Challenges and outcomes of management of anterior abdominal wall defects in a Nigerian tertiary hospital

Bedside reduction of gastroschisis: A preliminary experience in yaounde-cameroon

Background

Gastroschisis denotes a congenital or sporadic malformation of the anterior abdominal wall, which is rarely associated with other anomalies. The mortality in African countries is still high almost 100%.

Objective

The aim was to determine the feasibility and safety of bedside reduction of gastroschisis and factors affecting the outcome in low-income setting.

Methodology

This was a retrospective, descriptive and analytic study over a period of 6 years conducted in the Pediatric Surgery Service of the Yaoundé Gyneco-Obstetric and Pediatric Hospital. Only neonates with gastroschisis seen within 6 h of life without bowel necrosis and in whom bedside reduction was attempted in the neonatology unit under sedation (with 0.5 mg/kg of diazepam intra-rectally and 0.5-1 mg of atropine intravenously) were included in this study. Ethical clearance was obtained for the Ethical Committee of the Yaoundé Gyneco-Obstetric and Pediatric Hospital and a signed consent form was required from the parents of the children prior to the procedure.

Results

Twelve neonates with a mean age of 16.8 h (0 and 24 h) and mean birth weight of 2245 g (1860-3600 g) were enrolled. The mean time to presentation at hospital was 3.5 h (2-9 h). Bedside closure was successful in 10 patients. Two patients underwent primary closure in the theatre after failure of bedside reduction due to the volume of contents of gastroschisis. Mortality rate in our study was 33.3% and the morbidity was dominated by compartment syndrome and malnutrition.

Conclusion

Bedside reduction of gastroschisis under sedation in Yaoundé seems to be way to reduce the mortality.

A retrospective review of gastroschisis epidemiology and referral patterns in northern Ghana

PURPOSE

To describe the epidemiology and referral patterns of gastroschisis patients in northern Ghana.

METHODS

A hospital-based retrospective review was undertaken at Tamale Teaching Hospital (TTH) Neonatal Intensive Care Unit (NICU) between 2014 and 2019. Data from gastroschisis patients were compared to patients with other surgical diagnoses. Descriptive and inferential statistics were performed with SAS. Referral flow maps were made with ArcGIS.

RESULTS

From a total of 360 neonates admitted with surgical conditions, 12 (3%) were diagnosed with gastroschisis. Around 91% (n = 10) of gastroschisis patients were referred from other hospitals, traveling 4 h, on average. Referral patterns showed gastroschisis patients were admitted from three regions, whereas patients with other surgical diagnoses were admitted from eight regions. Only 6% (12/201) of expected gastroschisis cases were reported during the 6-year period in all regions. All gastroschisis deaths occurred within the first week of life.

CONCLUSIONS

Improving access to surgical care and reducing neonatal mortality related to gastroschisis in northern Ghana is critical. This study provides a baseline to inform future gastroschisis interventions at TTH. Priority areas may include special management of low birth weight newborns, better referral systems, empowerment of community health workers, and increasing access to timely, affordable, and safe neonatal transport.

Changing trend in the management of omphalocoele in a tertiary hospital of a middle-income country

BACKGROUND

The peri-operative management of omphalocoele in low- and middle-income countries is challenging owing to non-availability of neonatal intensive care units and equipment needed for the care of this anomaly.

AIM

This study examined our experience in the management of omphalocoele and compared the pattern and outcome with a similar study from the same centre conducted four decades ago.

METHODS

A retrospective study of neonates managed for omphalocoele from 2003 to 2017 (Group A) was performed. Their demographic characteristics, clinical presentation, management modality and outcome were obtained and statistical analysis was performed to determine the predictors of mortality. The findings were also compared with the findings of a similar study (Group B) published from this centre four decades ago from 1973 to 1978.

RESULTS

A total of 95 patients were managed in Group A and 33 in Group B. Their ages ranged from 1 to 15 days with a median age of 1 day and a median gestational age at birth of 37 weeks (range - 36-43 weeks) in Group A and 5-72 h in Group B. There were 54 (56.8%) boys and 41 (43.2%) girls in Group A and 17 (51.5%) boys and 16 (48.5%) girls in Group B. Rupture of the sac was observed in 18 (18.9%) patients in Group A and 13 (39.4%) in Group B. Operative management was adopted for 55 (57.9%) patients in Group A compared to 14 (42.4%) in Group B. Mortality was recorded in 16 (16.8%) patients in Group A and 16 (48.5%) in Group B. Following further analysis in Group A, management outcome was noted to be significantly associated with the state of the sac (P = 0.011), presence of associated sepsis (P = 0.002) at presentation and management modality (P = 0.048) with only associated sepsis independently predicting mortality.

CONCLUSION

Although epidemiological trend and clinical presentation are still similar, management outcome has improved over the years.

