Outcomes in omphalocele correlate with size of defect

BACKGROUND

Omphaloceles can be some of the more challenging cases managed by pediatric surgeons. Single center studies have not been meaningful in delineating outcomes due to the length of time required to accumulate a large enough series with historical changes in management negating the results. The purpose of this study was to evaluate factors impacting the morbidity and mortality of neonates with omphaloceles.

METHODS

A multicenter, retrospective observational study was performed for live born neonates with omphalocele between 2005 and 2013 at nine centers in the United States. Maternal and neonatal data were collected for each case. In-hospital management and outcomes were also reported and compared between neonates with small and large omphaloceles.

RESULTS

Two hundred seventy-four neonates with omphalocele were identified. The majority were delivered by cesarean section with a median gestational age of 37 weeks. Overall survival to hospital discharge was 81%. The presence of an associated anomaly was common, with cardiac abnormalities being the most frequent. Large omphaloceles had a significantly longer hospital and ICU length of stay, time on ventilator, number of tracheostomies, time on total parenteral nutrition, and time to full feeds, compared to small omphaloceles. Birth weight and defect size were independent predictors of survival.

CONCLUSION

This is the largest contemporary study of neonates with omphalocele. Increased defect size is an independent predictor of neonatal morbidity and mortality.

LEVEL OF EVIDENCE

Level II.

The effects of amoxicillin treatment of newborn piglets on the prevalence of hernias and abscesses, growth and ampicillin resistance of intestinal coliform bacteria in weaned pigs

This study investigated the effects of a single amoxicillin treatment of newborn piglets on the prevalence of hernias and abscesses until the age of nine weeks. We also studied whether the treatment was associated with growth and mortality, the need for treatment of other diseases, the proportions of ampicillin resistant coliforms and antimicrobial resistance patterns of intestinal Escherichia coli (E. coli). A total of 7156 piglets, from approximately 480 litters, were divided into two treatment groups: ANT (N = 3661) and CON (N = 3495), where piglets were treated with or without a single intramuscular injection of 75 mg amoxicillin one day after birth, respectively. The umbilical and inguinal areas of weaned pigs were palpated at four and nine weeks of age. At the same time, altogether 124 pigs with hernias or abscesses and 820 non-defective pigs from three pens per batch were weighed individually. Mortality and the need to treat piglets for other diseases were recorded. Piglet faecal samples were collected from three areas of the floors of each pen at four weeks of age. The prevalence of umbilical hernias or abscesses did not differ between the groups at four weeks of age, but it was higher in the CON group than in the ANT group at nine weeks of age (2.3% vs. 0.7%, P < 0.05). Numbers of inguinal hernias and abscesses did not differ between the groups at four or nine weeks of age. The ANT group, when it compared with the CON group, increased the weight gain between four and nine weeks of age (LS means ± SE; 497.5 g/d ± 5.0 vs. 475.3 g/d ± 4.9, P < 0.01), and decreased piglet mortality (19.5% ± 1.0 vs. 6.9% ± 1.0, P < 0.05) and the need to treat the piglets for leg problems (3.4% ± 0.3 vs. 1.9% ± 0.3%, P < 0.01) but not for other diseases by the age of four weeks. The proportion of ampicillin resistant intestinal coliform bacteria and the resistance patterns of the E. coli isolates were not different between the ANT and CON groups. In conclusion, our results showed that the amoxicillin treatment of new-born piglets produced statistically significant effect in some of the parameters studied. However, as these effects were only minor, we did not find grounds to recommend preventive antibiotic treatment. Further, continuous antimicrobial treatment of newborn piglets could negatively influence the development of the normal microbiota of the piglet and promote selection of antimicrobial resistance genes in herds. Therefore we suggest rejection of the use of routine administration of antimicrobial agents at birth.

Thorax-to-head ratio and defect diameter-to-head ratio in giant omphaloceles as predictor for fetal outcome

PURPOSE

To investigate the relationship between the thorax diameter and defect diameter of giant omphaloceles as a predictor for fetal outcome.

METHODS

In a retrospective study, 17 fetuses with isolated giant omphaloceles were included for evaluation. The anterior-posterior thorax diameter and the defect diameter were measured from ultrasound images. For analysis, the thorax-to-head ratio (T/HC), the defect diameter-to-head ratio (DD/HC), and the quotient of the defect diameter and the thorax diameter (DD/T) were calculated. The days of ventilation (t _ventilation), the duration until hospital discharge (t _hospital), and the type of treatment were recorded as outcome parameters.

RESULTS

No relationship was found between the calculated ratios (T/HC, DD/HC, or DD/T) and neither t _hospital (r = -0.418, p = 0.095; r = -0.153, p = 0.556; and r = -0.023, p = 0.929; respectively) nor t _ventilation (r = -0.391, p = 0.121; r = 0.041, p = 0.875; and r = 0.121, p = 0.645, respectively). The type of postnatal treatment was not associated with the three calculated ratios or t _hospital (r = 0.155, p = 0.553; r = 0.019, p = 0.942; and r = 0.012, p = 0.965; r = -0.009, p = 0.973, respectively). In 53% of cases, t _hospital was delayed due to additional and independent postnatal complications.

CONCLUSION

Thorax diameter or defect diameter of giant omphaloceles is not predictive for fetal outcome. The perinatal care of these abdominal wall defects still remains a multidisciplinary challenge, but the outcome of giant omphaloceles is favorable at experienced centers.

Past and present in omphalocele treatment in Romania

BACKGROUND

Omphalocele is a congenital abnormality whose prognosis has improved significantly over the last few decades, reaching a survival rate of 80-90% in developed countries. Currently, in Romania no comprehensive study on the incidence, treatment, and survival of patients with this defect of the anterior abdominal wall has been carried out.

METHODS

This retrospective analytical study was conducted over a period of 23 years and included 105 children with omphalocele. Prenatal diagnosis, referral to our hospital, children age upon admission, associated diseases, medical and surgical management, early and late postoperative complications, and the length of hospital stay were analysed.

RESULTS

The low rate of antenatal diagnosis (13.3%), the high frequency of associated congenital malformations (71.4%) and chromosomal abnormalities (27.6%), inadequate and delayed transport to a specialized pediatric surgery center together with an increased rate of sepsis (37.1%)resulted in a high mortality rate (54.3%).

CONCLUSIONS

The significantly reduced length of hospital stay and higher survival rate despite the apparently more frequent medical complications plead for the surgical treatment of omphalocele whenever not contraindicated by the presence of severe pulmonary hypoplasia, cardiac defects, immaturity and other severe congenital anomalies, when conservative treatment is indicated.

Omphalocele: comparison of outcome following prenatal or postnatal diagnosis

OBJECTIVES

To assess the impact of prenatal compared with postnatal diagnosis on outcome for liveborn infants with an isolated or with a non-isolated omphalocele.

METHODS

This was a retrospective analysis of 101 prenatally and 45 postnatally diagnosed cases of omphalocele. Cases were collected from the ultrasound database of the Division of Obstetrics and Prenatal Medicine and the patient database of the Department of Pediatric Surgery.

