The Association of Prenatal Diagnoses with Mortality and Long-Term Morbidity in Children with Specific Isolated Congenital Anomalies: A European Register-Based Cohort Study

OBJECTIVES

To compare 5-year survival rate and morbidity in children with spina bifida, transposition of great arteries (TGA), congenital diaphragmatic hernia (CDH) or gastroschisis diagnosed prenatally with those diagnosed postnatally.

METHODS

Population-based registers' data were linked to hospital and mortality databases.

RESULTS

Children whose anomaly was diagnosed prenatally (n = 1088) had a lower mean gestational age than those diagnosed postnatally (n = 1698) ranging from 8 days for CDH to 4 days for TGA. Children with CDH had the highest infant mortality rate with a significant difference (p < 0.001) between those prenatally (359/1,000 births) and postnatally (116/1,000) diagnosed. For all four anomalies, the median length of hospital stay was significantly greater in children with a prenatal diagnosis than those postnatally diagnosed. Children with prenatally diagnosed spina bifida (79% vs 60%; p = 0.002) were more likely to have surgery in the first week of life, with an indication that this also occurred in children with CDH (79% vs 69%; p = 0.06).

CONCLUSIONS

Our findings do not show improved outcomes for prenatally diagnosed infants. For conditions where prenatal diagnoses were associated with greater mortality and morbidity, the findings might be attributed to increased detection of more severe anomalies. The increased mortality and morbidity in those diagnosed prenatally may be related to the lower mean gestational age (GA) at birth, leading to insufficient surfactant for respiratory effort. This is especially important for these four groups of children as they have to undergo anaesthesia and surgery shortly after birth. Appropriate prenatal counselling about the time and mode of delivery is needed.

Gastroschisis in the neonatal period: A prospective case-series in a Brazilian referral center

BACKGROUND/PURPOSE

Gastroschisis is increasing in incidence and has low mortality and high morbidity. We describe the clinical and surgical characteristics of gastroschisis patients in a Brazilian referral center.

METHODS

Single-center prospective case series of gastroschisis patients. The following two groups were formed depending on the intestinal characteristics: simple and complex patients.

RESULTS

In total, 79 patients were enrolled, 89% of whom were classified as simple and 11% as complex. The baseline characteristics were similar between the groups, with the exception of the illness severity score. The complex group had a significantly smaller defect size, more reoperations and worse clinical outcomes than the simple group, with the initiation of feeding taking 1.5 times longer, the duration of total parenteral nutrition taking twice as long, and the length of hospitalization being 2.5 times longer; the complex group also included all the deaths that occurred. Overall, the survival rate was 96%. Patients who underwent the sutureless technique had significantly fewer wound infections and a decreased duration of mechanical ventilation than sutured patients.

CONCLUSIONS

This study provides a comprehensive picture of gastroschisis during the neonatal period in a Brazilian referral center, emphasizing the significantly higher risk for morbidity and mortality among complex patients than among simple patients and the few advantages of the sutureless technique over the sutured technique in terms of closing the defect.

TYPE OF STUDY

Prognostic.

LEVEL OF EVIDENCE

IV.

Assessment of gastroschisis risk factors in Egypt

AIM

Mortality in infants born with gastroschisis (GS) in low-to-middle-income countries (LMICs) is high. This study aimed to assess factors which might affect outcome in Egypt in order to improve survival.

METHODS

A prospective study over a 15-month duration was completed. Variables assessed covered patient, maternal, antenatal, treatment, and complications. The Gastroschisis Prognostic Score (GPS) was used to predict outcome. A validated questionnaire was used to assess socioeconomic status. The main outcome was mortality.

RESULTS

Twenty-four cases were studied. Median gestational age was 37 (26-40) weeks, and 9 (38%) were preterm. Mortality occurred in 15 (62%) infants. Median transfer time was 8 (1.5-35) hours, and 64% survived if transferred before 8 h. Median maternal age was 20 (16-27) years. All families were of a low or very-low socioeconomic level. Only 25% had antenatal scans. Most cases were simple GS, and only 3 (12.5%) were complex GS. Median length of stay was 14 (1-52) days, TPN duration was 12 (0-49) days, and days to full feeds was 5 (3-11) days. The GPS score ranged from 0 to 6 in the studied cases and negatively correlated with outcome (rS = -0.98; p = 0.03).

CONCLUSION

The mortality of GS in Egypt is very high, mainly due to sepsis and prematurity. Young maternal age and poor socioeconomic status are linked to GS. The GPS is a good indicator of morbidity and mortality in a LMIC setting. Survival improved with better resuscitation and strict management protocols. More effort is needed to improve antenatal detection, and transfer time should be ideally below 8 h.

LEVEL OF EVIDENCE

Level IV.

Mode of delivery and mortality among neonates with gastroschisis: A population-based cohort in Texas

BACKGROUND

Mode of delivery is hypothesised to influence clinical outcomes among neonates with gastroschisis. Results from previous studies of neonatal mortality have been mixed; however, most studies have been small, clinical cohorts and have not adjusted for potential confounders.

OBJECTIVES

To evaluate whether caesarean delivery is associated with mortality among neonates with gastroschisis.

METHODS

We studied liveborn, nonsyndromic neonates with gastroschisis delivered during 1999-2014 using data from the Texas Birth Defect Registry. Using multivariable Cox proportional hazards regression, we separately assessed the relationship between caesarean and death during two different time periods, prior to 29 days (<29 days) and prior to 365 days (<365 days) after delivery, adjusting for potential confounders. We also updated a recent meta-analysis on this relationship, combining our estimates with those from the literature.

RESULTS

Among 2925 neonates with gastroschisis, 63% were delivered by caesarean. No associations were observed between caesarean delivery and death <29 days (adjusted hazard ratio [aHR] 1.00, 95% confidence interval [CI] 0.63, 1.61) or <365 days after delivery (aHR 0.99, 95% CI 0.70, 1.41). The results were similar among those with additional malformations and among those without additional malformations. When we combined our estimate with prior estimates from the literature, results were similar (combined risk ratio [RR] 1.00, 95% CI 0.84, 1.19).

CONCLUSIONS

Although caesarean rates among neonates with gastroschisis were high, our results suggest that mode of delivery is not associated with mortality among these individuals. However, data on morbidity outcomes (eg intestinal damage, infection) were not available in this study.

Gastroschisis in Uganda: Opportunities for improved survival

PURPOSE

Neonatal mortality from gastroschisis in sub-Saharan Africa is high, while in high-income countries, mortality is less than 5%. The purpose of this study was to describe the maternal and neonatal characteristics of gastroschisis in Uganda, estimate the mortality and elucidate opportunities for intervention.

METHODS

An ethics-approved, prospective cohort study was conducted over a one-year period. All babies presenting with gastroschisis in Mulago Hospital in Kampala, Uganda were enrolled and followed up to 30days. Univariate and descriptive statistical analyses were performed on demographic, maternal, perinatal, and clinical outcome data.

RESULTS

42 babies with gastroschisis presented during the study period. Mortality was 98% (n=41). Maternal characteristics demonstrate a mean maternal age of 21.8 (±3.9) years, 40% (n=15) were primiparous, and fewer than 10% (n=4) of mothers reported a history of alcohol use, and all denied cigarette smoking and NSAID use. Despite 93% (n=39) of mothers receiving prenatal care and 24% (n=10) a prenatal ultrasound, correct prenatal diagnosis was 2% (n=1). Perinatal data show that 81% of deliveries occurred in a health facility. The majority of babies (58%) arrived at Mulago Hospital within 12h of birth, however 52% were breastfeeding, 53% did not have intravenous access and only 19% had adequate bowel protection in place. Four patients (9%) arrived with gangrenous bowel. One patient, the only survivor, had primary closure. Average time to death was 4.8days [range<1 to 14days].

CONCLUSION

The mortality of gastroschisis in Uganda is alarmingly high. Improving prenatal diagnosis and postnatal care of babies in a tertiary center may improve outcome.

Sonographic Detection and Clinical Importance of Growth Restriction in Pregnancies With Gastroschisis

OBJECTIVES

The purpose of this study was to estimate the utility of sonography to detect small-for-gestational-age (SGA) neonates in pregnancies with gastroschisis and to evaluate neonatal outcomes according to birth weight percentile.

