CONGENITAL DEFECTS OF ANTERIOR ABDOMINAL WALL IN NEWBORNS: TRADITIONS AND NEW TENDENCIES

Abstract

Introduction. The problem of treatment of newborns with congenital malformations of the anterior abdominal wallremains relevant due to the increasing number of malformations such as gastroschisis and omphalocele in newborns as wellas high complications and mortality.The aim of this work is to improve the effectiveness of treatment of newborns suffering from gastroschisis andomphalocele by optimizing pre-, intra- and postoperative management of patients.Material and research methods. The results of examination and treatment of 55 newborns with gastroschisis and 22 newbornswith omphalocele were analyzed for the period from 1993 to 2021. Examination algorithm included: antenatal counseling ofpregnant women, postnatal consultation and transportation of the newborn to the institution where the defect correction, clinical,laboratory and instrumental examination, bacteriological examinations, histological examination of surgical material, measurementof intra-abdominal pressure will be performed to determine adequate surgical correction of the malformation.Results and discussion. Studies in infants suffering from gastroschisis and omphalocele and viscero-abdominaldisproportion have shown an increase in the intra-abdominal pressure at all stages of correction, which significantly affectedthe mechanical properties of the lungs and manifested a decrease in lung distension, increased airway resistance andincreased inspiratory pressure. During surgical correction of viscero-abdominal disproportion at all stages of the study, themechanical properties of the newborn's lungs changed (compliance decreased, airway resistance increased), being directlydependent on the level of intra-abdominal pressure, as evidenced by the main groups of patients suffering from omphalocele.The maximum change in the mechanical properties of the lungs was observed at 24-48 hours after correction of visceroabdominal disproportion and coincided with the maximum figures for the increase in intra-abdominal pressure in newborns.Adequate lung ventilation under conditions of maximum increase in intra-abdominal pressure in newborns was achievedby increasing PIP to high numbers (up to 20-22 cm of water column) at 24-48 hours after correction of viscero-abdominaldisproportion with a gradual moderate decrease and retention of PEEP within the limits of 4-5 cm of water column.In the main groups of patients suffering from gastroschisis and omphalocele, normalization of disturbance of themechanical properties of the lungs (compliance and resistance) was faster than in the comparison groups. This was due to thefact that the level of intra-abdominal hypertension was taken into account when choosing the method of surgical correctionand infusion therapy in the mode of normovolemic hemodilution. In the study of peripheral hemodynamics (abdominal bloodflow) it was found that in the comparison groups in patients suffering from gastroschisis and omphalocele, higher indicesof resistance in the superior mesenteric and renal arteries, indicating impaired blood flow in the above vessels. In the main groups of patients suffering from gastroschisis and omphalocele, these indicators were significantly lower, which indicatesa better abdominal blood flow in patients in whom the choice of surgical correction method was taken into account whenchoosing the method of surgical correction.Intra-abdominal hypertension is one of the important reasons for the development of negative consequences when closingthe malformation of the anterior abdominal wall in newborns suffering from gastroschisis and omphalocele. Therefore,one of the main directions of improving the results of treatment of newborns with congenital malformation of the anteriorabdominal wall is the development and introduction of new methods for diagnosis of intraabdominal hypertension in practicalneonatal surgery and taking measures to prevent abdominal compartment syndrome.Depending on the condition of the child and the type of congenital malformation of the anterior abdominal wall, thetreatment tactics foresaw the following three options:1. Primary radical operation.2. Stage-by-stage surgical treatment.3. Conservative treatment followed by surgery.While analyzing the results of the study, it can be noted that a total of 26 newborns died of congenital defects of theanterior abdominal wall after surgery, including 18 children from the comparison group (1993-2004) and 8 from the mainstudy group (2005-2021), which amounted to 52,94% and 18,60% respectively. The main causes of death were neonatalsepsis, profound prematurity and severe comorbidities.Conclusions:1. Taking into account the results of treatment of newborns suffering from gastroschisis and omphalocele, it can bestated that the reduction of mortality in newborns by 3 times is primarily due to the introduction of neonatal surgery innew approaches to diagnosis, pre- and postoperative management, anesthesia and individualized surgical correction of thispathology.2. Intra-abdominal hypertension in case of congenital malformations of the anterior abdominal wall leads to a significantdeterioration of the mechanical properties of the lungs, hemodynamic disorders, oliguria, intestinal ischemia, decreasedorgan perfusion.3. Increased intra-abdominal hypertension was an indication for a change in surgical tactics - the abandonment of radicalplastic surgery of the abdominal wall and the transition to staged intervention or the use of surgical techniques that increasethe volume of the abdominal cavity.