RESULTS

Following confirmation at delivery or autopsy, prenatally diagnosed omphaloceles included 21 isolated cases, 44 non-isolated cases with a normal karyotype and 36 non-isolated cases with an abnormal karyotype. Of the prenatally diagnosed apparently isolated cases (n = 31), 12 (39%; 95% CI, 22-58%) revealed associated anomalies after delivery. Liveborn infants with an isolated omphalocele had significantly worse short-term morbidity following prenatal diagnosis (n = 14) compared with diagnosis at birth (n = 29), having a lower gestational age at delivery, lower Apgar scores, longer duration of ventilation and parenteral nutrition, more readmissions and a longer hospital stay. The prenatally diagnosed subset contained more infants with a giant omphalocele (9/14 vs. 3/29, P = 0.001) and liver herniation (8/14 vs. 6/29, P = 0.02). The outcome of liveborn infants with a non-isolated omphalocele diagnosed prenatally (n = 17) was not different from that of those diagnosed at birth (n = 16), except for a greater need for ventilation and parenteral nutrition in the prenatal subset.

CONCLUSION

When counseling patients with a prenatal diagnosis of isolated omphalocele, it is important to remember that over one third could turn out to have associated anomalies. Liveborn infants with an isolated omphalocele detected prenatally have worse short-term morbidity than do cases detected at birth. Those with non-isolated omphaloceles detected prenatally have an increased need for ventilation and parenteral nutrition compared with those detected at birth.

[Intrapartum operation on fetuses with birth defects and its outcome]

OBJECTIVE

To discuss the value of intrapartum operation in management of birth defects and the prognosis.

METHODS

From August 2008 to November 2009, 11 fetuses were identified with birth defects through 3D color Doppler ultrasound and confirmed by MRI and fetal karyotype in the Maternal Fetal Medicine Center, Affiliated Shengjing Hospital, China Medical University including three lymphangiomas, two congenital diaphragmatic hernias (CDH), one sacrococcygeal teratoma, three omphalocele and two gastroschisi. All the above identified birth defects were indications for surgery. All fetuses were born abdominally and received intrapartum operations, including three intrapartum fetal operations with placental infusion (two repairs of CDH, one sacrococcygeal teratoma resection), six ex-utero intrapartum treatment (EXIT; two repairs of omphalocele, two repairs of gastroschisi, two lymphangioma resection) and two surgeries in house (one omphalocele repair and one lymphangioma resection). Both the mothers and fetuses were regularly followed up.

RESULTS

(1) OPERATIONS: the average operating time for the three intrapartum fetal operations was 89 minutes, 5.5 minutes for the six EXIT, during which EXIT was performed first, followed by blocking the umbilical circulation and neonatal surgery, and 37 minutes for the two surgeries in house. All neonates survived except for one death from severe CDH at 3.5 hours after the operation. The average blood loss for cesarean section and fetal operation was 275 ml. All mothers recovered soon without fever or infection and were discharged three to five days after the operation. (2) Follow-ups: the ten survived neonates were followed up at 1-18 months at the pediatric clinics and all were growing and developing normally except for one baby with gastroschisi suffered from enteral torsion and feeding intolerance showed lower weight than babies at the same age, but caught up to normal at four months old after posture therapy. One baby with mild CDH developed pulmonary infection at two months after operation with 1/4 pneumothorax on chest X-ray, and were hospitalized for two weeks. At six months old, patent ductus arteriosus was diagnosed in the same baby and chest X-ray was normal. The baby with omphalocele was complicated with ventricular septal defect before operation and the cardiac function was normal during follow-ups for one year. The baby with sacrococcygeal teratoma was reported to have no automatic micturition, but recovered to normal at one month of age.

CONCLUSION

Babies with certain birth defects can be managed through intrapartum operation with better outcomes.

Neonatal care in patients with giant ompholocele: arduous management but favorable outcomes

OBJECTIVES

The objectives of the study were to provide a review of patients with giant omphalocele managed in a single institution (2001-2006), focusing on medical management in the neonatal period, and to evaluate short-term outcomes.

METHODS

Data from 14 neonates with giant ompholocele (abdominal wall defect >5 cm and/or containing liver) and the absence of malformation and chromosomal anomalies during fetal screening were retrospectively reviewed. All were intubated and sedated before surgical treatment. Initial management consisted of progressive reduction of the herniated organs by gentle compression. After sequential reduction, abdominal wall closure was attempted at the skin and fascia level and, when necessary, with a Gore-Tex patch.

RESULTS

Median gestational age was 39 weeks (38-40), and median birth weight was 3100 g (2470-3700). Median age at closure was 6 days (0-20). A central Gore-Tex patch was inserted in 10 cases. Median ventilation length was 26 days (2-78). Full enteral diet was achieved after an average of 33 days (8-82), and median time until discharge from the intensive care unit was 24.5 days (11-85). Nine patients developed sepsis in the postoperative course. In 10 patients, at least 1 associated malformation was diagnosed in the postnatal course, among which cardiac and diaphragmatic defects were the most common. Survival rate was 85.7%.

CONCLUSION

Mortality rate of giant omphalocele without chromosomal anomaly or major malformations is low when treated by gradual reduction of the contents. Parents should be informed of the long hospitalization in the intensive care unit at birth, the potential nonthreatening associated malformations to be diagnosed after birth, and the high risk of sepsis.

Exomphalos major: the Northern Ireland experience

PURPOSE

In exomphalos major (EM), closure of the defect in the abdominal wall presents a challenge. The aim of this study is to evaluate a single centre experience of EM.

MATERIALS

A 15-year retrospective case-note review; data presented as median (range).

RESULTS

Fourteen infants (7 female) were born with EM: birth weight 2.9 (1.2-3.8) kg, gestational age 38 (31-39) weeks. One infant died in utero and one within the first hour of life. Severe pulmonary hypoplasia was present in 7/13 (54%), and there was a mortality of 6/13 (46%) live births. Infants were treated non-operatively primarily. Two infants underwent early surgery: one infant, born with a ruptured sac, had a surgical silo constructed on day 1 and closure on day 8, while a second infant had partial closure (skin only) on day 11. Ten infants had application of silver sulphadiazine to the sac 2-3 times per week. Enteral feeds were established soon after birth. They were discharged from hospital to allow granulation. Ventral hernia closure was performed on a subsequent admission.

CONCLUSIONS

Exomphalos major can be successfully treated non-operatively, allowing immediate enteral feeding and early discharge while granulation takes place. In this series, exomphalos major has an incidence of 1 in 26,000, mortality is 46% and severe pulmonary hypoplasia is present in 54% of infants.

Gastroschisis and omphalocele: treatments and long-term outcomes

Between February 1994 and April 2004, we treated 40 children with gastroschisis and 26 children with omphalocele. We recorded the course of pregnancy, pre- and post-natal complications, delivery, operation, post-operative therapy, and long-term outcomes. Additionally, we conducted follow-up examinations of 37 of these 66 children (56%). We analysed their abdominal musculature, development, cosmetic result and quality of life. The median duration of follow-up was 6.3 years (range 1-10). In 35/40 children (88%) with gastroschisis and in 18/26 children (69%) with omphalocele, there had been prenatal diagnosis. The average maternal age of 23.9 years in the gastroschisis group was lower than in the omphalocele group (29.9 years). Delivery was by caesarean section in 93% of the gastroschisis group and 65% of the omphalocele group. Outcomes following vaginal delivery were no worse than those after caesarean section. Further, congenital abnormalities were shown in 28% of gastroschisis cases, and were limited to the gastrointestinal tract. Of the omphalocele cases 81% showed further abnormalities. Direct closure of the abdominal wall defect was possible in 31/40 (78%) of the gastroschisis cases and 15/26 (58%) of the omphalocele cases. Mortality in gastroschisis was nil; two children with omphalocele died (8%). Outcomes were better after primary closure than in stepwise reconstruction. Follow-up showed good results in all categories. Developmental delays were rapidly made up after treatment, and 75% of the children had no gastrointestinal problems, or suffered from these rarely. Almost all the children were of normal weight and height, and physical and intellectual development were delayed in only one third of the children. The surgical scar was rated as good or very good in about 80% of the cases. Except for those with severe defects, the children had good ratings for quality of life. Improvements in short-term results of gastroschisis and omphalocele treatment can be attributed to recent developments in prenatal diagnosis and the advancements of centralised perinatal care. Our long-term results clearly demonstrate that initial gastrointestinal problems and developmental delays were made up during the first two years of life. Prenatal counselling can now be more optimistic.