METHODS

We conducted a retrospective cohort study of singleton pregnancies with fetal gastroschisis delivered at our hospital between August 1997 and December 2012. Diagnosis of growth restriction was based on estimated fetal weight below the 10th percentile using the nomogram of Hadlock et al (Am J Obstet Gynecol 1985; 151:333-337), evaluated at 4-week intervals throughout gestation and compared with subsequent birth weight, to evaluate the accuracy of sonography to detect and exclude SGA neonates. Pregnancy and neonatal outcomes were evaluated according to birth weight percentile.

RESULTS

There were 111 births with gastroschisis (6 per 10,000), and one-third (n = 37) had birth weight below the 10th percentile. The sensitivity and negative predictive value of sonography for an SGA neonate both approached 90% by 32 weeks and were approximately 95% thereafter. Detection increased with advancing gestational age (P = .02). The birth weight percentile was not associated with preterm birth, infection, bowel complications requiring surgery, duration of hospitalization, or perinatal mortality. Delayed closure of the gastroschisis defect was more frequent with birth weights at or below the 3rd percentile (P = .03).

CONCLUSIONS

Sonography reliably identified SGA neonates with gastroschisis in our series, and its utility improved with advancing gestation. Apart from delayed closure of the defect, a low birth weight percentile was not associated with an increased risk of morbidity or mortality in the immediate neonatal period.

(1)H MRS: a potential biomarker of in utero placental function

The placenta is a temporary organ that is essential for a healthy pregnancy. It performs several important functions, including the transport of nutrients, the removal of waste products and the metabolism of certain substances. Placental disorders have been found to account for over 50% of stillbirths. Despite this, there are currently no methods available to directly and non-invasively assess placental function in utero. The primary aim of this pilot study was to investigate the use of (1)H MRS for this purpose. (1)H MRS offers the possibility to detect several placental metabolites, including choline, lipids and the amino acids glutamine and glutamate (Glx), which are vital to fetal development and placental function. Here, in utero placental spectra were acquired from nine small for gestational age (SGA) pregnancies, a cohort who are at increased risk of perinatal morbidity and mortality, and from nine healthy gestation-matched pregnancies. All subjects were between 26 and 39 weeks of gestation. Placenta Glx, choline and lipids at 1.3 and 0.9 ppm were quantified as amplitude ratios to that of intrinsic H2O. Wilcoxon signed rank tests indicated a significant difference in Glx/H2O (p = 0.024) between the two groups, but not in choline/H2O (p = 0.722) or in either lipid/H2O ratio (1.3 ppm, p = 0.813; 0.9 ppm, p = 0.058). This study has demonstrated that (1)H MRS has potential for the detection of placental metabolites in utero. This warrants further investigation as a tool for the monitoring of placental function.

Infant, maternal, and geographic factors influencing gastroschisis related mortality in Zimbabwe

INTRODUCTION

Survival for infants with gastroschisis in developed countries has improved dramatically in recent decades with reported mortality rates of 4-7%. Conversely, mortality rates for gastroschisis in sub-Saharan Africa remain as great as 60% in contemporary series. This study describes the burden of gastroschisis at the major pediatric hospital in Zimbabwe with the goal of identifying modifiable factors influencing gastroschisis-related infant mortality.

METHODS

We performed a retrospective cohort study of all cases of gastroschisis admitted to Harare Children's Hospital in 2013. Univariate and multivariate analyses were performed to describe infant, maternal, and geographic factors influencing survival.

RESULTS

A total of 5,585 neonatal unit admissions were identified including 95 (1.7%) infants born with gastroschisis. Gastroschisis-related mortality was 84% (n = 80). Of infants with gastroschisis, 96% (n = 91) were born outside Harare Hospital, 82% (n = 78) were born outside Harare Province, and 23% (n = 25) were home births. The unadjusted odds of survival for these neonates with gastroschisis were decreased for low birth weight infants (<2,500 grams; odds ratio [OR], 0.15; 95% CI, 0.05-0.51), preterm births (<37 weeks gestational age; OR, 0.06; 95% CI, 0.01-0.50), and for those born to teenage mothers (<20 years of age; OR, 0.05; 95% CI, 0.01-0.46). There was also a trend toward decreased odds of survival for home births (OR, 0.16; 95% CI, 0.02-1.34) and for those born outside Harare Province (OR, 0.35; 95% CI, 0.10-1.22).

CONCLUSION

Gastroschisis-related infant mortality in Zimbabwe is associated with well-known risk factors, including low birth weight, prematurity, and teenage mothers. However, modifiable factors identified in this study signify potential opportunities for developing innovative approaches to perinatal care in such a resource-constrained environment.

Advances in the Surgical Treatment of Gastroschisis

Gastroschisis (GS) is a structural defect of the anterior abdominal wall, usually diagnosed antenatally, that occurs with a frequency of approximately 4 per 10,000 pregnancies. Babies born with GS require neonatal intensive care and surgical management of the abdominal wall defect soon after birth. Although contemporary survival rates for GS are over 90%, these babies are at risk for significant morbidity, and require 4 to 6 weeks of costly, resource-intensive care in specialized neonatal units. Much consideration has been given to how best to treat the abdominal wall defect of GS. The traditional approach, necessitated by a need to establish enteral feeding as quickly as possible, consists of early postnatal visceral reduction and sutured abdominal closure. Advances in neonatal nutritional support have enabled the development of surgical approaches, which permit gradual visceral reduction and delayed abdominal closure. In cases where early visceral reduction cannot be achieved, delayed closure enabled by the initial placement of a prosthetic silo has been a live-saving alternative. The development of preformed silos has simplified their use and led to an interest in treating all cases with a delayed closure philosophy. Most recently, a sutureless technique of abdominal closure has been reported, which has the benefit of avoiding general anesthesia and offers other outcome improvements over sutured closure of the defect. The debate over primary closure versus silo placement and delayed closure continues to receive much attention. The goal of this article is to review historical aspects of gastroschisis closure, and then focus on current surgical techniques, including the innovative sutureless closure, with an analysis of the comparative clinical effectiveness of these approaches to treatment of the abdominal wall defect in GS.

Birth Weight, Compromised Bowel and Sepsis are the Main Variables Significantly Influencing Outcome in Gastroschisis

BACKGROUND

The survival rate for gastroschisis has improved to more than 90% in the developed countries, but increased mortality, morbidity, consequent long hospitalisation and high costs are the rule in Romania.

METHODS

Analytic retrospective study of all patients with gastroschisis treated at our department between 1990 and 2012. The study protocol included: demographic data, antenatal diagnosis, prematurity, mode of delivery, birth weight,associated anomalies, time to surgery, presence of compromised bowel, type of repair, post-operative complications, time to full enteral feeding, length of hospitalisation, mortality.

RESULTS

115 newborns with gastroschisis were treated during 23 years. Antenatal diagnosis was made only in 13 cases ata mean gestational age of 25 weeks. Delivery was vaginal in 80.8%. Associated malformations were present in 47 patients. Twenty-four patients had complex gastroschisis.Primary repair was done in 90 cases (79%) and in 24 patients a silo was used. Overall survival was only 29.8%, the main cause of death being severe sepsis with multiple organ failure(61.4%) and bronchopneumonia (52.6%). The rate of complications associated with closure, needing reintervention was 19.3%.

CONCLUSIONS

Analysis of risk factors by logistic regression showed that low birth weight increased the risk of postoperative complications 17.4 times, sepsis increased the risk of complicated postoperative course 12.2 times, and the presence of compromised intestinal loops (complex gastroschisis) 5.5 times.

Considerations on gastroschisis repair

BACKGROUND

Although primary closure of the gastroschisis is possible in many cases, there have been various strategies published and materials used to cover the eviscerated bowel when the abdominal wall defect cannot be closed in one step, providing bowel protection and reduction of heat and fluid loss. There have been suggestions of coverage materials such as skin graft, lyophilized dura mater graft, free flap corium and meshed skin graft (1,2).

PURPOSE

We highlight an alternative repair method of gastroschisis in those cases where there is a disproportion between the amount of eviscerated organs and the hypoplastic abdominal cavity. If in this case primary closure of the abdominal wall is chosen, the difference in volume can cause a significant increase in intraabdominal pressure.

METHOD

In some cases, when complete primary closure was not possible, we used an alternative method to repair the parietal defect using umbilical cord patch.

RESULTS

This technique creates a mesothelial surface in contact with the bowel. Remote tracking of these patients showed excellent results.

