Outcomes of Abdominal Wall Closure in Babies With Gastroschisis: Does Plastic Closure Measure Up?

Abstract

Introduction: Gastroschisis is a congenital abdominal wall defect in which the viscera develop outside the abdominal cavity. Exposure to amniotic fluid, intestinal edema and obstruction result in long-term morbidities including dysmotility and atresias. After reduction of abdominal contents, closure involves either a traditional suture closure (SC) of the fascia or a “sutureless” plastic closure (PC). The advantages of plastic closure are rapid coverage, limited utilization of resources, and avoidance of abdominal compartment syndrome. We compared outcomes of SC and PC in gastroschisis babies, with and without Silo. Methods: With IRB approval, we completed a retrospective case control study of 80 gastroschisis babies treated from 2000-2009. There were 31 silos placed; 52 babies underwent PC and 28 SC. Outcomes were defined as: days on the ventilator, days to start enteral feeds, days to reach goal enteral feeds, days on TPN, complications, length of stay, hospital charges, and mortality. Using SAS 9.2, multivariate analyses were performed to achieve statistical control for this retrospective study. Results: There were two mortalities and three failed closures. The mean length of follow up was 11.4 months. Mean gestational age was 36 weeks, mean birth weight was 2393 grams, and mean APGAR score at 1 minute was 6. Multivariate analysis has shown that babies treated with PC spent 3.9 fewer days on the ventilator than those undergoing SC (p=<0.01). PC achieved similar results to SC when comparing days to start enteral feeds, days to reach goal enteral feeds, days on total parenteral nutrition, length of stay, complications, hospital charges, and mortality. Ventral hernias (VH) were noted in 46 of the 80 patients, 32/52 after PC (OR= 2.20, CI= 0.69-7.04). VH repair was required in 16 babies, 11 after PC (OR= 1.089; CI= 0.69-4.27). Of the 31 babies initially treated with a Silo, 15 underwent PC and 16 SC. PC babies required 8.59 fewer days to start enteral feeds (p=<0.0001). In the Silo subset, there were no other differences between the two treatment groups. Conclusions: PC is a safe and effective method to treat gastroschisis, either as a primary procedure or following Silo placement. The incidence of VH and other complications are not statistically different after PC or SC. In multivariate analysis, PC was associated with fewer ventilator days, thereby reducing the risk of barotrauma, ventilator associated pneumonia or tracheal stenosis. Novel to this study is the successful application of PC following Silo placement. Additionally, Silo patients treated with PC may be able to start enteral feeds earlier. In many babies, PC following Silo may be performed without mechanical ventilation, general anesthesia, or an operating room. This could markedly lessen the utilization of valuable resources. In developing countries, where gastroschisis might go untreated and mortality can approach a staggering 43%, Silo followed by PC has the potential to improve survival and reduce morbidity.