Parity effect on preterm birth and growth outcomes among infants with isolated omphalocele

OBJECTIVE

To assess the association between parity and fetal morbidity outcomes among omphalocele-affected fetuses.

STUDY DESIGN

We carried out a retrospective study of 498 cases of isolated omphalocele (210 born to nulliparous and 288 to multiparous mothers) in New York State from 1983 through 1999. Infants of nulliparous mothers were compared to those of multiparous gravidas using adjusted odds ratios generated from a logistic regression.

RESULTS

Omphalocele-affected fetuses of nulliparous mothers had a lower risk of being delivered preterm (odds ratio (OR)=0.49; 95% CI=0.27-0.90) but comparable risks for low birth weight (OR=1.01; 95% CI=0.60-1.72), very low birth weight (OR=0.33; 95% CI=0.09-1.20), very preterm birth (OR=0.42; 95% CI=0.15-1.16), and small size for gestational age (SGA) [OR=0.61; 95% CI=0.23-1.63].

CONCLUSION

Omphalocele-affected fetuses of multiparous mothers have double the risk for preterm birth compared to their nulliparous counterparts. This information is potentially useful in counseling parents whose fetuses have omphaloceles.

Segmental dilatation of the intestine

PURPOSE

The aim of this work is to discuss the pathogenesis of the segmental dilatation of the intestine (SDI) and to review its clinical presentation and the ways to confirm the diagnosis.

METHODS

Eight cases of pathologically proven SDI from 1987 to 2003 were reviewed and discussed. There were 7 newborns and a 1-year-old boy.

RESULTS

Our patients are 5 boys and 3 girls. In all cases, the diagnosis was not suspected before surgery. Two patients presented with a low neonatal bowel obstruction. Six patients were operated for omphalocele, which was the most frequent associated malformation. The SDI involved the ileum in all patients. The treatment consisted on a resection of the dilated segment with an end-to-end anastomosis. Histological examination demonstrated the presence of ganglion cells in all cases. The muscular layer was hypertrophied in two cases and very thin in one case. A heterotopic gastric mucosa was observed in one case. No anomalies were observed in 5 cases. The postoperative course was uneventful in 6 cases with a mean follow-up of 5 years.

CONCLUSIONS

Segmental intestinal dilatation is an exceptional pathology with an unknown etiology and a misleading clinical presentation. Several theories were proposed to explain this malformation; however, most authors are rather inclined to an embryological theory incriminating an extrinsic intrauterine intestinal compression. Most cases are neonatal discoveries. The clinical polymorphism and the lack of specificity of radiological investigations explain the difficulties to have a preoperative diagnosis. However, this difficulty is compensated by the favorable evolution after the resection of the dilated segment.

[Prenatal diagnosis of omphalocele: a report of four cases]

Fetal omphalocele is a congenital midline defect of the ventral abdominal wall with herniation of abdominal contents into the base of ombilical cord. The prenatal diagnosis of omphalocele by real-time sonography is important for intrauterine and neonatal management and prognosis. The prognosis and mortality rate is determined rather by the presence of serious associated anomalies, such as cardiovascular and chromosomal defects, than by the omphalocele itself. MRI should be used to screen for other associated anomalies. In this report we describe four cases of fetal omphalocele diagnosed by sonography. In one case an MR examination was performed for suspected associated nervous anomalies. Prenatal literature is further reviewed to assess the clinical significance of this finding.

Poor outcomes in cirrhosis-associated hernia repair: a nationwide cohort study of 32,033 patients

Cirrhosis is a significant marker of adverse postoperative outcome. A large national database was analyzed for abdominal wall hernia repair outcomes in cirrhotic vs. non-cirrhotic patients. Data from cirrhotics and non-cirrhotics undergoing inpatient repair of abdominal wall hernias (excluding inguinal) from 1999 to 2004 were obtained from the University HealthSystem Consortium (UHC) database. Differences (P < 0.05) were determined using standard statistical methods. Inpatient hernia repair was performed in 30,836 non-cirrhotic (41.5% male) and 1,197 cirrhotic patients (62.7% male; P < 0.0001). Cirrhotics had a higher age distribution (P < 0.0001), no race differences (P = 0.64), underwent ICU admission more commonly (15.9% vs. 6%; P < 0.0001), had a longer LOS (5.4 vs. 3.7 days), and higher morbidity (16.5% vs. 13.8%; P = 0.008), and mortality (2.5% vs. 0.2%; P < 0.0001) compared to non-cirrhotics. Several comorbidities had a higher associated mortality in cirrhosis: functional impairment, congestive heart failure, renal failure, nutritional deficiencies, and peripheral vascular disease. The complications with the highest associated mortality in cirrhotics were aspiration pneumonia, pulmonary compromise, myocardial infarction, pneumonia, and metabolic derangements. Cirrhotics underwent emergent surgery more commonly than non-cirrhotics (58.9% vs. 29.5%; P < 0.0001), with longer LOS regardless of elective or emergent surgery. Although elective surgical morbidity in cirrhotics was no different from non-cirrhotics (15.6% vs. 13.5%; P = 0.18), emergent surgery morbidity was (17.3% vs. 14.5%; P = 0.04). While differences in elective surgical mortality in cirrhotics approached significance (0.6% vs. 0.1%; P = 0.06), mortality was 7-fold higher in emergencies (3.8% vs. 0.5%; P < 0.0001). Patients with cirrhosis carry a significant risk of adverse outcome after abdominal wall hernia repair compared to non-cirrhotics, particularly with emergent surgery. It may, however, be safer than previously thought. Ideally, patients with cirrhosis should undergo elective hernia repair after medical optimization.

Staged repair of giant omphalocele in the neonatal period

BACKGROUND/PURPOSE

The aim of this study was to analyze the outcome of giant omphalocele repaired in the neonatal period.

METHODS

Twelve consecutive (1997-2004) neonates with giant omphalocele (defect >6 cm with liver herniation) were reviewed. A silo of Prolene mesh (Ethicon) was attached to the fascia and the defect was closed without opening the amniotic sac after sequential reduction. In 2 neonates with ruptured omphalocele a plastic sheet was inserted below the mesh. Data are reported as median and range.

