Outcome In Gastroschisis Research Articles

The association of perinatal and clinical factors with outcomes in infants with gastroschisis\u2014a retrospective multicenter study in Finland

The aim of the present study was to assess the prognostic factors for the outcome of gastroschisis in Finland. A retrospective multicenter study of gastroschisis patients born between 1993 and 2015 in four Finnish university hospitals was undertaken, collecting perinatal, surgical, and clinical data of neonates for uni- and multifactorial modeling analysis. The aim of the present study was to identify risk factors for mortality and the composite adverse outcome (death and/or short bowel syndrome or hospital stay > 60 days). Of the 154 infants with gastroschisis, the overall survival rate was 90.9%. In Cox regression analysis, independent risk factors for mortality included liver herniation, pulmonary hypoplasia, relaparotomy for perforation or necrosis, abdominal compartment syndrome, and central line sepsis. Furthermore, a logistic regression analysis identified central line sepsis, abdominal compartment syndrome, complex gastroschisis, and a younger gestational age as independent predictors of the composite adverse outcome.Conclusion: The risk of death is increased in newborns with gastroschisis who have liver herniation, pulmonary hypoplasia, abdominal compartment syndrome, relaparotomy for perforation or necrosis, or central line–associated sepsis. Special care should be taken to minimize the risk of central line sepsis in the clinical setting.What is known:• Gastroschisis is a relatively rare congenital anomaly of the abdominal wall and its incidence is increasing.• Complex gastroschisis has been reported to increase risk of mortality and complications.What is new:• Central line sepsis was found to be independently associated with mortality in gastroschisis patients.• Liver herniation was also significantly associated with mortality.

Does Use of a Feeding Protocol Change Outcomes in Gastroschisis? A Report from the Midwest Pediatric Surgery Consortium.

Gastroschisis feeding practices vary. Standardized neonatal feeding protocols have been demonstrated to improve nutritional outcomes. We report outcomes of infants with gastroschisis that were fed with and without a protocol. A retrospective study of neonates with uncomplicated gastroschisis at 11 children's hospitals from 2013 to 2016 was performed.Outcomes of infants fed via institutional-specific protocols were compared with those fed without a protocol. Subgroup analyses of protocol use with immediate versus delayed closure and with sutured versus sutureless closure were conducted. Among 315 neonates, protocol-based feeding was utilized in 204 (65%) while no feeding protocol was used in 111 (35%). There were less surgical site infections (SSI) in those fed with a protocol (7 vs. 16%, p = 0.019). There were no differences in TPN duration, time to initial oral intake, time to goal feeds, ventilator use, peripherally inserted central catheter line deep venous thromboses, or length of stay. Of those fed via protocol, less SSIs occurred in those who underwent sutured closure (9 vs. 19%, p = 0.026). Further analyses based on closure timing or closure method did not demonstrate any significant differences. Across this multi-institutional cohort of infants with uncomplicated gastroschisis, there were more SSIs in those fed without an institutional-based feeding protocol but no differences in other outcomes.

It Is Complex: Predicting Gastroschisis Outcomes Using Prenatal Imaging

BackgroundGastroschisis occurs in one of 2000 births with survival rates partially contingent on intestinal complications and time to establishing feeding. Enhancements in prenatal imaging have given better insight into postnatal outcomes. The goal of this study was to examine the gastroschisis patient population at a single children's hospital in the modern era and to use prenatal ultrasound (US) to develop new prenatal prognostic indicators. MethodsWe performed a retrospective review of gastroschisis patients at a quaternary-care referral children's hospital from 2010 through 2018. We recorded demographics, prenatal data and imaging, early postnatal data, operative data, and patient outcomes. We compared patients within our cohort born with complex gastroschisis (bowel atresia/perforation) to uncomplicated gastroschisis patients. Second trimester and third trimester prenatal US were evaluated for changes in amniotic fluid level, amount of external bowel, bowel dilatation, and bowel wall edema to identify prognostic indicators of the status of the bowel at birth. For categorical variables, chi-square tests were used to assess for significance. Univariate and multivariable analyses were used to assess significance between categorical and continuous variables using medians and interquartile ranges or means. ResultsA total of 134 patients were included in the study: complex (n = 24), uncomplicated (n = 110). Compared with uncomplicated gastroschisis, complex patients required longer median days to feeding initiation (44 versus 10; P < 0.001), full feeding (80 versus 23; P < 0.001), length of stay (83 versus 33; P < 0.001), and total parenteral nutrition at discharge (P = 0.004). Full US data were available on 81% of patients, and partial data were identified on 19%. Prenatal US analysis showed significantly more complex patients had polyhydramnios on third trimester US (23.5%-4.3%; P = 0.018). US analysis showed these additional factors to be most associated with complex gastroschisis: large amount of external bowel on third trimester US, increase in bowel edema on third trimester US, and increase in external bowel dilation on third trimester US. Multivariable logistic regression analyses revealed amniotic fluid on third trimester US to be the most significant predictor of complex gastroschisis (P = 0.01). Polyhydramnios in combination with two-thirds of the other US factors had both sensitivity and positive predictive value for predicting complex gastroschisis of 75%. Patients with two or less of these positive US factors had high specificity (96.8%) and negative predictive value (87.5%), suggesting uncomplicated disease. There were no differences in perioperative or long-term complications in the complex group when compared with the group with uncomplicated gastroschisis. ConclusionsPolyhydramnios on third trimester prenatal US on babies with gastroschisis can predict complex gastroschisis at birth, whereas the absence of markers on prenatal US can suggest uncomplicated disease. Complex gastroschisis is associated with increased time to feeds and length of stay.