CONCLUSIONS

This technique is easy to apply and very useful for infants with gastroschisis especially when primary closure is not possible. The use of autologous material, in this case as the umbilical cord, has several advantages, including wide availability, a lower rate of infection and significantly reduced costs.

Gastroschisis treatment: what are the causes of high morbidity and mortality rates?

INTRODUCTION

Gastroschisis is one of the most common birth defects of the anterior abdominal wall, in recent decades being witnessed a significant increase in the survival of children with such a condition. This study aims to discover the causes of the increased perinatal morbidity and mortality rates from gastroschisis in our country.

METHODS

Retrospective study on 54 infants with gastroschisis. Patient data were statistically processed and the demographic characteristics, antenatal diagnosis, presence of associated anomalies, method of surgical treatment, postoperative complications, number of hospital stay days and survival rate were analysed.

RESULTS

Most demographic data and associated malformation rate in the study patients are in agreement with the data in the literature, except for prenatal diagnosis rate (16.7% vs 68- 88%), rapid hospital arrival and surgery (6.8 vs 4.3 hours), and the worst, the high rate of infections (68.5%) and hence mortality rate (63% vs. 6-7%).

CONCLUSIONS

Although the therapeutic approach in our clinic complies with the international trend, the mortality rate is still very high, its main cause in the study group proving to be prolonged sepsis and multiple organ failure, probably favored by the low rate of antenatal diagnosis leading to delay in the appropriate surgical management.

Can antenatal ultrasounds help predict postnatal outcomes in babies born with gastrochisis? The West Virginia experience

OBJECTIVE

Gastrochisis is a congenital condition resulting in significant morbidity and mortality. Multiple studies have been done to evaluate the value of prognostic indicators with conflicting results. The aim of this study was to evaluate the role of ultrasound in this condition at a single institution while limiting the provider variables that may affect neonatal outcome.

METHODS

The antepartum charts of expectant mothers of affected fetuses as well as the neonatal hospital charts were reviewed at length. The cases were identified over a period of 4 years from April 1998 to February 2002. In addition, the archived photographs of ultrasounds performed on these fetuses were also reviewed and reread by two independent providers who were blinded to the outcome. Adverse neonatal outcome, including death and time to feeding (amongst many other variables) were assessed against the different ultrasound parameters including bowel thickness and dilation.

RESULTS

25 patients were identified in the stated time frame. Six cases had to be dropped from the final analysis due to incomplete data including the transfer of 3 babies. There were 4 neonatal deaths. The mean birth weight was 2384 grams. There was a significant association with dilation and delta dilation (defined as the difference in bowel dilation from the final ultrasound from the baseline ultrasound cutoff of 4 mm) and time to feeding, time on ventilator and hospital stay. (P< 0.005). Other ultrasound parameters were not significantly correlated with neonatal outcome.

CONCLUSION

Most ultrasound parameters do not help prognosticate the neonatal outcome in babies affected with this condition except for dilation and delta dilation, which are strong predictors of morbidity in the post delivery period. This information may be helpful to providers and parents of affected fetuses.

Postnatal outcome of fetuses with the prenatal diagnosis of gastroschisis

OBJECTIVES

The purpose of this study was to assess the postnatal outcome and complications that arise in infants with the prenatal diagnosis of gastroschisis.

METHODS

Prenatal sonograms with the diagnosis of gastroschisis were identified. Maternal age, indication for sonography, gestational age at diagnosis, other sonographic abnormalities, and postnatal outcome were recorded.

RESULTS

Ninety-eight fetuses at 14.3 to 36 weeks' gestation had the diagnosis of gastroschisis on sonography. In 14 cases (14%), other fetal anomalies were identified, including hydronephrosis, hydrocephalus, coarctation of the aorta, and a limb anomaly. Bowel dilatation developed in 72 of 84 cases (86%) followed prenatally with sonography, and bowel wall thickening developed in 40 of 73 cases (55%). On postnatal follow-up, 57 of 68 infants (84%) had postnatal complications, many with multisystem complications, including 6 deaths, 40 with bowel-related complications, 30 with infectious complications, and 32 with anomalies involving other systems (genitourinary, cardiac, and central nervous system). The postnatal outcome did not correlate with the presence of bowel dilatation or bowel wall thickening on prenatal sonography. Only 11 infants (16.2%) had a completely uncomplicated postsurgical course. Hospital stays in survivors (n = 92) ranged from 8 to 307 days (mean, 53 days).

CONCLUSIONS

Although reported survival rates are good for gastroschisis, the postoperative hospital stay is often lengthy, and complications are very common, especially those related to the gastrointestinal tract. Associated anomalies were more common in our study than previously reported.

[Influence of selected factors on the treatment and prognosis in newborns with gastroschisis on the basis of own experience]

AIM

The purpose of the study was to evaluate the influence of selected prognostic factors for postoperative course and prognosis in newborns with gastroschisis.

MATERIAL AND METHODS

A study of all newborns with gastroschisis treated between 2000-2010 in the Clinic of Surgery of Children and Adolescents, Institute of Mother and Child was performed. Data collected from medical documentation included the following: presence or lack of prenatal diagnosis, mode of delivery, gestational age (below or above 37 weeks), birth weight, necessity on transportation from provincial hospitals or transfer within Institute, condition of the bowel (good - little fibrinous inflammation or bad - massive inflammatory peel, necrosis, perforation, atresia), interval between delivery and operation, kind of surgery (primary repair, silo closure), complication requiring secondary operation, period of ventilatory support (PVS), time needed to achieve full enteral feeding (FEF), total length of hospital stay (TH), number and cause of death. Selected information obtained from the data of the patients were separated into two periods of time: 2000-2005 and 2006-2010 for better evaluation of the influence of individual factors on the efficiency of treatment and prognosis. Multivariate logistic regression was used to investigate the association between selected risk factors and end points (PVS,FEF,TH). Statistical analyses were performed using Stata v.10 (College Station, TX, Stata Corporation LP 2007).

RESULTS

During the study period 32 newborns with gastroschisis were treated. Prenatal diagnosis was made in 22 patients (69%) and the mean age of diagnosis was 30.7 weeks. Cesarean section was performed in 25 cases and vaginal delivery occurred in 7 cases. The mean gestational age during delivery was 35.7 weeks, mean weight was 2430 g. Twenty one newborns were delivered before 37 week of gestation, eleven after 37 week. Fifteen patients were transported from provincial obstetrics hospitals, seventeen were transferred within the Institute (from the Obstetrics Clinic to Clinic of Pediatric Surgery). A good condition of the externalized bowel was found in 18, a bad condition in 14 patients (therein necrosis with perforation in 2, atresia in 2). Mean delivery - operation interval was 6.3 hours. The operation was performed till 3rd hour after birth in 12, over 3rd hour in 20 newborns. During the first surgical intervention primary closure was possible in 29 cases, silo was used in 3 patients. Five patients required more than one surgical intervention (2 patients after silo closure and 3 patients after primary repair). For patients who survived mean PVS was 4.6, mean time FEF was 24.7 days, TH was 34.5 days. Five patients died. The reasons for death were heart tamponade in 2 and complications in the course of sepsis in 3 patients. In the period 2006-2010 versus 2000-2005 number of prenatal diagnosis significantly increased (46% and 84% respectively), mean age at delivery decreased (38.6 and 35.3 respectively), period between delivery and operation shortened from 8.8 to 3.8 hours, more patients were operated on during first three hours after birth (7.6% and 58% respectively). The condition of the bowel was assessed similarly in both periods (bad condition 38% and 47% respectively). All deaths occurred in newborns treated in the years 2000-2005. Multivariate logistic regression showed there was one independent risk factor that influenced the two end points: the period of respiratory support and the length of hospital stay, i. e. the delivery - operation interval. Patients with delivery - operation interval over 3 hours after birth had a significantly higher risk of long-standing ventilatory support or death (OR=12.4, 95%CI {1.7, 89.3}, p=0.013) and a significantly higher risk of longer total hospital stay or death (OR=12.7, 95%CI {1.7, 97.0}, p=0.014). None of the factors analyzed had statistical significance with respect to the length of time needed to achieve full enteral feeding.

CONCLUSION

The main independent risk factor having influence on the course of treatment and prognosis was the delivery - operation interval. Early repair of gastroschisis makes primary closure easier and shortens the post-operative course. Newborns with gastroschisis despite progress in prenatal diagnostics, neonatal intensive care and surgical methods remains a serious therapeutic problem requiring multidisciplinary care and long-standing hospital stay.