RESULTS

Gestational age was 38 weeks (range, 32-40 weeks) and birth weight was 2.9 kg (range, 1.0-3.1 kg). The final closure was achieved at 26 days (range, 16-62 days). Three neonates (25%) died before final closure (causes: ruptured omphalocele, lung hypoplasia, cardiac anomalies, and intestinal failure). In the 9 surviving neonates, mechanical ventilation was required for 8 days (range, 2-20 days), hospital stay was 42 days (range, 23-73 days), and full enteral feeding was achieved on day 12 (range, 4-53 days). Complications included wound infection in 5 neonates and midgut volvulus in 1. Prophylactic Ladd's procedure was performed laparoscopically at a later stage in 4 children. At laparoscopy, intraperitoneal adhesions were minimal and the central liver did not preclude the operation. The 9 survivors are all well after 46 months (range, 12-67 months).

CONCLUSIONS

Giant omphalocele can be safely repaired in the neonatal period without opening the amniotic sac. Intestinal malrotation should be excluded and Ladd's procedure can be performed laparoscopically at a later stage.

Omphalocele and gastroschisis: Black-White disparity in infant survival

BACKGROUND

Racial/ethnic variations in the occurrence of abdominal wall defects have been previously noted but it remains poorly understood whether race/ethnicity is a determinant of survival among affected infants.

METHODS

Study was conducted on cases of gastroschisis and omphalocele recorded for the years 1983-1999 at the New York Congenital Malformation Registry. Adjusted and unadjusted hazard ratios were generated from a Proportional Hazards Regression model to compare survival among affected Blacks, Hispanics and Whites. The major end point of analysis was differences in all cause mortality among infants with abdominal wall birth defects across different racial/ethnic groups.

RESULTS

Among the three racial/ethnic groups, 1481 infants were diagnosed with either omphalocele (978 or 66%) or gastroschisis (503 or 34%). Overall infant mortality rate (IMR) was 182 per 1000, with 74% of the deaths occurring within the first 28 days of life. Omphalocele infants had significantly higher infant mortality (IMR = 215 per 1000) than infants with gastroschisis (IMR = 118 per 1000)[p < 0.0001]. Overall, Black infants with abdominal wall defects had lower mortality indices than Whites and Hispanics. However, when considered as separate disease entities, Black infants were twice as likely to survive as compared to Whites if they had omphalocele [Adjusted Hazard Ratio (AHR) = 0.52; 95% Confidence Interval (CI) = 0.37-0.74], and twice as likely to die as Whites if they had gastroschisis instead (AHR = 2.23; 95% CI = 1.16-4.28). For both defect subtypes, Hispanics have risks for infant mortality comparable to Whites.

CONCLUSIONS

The natural history of omphalocele and gastroschisis co-varies with race. Black infants with gastroschisis have worse survival outcomes while those with omphalocele have better chances of survival than their White or Hispanic counterparts.

Prenatally diagnosed giant omphaloceles: short- and long-term outcomes

OBJECTIVES

To review prenatal findings, short- and long-term outcomes of giant omphaloceles (GO) managed at a single institution (1996-2001).

METHODS

Prenatal findings and early postnatal outcomes were retrospectively reviewed. Clinical short- and long-term outcomes were analyzed in eight and five children respectively. Parents and physicians of the children were surveyed by written questionnaires about the children's subsequent health issues. (IRB 2002-2-2683).

RESULTS

Seventeen pregnancies with GO were identified: Eight fetuses were live born, four ended in (terminations), two died in utero and three were lost to follow-up. Live-born fetuses had prenatal ascites, extreme levocardia and were delivered by cesarean section at a mean of 37 weeks' gestation with a mean birth weight of 2903 g. All neonates required intubation. Two infants (2/8) died within one year. Four of the six survivors had respiratory insufficiency with a mean ventilation time of 76 days. Respiratory and feeding problems complicated the early neonatal course. Long-term follow-up was available for five patients (mean age of 33.2 months). Asthma, recurrent pulmonary infections, feeding problems, gastroesophageal reflux and failure to thrive were the major problems.

CONCLUSIONS

Respiratory and feeding problems were the most common neonatal and long-term medical management issues. Parents need to be counseled prenatally about the probability of multiple surgeries and long hospitalization following birth.

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.

[Evaluation of the management of omphalocele at Dakar]

Omphalocele is a congenital malformation of the abdominal wall of children, characterized by an ombilical defect living the abdominal organ visible through a translucent amniotic membrana. The goals of this study were to describe the epidemiological, clinical and therapeutic characteristics at the University Teaching Hospital of Dakar. We conducted a retrospective study at the UniversityTeaching Hospital of Dakar from January 1997 to December 2002. Fifty cases of Omphalocele diagnosed at the Unit of Paediatric Surgery of the Department of General Surgery at Aristide Le Dantec Hospital, were included in this study. We described the epidemiological, clinical and therapeutic characteristics of omphalocele. Omphalocele is a condition diagnosed late in boys from poor sphere. The study revealed that weight from birth, omphalocele size, local state, and existance of associated malformation correlated with death rate. The treatment option was a spontaneous epidermisation as described by Grob in the absence of omphalocele rupture wich imposed a primary closure of abdominal wall. The overall death rate was 42%. The improvement of results will need an antenative diagnosis, paediatric reanimation unit wich will notably reduce death rate.

[Therapeutic approaches for omphalocele in developing countries: experience of Central University Hospital of Yopougon, Abidjan, Côte d'Ivoire]

A retrospective study about 80 cases of exomphalos treated in the digestive unit of the paediatric surgery department in Abidjan teaching hospital--Côte d'Ivoire had been performed to analyse the result of this malformation treatment during 8 years. Prenatal diagnosis was made in two cases on six antenatal ultrasounds. Prematurity involved 7% of newborn and their birth weight ranged from 2500 to 4000 grams in 70% of cases. Treatment began in 64% at birth, conservative treatment with merbromine tannage was systematic on the non disrupted exomphalos. Surgery was indicated in the disrupted exomphalos and in the complicated cases of conservative treatment. Intestinal occlusion was the main fatal complication observed in both treatments but most of the time it occurred with surgical closure. Total lethality reached 30%, influenced by exomphalos super infection and by neonatal resuscitation insufficient means. Authors think exomphalos lethality reduction implies antenatal ultrasonographic for early diagnosis which could indicate a possible caesarian section in case of the voluminous exomphalos in order to prevent disruption and neonatal resuscitation operation.

[Morbidity and mortality in newborns with omphalocele and gastroschisis anterior abdominal wall defects]

OBJECTIVE

To identify morbidity and mortality in newborns with congenital defects of the anterior abdominal wall.

DESIGN

Descriptive, comparative, and retrospective study.

PATIENTS

Thirty nine patients with gastroschisis and 26 patients with omphalocele.

RESULTS

Median size of the defect in the gastroschisis group was 4 cm. Infants underwent primary closure en 41% of cases. Post-surgical morbidity occurred in 74% of patients with sepsis the main complication in 61.5%. A total of 16.2% died mainly due to acute renal failure and sepsis. In the omphalocele group, median size of defect was 5.5 cm. Primary closure was done in 65% of patients. Complications occurred in 65% of newborns, sepsis was the most frequent complication (46%). Mortality rate was 16.6% related to acute renal failure and cardiogenic shock.

CONCLUSIONS

The main causes of morbidity in the two groups were infections and acute renal failure. Mortality rate was similar to that reported in the world literature for gastroschisis and slightly lower for omphalocele.