Investigating the use of ultrasonography for the antenatal diagnosis of structural congenital anomalies in low-income and middle-income countries: a systematic review

BACKGROUND

Congenital anomalies are the fifth leading cause of under-5 mortality globally. The greatest burden is faced by those in low/middle-income countries (LMICs), where over 95% of deaths occur. Many of these deaths may be preventable through antenatal diagnosis and early intervention. This systematic literature review investigates the use of antenatal ultrasound to diagnose congenital anomalies and improve the health outcomes of infants in LMICs.

METHODS

A systematic literature review was conducted using three search strings: (1) structural congenital anomalies; (2) LMICs; and (3) antenatal diagnosis. The search was conducted on the following databases: Medline, Embase, PubMed and the Cochrane Library. Title, abstract and full-text screening was undertaken in duplicate by two reviewers independently. Consensus among the wider authorship was sought for discrepancies. The primary analysis focused on the availability and effectiveness of antenatal ultrasound for diagnosing structural congenital anomalies. Secondary outcomes included neonatal morbidity and mortality, termination rates, referral rates for further antenatal care and training level of the ultrasonographer. Relevant policy data were sought.

RESULTS

The search produced 4062 articles; 97 were included in the review. The median percentage of women receiving an antenatal ultrasound examination was 50.0% in African studies and 90.7% in Asian studies (range 6.8%-98.8%). Median detection rates were: 16.7% Africa, 34.3% South America, 34.7% Asia and 47.3% Europe (range 0%-100%). The training level of the ultrasound provider may affect detection rates. Four articles compared morbidity and mortality outcomes, with inconclusive results. Significant variations in termination rates were found (0%-98.3%). No articles addressed referral rates.

CONCLUSION

Antenatal detection of congenital anomalies remains highly variable across LMICs and is particularly low in sub-Saharan Africa. Further research is required to investigate the role of antenatal diagnosis for improving survival from congenital anomalies in LMICs.

PROSPERO REGISTRATION NUMBER

CRD42019105620.

Challenges and Outcome of Management of Gastroschisis at a Tertiary Institution in North-Eastern Nigeria

Introduction: Gastroschisis is a congenital anterior abdominal wall defect characterized by herniation of abdominal contents through a defect usually located to the right side of the umbilical cord. It occurs in about 1 in 2,000-4,000 live births and is slightly commoner in males. Management has remained challenging in the low and middle-income countries (LMICS), with high mortality rates. This study highlights the clinical presentation, treatment, outcomes, and challenges in the management of gastroschisis at a tertiary healthcare center in a resource-limited setting. Methods: This was a retrospective review of the records of all patients with gastroschisis managed over a period of 30 months (January 2016-June 2018). Data on patients' demographics, age, birth weight, clinical presentation, method of gastroschisis reduction and closure, complications, and outcomes were collated. Statistical analysis was performed using SPSS version 20. A p-value of >0.05 was considered significant. Results: Twenty-four patients with gastroschisis were managed. Of these, 18 patients had data available for analysis. There were 14 males, with a male-female ratio of 3.5:1. The median age at presentation was 11.0 h (range 1-36 h). Ten patients (55.6%) were delivered in a medical facility. One patient had type II jejunal atresia and transverse colonic atresia as associated anomalies. Improvised silos were applied by the bedside in 15 (83.3%) patients, while two patients (11.1%) had primary closure under general anesthesia. One patient died before definitive treatment could be done. Sterile urobags and female condoms were used for constructing improvised silos in 9 (60%) and 6 (40%) patients, respectively. Eight patients who had initial silo application had complete bowel reduction over a median time of 8.0 days (mean 10.0 ± 6.5 days, range 2-23 days). Total parenteral nutrition (TPN) was not available. The average time to commencement of feeding was 8.0 days ± 6.6 (median 6.0 days, range 2-22 days). Full feeding was achieved in five patients (two patients in the primary closure group and three from the silo group) over a mean time of 16.8 days ± 10.4 (median 14.0 days). Sepsis was the commonest complication. Four patients (22.2%) survived. Conclusion: Management of gastroschisis remains challenging in resource-limited regions.

Omphalocele: a review of common genetic etiologies

Omphalocele is one of the most common congenital defects in the anterior abdominal wall. The malformation is associated with various pathologies especially with chromosomal disorders. The developmental defect is observed in Congolese hospitals, but risk factors are not well precised on the published case reports, which are more often focused on management. We aim in this paper to make a review on the condition, insisting on the risk factors of omphaloceles mainly of those of genetic origins.

Does omphalocele major undergo spontaneous closure?

The early surgical management of omphalocele major in Africa predisposes neonates to surgical complications which are often worsened by the presence of associated anomalies. Conservative management using available escharotics results in early skin cover by secondary wound healing. This delays the need for fascial closure and avoids neonatal surgical risks thus improving survival. We present a case of omphalocele major that underwent spontaneous closure during conservative management with honey dressing without surgical intervention.

Mortality-related factors in gastroschisis - a Jamaican perspective

OBJECTIVE

To determine the mortality rate of patients treated with gastroschisis at a Jamaican pediatric hospital, and to identify factors that contribute significantly to mortality.