[Closing gastroschisis: a distinct entity with high morbidity and mortality]

PURPOSE

We correlate severe bowel damage in gastroschisis to the rare intrauterine event of narrowing of the abdominal wall around the protruding intestines. We describe this "closing gastroschisis" as a distinct entity. Prenatal ultrasound findings as gastric or bowel dilation were compared to the postnatal findings in order to find markers for an early in utero diagnosis of closing gastroschisis. Early diagnosis could prompt timely delivery to save the compromised bowel and avoid short gut syndrome.

MATERIALS AND METHODS

We documented the pre- and postnatal course of our patients with gastroschisis from 2007 to 2009.  Closing gastroschisis was suspected antenatally and confirmed postnatally. We identified 5 out of 18 patients showing closure of the abdominal wall with varying degrees of bowel damage. Prenatal ultrasound findings were correlated to the postnatally confirmed extent of intestinal damage.

RESULTS

We could not find consistent ultrasound markers for prenatal diagnosis of closing gastroschisis. In prenatal ultrasound three patients presented significant gastric dilation and then experienced severe courses postnatally due to segmental gut necrosis. One of these three died and the other two developed short gut syndrome. In one case progressive intraabdominal loop dilation with simultaneous shrinking of the extraabdominal loops occurred corresponding to closing gastroschisis with segmental midgut necrosis.

CONCLUSION

Closing gastroschisis must be seen as a special form of gastroschisis. Extended intestinal damage is often life-threatening. In longitudinal observation dynamics of fetal ultrasound findings can lead to the diagnosis of closing gastroschisis. Progressive intraabdominal loop dilation is always highly suspicious and must lead to close follow-up and timely delivery.

The gastroschisis prognostic score: reliable outcome prediction in gastroschisis

BACKGROUND/PURPOSE

Disease-specific outcome predictors are required for gastroschisis. We derived and validated a gastroschisis prognostic score (GPS) based on bowel appearance after birth.

METHODS

Visual scoring of bowel matting, necrosis, atresia, and perforation generated a novel gastroschisis bowel injury score recorded in a national database. Reweighting of score components by regression analysis led to assessments of model calibration and goodness of fit. The GPS was validated in subsequent cases.

RESULTS

Records from 225 infants were used for model derivation. Only intestinal necrosis independently predicted mortality by regression analysis (odds ratio, 11.5; 95% confidence interval, 4.2-31.4). Model recalibration identified that a GPS of 4 or more predicted mortality in 75% of nonsurvivors and 99% of survivors (P = .0001). A GPS of 2 or more demonstrated significantly worse survival outcomes compared with scores of 0 or 1 (length of stay: P = .011, days to first enteral feed: P = .013, days on total parenteral nutrition: P = .006). Model validation with 184 new patients yielded continued high-quality discrimination of outcomes. The GPS demonstrated "near-perfect" interobserver reliability between 2 surgeons (κ ≥ 0.86).

CONCLUSIONS

The GPS allows the accurate and reliable identification of high-risk groups for mortality and morbidity based on bowel appearance at birth. This information can drive discussions regarding family counseling, resource allocation, and new therapies for these patients.

[Modifiable prognostic factors in the morbidity-mortality of gastroschisis]

OBJECTIVE

The low incidence of gastroschisis makes impossible a consistently study of the factors that determine its evolution. The presence of other alterations associated is an important determinant of prognosis known. We analyze the factors implicated in morbidity and mortality in our center that can be modified.

MATERIAL AND METHODS

We performed a retrospective study from hospital records. We analyzed the morbidity and mortality versus gestational age, mode of delivery, surgery performed, presence of prenatal diagnosis, herniated viscera and associated anomalies. We studied the postoperative differences occurred as a result of implantation of fetal surgery group. The variables were analyzed with SPSS 15.0 using non-parametric test.

RESULTS

Since 1987 25 patients have been operated (12 men) with a mean birth weight of 2,328 g +/- 364. The 44% of them had prenatal diagnosis and 72% were born by cesarean. Only 4 had intestinal atresia. Preterm birth (< 36 weeks) did not improve the complications, but did reduce hospital stay in 10.68 days and the time of parenteral nutrition in 6 days. Cesarean delivery and prenatal diagnosis was improved all the previous factors. Primary closure however was associated with higher rates of postsurgical complications (46.2% vs. 18.2%). The 5 patients who died was during the immediate postoperative period, all before developing the fetal diagnostic program.

CONCLUSIONS

Prenatal diagnosis and preterm delivery by elective cesarean reduces the complications of gastroschisis. Interdisciplinary coordination is essential to improve the prognosis of these patients.

Gastroschisis: one year outcomes from national cohort study

OBJECTIVE

To describe one year outcomes for a national cohort of infants with gastroschisis.

DESIGN

Population based cohort study of all liveborn infants with gastroschisis born in the United Kingdom and Ireland from October 2006 to March 2008.

SETTING

All 28 paediatric surgical centres in the UK and Ireland.

PARTICIPANTS

301 infants (77%) from an original cohort of 393.

MAIN OUTCOME MEASURES

Duration of parenteral nutrition and stay in hospital; time to establish full enteral feeding; rates of intestinal failure, liver disease associated with intestinal failure, unplanned reoperation; case fatality.

RESULTS

Compared with infants with simple gastroschisis (intact, uncompromised, continuous bowel), those with complex gastroschisis (bowel perforation, necrosis, or atresia) took longer to reach full enteral feeding (median difference 21 days, 95% confidence interval 9 to 39 days); required a longer duration of parenteral nutrition (median difference 25 days, 9 to 46 days) and a longer stay in hospital (median difference 57 days, 29 to 95 days); were more likely to develop intestinal failure (81% (25 infants) v 41% (102); relative risk 1.96, 1.56 to 2.46) and liver disease associated with intestinal failure (23% (7) v 4% (11); 5.13, 2.15 to 12.3); and were more likely to require unplanned reoperation (42% (13) v 10% (24); 4.39, 2.50 to 7.70). Compared with infants managed with primary fascial closure, those managed with preformed silos took longer to reach full enteral feeding (median difference 5 days, 1 to 9) and had an increased risk of intestinal failure (52% (50) v 32% (38); 1.61, 1.17 to 2.24). Event rates for the other outcomes were low, and there were no other significant differences between these management groups. Twelve infants died (4%).

CONCLUSIONS

This nationally representative study provides a benchmark against which individual centres can measure outcome and performance. Stratifying neonates with gastroschisis into simple and complex groups reliably predicts outcome at one year. There is sufficient clinical equipoise concerning the initial management strategy to embark on a multicentre randomised controlled trial comparing primary fascial closure with preformed silos in infants suitable at presentation for either treatment to determine the optimal initial management strategy and define algorithms of care.

Clinical outcome of patients with gastroschisis: what are the differences from the past?

OBJECTIVE

The aim of the present study was to review the experience in management of neonates with gastroschisis and analyze the differences in the clinical outcome during a 24-year period.

MATERIAL AND METHOD

A retrospective study of patients with gastroschisis treated at Queen Sirikit National Institute of Child Health (QSNICH) between 1986 and 2009 was conducted. Patients' information was compared between the first period (1986-1997) and the second period (1998-2009) regarding demographic data, modes of operative procedures and results of the treatment. The statistical differences were analyzed by the Chi-square, Fisher exact and student t-test with a p-value less than 0.05 considered significant.

RESULTS

During a 24-year period, 919 neonates with gastroschisis were treated at QSNICH; 342 cases (161 males and 181 females) in the first 12-year period and 577 cases (295 males and 282 females) in the second 12-year period. The incidence of gastroschisis at Rajavithi Hospital was 0.26: 1,000 live births in the first period and 1.03: 1,000 live births in the second period. Average birth weight of the patients and average maternal age in both periods were not significantly different (p > 0.05). Congenital anomalies were found in approximately 15% of the patients in each period. Regarding modes of the operative treatment, primary closure of the abdominal wall defect was attempted in 23.7% of the patients during the first period and increased to 44% in the second period. The overall survival rate in the second period was better than the first period with statistical significance (92.4% vs. 75.4%, p < 0.001). In addition, complications in the second period were less than those in the first period, except for necrotizing enterocolitis, which was more frequent in the second period.