Omphalocele and gastroschisis in Taiwan

The purpose of this study was to analyse the clinical differences between omphalocele and gastroschisis in Taiwan, with special reference to associated anomalies and outcomes. A retrospective review was conducted of 115 cases seen between January 1990 and June 2000 at two tertiary medical centres in Taiwan. Data included perinatal events and associated anomalies. Of 115 patients, 65 were classified as having gastroschisis and 50 as having omphalocele. Other anomalies were found in 24 omphalocele cases, compared with 23 gastroschisis cases. The range of anomalies associated with omphalocele varied more widely than in the gastroschisis cohort. Of patients with omphalocele and associated anomalies, six had chromosomal abnormalities compared with none of the patients with gastroschisis. In patients with gastroschisis and additional malformations, 17 had gastrointestinal anomalies, the most common of which was intestinal malrotation. A comparison of perinatal data revealed that infants with gastroschisis were more likely to be small for gestational age. Gastroschisis was associated with a younger overall maternal age than omphalocele and a lower birth weight. There was a male predominance among omphalocele patients, but this did not reach statistical significance.

CONCLUSION

Gastroschisis was frequently associated with intestinal anomalies and transient dysfunction, and outcomes were related to postoperative complications. Infants with gastroschisis more frequently required prolonged parenteral nutrition supplement, resulting in longer hospital stay. Omphalocele was often accompanied by chromosomal disorders leading to early neonatal death, so we recommend that amniocentesis should be indicated if omphalocele is suspected on fetal ultrasonography.

Abdominal wall defects

Survival for newborns with congenital abdominal wall defects (primarily omphalocele and gastroschisis) has improved, but controversy remains regarding etiology, anatomy and embryology, the role of prenatal diagnosis and mode of delivery, and initial management. A number of recent studies have added to our knowledge and understanding of several of these topics, while several others have raised questions regarding traditional initial management of these infants. Continued improvement in the survival of these infants can be anticipated with further understanding of the in utero and antepartum diagnosis and management of infants with these common congenital abnormalities.

Omphalocele: clinical review and surgical experience using dura patch grafts

Over a period of 15 years we surgically treated 50 cases of omphaloceles. The pathology occurred more frequently in boys (n = 30) than in girls (n = 20). The mean birth weight was 2995 g and mean gestational age was 38 weeks. Four infants (8%) were delivered vaginally and the rest (92%) by cesarian section. Eleven infants (22%) underwent primary closure, but in 20 infants (40%) with larger defects a primary closure of the skin was possible; however, a single solvent-dried dura graft implant was employed for the fascia enlargement. The remaining 19 infants (38%) had extremely large defects, and optimal closure of the defect required a two layered graft implantation. Twenty-five infants (50%) had associated anomalies, the majority being congenital cardiac anomalies. Five patients (10%) required secondary laparotomies due to bowel associated complications. Four patients (8%) experienced non-bowel-associated complications. The average postoperative mechanical ventilation required was for a period of 3.2 days and the average hospital stay was 45.7 days. The overall mortality rate was 8% (n = 4) and was largely due to severe congenital heart anomalies. Solvent-dried dura was successfully employed in the management of the larger defects with no major complications; only one patient (2%) had a local abscess around the area of the implant and was managed conservatively. Our experience favors the employment of solvent-dried dura graft implants for the repair of large omphaloceles. The solvent-dried dura grafts are biomaterials that promote rapid scar formation and integration with the adjacent skin tissue and do not produce any foreign body reactions at the site of implantation.

[Follow-up evaluation of omphalocele treatment in children. The experience of the department of Pediatric Surgery and Orthopedics No.1 University Hospital Craiova]

Abdominal wall malformations are a frequent category of congenital malformations in the last years in all Departments for Pediatric Surgery from our country. The authors are presenting a serie of 35 cases of newborns admitted and treated in the Pediatric Surgery and Orthopedics Department of the Clinical University Hospital No. 1 Craiova and in the same time they are evaluating in time the results after different surgical technics. From the point of view of the surgical techniques applied in the last 20 years the authors are communicating their results with the following procedures: Gross, Allen-Wren, Fufezan, and also their results with a nonsurgical procedure (Grob). The authors are manchenning that it is possible to combine (depending on the anatomo-clinical) the surgical approach with the non-operative management of the case. Clinical parameters such as sex, birthweight, immaturity, associated malformations, size of the abdominal deffect are the main element to predict the outcome of these patients and to choose the right management strategy, thus it is very important to investigate the pregnancy evolution and the birth period. The good results (82.9% surviving) are representing the prove of a good therapeutic decision being impossible to use synthetic materials for substitution (silicon, dacron, teflon, etc.) and in the same time an important guide for our future activity.

Presentation and outcome of incarcerated external hernias in adults

BACKGROUND

Incarcerated external hernias are the second most common cause of small-intestinal obstructions. The purpose of this study was to examine the presentation and management of incarcerated external hernia.

METHODS

The records of 385 consecutive patients undergoing emergency surgical operation for incarcerated external hernias in a large volume teaching hospital between August 1996 and October 1999 were analyzed. The patients' ages ranged from 15 to 100 years (mean 55.1). There were more men than women (250 and 135, respectively), and 165 (42.9%) patients were over 60 years of age. Inguinal and umbilical hernias were encountered most frequently, in 291 (75.5%) and 48 (12.5%) patients, respectively. The intestine was resected in 53 patients, 31 of whom were over 60 years of age (58.5%). Two hundred fifty-two (84.9%) patients presented 48 hours or more from the onset of symptoms. Significant concomitant diseases were noted in 52 men and 19 women.

RESULTS

The overall complication rate amounted to 19.5%, major complications 15.1%. The most serious postoperative complications were pulmonary and cardiovascular. Adult respiratory distress syndrome developed in 10 patients, and congestive heart failure developed in 14 patients. Postoperative mortality was 2.9%. Nine (81.8%) of the dead patients were older than 60. Nine (81.9%) of the dead patients were admitted to hospital more than 24 hours after incarceration. Mortality was high in patients with serious coexisting diseases whereas morbidity was linked with the duration of symptoms prior to admission.

CONCLUSIONS

Older age, severe coexisting diseases, and late hospitalization were the main causes of unfavorable outcomes of the management of incarcerated hernias.

[Omphalocele and gastroschisis. Outcome--complications--follow-up--quality of life]

From 1970 to 1998, 35 children with omphalocele (OC) and 31 with gastroschisis (GS) were treated at the Department of Paediatric Surgery at Lübeck Medical University. Forty of 43 survivors were examined in 1990, the data of 30 patients were renewed in 1999 and 12 new cases added. Total follow-up was 1-28 years. Primary closure was possible in 25 OCs and 20 GSs. Eighteen children with OC and 8 with GS suffered from additional abnormalities, which were treated simultaneously. Twenty percent of the babies with OC died mostly because of severe congenital anomalies and 12.9% of GS because of infectious complications in combination with other diseases. There were no more deaths in the last decade. Accordingly, there was a reduction in consecutive operations. Improvements were due to better operative and perioperative treatment as well as abortions following improved ultrasound examinations. The results of the literature and our own experience show the benefit of primary closure. A two-stage approach with dura/amnion or a silo procedure prevents high intra-abdominal pressure, therefore, indirect measurements of intra-abdominal pressure can be used exceptionally. Umbilical preservation offers better cosmetic results. Long-term follow-up reveals normal growth and development of the children except for those with severe congenital anomalies. All the others are participating without problems in normal activities and education without reduction in their quality of life. Today an isolated OC or GS is not an indication for abortion. If prenatal OC or GS is diagnosed, paediatric surgeons should be involved in the consultations.

