consumption (VO2 max) and continuous recording of vital parameters. Respiratory function also was assessed by Forced Vital Capacity (FVC).

RESULTS

Ergometric data were compared with those of a normal pediatric population. All patients were able to perform the stress test with no cardiovascular abnormalities detected at rest or on exertion. Maximum heart rate was reached after a significantly shorter TE, and VO2 max was significantly reduced when comparing normal subjects with AWD subjects and AWD subjects in sports with those sedentary. FVC was only slightly reduced in AWD patients without reaching statistical significance.

CONCLUSIONS

These findings indicate that patients operated on for AWD at birth exhibit a normal cardiorespiratory function; decreased TE and VO2 max are likely to reflect a lack of physical activity with a lower degree of fitness. Therefore, no limitations to motor performances should exist for these patients. Well-being may be greatly improved by regular exercise.

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

BACKGROUND

In children with congenital abdominal wall defects (CAWD), surgical treatment of the abdominal defect and the associated anomalies cause considerable morbidity in the first years of life. Afterward, most of the CAWD patients with correctable anomalies develop as other children. The morbidity and quality of life (QoL) of CAWD patients who have reached their adulthood is less well known and the subject of this study.

METHODS

A 3-part questionnaire was sent to 75 former patients with CAWD, aged 17 years or more. The first part included questions about health, symptoms, and education; the second part consisted of 3 tests of psychosocial functioning; and the third part was a SF-36 questionnaire measuring the QoL.

RESULTS

Of the 75 patients, 57 (76%) answered: (25 males, 32 females); omphalocele (n = 16) gastroschisis (n = 11); median age, 27 (range, 17 to 48) years. With the exception of rheumatoid arthritis (in 7% of patients), the prevalence of acquired diseases in CAWD patients was comparable with that of the general population; 50 of 57 (88%) considered their health good. The most frequent causes of morbidity were disorders in the abdominal scar in 21 (37%) patients, and functional gastrointestinal disorders in 29 (51%) of patients. Low self-esteem was found in 12% of patients, but the QoL and educational level of CAWD patients were not different from that of the general population.

CONCLUSIONS

In CAWD patients the morbidity from acquired disorders is similar to morbidity in the general population. Disorders with the abdominal scar and various functional gastrointestinal disorders are common, but they rarely cause serious problems. The majority of CAWD patients have a quality of life not different from the general population.

Fatores prognósticos para óbito em recém-nascidos com gastrosquise

O prognóstico de gastrosquise permanece adverso nos países em desenvolvimento e os fatores associados a óbito não são conhecidos. O estudo objetivou avaliar os fatores associados com morte neonatal em casos de gastrosquise atendidos no IMIP. Foram incluídos 49 casos de gastrosquise atendidos no IMIP, Recife-Brasil, entre 1995 e 2001. A variável dependente foi morte neonatal e as independentes foram: diagnóstico pré-natal, local e tipo de parto, idade gestacional, peso ao nascer, intervalo entre parto e admissão e parto-cirurgia, correção cirúrgica primária ou em estágios, necessidade de ventilação mecânica e infecção pós-operatória. Calculou-se a razão de prevalência (RP) de morte neonatal com intervalo de confiança a 95%, realizando-se análise de regressão logística para determinar o risco ajustado de óbito. A mortalidade foi de 53% (26 casos), sendo infecção a principal causa de óbito (92%). O diagnóstico pré-natal associou-se com significante redução (74%) do risco de morte. Esse risco foi significantemente aumentado ( > 2 vezes) para RNs, com peso menor que 2,5Kg e provenientes de outros hospitais. Também verificou-se aumento significante do risco para o intervalo entre parto-admissão e parto-cirurgia maior que duas e quatro horas (respectivamente, 2,5 e 3,4). O risco de morte foi 2,6 vezes maior nos casos com ventilação mecânica. Na análise multivariada, persistiram associadas ao óbito a prematuridade e o intervalo entre parto e cirurgia maior que 4h. Observou-se uma elevada mortalidade entre recém-nascidos com gastrosquise, que pode ser explicada por fatores como ausência de pré-natal, prematuridade, baixo peso, parto fora dos centros terciários, longos intervalos entre parto e cirurgia e necessidade de ventilação mecânica.

Risk factors for adverse outcome of newborns with gastroschisis in a Brazilian hospital

BACKGROUND/PURPOSE

The aim of this study was to determine the frequency of postoperative death and to identify factors associated with adverse prognosis in cases of gastroschisis managed in a tertiary hospital of Brazil.

METHODS

A retrospective transverse study was conducted including all cases of gastroschisis managed at Instituto Materno-Infantil De Pernambuco (IMIP), Recife, Brazil, between January 1995 and December 1999 (n = 31). Prevalence risk (PR) was determined for several prenatal, intraoperative, and postoperative factors.