CONCLUSION

The obvious differences in patients with gastroschisis during the 24-year period were the increased incidence, increased successful primary closure of the abdominal wall defect and increased overall survival rate between 1998-2009. Improvement of the clinical outcomes reflected improved neonatal care including surgical techniques, parenteral nutrition, respiratory care and anesthetic practice.

Preterm elective caesarean section and early enteral feeding in gastroschisis

AIMS

To evaluate the effect of elective caesarean section (CS) before term and early enteral nutrition on length of parenteral nutrition and hospital stay in infants with gastroschisis.

METHODS

Retrospective review of all infants with gastroschisis treated in a regional level III hospital from 1993 to 2008. During 1993-97, there was no established standard for management of pregnancy or delivery while a protocol on close foetal monitoring and early elective CS was adhered to for 1998-2008. Introduction of human milk on the first day after complete closure of the abdominal wall and rapid increase was the policy during the whole period.

RESULTS

With early elective CS, no foetal deaths occurred after 28-week gestational age (GA). Ten infants were born during the first period and 20 during the second period at a median GA (range) of 36.5 (34-40) and 35 (34-37) weeks (p = 0.013). Seven and 20, respectively, were born by CS. Median (range) days before full enteral feeds and hospital stay were 11.5 (7-39) and 13.0 (7-46) (p = 0.85), and 17.5 (12-36) and 22.5 (13-195) (p = 0.67), respectively. One child died of volvulus after discharge.

CONCLUSION

Close surveillance of pregnancy, elective preterm caesarean section, early surgery and active approach to primary closure and early enteral feeds appears to be a safe and effective line of management in gastroschisis.

Clinical features of newborns with gastroschisis and outcomes of different initial interventions: primary closure versus staged repair

BACKGROUND

Gastroschisis requires surgical management soon after birth. Few publications have reached conclusion regarding the differences of outcomes between primary closure (PC) and a staged repair with silo pouch reduction (SR); as the initial management of gastroschisis.

METHODS

A retrospective review was conducted in 44 newborns with gastroschisis between 1996 and 2007 at Chang Gung Children's Hospital. We recorded and analyzed basic demographic data, including birth body weight, gestational age, size of the wall defect, initial operative procedure, outcomes, and mortality.

RESULTS

The male-to-female ratio was 21:23. Patients had a low birth body weight (2263 ± 539g, mean ± SD) and were borderline premature (gestational age = 36.3 ± 1.86 weeks). Thirty-two patients received PC and 12 received SR as the initial treatment. Seven of the newborn infants died because of delayed initial surgical intervention (n = 2), operation-related complications (n = 4), or underlying multiple congenital anomalies (n = 1). The mortality rate was 16%. When comparing PC and SR (excluding "complicated" gastroschisis), there were no significant differences in survival, days of ventilator use, days to reach full enteral feeding, and hospitalization.

CONCLUSION

PC and SR are comparable as initial treatment modalities for gastroschisis. In addition to underlying gastrointestinal anomalies, the factors that led to significant morbidity in our study were bowel gangrene or perforation resulting from postponed surgical management and the development of abdominal compartment syndrome.

[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.

Intestinal atresia in association with gastroschisis: a 26-year review

PURPOSE

We reviewed our experience with gastroschisis (GS) complicated by intestinal atresia over the last 26 years. Our aim was to determine the effect of different management strategies employed and the morbidity associated with this condition in our unit.

METHODS

A retrospective casenote review was carried out. Data regarding the operative management of the GS and atresia was recorded. Primary outcome measures included time to commence and establish full enteral feeds, duration of parenteral nutrition, complications and outcome.

RESULTS

Of 179 neonates with GS, 23 also had intestinal atresia. 13 underwent primary closure of the defect, 5 had patch closure and 5 had a silo placed. 4 atresias were 'missed' at first operation. The 19 recognised atresias were managed either by stoma formation, primary anastomosis or deferred management with subsequent primary anastomosis. There was wide variation in the outcomes of patients in each group.

CONCLUSION

Differences in outcome between the management strategies are likely to reflect an inherent variability in patient condition, site of atresia, and bowel suitability for anastomosis at first surgery, rather than the mode of surgical management. Individual management plans should be tailored to the clinical condition of each patient.

Gastroschisis: delivery and immediate repair in the operating room

BACKGROUND

Gastroschisis is a congenital abdominal wall defect with the small and large bowel protruding through. Early closure prevents heat and water loss, infection, and bowel edema. Immediate primary fascial closure should be done when possible.

OBJECTIVE

To compare the outcome of a group of gastroschisis neonates diagnosed before birth who underwent delivery and immediate surgical repair in the operating room (IOR group) with another group who underwent delivery outside the operating room and urgent surgical repair in the operating room later (OOR group).

MATERIAL AND METHOD

A retrospective cross sectional study between January 1, 2005 and December 31, 2007 was conducted on 49 neonates with gastroschisis treated at Khon Kaen Regional Hospital by one pediatric surgeon.

RESULT

Thirteen neonates were in the IOR group and 36 in the OOR group. Statistical significance was observed between both groups with regard to delivery-operation interval and operative procedure. The time interval from birth to operative repair of IOR group was shorter (0.8 +/- 0.4 vs. 11.4 +/- 4.2, p < 0.001). The abdominal wall defect of all neonates in IOR group could be corrected by primary fascial closure (100%) compared with only 61.1% in the OOR group (p < 0.01). There were no statistical significant difference between the two groups regarding days to extubation (4.7 +/- 2.7 vs. 8.3 +/- 6.3, p < 0.058), days to enteral feedings (10.5 +/- 4.5 vs. 13.7 +/- 5.9, p < 0.092), and length of stay (21.7 +/- 9.9 vs. 28.7 +/- 19.6, p < 0.235), but there was a trend in the IOR group toward earlier extubation, toleration of enteral feeding, and discharge. Overall mortality rate was 14%. All of the IOR group survived There were 19% deaths in the OOR group.

CONCLUSION

Delivery and immediate surgical repair in the operating room appear to be safe and feasible. Delivery-operation interval was decreased. The repair was easier and increased the possibility of primary fascial closure. The patients ate sooner and were discharged earlier. A policy of making immediate surgical repair upon the delivery in the operating room leads to decreased morbidity in infants with gastroschisis. A well prepared team is an important factor for this policy.

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.

Outcomes of Pregnancies With Fetal Gastroschisis

OBJECTIVE

To describe pregnancy outcomes with fetal gastroschisis, including the associations of prenatal ultrasound findings with neonatal surgical complications and other morbidities.

METHODS

This was a review of pregnancies complicated by fetal gastroschisis and delivered from January 1998 through June 2006. The last ultrasonogram before delivery was reviewed to determine stomach dilatation, bowel dilatation, or abnormalities of amniotic fluid volume. Neonatal records were reviewed to determine type of closure and any bowel complications.

RESULTS

There were 66 pregnancies with gastroschisis, 1 per 2,000 deliveries. There were three stillbirths and three neonatal deaths. Delayed closure was necessary in 49% who underwent surgery. Birth weight below the third percentile, which occurred in 38%, was associated with need for delayed closure, 64% compared with 25% without growth restriction, P<.001, but was not associated with longer hospital stay or neonatal death. Fetal gastroschisis was diagnosed by prenatal ultrasonography in 58 cases. Bowel complications requiring surgery were more frequent when ultrasonography had demonstrated stomach dilatation (five cases), 60% compared with 10%, P=.002. Fetuses with defects so large that no normal ventral wall could be visualized ultrasonographically (three cases) were at increased risk for neonatal death, 100% compared with 0%, P<.001.

CONCLUSION

Ultrasound findings associated with adverse outcome in fetal gastroschisis included stomach dilatation and a defect so large that no normal ventral wall could be visualized. Fetal growth restriction was common, and such infants were more likely to require delayed gastroschisis closure. Despite more than 90% survival, morbidity with gastroschisis remains high.

LEVEL OF EVIDENCE

II.

[Prenatal care and postnatal outcome for fetuses with laparoschisis]

OBJECTIVES

To assess the relevance and the quality of gastroschisis's care in a mid level referral centre.

METHOD

A retrospective analysis was performed for infants diagnosed or born with gastroschisis between 1992 and 2003 at the Citadelle hospital, Department of Obstetrics and Gynaecology, University of Liège.