[Diagnosis and treatment of embryonal hernia]

In 1994-1999 years in clinic 19 children with omphalocele were treated, 8 of them died. Authors proposed tactic of treatment of their own, giving preference to conservative method, what permitted to reduce mortality of children with embryonal hernia.

Ruptured exomphalos and gastroschisis: a retrospective analysis of morbidity and mortality in Nigerian children

The survival of infants with major abdominal-wall defects (AWD) has improved over the years in developed countries. In Zaria, northern Nigeria, survival from intact exomphalos (EX), has improved with the adoption of non-operative management. Ruptured EX (REX) and gastroschisis (GS), however, remain problematic. This is a report of the mortality in REX and GS in a retrospective review of 16 infants with REX and 14 with GS managed over 10 years at the Ahmadu Bello University Teaching Hospital, Zaria. The median age at presentation was 3 days and 24 h for REX and GS, respectively; 29 of the 30 patients were delivered at home. Two patients with REX and 4 with GS had associated anomalies involving mostly the gastrointestinal tract. Bowel or omental strangulation occurred in 13 patients, resulting in gangrene in 8. Fascial closure was achieved in 20 patients, skin closure only in 4, and in 4 improvised silo coverage was used, the latter associated with high infection rate. Neonatal intensive care units (NICU) and total parenteral nutrition (TPN) were not available. The overall mortality was 18.6% (gastroschisis 10, ruptured exomphalos 8, 11 from sepsis and 7 due to respiratory embarrassment). The management of these AWDs thus continues to be problematic in our environment, and mortality remains high. Provision of more modern supportive facilities (NICU and TPN) may improve the survival in our and similar environments.

The management of exomphalos

BACKGROUND/PURPOSE

The management of exomphalos in the authors' department over a 26-year period is reported together with a technique for delayed closure of the ventral hernia resulting from conservative treatment of exomphalos major.

METHODS

Patients were classified into exomphalos minor and major. Exomphalos minor was treated by early surgical closure. Exomphalos major was treated preferentially conservatively with delayed repair of the ventral hernia.

RESULTS

There were 104 patients (68 boys and 36 girls; exomphalos minor, 45; exomphalos major, 59). Forty-two patients with exomphalos minor underwent operation. Three patients died before surgery, and 9 others postoperatively of overwhelming sepsis. Fifteen babies with exomphalos major needed early operation (skin closure only in 3 and prolene mesh repair in 12), there were 2 preoperative and 4 postoperative deaths. Forty-two patients were treated conservatively, among these, 8 died of sepsis. Thirty-four children had closure of the ventral hernia (prolene mesh, 7 and native tissue, 27); there was no morbidity. Two children died after laparotomy for adhesive intestinal obstruction.

CONCLUSION

Mortality rate was related to sepsis, complications of delayed presentation, and severe congenital anomalies. There were no ill effects attributable to mercury or iodine absorption. Delayed ventral hernia repair by double breasting of the fibrous tissue sheet underlying the skin was found to be a reliable technique with low morbidity.

Morbidity in infants with antenatally-diagnosed anterior abdominal wall defects

The aims of this study were to compare the morbidity of infants with gastroschisis (GS) with that of infants with exomphalos (EX) without lethal abnormalities and to identify factors predictive of adverse outcome: a requirement for parenteral nutrition (PN) for over 1 month and hospital admission for over 2 months. The medical records of 45 infants with anterior wall defects (32 with GS) diagnosed antenatally who consecutively received intensive care in one institution from 1993 were reviewed. Both the GS and EX infants had a median gestational age of 37 weeks, but the former were lighter at birth (P < 0.01). Fourteen infants (all with GS) were able to start feeds only after 2 weeks; 10 (8 with GS) developed liver dysfunction; and 5 (all with GS) died. The GS compared to the EX infants required a longer period of PN (median 20 vs 10 days, P < 0.01) and longer hospital admission (median 40 vs 25 days, P < 0.01). In the GS group the time to start feeding related independently to prolonged hospital stay, and the existence of structural bowel abnormalities (SBA) related independently to both measures of adverse outcome, with a positive predictive value of 100%. We conclude that infants with GS, particularly those with SBA, suffer greater morbidity than infants with EX without lethal abnormalities.

Omphalocele delivery enigma: the best mode of delivery still remains dubious

OBJECTIVE

To determine an optimal route of delivery for fetuses with prenatally diagnosed omphalocele.

DATA SOURCE

MEDLINE search of years 1966-1996.

RESULTS

Descriptive retrospective analyses do not support the idea that cesarean delivery of fetuses with omphalocele is associated with an improved survival rate. However, most of those studies do not control for confounding variables like type and severity of associated anomalies, omphalocele size, prematurity rate, presence of trial of vaginal delivery, rate of intrapartum sac rupture, tertiary treatment centers accessibility, time and type of surgical correction, and postoperative morbidity. There is no evidence that vaginal delivery is safer than cesarean for fetuses with isolated small omphalocele. Fetuses with giant (>5 cm) omphalocele should be delivered by cesarean section. Vaginal delivery at term is offered for fetuses with coexisting life-threatening anomalies.

CONCLUSIONS

We propose that until randomized trial of vaginal and cesarean delivery for fetal omphalocele is available, the preferred mode of delivery would be the vaginal route as that is safer for the mother.

Improved survival of infants with omphalocele

BACKGROUND

The surgical management of patients with omphalocele has evolved over the past 4 decades. Despite many improvements in care, the reported mortality has been over 10%.

METHODS

This study reviewed the characteristics, management, and outcome of 31 patients with omphalocele who underwent surgical care between 1980 and 1995 at a single hospital.

RESULTS

Twenty-five patients had additional congenital anomalies. All but 1 patient underwent operative repair; 13 of these patients with large defects had a silo chimney constructed initially. Fourteen patients underwent primary fascial and skin closure at the initial operation. Only 1 patient died perioperatively; another patient died without operation due to other major malformations.

CONCLUSIONS

The results following surgical repair of omphalocele defects depend on the degree of visceroabdominal disproportion and on the severity of associated anomalies. The operative mortality for staged omphalocele repair with limited elevation of intraabdominal pressure is low, and the long-term quality of life of these patients is good.

Morbidity from nonrespiratory diseases and mortality in dairy heifers during the first three months of life

OBJECTIVE

To describe causes of death, mortality, and morbidity from nonrespiratory diseases in dairy calves.

DESIGN

Prospective observational cohort study.

ANIMALS

Convenience sample of 410 dairy heifers born between January and December 1990 in 18 south-western New York herds.

PROCEDURE

Heifers were examined weekly by a veterinary clinician during the first 3 months of life and all disease conditions were recorded.

RESULTS

Crude risks for diarrhea, umbilical infection, and umbilical hernia were 28.8, 14.2, and 15.1%, and the median ages at first diagnoses were 2, 1, and 3 weeks, respectively. Mean durations of umbilical infection and umbilical hernia were 3.7 and 6.7 weeks, respectively. Crude mortality was 5.6%. Case-fatality risks were 12.8% for diarrhea during the first week of life, 5.1% for diarrhea after the first week of life, and 0% for umbilical infection and umbilical hernia. Diarrhea was diagnosed by the caretaker of the clinician; umbilical conditions were diagnosed by the clinician. The primary cause of death was diarrhea in 43%, pneumonia in 24%, septicemia in 10%, and other single causes in the rest of the 21 necropsied calves.