RESULTS

Overall mortality rate was 52% (16 cases), and sepsis was the main cause of death (93.8%). Prenatal diagnosis reduced about 70% the risk of death. Preterm and low birth weight babies had about 3 times increase in the risk of death. Risk of death was increased twice among outborn babies, but there was no association with delivery route. Increase in risk of neonatal death was related to these other factors: birth-to-admission interval longer than 2 hours and birth-to-surgery interval longer than 4 hours. Prevalence risk also was greater with staged silo repair, poor clinical conditions before surgery, and when mechanical ventilation was needed.

CONCLUSIONS

A high mortality rate was associated with absence of prenatal diagnosis, prematurity, low birth weight, delivery outside the tertiary center, and delayed surgery, worsening clinical conditions that preclude primary closure and increases need of mechanical ventilation. J Pediatr Surg 36:559-564.

Cost-effectiveness of neonatal surgery: a review

BACKGROUND/PURPOSE

Technological developments have revolutionized both diagnosis and treatment in neonatal surgery. However, it has been increasingly recognized that financial resources might become insufficient to provide all the medical care that is technically feasible or that patients and families might desire. The purpose of this study is to apply the theory of health economics to neonatal surgery and to explore the extent and the kind of economic evaluation done in neonatal surgery.

METHODS

To explore the work done so far, the authors undertook a literature search aimed at costs and effects of surgical interventions in newborns with Ravitch' surgical index diagnoses of congenital anomalies. Common keywords in cost-effectiveness analysis were used to search Medline.

RESULTS

Evidence about the cost effectiveness of neonatal surgery is largely lacking. This is probably because of difficulties in long-term tracking of the patients and to the problem that most generic quality-of-life measures are not applicable in children yet.

CONCLUSIONS

Further cost-effectiveness research in neonatal surgery is warranted to settle priority discussions in health care when neonatal surgery is part of such discussions. Methodology for generic quality-of-life measurement in children is badly needed.

Omphalocele in a foal

An omphalocele was detected at birth in a male Arabian foal. The mass contained small intestine and after releasing a constricting band at the body wall, the contents slipped easily back into the abdomen. On the outside was the hairless pink membrane. The interior, now empty of small intestine, contained the umbilical arteries and vein, and a large urachus that extended from the bladder to the opening at the extremity of the mass. Six days after corrective surgery the foal was sent home and remained healthy.

Patch incorporation in diaphragmatic hernia

BACKGROUND/PURPOSE

Biomaterial insertion often is required for closure of congenital diaphragmatic hernia (CDH). The optimal biomaterial remains uncertain. This study was designed to compare a commonly used patch (polytetrafluoroethylene) with a recently available fabric, fluorinated polyester. The aim of this study was to determine the clinical performance, histological tissue-polymer interaction, bacterial adhesion, and shrinkage rates of biomaterial inserted endoscopically into a CDH lamb model.

METHODS

Polytetrafluoro-ethylene (PTFE) and fluorinated polyester (FP) were randomised for laparoscopic patch insertion into 12 lambs. All lambs (age <4 weeks) underwent 3-port laparoscopy, surgical creation of diaphragmatic hernia, and sutured patch placement. Two PTFE and 2 FP lambs were killed at 1-, 3-, and 6-month intervals postoperatively. Postmortem examination histopathology, electron microscopy, and specific bacterial broth immersion (Escherichia coil, Staphylococcus aurens, and epidermidis) were performed.

RESULTS

All 12 lambs completed the study with intact patches that were fully peritonised. One abdominal adhesion was noted in a FP lamb at 6 months. FP was comparatively easier to insert, manipulate, and suture endoscopically. Histopathology findings showed that PTFE patches created a strong peripheral foreign body reaction with dystrophic calcification, whereas FP was well incorporated with intrapatch fibroblastic activity and neovascularsation. No significant difference in resistance to bacterial adhesion of relevant organisms was noted between the materials. Graft shrinkage for FP was 7% in one direction only, evident by 3 months.

CONCLUSIONS

Fluorinated polyester has advantages in this laparoscopic lamb model. It shows rapid and sustained incorporation with intrapatch neovascularisation when compared with polytetrafluoro-ethylene's significant foreign body reaction. It was preferred for its endoscopic handling and suturing properties. The laparoscopic techniques used may contribute to the general lack of adhesions, and insufficient data are available to comment on the comparative effect of the materials on adhesion formation. No difference was demonstrated in resistance to bacterial adherence in the harvested materials.

The survivors of gastroschisis

AIMS

To assess the long term morbidity and quality of life in survivors of gastroschisis.

DESIGN

All babies born with gastroschisis between 1972 and 1984 and who survived more than one year were identified. Those who could be traced were questioned about their general health, growth, abdominal symptoms, cosmetic concerns, education, employment, and fertility.