RESULTS

Twenty-four cases of gastroschisis were identified. For 22 of them (92%) antenatal sonographic diagnosis was performed at a mean gestational age of 23 weeks. Antenatal diagnosis did not allow to identify additional malformation or chromosomal anomaly. Postnatal diagnosis allows to identify 3 infants with minor cardiac anomalies without functional consequence and one X fragile syndrome. One pregnancy was electively terminated at 24 weeks and one late intrauterine death was reported at 35 weeks. Bowel atresia, stenosis or ischemia were present at birth for 8 cases (33%). Out of 24 cases 22 were live born. 10 infants out of 22 (45%) underwent uncomplicated primary surgical repair. Three infants out of 22 (14%) underwent delayed closure without complications. Nine infants out 22 (41%) underwent multiple surgery (2 to 6). In this group all had postnatal complications, some with multisystem complications, including 3 deaths, 6 with infectious complications, 5 with gastrointestinal complications and 2 with genitourinary or haematological complications. Hospital stay range from 19 to 378 days (median, 51 days). Length of stay and time to full enteral feeding were longer if oligohydramnios or sonographic signs of intestinal damage were found. Among infants born before 35 weeks, only those with intestinal damage at birth had length of stay or time to full enteral feeding longer. Out of 22 live born infants 19 survived (86%) after one year. Survival rate without handicap due to gastroschisis is 84%.

CONCLUSION

Sonographic examination is a valid method for prenatal diagnosis and surveillance. Our survival rate agrees with recent data in the literature. It has to be noticed that hospital stay is lengthy and complications are frequent. The most important prognostic factor is the condition of the bowel at birth and there is no antenatal means to predict severe damage.

Development and validation of a risk stratification index to predict death in gastroschisis

BACKGROUND

Gastroschisis is a rare congenital anomaly, the improved surgical management of which has contributed to a survival rate greater than 90%. Development of an accurate risk stratification system to help identify the subset of patients at greatest risk for death may lead to further improvements in outcome.

METHODS

Infants with gastroschisis were identified from 16 years of the National Inpatient Sample database and the Kids' Inpatient Database using the International Classification of Diseases, Ninth Revision, Clinical Modification procedure code 54.71 (repair of gastroschisis) and an age of less than 8 days. Logistic regression analysis determined which coexisting diagnoses were significantly associated with death. Odds ratios from the logistic regression model were simplified and used as weighting factors to create an additive index. The index was validated using the 2003 Kids' Inpatient Database data set.

RESULTS

Intestinal atresia, necrotizing enterocolitis, rare cardiac anomalies, and lung hypoplasia were strongly associated with death and used to create a scoring system with a potential range of 0 to 10. Every point increase on the scale of gastroschisis risk stratification index is associated with a 95% relative increase in the likelihood of death.

CONCLUSION

We have developed a novel index, which is superior to previous classification systems in identifying patients with gastroschisis who are at highest risk for death.

Outcome of gastroschisis: a 20-year case review of infants with gastroschisis born in Galveston, Texas

BACKGROUND/PURPOSE

In the past decade, the preferred method of closure of gastroschisis at our institution has been staged reduction using a silo with repair on an elective basis (SR) rather than primary surgical closure (PC). We performed a 20-year case review of infants with gastroschisis at a university hospital to compare these shifts in management and to determine factors affecting outcome.

METHODS

Seventy-two cases were reviewed from 1983 to 2003. Times to first and full feeds were outcome variables for statistical analysis.

RESULTS

The prevalence of gastroschisis increased from 0.03% to 0.1% since 1983. Patients had low birth weights (mean = 2294 g) and were borderline premature (mean = 35.8 weeks). Only 3% of the infants were African American. There was a high rate of cesarean deliveries (57%). Ten patients (15%) had gastroschisis complicated by liver herniation, intestinal atresia(s), and/or necrosis/perforation. Most patients were managed by SR (67%). Eight percent of the infants died, 9% developed necrotizing enterocolitis, and 50% had other gastrointestinal complications. Twenty-seven percent of the infants managed with SR did not need initial mechanical ventilation. However, the patients who underwent SR were ventilated longer after birth as compared with those who underwent PC (P < .08). Infants with a complicated gastroschisis had significantly longer times to first and full feeds (P < .001). Patients managed with SR took significantly longer to reach full feeds (P = .001), and there was a trend of starting feeds later (P = .06). When patients with a complicated gastroschisis were excluded, the differences between the SR and PC groups were even greater (P = .01; P < .001).

CONCLUSIONS

In our patient population, the prevalence of gastroschisis increased by more than 400% since 1983. The defect was rare in African-American infants. Management by SR was associated with longer ventilation times and longer times to first and full feeds for both uncomplicated and complicated gastroschisis cases.

Gastroschisis: ward reduction compared with traditional reduction under general anesthesia

BACKGROUND/PURPOSE

In gastroschisis it is proposed that gut reduction may be achieved without intubation or general anesthesia (GA) through ward reduction. The authors aimed to determine if ward reduction decreased morbidity and duration of treatment.

METHODS

Infants born from January 1, 1995, to December 31, 2001, with gastroschisis were managed with either reduction under GA in the operating theatre (OT group)--up to September 1999, or ward reduction (when eligible) in the neonatal unit without GA/ventilation (ward reduction [WR] group)--from September 1999.

RESULTS

Of the 37 infants, 31 were eligible for ward reduction-15 from the OT group, 16 from the WR group. All infants in the OT group had at least 1 episode of ventilation and 1 GA: 62% of infants in the WR group avoided ventilation (P = .0002) and 81% avoided GA (P < .0001). Infants who had ward reduction had significantly shorter durations of ventilation and oxygen therapy. Septicemia occurred in 31% of the WR group and 7% of the OT group (P = .17). Infants who had ward reduction left intensive care 16 days earlier (P = .02) and tended to reach full enteral feeds 8 days sooner (P = .06) and be discharged from hospital 15 days earlier (P = .05).

CONCLUSIONS

Infants who had ward reduction do better in terms of avoiding GA/ventilation, establishing feeds, and going home earlier. A randomized, controlled trial comparing the 2 approaches is feasible, safe, and worthwhile.

Perinatal management of gastroschisis: analysis of a newly established clinical pathway

PURPOSE

The authors developed a clinical pathway for optimal management after antenatal diagnosis of gastroschisis. This is the outcomes analysis of our first 30 consecutive patients.

METHOD

Antenatal counseling was provided for all families with in-utero diagnosis of gastroschisis. Bowel dilatation, thickness, motility, amniotic fluid volume, and fetal development were followed by ultrasonography every 4 weeks. Babies were delivered by cesarean section between 36 and 38 weeks gestation if the lungs were mature or earlier for bowel complications. Gastroschisis repair was scheduled 90 minutes after birth. Primary repair was attempted in all through the abdominal wall defect without an additional incision, resulting in an umbilicus with no abdominal scar.

RESULTS

Primary repair was achieved in 83%. Babies needed assisted ventilation for 3 days, reached full feeds by 19 days, and were discharged by 24 days (all medians). There were 3 (10%) deaths, all after staged repair.

CONCLUSIONS

Our new protocol of both scheduled elective cesarean section and early gastroschisis repair resulted in a higher proportion of primary repair, shorter duration of mechanical ventilation, earlier full feeds, and shorter length of stay. There was no increase in mortality or morbidity. The primary-repair babies had no mortality and had excellent cosmesis.

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.

The timing of delivery of infants with gastroschisis influences outcome

BACKGROUND

The delayed onset of intestinal function in children with gastroschisis may be because of the injurious effects of amniotic fluid on the exposed bowel. This has led to consideration of early delivery to minimize intestinal damage and improve outcome, although this has not been carefully evaluated. The authors hypothesized that timing of delivery influences outcome in children with gastroschisis, and sought to evaluate the relative impact of factors that predict outcome in this disease.

METHODS

All consecutive patients with gastroschisis (1992-2002) were divided into those delivered before ("early") or after ("late") 36 weeks. Bowel peel was described as "thin" or "thick," based on operative reports. Individual measures were analyzed by univariate analyses (chi2 /Student's t test), and logistic regression was used to identify significant factors for the length of stay (LOS) longer than the population average of 55 days.

RESULTS

In 75 patients, 53.4% were "early" and 46.6% were "late." Groups were similar with respect to maternal age, birth weight, delivery mode, sex, and associated anomalies. Thickness of bowel peel was not affected by delivery time, yet "early" patients had significantly longer LOS and time to enteral feeds. Significant predictors of LOS more than 55 days included gestational age of 36 weeks or younger, time to enteral feeds of more than 26 days, and associated anomalies. Nonsignificant predictors included size of the defect, thickness of bowel peel, and need for silo.