CLINICAL IMPLICATIONS

The high incidence and somewhat long duration of umbilical infection, the finding that diarrhea was the primary cause of death, and the high case-fatality risk for diarrhea during the first week of life suggested that calf caretakers need training in the prevention and treatment of these conditions.

Chromosomal anomalies in newborns with omphalocele

Omphalocele is the most common congenital abdominal wall defect; its reported incidence is 1 in 4,000 to 5,000 live births. With large defects, the liver is a median organ and lies within the sac (extracorporeal liver [ECL]). With small defects, only bowel or stomach is found outside the abdominal cavity (intracorporeal liver [ICL]). The goal of this study was to determine whether a relationship exists between the sac contents or the timing of diagnosis and the incidence of chromosomal abnormalities or survival among fetuses and newborns with omphalocele. From 1985 to 1995, 83 cases of omphalocele were managed at the authors' institution. In 50 cases the diagnosis was made using prenatal ultrasonography. All patients underwent fetal cardiac echography and amniocentesis. Twenty-four pregnancies were terminated electively because of severe associated anomalies. Of the 59 live births, 41 patients (69%) survived. The incidences of cardiac, chromosomal, and other anomalies were 24% (14), 10% (6), and 21% (16), respectively. Omphalocele with ICL is associated with a better survival rate than omphalocele with ECL (82% v 48%; P < .01) despite the significantly higher rate of karyotype abnormalities (16% v 0%; P < .05). The prognosis was poorer for patients with prenatally diagnosed omphalocele than for those with a postnatal diagnosis (mortality rate, 42% v 21%) because the former group had a higher percentage (70% v 9%) of ECL. Although the incidence of cardiac anomalies was similar for the ECL and ICL groups (33% v 18%), the former had more complex malformations. Death usually occurred in newborns who had neonatal respiratory distress owing to prematurity, or in those with chromosomal or cardiac anomalies. Chromosomal anomalies occurred mainly in cases of small omphaloceles that contained gut only, and it was the major cause of death among this group. In ECL cases, survival was primarily affected by the associated complex cardiac anomalies.

Gastroesophageal reflux in neonates with congenital abdominal wall defect

Gastroesophageal reflux (GER), not yet described as a real complication, takes place very often in neonates with congenital abdominal wall defect. Our aim was to determine whether it is due to abdominal hyperpressure alone, or if another factor is involved in this occurrence. Thus we studied one group of 80 gastroschises and one of 67 omphaloceles, treated in our department between December 82 and December 92. Overall occurrence was found to be about 50% in both groups. The main feature is the particular severity of GER in neonates with wide omphalocele who required staged closure, leading to further surgical antireflux procedure. We suggest that this procedure could be performed earlier, at the time of closure, for these babies in whom moreover the anatomic approach is favorable.

Nonoperative initial management versus silon chimney for treatment of giant omphalocele

Giant omphalocele is a major clinical challenge for pediatric surgeons. Whereas small- to medium-sized defects can be repaired primarily, larger omphaloceles cannot be closed at birth because the liver and small bowel have lost the right of domain to the abdomen. Two divergent strategies have evolved for treating these giant defects: (1) use of a silon chimney with gradual reduction of the contents of the sac, and (2) initial nonoperative management (epithelialization) of the omphalocele followed by repair of the residual ventral hernia. In an 18-year retrospective study, we have reviewed our experience with these treatment methods. Ninety-four infants underwent treatment for omphalocele between 1975 and 1993. Primary closure (PC) was possible in 55 patients, silon chimney (SC) was used in 15, and 7 had nonoperative management (NM) with epithelialization. In the remaining 17 infants, surgery was believed to be inappropriate because of the lethality of their associated anomalies. Major (but potentially survivable) anomalies were present in 26% of PC, 13% of SC, and 71% of the NM group patients. The majority of the liver was present in 73% of SC- and 86% of NM-treated omphaloceles. There was a decrease in length of stay, time to enteral feeding, and mortality over the 18-year period. However, those patients whose defects could not be closed primarily had consistently longer hospital stays. This was particularly true for the SC patients. The decreased use of total parenteral nutrition seems to reflect a shift from SC to NM rather than a decrease in the interval to full enteral feeding in any given treatment group over time.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of and factors associated with umbilical hernias in a swine herd

Of 2,958 pigs from a 320-sow, farrow-to-finish herd that were evaluated from birth to slaughter, 44 (1.5%) developed umbilical hernias. Hernias were detected mostly (34/44) when the pigs were between 9 and 14 weeks of age and were not fatal despite lack of treatment. Among littermates, weight gain prior to weaning was significantly (P = 0.04) lower in pigs that developed hernias (144.7 g/d) by 30 weeks of age than for nonaffected pigs (163.3 g/d), but growth rates from weaning to about 45 kg did not differ significantly. Records of pigs sired by 13 purebred boars were used to evaluate breed-of-sire associations. Pigs sired by American Spotted (n = 19; relative risk [RR] = 8.3; 95% confidence interval [CI] = 2.1 to 32.7) and Duroc boars (n = 378; RR = 2.1; 95% CI = 1.0 to 4.5) were more likely to develop umbilical hernias than were pigs (n = 1,644) sired by Yorkshire boars. Umbilical lesions (omphalitis or umbilical abscess) were associated (RR = 7.6; 95% CI = 1.2 to 49.5) with umbilical herniation on an individual basis, but the association was not evident (RR = 1.2; 95% CI = 0.2 to 7.6) when the litter was the unit of analysis. Analysis of sire associations, stratified by umbilical lesion status, indicated increased risks in the nonlesioned stratum for the American Spotted (RR = 8.7) and Duroc sires (RR = 2.2). Adequate comparisons of sire breed in the lesioned stratum could not be made, because umbilical lesions were an infrequent finding (9/2, 958).(ABSTRACT TRUNCATED AT 250 WORDS)

[Outcome of treatment of incarcerated hernia]

Experience in surgical treatment of 632 patients for incarcerated hernias of different localization is analysed. The patients' ages ranged from 39 to 91, 448 (70.9%) patients were over 60 years of age. Inguinal and umbilical hernias were encountered most frequently--62.5%. The intestine was resected in 93 patients, 80 of them were over 60 years of age (86%). Among these patients 63 were admitted to the clinic 1 to 4 days after the incarceration had occurred. The causes of late hospitalization: through the patient's fault in 80 (24.8%) cases, due to the doctor's errors in the prehospital stage in 39 (12.1%) cases. Kerte's method for determining the viability of the incarcerated intestine is subjective to a certain measure--the surgeons made errors in 14% of cases (confirmed histologically). The mortality was 13.4%, in 85% death occurred at an age over 70 and in 74% of cases the patients were admitted 24 hours to 4 days after the incarceration. Incompetence of the sutures of the anastomosis (41%) was the main cause of death. Late hospitalization, elderly and old age, severe concomitant complications, and unwarrantably extended volume of the interventions were the main causes of unfavorable outcomes of the management of this category of patients.

Evaluation of conservative therapy for exomphalos

Two management patterns were identified in 36 patients with exomphalos--primary surgical closure and initial topical therapy with delayed surgical closure. Primary surgical closure of minor exomphalos was well tolerated in 15 patients, but was associated with a high local and systemic morbidity rate in 14 patients with major defects. In contrast, initial topical therapy with silver sulphadiazine and delayed closure in seven matched patients with a major defect were well tolerated and did not prolong duration of hospitalization. Enteral feeding was more readily established and subsequent fascial closure facilitated in the conservatively treated group. It was suggested that this method should be more often considered in the management of all instances of major exomphalos.