METHODS

Eighty-five patients were treated with gastroschisis between November 1, 2006 and November 30, 2015. Of these, 80 records were recovered and reviewed retrospectively. Records were analyzed for maternal and patient characteristics, and details of the clinical course. Death during admission was the primary outcome measure.

RESULTS

63 of the 80 patients died during admission, giving a mortality rate of 78.8%. Sepsis was the main cause of death (82.4%). 27 patients (33.8%) had complicated gastroschisis (necrosis, perforation and/or atresia), all of whom died. Only preterm gestational age, complicated gastroschisis, and the lack of parenteral nutrition were found to be statistically associated with increased mortality.

CONCLUSION

Our mortality rate is higher than those quoted in high-income countries, and correlates to those found in low- to middle-income countries. Mortality in our cohort was significantly associated with prematurity, complicated gastroschisis, and the lack of parenteral nutrition. Efforts to improve outcome must focus on improving antenatal care, establishing transfer protocols, and optimizing nutrition for all patients with gastroschisis.

STUDY TYPE

Prognostic/Retrospective Study LEVEL OF EVIDENCE: Level II.

Congenital anomalies in the context of global surgery

Surgery is increasingly recognized as an essential component of global health development. This article will review the state of global pediatric surgery, utilizing congenital anomalies as a framework in which to discuss the promise of pediatric surgery in reducing the global burden of disease. Congenital anomalies are responsible for a substantial burden of morbidity and mortality in low- and middle-income countries (LMICs), as well as significant emotional and economic harms to the families of children with congenital anomalies. Limited pediatric surgical capacity in many LMICs has culminated in a devastating burden of avertable disability and death. Pediatric surgery is an effective and cost-effective means to reduce this burden. Pediatric surgeons must continue to drive the growth of global pediatric surgery by engaging in clinical practice, educational partnerships, and research initiatives.

Postnatal outcomes of infants with gastroschisis: a 5-year follow-up in a tertiary referral center in Brazil

OBJECTIVE

The aim of this study was to evaluate postnatal outcomes in fetuses with gastroschisis.

METHODS

This is a retrospective study (2009-2013) of patients with gastroschisis at the Hospital São Paulo (Federal University of São Paulo, Brazil).

RESULTS

A total of 44 infants with gastroschisis were examined. The mean maternal age was 21.1 years and mean gestational age at delivery was 36.1 weeks. Delivery occurred before 34 weeks in 13.6%, between 34 and 36 weeks and 6 d in 40.9%, and after 37 weeks in 45.5%. The mean birth weight was 2349 g, with 37.2% small-for-gestational age infants. The mean umbilical cord blood pH was 7.32. Bowel resection and delayed fascial closure was performed in 14.6% and 19.5%, respectively. The mean hospitalization time in the neonatal intensive care unit was 52.7 d. Neonatal infection was detected in 52.4%, with a positive blood culture; 77.3% of those cases were coagulase negative staphylococci. The overall rate of mortality was 25%; 18.2% before birth, 45.4% during the neonatal period, and 36.4% in infants. The main cause of postnatal death was septicemia (55.5%).

CONCLUSIONS

Despite advances in perinatal care and surgical techniques, infants with gastroschisis still present high rates of complications and death.

Epidemiology, management and outcome of gastroschisis in Sub-Saharan Africa: Results of an international survey

BACKGROUND

The aim was to compare gastroschisis (GS) epidemiology, management and outcome in low-income countries (LIC) in Sub-Saharan Africa (SSA) with middle- (MIC) and high-income countries (HIC).

MATERIALS AND METHODS

A 10-question survey was administered at the 2012 Pan-African Paediatric Surgery Association Congress. RESULTS are presented as median (range); differences were analysed using contingency tests.

RESULTS

A total of 82 delegates (28 countries [66 institutions]) were divided into LIC (n = 11), MIC (n = 6) and HIC (n = 11). In LIC, there were fewer surgeons and more patients. LIC reported 22 cases (1-184) GS/institution/year, compared to 12 cases (3-23)/institution/year in MICs and 15 cases (1-100)/institution/year in HICs. Antenatal screening was less readily available in LIC. Access to parenteral nutrition and neonatal intensive care in LIC was 36% and 19%, compared to 100% in HIC. Primary closure rates were similar in LIC and HIC at 58% and 54%, respectively; however, the majority of staged closure utilised custom silos in LIC and preformed silos in HIC. In LIC, mortality was reported as >75% by 61% delegates and 50-75% by 33%, compared to <25% by 100% of HIC delegates (P < 0.0001).

CONCLUSIONS

Gastroschisis is a problem encountered by surgeons in SSA. Mortality is high and resources in many centres inadequate. We propose the implementation of a combined epidemiological research, service delivery training and resource provision programme to help improve our understanding of GS in SSA whilst attempting to improve outcome.