RESULTS

Of the 35 patients, two have died, seven could not be traced, and three declined to be interviewed. Twenty three subjects (70% of survivors) with a median age of 16 years (range 12-23 years) responded. Twenty two (96%) were in good health and overall growth was within normal limits. Eight subjects (35%) have had further surgery related to gastroschisis, including two for adhesive small bowel obstruction and three for scar complications. In 13 (57%), absence of an umbilicus caused distress during childhood.

CONCLUSION

Most gastroschisis survivors can eventually expect normal growth and good health. Adhesive bowel obstruction is an uncommon, but potentially late, complication. The umbilicus should be conserved during gastroschisis repair.

Transdiaphragmatic pressure gradients and the lower esophageal sphincter after tight abdominal wall plication in the rat

BACKGROUND

Gastroesophageal reflux (GER) is increasingly recognized as a complication of surgical closure of gastroschisis and omphalocele.

AIM

This study tests the hypothesis that forceful abdominal wall closure reinforces the transdiaphragmatic pressure gradients that constitute the main GER-driving force and challenges the antireflux barrier.

MATERIALS AND METHODS

Abdominal and esophageal pressures as well as lower esophageal sphincter pressures (LESP) and length (LESL) were measured in 17 adult rats before tight abdominal wall plication, after it, and 1 week later.

RESULTS

This maneuver increased the transdiaphragmatic expiratory gradient from 0.67 +/- 1.31 to 6.97 +/- 2.68 mm Hg (P < .01) and the inspiratory gradient from 4.36 +/- 1.13 to 10.79 +/- 2.31 mm Hg (P < .01) by markedly increasing both the expiratory (from 1.47 +/- 0.74 to 9.44 +/- 1.85 mm Hg; P < .01) and inspiratory (from 0.98 +/- 0.69 to 6.83 +/- 1.55 mm Hg; P < .01) intraabdominal pressures. These changes were transient, and all pressures became normal after 1 week. The antireflux barrier functioned properly under these new conditions because both LESP and the diaphragmatic pinch-cock pressure (DPP) increased, from 20.3 +/- 3.63 to 26.5 +/- 4.31 mm Hg (P < .01) and from 16.4 +/- 7.25 to 22.5 +/- 4.36 mm Hg (P < .01), respectively, while LESL remained unchanged.

CONCLUSION

Tight abdominal wall plication in the rat generates high intraabdominal pressures and thus reinforces the transdiaphragmatic pressure gradients, but these conditions elicit a healthy barrier response with sphincteric reinforcement. In addition, these changes are transient and fade out some time after operation. These facts should be taken into account for understanding the pathogenesis of GER after repair of abdominal wall defects in human babies.

Treatment of congenital abdominal wall defects -a 25-year review of 132 patients

The outcome data of 132 patients treated at the Department of Pediatric Surgery in Mainz during the last 25 years were reviewed. Prenatal diagnosis of abdominal wall defects (AWDs) and associated malformations led to increasing selection of the patient population. The aim of primary closure of the abdominal wall can be achieved more frequently in gastroschisis (GS) than omphalocele (OC), while the postoperative course is more complicated and of longer duration in GS. Delayed or secondary closure extended the hospitalization period but had no negative effects on the outcome. Reoperations or planned secondary operations were performed in 23 patients with GS and 14 with OC. Early mortality was 15/55 for OC and 21/77 for GS over the period of 25 years. In recent years, a drastic reduction in mortality has occurred, and mortality is now mainly due to additional malformations. Further development and quality of life are not significantly reduced after survival of an isolated AWD. Malpositioning of parenchymatous organs after closure of AWDs has to be considered during pregnancy and abdominal operations.

End-tidal carbon dioxide for monitoring primary closure of gastroschisis

Previous criteria for primary reduction of the herniated viscera in newborn infants with gastroschisis included intraoperative respiratory rate, cardiac indices, degree of viscero-abdominal disproportion, size of defect, and lower extremity turgor. From 1976 through 1993, 129 neonates with gastroschisis were treated at Children's Hospital of Oklahoma. Intraoperative end-tidal carbon dioxide (ETCO2) monitoring was standard therapy beginning in 1985. The authors evaluated the effect of abdominal closure on ETCO2 to determine if there was a particular ETCO2 level at which closure was not feasible. There was no difference in overall mortality, birth weight, or postoperative ventilation requirements between children who had closure before 1985 (ie, without ETCO2 monitoring) and those who had repair after 1985. However, more cases in the 1985-1993 group had primary closure, and none of these required conversion to a staged procedure. An ETCO2 of > or = 50 suggests that primary closure may be unsafe. These data suggest that infants with gastroschisis can have primary closure based on intraoperative ETCO2 monitoring; no additional invasive monitoring would be necessary to assess closure.