A five-year U.S. Army experience with 36,250 abdominal hernia repairs

Thirty-six thousand two hundred fifty abdominal hernia repairs were performed in U.S. Army medical treatment facilities during a five-year period. This study presents data about the type of hernia, incidence of complications by obstruction or strangulation, age, sex, and mortality. Hernias occurring with intestinal obstruction or gangrene (strangulation) are referred to as complicated hernias. Inguinal hernias in children less than two years of age, femoral hernias, and unusual (such as internal or obturator) hernias were found to have an increased incidence of complications. Surgical repair of ventral, umbilical, and femoral hernias was done with a low surgical risk and the presence of complications did not significantly increase this risk. An increased risk of mortality is associated with the repair of complicated unusual hernias and complicated inguinal hernias in patients more than 60 years of age.

[Gastroschisis and omphalocele. Treatment and results]

Between 1976 and 1988, 28 neonates with gastroschisis and 44 with omphalocele were treated. In 44 patients primary closure was achieved, while silastic prostheses were used in 23 patients, and dura implant in three patients. Two patients were not treated. The mortality rate was 8% (4/52) among the patients without serious congenital defects and birth weights over 1,800 g. This mortality was mainly caused by bowel infarction and, in infants with birth weights below 1,800 g, by the respiratory distress syndrome. Our experience suggests that ventilatory assistance with total paralysis is mandatory per- and postoperatively. The handling of these abdominal wall defects demands transport in an incubator with a nasogastric tube in place, a sterile bowel bag and replacement of fluid loss. Bowel stretch at the edge of the defect should be minimized in order to reduce the risk of bowel infarction. The favorable results of treatment of these malformations depend less on birth weight than on the presence of other serious congenital defects which are decisive for the mortality.

The effect of mode of delivery on the perinatal outcome in fetuses with abdominal wall defects

A descriptive study of 125 infants with abdominal wall defects was undertaken to determine the effect of mode of delivery on outcome. Fifty-six infants had gastroschisis and 69 had omphalocele. Overall, there were no differences between the omphalocele and the gastroschisis groups in either cesarean section rate (22% vs 26%) or prematurity rate (26% vs 30%). However, the omphalocele group had a significantly higher infant death rate (22% vs 7%, p less than 0.001), a significantly higher incidence of associated major congenital anomalies (29% vs 5%, p less than 0.001), and a higher incidence of long-term infant morbidity (14.5% vs 8.9%). Within either group there was no significant difference between vaginal and cesarean delivery regarding either infant mortality, acute or long-term infant outcome, or frequency of associated major anomalies. We conclude that vaginal delivery of infants with abdominal wall defects does not adversely affect infant outcome.

Gastroschisis and exomphalos: recent trends and factors influencing survival

The present study examined the treatment and survival of patients with gastroschisis and exomphalos in the 5-year period January 1982-December 1987, at the Prince of Wales Children's Hospital. There were 15 cases of gastroschisis and 17 cases of exomphalos. The influences of temperature on arrival, birthweight, method of repair and associated anomalies on survival were examined. More patients presenting with gastroschisis survived than those with exomphalos (14 of 15 compared with 10 of 17, respectively). Of all the factors examined, the presence and nature of associated anomalies is the most important in determining survival.

Herniorrhaphy and concomitant peritoneovenous shunting in cirrhotic patients with umbilical hernia

From 1981 to 1987, a total of 40 cirrhotic patients with umbilical hernia were treated either by conventional herniorrhaphy (26) or by herniorrhaphy and concomitant insertion of a peritoneovenous (PV) shunt (14). The aim of concomitant PV shunt insertion was to reduce postoperative complications of herniorrhaphy in those patients with intractable ascites, or in whom difficulty to control postoperative ascites was contemplated. In the group of patients with PV shunt, 8 were class B and 6 were class C according to Child's classification; 7 patients had complicated hernia including 2 patients with skin ulceration, 4 with rupture, and 1 with incarceration. In the group with standard herniorrhaphy, 5 patients were class A and 21 were class B; 13 patients were operated on electively for uncomplicated hernia without ascites, 6 had incarceration, and 7 had skin ulceration. The technical procedure of concomitant PV shunting and hernia repair included: insertion of the valve, surgical repair of the hernia, and insertion of the venous tube. In that order, in-hospital mortality was nil. Postoperative complications included sepsis in 2 patients who had concomitant insertion of a PV shunt, and massive ascitic fluid production in 5 patients treated by conventional herniorrhaphy, resulting in ascitic leak from the surgical wound in 1 case. Recurrence of the hernia was observed in 6 patients treated by conventional herniorrhaphy, and in none who had a patent PV shunt.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of the fetus with an abdominal wall defect: experience of 31 cases

The diagnosis of ventral abdominal wall defect can now be made prior to birth. With this diagnosis, the family can make decisions and a planned optimal management can lead to a successful outcome. There were 31 cases of ventral wall defect identified at Chang Gung Memorial Hospital (CGMH) from January 1979 through March 1988. Twenty of them were classified as gastroschisis; among them, 17 (85%) were born in outside clinics and none of them had associated anomalies. In contrast, among 11 cases of omphalocele, there was a lower frequency of transferred cases (27% vs 85%), and 4 cases had additional defects, including two multiple anomalies and two bladder exstrophies. There were no significant differences between gastroschisis and omphalocele in the mortality rate (30% vs 36%), in the incidence of intrauterine growth retardation (IUGR) (30% vs 27%) and in the Cesarean section rate (15% vs 18%). All 4 cases of prematurity (less than 36 weeks of gestational age) expired after delivery and 2 of these had body weights of less than 1500 g. Three out of 5 cases delivered by Cesarean section expired; the mortality (60%) was higher than that of vaginal delivery (28%). All 3 cases were gastroschisis, 2 of them were transferred from outside clinics and all expired due to sepsis. The diagnosis of ventral wall defect should be made prenatally, with obstetric ultrasonography, maternal serum alpha-fetoprotein screening and fetal karyotyping. Therefore, fetal transport in utero to a referral center and optimal perinatal care for those fetuses with potentially correctable lesions can be well planned.

Plastic infusion bag, an alternative to Dacron reinforced (silastic) pouch in the management of ruptured omphalocele

An empty infusion bag of normal saline, fashioned into a silo, was used in the management of ruptured omphaloceles with satisfactory result. This new approach places within the reach of an average surgeon a cheap, safe and easy-to-make device in the management of this lethal condition in situations where the established but expensive silastic pouch is unavailable.

Surgical options in the management of large omphaloceles

Forty-six neonates with omphaloceles seen at the Children's Hospital and Medical Center in Seattle from 1975 to 1985 were reviewed. There was an 87 percent survival rate in those surgically managed. The 23 neonates who underwent primary closure all survived. The 13 neonates with giant omphaloceles with the liver in the defect who received silon chimneys had a 46 percent mortality rate and a high complication rate, with prolonged hospitalization. Two neonates with giant omphaloceles were managed by leaving the sac intact, and silver sulfadiazine cream was used as an escharotic agent. We believe it is a safer alternative than the silon chimney in neonates whose defects cannot be closed primarily.