CONCLUSIONS

Delivery before 36 weeks is associated with longer hospitalization and increased tune to attainment of full feeds compared with later delivery. Fetal well-being should thus be the primary determinant of delivery for gastroschisis, as opposed to considerations regarding possible injurious effects to the bowel of prolonged gestation.

Gastroschisis, low maternal age, and fetal morbidity outcomes

OBJECTIVE

To determine if the risk for fetal growth inhibition among gastroschisis-afflicted fetuses is heightened among younger gravidas (teen mothers).

METHOD

This was a retrospective cohort study on live-born infants with isolated gastroschisis delivered in New York State from 1983 through 1999. We compared infants of mature (>20 years) mothers with those of younger (<20 years) mothers with respect to the following indices of fetal morbidity outcomes: low birth weight and very low birth weight, preterm and very pre-term, and small for gestational age. We used adjusted odds ratios to approximate relative risks.

RESULTS

A total of 368 infants with isolated gastroschisis were analyzed. The two groups differed in terms of mean gestational age at delivery [Mean + standard deviation(SD) for infants with gastroschisis born to mature mothers = 37.2 weeks +/- 2.8 versus 36.3 weeks + 3.6 for those of teenage mothers(p = 0.01)], as well as mean birth weight [mean birth weight +/- SD for infants with gastroschisis born to mature mothers = 2562.4 grams +548.8 versus 2367.9 grams +/- 645.2 for those of younger mothers (p = 0.004)]. Infants of teen mothers were about twice as likely to be of low birth weight (OR = 1.70; 95% CI = 1.05-2.77) and about three times as likely to be born very preterm when compared to those of mature mothers (OR = 2.80; 95% Cl = 1.02-8.00). No significant differences were observed with respect to very low birth weight, pre-term and small for gestational age.

CONCLUSION

Low maternal age appears to be a risk factor for low birth weight and very preterm birth among gastroschisis-affected fetuses. This information is potentially useful for planning by care providers and in counseling affected parents.

Mode of Delivery and Neonatal Survival of Infants With Isolated Gastroschisis

OBJECTIVE

We sought to compare neonatal survival of infants with gastroschisis by mode of delivery.

METHODS

We conducted a retrospective cohort study on infants with gastroschisis who were delivered in New York State from 1983 through 1999. We compared neonatal mortality between infants born vaginally and those delivered by cesarean using adjusted hazard ratios derived from Cox proportional hazards regression models.

RESULTS

A total of 354 infants were found to have isolated gastroschisis. Of these, 174 were delivered vaginally, whereas 180 were delivered by cesarean. Neonatal mortality was registered among 18 infants (5.1%); 12 (6.9%) in the vaginal and 6 (3.3%) in the cesarean group. After controlling for potential confounders, the risk for neonatal demise was similar in both the vaginal and cesarean subcohorts (adjusted hazard ratio 0.84, 95% confidence interval [CI] 0.29-2.43). Preterm birth was the morbidity pathway that explained the early demise of infants with gastroschisis, irrespective of mode of delivery (adjusted hazard ratio 3.4, 95% CI 1.10-10.4) whereas small for gestational age did not predict mortality (adjusted hazard ratio 1.04, 95% CI 0.13-8.14).

CONCLUSION

In this study the mode of delivery was not found to be associated with neonatal survival of infants with gastroschisis. Preterm birth rather than small for gestational age was the predictor of neonatal death among gastroschisis infants.

LEVEL OF EVIDENCE

III

The significance of intrauterine growth restriction is different from prematurity for the outcome of infants with gastroschisis

BACKGROUND/PURPOSE

Recent reviews of gastroschisis identify prematurity and low birth weight as predictors of morbidity and mortality. The authors compared the outcomes of intrauterine growth-restricted infants (IUGR) with gastroschisis to those without growth restriction because IUGR is different from prematurity.

METHODS

A retrospective analysis was performed for infants born with gastroschisis between 1990 and 2000 at 2 pediatric hospitals. Patients were segregated into 3 groups based on birth weight corrected for gestational age: group 1 (IUGR, <fifth percentile), group 2 (fifth to 25th percentile), and group 3 (>25th percentile). Patient demographics, method of closure, number of surgeries, presence of atresia, and time to full enteral feedings (FPO days) were assessed. Mortality rate, length of stay (LOS), and readmission rates were also compared. Analysis of variance (ANOVA)/Student's t test and Fisher's. Exact tests were used for statistical analysis (P <.05 significant). Regression analysis was also performed.

RESULTS

One hundred thirteen patients were included (group 1 = 17; group 2 = 43; group 3 = 53). Overall, infants with IUGR had similar outcomes to non-IUGR infants, including FPO and total parenteral nutrition (TPN) days, LOS, readmission, and mortality rates. The method of closure did not affect outcome. Infants with atresia had significantly increased times to full feeding (95 v 34 days; P =.034), more surgeries (2.7 v 1.4; P =.002), and longer LOS (106 v 48 days; P =.011). Infants born at less than 37 weeks' gestation had significantly increased fasting (NPO) days (28 v 18 days; P =.005) and longer LOS (65 v 37 days; P =.006) when compared with infants born at greater than 37 weeks. Logistic regression analysis identified the presence of atresia as an independent risk factor for gastrointestinal dysfunction and the need for prolonged TPN. Prematurity also adversely affected these same parameters, although it did not reach statistical significance.

CONCLUSIONS

Although infants with gastroschisis are generally small for gestational age, the outcomes of growth-restricted infants are similar to those of other infants. The type of closure does not affect outcome, regardless of birth weight. The presence of atresia or prematurity does lead to longer times for full feeding and LOS. Therefore, routine premature delivery of infants with gastroschisis should not be advocated, even in the context of IUGR.

Intrauterine repair of gastroschisis in fetal rabbits

OBJECTIVE

Infants with gastroschisis (GS) still face severe morbidity. Prenatal closure may prevent gastrointestinal organ damage, but intrauterine GS repair (GSR) has not been established yet.

METHODS

In New Zealand White rabbits we developed and compared GS versus GSR: creation of GS was achieved by hysterotomy, right-sided laparotomy of the fetus and pressure on the abdominal wall to provoke evisceration. GSR was accomplished by careful reposition of eviscerated organs and a running suture of the fetal abdominal wall. For study purposes, 18 animals were divided equally into 3 groups: GS, GS with GSR after 2 h, and unmanipulated controls (C). Vitality was assessed by echocardiography. After 5 h all animals were sacrificed.

RESULTS

GSR inflicted no increased mortality, because all fetuses survived GS or GS with GSR. All fetuses with GS demonstrated significant evisceration of abdominal organs. In contrast, the abdominal wall of the fetuses from GSR was intact.

CONCLUSION

The present animal model demonstrated the technical feasibility and success of an intrauterine repair of GS for the first time. However, further long-term studies (leaving GS and GSR in utero for several days) will be necessary to compare survival rates and intestinal injury, motility or absorption. The clinical application of GSR in utero remains a vision so far.

Gastroschisis: A sixteen-year review

PURPOSE

The aim of this study was to examine the incidence of gastroschisis in Saskatchewan over a 16-year period and identify risk factors associated with mortality.

METHODS

Information was obtained by retrospective review of all infant charts at the only 2 provincial neonatal intensive care centers from January 1985 through December 2000. Factors recorded were gestational age, birth weight, gender, Apgar score, time to operation, method of closure, time to attain full feedings, presence of sepsis, and length of hospital stay. Live birth data for the province was obtained, and the incidence per 10,000 live births for 3 time intervals was calculated. Analysis was performed with mortality as the dependent variable.

RESULTS

Seventy-one infants were identified. Overall survival rate was 93% (66 of 71). During the 3 time intervals examined, the incidence of gastroschisis per 10,000 live births increased from 1.85 in 1985 to 1990 to 3.66 in 1991 to 1995 to 4.06 in 1996 to 2000. The analysis found that intestinal atresia P =.009, OR = 18.3 (95%CI: 2.457-136) and intestinal necrosis P =.050, OR = 10.33 (95%CI: 1.32-80.68) were significantly associated with mortality.

CONCLUSIONS

The incidence of gastroschisis is increasing. Intestinal atresia and the development of intestinal necrosis were associated with poor outcome. Patients who had these complications all had short bowel, and full feedings could not be established. They required continuation of total parenteral nutrition and experienced episodes of sepsis.

