Initial nonoperative management and delayed closure for treatment of giant omphaloceles

Abstract

Purpose Traditional treatment of giant omphaloceles with silo closure has been associated with respiratory insufficiency, hemodynamic compromise, dehiscence, and inability to close the abdomen with subsequent death. To minimize such complications, initial nonoperative management with delayed closure of the defect has been used. Methods Between January 1981 and December 2002, 111 patients with omphaloceles were treated. Twenty-two patients with giant omphaloceles (19 containing liver) underwent initial nonoperative management consisting of silver sulfadiazine dressing changes. After pulmonary and other comorbidities stabilized, the contents were gradually reduced with a loose elastic bandage, and delayed closure was planned at 6 to 12 months. The medical records of these 22 patients were retrospectively reviewed to determine the efficacy and safety of this technique in the setting of severe associated anomalies. Those 15 patients (n = 15) from the latter 10 years were further reviewed to determine additional end points (length of hospital stay, length of intensive care unit stay, duration of mechanical ventilation, time to feed, time to closure, and type of closure). Results Of the 15 patients treated during the latter 10 years, mean gestational age and birth weight were 38 ± 1.4 weeks and 3.1 ± 0.57 kg, respectively. Median length of stay after birth was 20 days (range, 5-239 days). Median time to full diet was 8 days (range, 4-80 days). Four patients were discharged on oral feedings only, 7 with combination oral/gavage, and 4 with tube feedings. Pulmonary hypoplasia or pulmonary hypertension was present in 11 (50%) of 22 patients. There were 11 patients with major cardiac anomalies, 14 with a patent ductus arteriosus, and 8 with a patent foramen ovale. Three early complications (2 ruptured sacs and 1 bleeding sac) and 1 late complication (gastric necrosis) occurred in the initial nonoperative period. In addition, 4 patients were treated for line sepsis, 1 patient for acute renal insufficiency, and 1 for aspiration pneumonia. Three patients required tracheostomy and were discharged with home ventilators. There were no complications associated with the use of silver sulfadiazine. Of the 22 patients, 16 have undergone delayed repair, 2 did not require repair, 1 is awaiting repair, 2 died before closure, and 1 was lost to follow-up. Delayed closure was achieved at a median age of 14 months (range, 2-28 months) and mean weight of 8.8 ± 3.3 kg. Four patients required implantation of mesh for definitive closure. Median postoperative length of stay was 4 days (range, 2-21 days). Postoperative complications included prolonged ileus, recurrent ventral hernia, and prolonged intubation. Overall mortality rate was 9.1%. One death occurred after diaphragmatic hernia repair, and 1 death was from overwhelming sepsis in the patient with a late gastric perforation. Conclusion The use of silver sulfadiazine dressing changes for initial nonoperative management of giant omphaloceles is a safe and effective bridge to delayed closure. We recommend this method as initial nonoperative management given the high incidence of associated cardiopulmonary malformations because it may facilitate enteral feeding, minimize respiratory compromise, and reduce morbidity and mortality.