Gastroschisis: small hole, big cost

BACKGROUND/PURPOSE

This study was designed to assess the outcome and financial costs incurred for the treatment of gastroschisis.

METHODS

A retrospective analysis was conducted of all patients with gastroschisis at a single institution over the past decade (n = 69). Hospital costs were determined and standardized to December 2001 dollars.

RESULTS

Of the 69 patients, average gestational age at delivery was 35.9 weeks. Thirty-six patients had a primary fascial closure; 33 had a silo placed. The mean time to first feeding was 22 days and full feeding, 33 days. Average length of stay was 47 days. There were 3 deaths (2 shortly after birth, and one 131 days later owing to sepsis). The average cost of hospitalization and physician fees for patients with gastroschisis was $123,200. Using multivariate regression analysis, significant variables (P <.05) associated with cost of hospitalization were number of operative procedures, ventilatory days, male gender, and length of stay. Room expenses (43%), physician fees (15%), respiratory and pulmonary care (10%), and supply and devices (10%) made up the majority of costs.

CONCLUSIONS

Cost of care associated with treatment for gastroschisis is high. Strategies designed to reduce cost must limit gastrointestinal, respiratory, and operative complications and reduce length of stay.

[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.

Elective delayed midgut reduction-No anesthesia for gastroschisis: Selection and conversion criteria

BACKGROUND/PURPOSE

In 1998 Bianchi and Dickson published their proposal for elective delayed midgut reduction without anaesthesia (EDMR-No GA). The study has been prospectively extended to develop "selection and conversion criteria" to ensure safe application of the technique.

METHODS

In a prospective study from 1993 to date, EDMR-No GA was considered as first-line postnatal management in 35 children. The protocol and technique were those described by Bianchi and Dickson in 1998.

RESULTS

EDMR-No GA was completed successfully in 25 children, of whom, 23 are normal with an aesthetic, scarless abdomen. Two children had bowel necrosis and died of short bowel state. A trial EDMR-No GA was converted to a staged silo reduction in 2 children who are both alive and well. EDMR-No GA was considered contraindicated in 8. Five had an elective, staged silo reduction, 2 had EDMR under anesthesia, and one 27-week-gestation baby died of severe hypothermia and acidosis before any procedure.

CONCLUSIONS

No single technique is applicable in all circumstances, and "selection and conversion criteria" are relevant to safe EDMR-No GA. These include poor general condition, significant vital organ anomaly, bowel-to-abdomen disproportion and "at risk" bowel circulation. The development of distress and progressive metabolic acidosis during and after EDMR-No GA, are indications for urgent conversion to avoid serious bowel injury. Experience with EDMR-No GA hones the surgeon's sensitivity in assessing abdominal.

The outcome and analysis of 40 cases of fetal gastroschisis

OBJECTIVES

This collaborative retrospective study was undertaken at Royal Medical Services Hospital, Amman, Jordan, between 1993 through to 2000. Its purpose was to assess the difference in terms of morbidity and mortality in neonates with gastroschisis delivered by cesarean section versus vaginal delivery.

METHODS

The records of all neonates born with gastroschisis (n=40, 26 females, 14 males) from 1993-2000 were analyzed. The mode of delivery was noted. Those babies delivered by cesarean section (n=22) were labelled group one, while those delivered vaginally (n=18) were labelled group 2. The mean maternal age was 26.45 +/- 5.97 and 28.30 +/- 4.22 years for groups one and 2 (P<0.05). Statistical analysis was carried out using standard deviation (SD), Fisher's exact test and Mann-Whitney U test.

RESULTS

The mean gestational age at diagnosis was 17.59 +/- 1.58 for group one, and 17.95 +/- 1.44 weeks for group 2 (P>0.05). The mean gestational age at cesarean section was 36.04 +/- 1.02, and for vaginal delivery, 38.40 +/- 1.10 (P>0.05). The mean maternal age was 26.45 +/- 5.97 for group one, and 28.30 +/- 4.22 years for group 2 (P<0.05). The mean birth weight was 2.39 +/- 0.39 kg for group one, and 3.10 +/- 0.20 for group 2 (P<0.05). Surgical repair was immediate after delivery and the mean neonatal age was 41.04 +/- 6.40 minutes for both groups. The mean days of stay at hospital were 24.26 +/- 8.75 for group one, and 34.20 +/- 7.30 days for group 2 (P<0.05).

CONCLUSION

Our study demonstrated that complications and morbidity were less in the cesarean section group compared to the vaginal delivery group. Immediate surgery for the neonate, in either group, was performed either by primary or secondary closure. However, a large multicenter, prospective randomised study is needed to ascertain the suitable route for delivery in gastroschisis fetuses.

Gastroschisis: a 15-year, single-center experience

70 cases of gastroschisis (GS) were surgically treated at the Pediatric Surgical University Clinic, Münster, from 1984 through 1998. The defect occurred more frequently in males (44) than females (26). The average birth weight was 2,383 g and mean gestational age 36.8 weeks. 9 infants (12.9%) were delivered vaginally and the rest (87.1%) by cesarean section; 34 of the 61 (55.7%) cesarean sections were done solely for prenatal ultrasonic identification of the abdominal-wall defect. 10 infants (14.3%) underwent primary closure; in 19 (27.1%) primary closure of the skin was possible, however, a single solvent-dried dura (SDD) graft was required for fascial enlargement. The remaining 41 infants (58.6%) had extensive defects and required two grafts for optimal closure. 22 patients (31.4%) had associated anomalies, the most common being bowel atresias and undescended testis. 14 (20%) required secondary laparotomies because of bowel-associated complications and 1 (1.4%) for a urinary-bladder perforation. 11 patients (15.7%) had non-bowel-associated complications. The average postoperative tracheal intubation time was 3.9 days and the average hospital stay was 75.6 days. The overall mortality was 2.8%. No major complications associated with SDD implants were encountered; only 4 patients (5.7%) had minor complications such as local inflamation and infection and were managed conservatively. The present data support the employment of SDD implants as acceptable biomaterial for the repair of large GS defects.

Is unexplained third trimester intrauterine death of fetuses with gastroschisis caused by umbilical cord compression due to acute extra-abdominal bowel dilatation?

We report on a case of gastroschisis in which sudden dilatation of extra-abdominal bowel at 34+1 weeks was followed by an unusual umbilical flow velocity waveform (diastolic notching). The condition was associated with normal umbilical Doppler indices, brain sparing effect and a non-reactive cardiotocograph (CTG). Findings at postnatal surgery strongly suggested severe cord compression by the herniated dilated bowel. The significance of notching in the umbilical artery waveform is discussed, as is the potential importance of this sign in the prepartum management of fetuses with gastroschisis.

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.

Patterns of first-year survival among infants with selected congenital anomalies in Texas, 1995-1997

BACKGROUND

Few registry-based studies have investigated survival among infants with congenital anomalies. We conducted a registry-based study to examine patterns and probability of survival during the first year of life among infants with selected congenital anomalies.

METHODS

Data from the Texas Birth Defects Monitoring Division were merged with linked birth-infant death files for 2,774 infants born January 1, 1995 to December 31, 1997, with at least 1 of 23 common anomalies. Deaths before the first birthday were assessed from infant death files. Kaplan-Meier was used to estimate first-year survival; first-year survival was assessed for specific anomalies and by the number of life-threatening anomalies.

RESULTS

Overall, 80.8% of infants with these 23 anomalies survived the first year of life. We observed the highest survival rates for infants with gastroschisis (92.9%, 95% CI = 86.8, 96.3), trisomy 21 (92.3%, 95% CI = 89.5, 94.4) or cleft lip with or without cleft palate (87.6%, 95% CI = 84.0, 90.5). Infants with intermediate survival rates included those with microcephaly (79.7%; 95% CI = 73.6, 84.6), tetralogy of Fallot (75.0%; 95% CI = 65.5, 82.2), or with diaphragmatic hernia (72.8%; 95% CI = 61.8, 81.2). As expected, all infants with anencephaly and almost all infants with trisomy 13 or trisomy 18 died during the first year of life. First-year survival declined as the number of co-occurring life-threatening anomalies increased.

CONCLUSIONS

Overall, first-year survival for infants with congenital anomalies was high. Additional population-based studies are needed to quantify improvements in first-year survival.