Long-term core outcomes of patients with simple gastroschisis

PurposeTo report the long-term core outcome set of patients with simple gastroschisis. MethodsThis was a retrospective chart review of all patients with simple gastroschisis managed at our hospital between August 2008 and July 2016. We collected all data included in the core outcome set developed for the standardization of gastroschisis outcomes reporting. We conducted a phone survey of the patients' parents using the PedsQL™ Pediatric Quality of Life Inventory, Cognitive Functioning Scale, and Gastrointestinal Symptoms Scale (GSS). Additionally, parents reported their subjective evaluation of the patients' cosmetic result and overall quality of life. ResultsThere were 124 patients included in the study. The majority (76.5%) was born prematurely at a median gestational age of 36 (range 27.6–38) weeks. At neonatal discharge (median 36 days [18–150] days) most patients were below the 10th percentile for height (81.4%) and weight (87%). Their growth, however, normalized during early childhood. Seven patients (5.6%) required at some point an operation for acute abdominal complications. One-third of patients required long-term treatment for constipation and one-third of patients required long-term treatment for gastroesophageal reflux disease (GERD). Thirty-five parents participated in the phone survey. Mean parent-reported quality of life score was better than healthy controls (87.5% vs. 82.3%, p = 0.049). Cognitive functions and gastrointestinal symptoms scores were similar to healthy controls. All patients are alive. ConclusionGrowth restriction in patients with simple gastroschisis is common at birth and during the neonatal period, but it improves during the first three years of life. Abdominal operations are rarely needed in patients with simple gastroschisis. GERD and constipation, on the other hand, are common and often require long-term medical management. The overall parent-reported quality of life of patients with simple gastroschisis is excellent. Level of evidenceLevel II.

Giant gastroschisis with complete gastric herniation: A case report and review of the literature

Introduction: We report a case of gastroschisis seen in our center, highlighting the rarity of this clinical entity. The author equally reviewed the existing literature covering the epidemiology, etiopathogenesis, management options, and outcomes of gastroschisis in low-income countries in sub-Saharan Africa and compares the reports with middle-income and high-income countries across the world. Case presentation: A preterm female neonate with a clinical diagnosis of gastroschisis at a primary care center was referred to the Neonatology Service of our tertiary care institution. She received optimal resuscitation and interdisciplinary management. Besides, the baby underwent an initial covering with an improvised silo bag of exposed bowel with unfavorable outcomes. Conclusion: The specific etiological factors for gastroschisis are yet to be established. The condition is considered a multifactorial disease. More frequently than ever, it's becoming easy to make prenatal diagnosis utilizing ultrasonography with high yield. Gastroschisis is a low-prevalence disease with an excellent prognosis if initial management is adequate. Interestingly, the condition requires highly skilled personnel of both specialized and primary care. Once the clinicians are well equipped, they can readily ensure correct initial management. Besides, the patient can equally benefit from an appropriate and timely referral to tertiary care centers to avoid future complications.

Epidemiology and outcomes of gastroschisis in Tasmania.

To describe the epidemiology and outcomes of gastroschisis in Tasmania. A retrospective analysis of all pregnancies complicated by gastroschisis in Tasmania from 1996 to 2015 was undertaken (epidemiology cohort), and the presentation, surgical management and outcomes (surgery cohort) were reviewed for the period between September 1990 and July 2015. Gastroschisis was detected in 58 pregnancies during the 20-year epidemiology cohort period, giving an incidence of 4.4 per 10 000 live births for the 20-year period. Two of the four stillbirths occurred after 36 weeks' gestation. Of the 65 babies with gastroschisis treated at the Royal Hobart Hospital, 51 had a staged surgical repair (silo in 47, stoma formation in 4), and 14 had a primary closure. Staged repair was associated with a significantly longer duration of ventilation and stay in the neonatal intensive care unit. There were six post-natal deaths, all born in the first epoch. Death was significantly associated with the condition of the intestine at delivery (P = 0.02). There were no deaths in babies with simple gastroschisis. Complex gastroschisis was significantly associated with longer duration of total parenteral nutrition (P = 0.0002) and longer stay in hospital (P = 0.03). The incidence of gastroschisis in Tasmania is similar to that reported in other Australian regions and has not increased over the 20-year period of study. The high risk of stillbirth, and the significant association between mortality and the condition of the intestine at birth necessitates close fetal surveillance. Complex gastroschisis imposes a significant burden on hospital resources.

Outcome of management of gastroschisis: comparison of improvised surgical silo and extended right hemicolectomy

BackgroundGastroschisis is onea of the major abdominal wall defects encountered commonly in pediatric surgery. Whereas complete reduction and abdominal closure is achieved easily sometimes, a daunting situation arises when the eviscerated bowel loops and other viscera cannot be returned immediately into the abdominal cavity. This situation is a major contributor to the outcome of the treatment of gastroschisis in our region. In our efforts to improve our outcome, we have adopted the technique of extended right hemicolectomy for cases where complete reduction and primary abdominal wall closure is otherwise not possible. This study compared the management outcome of gastroschisis using our improvised silo, and performing an extended right hemicolectomy.ResultsThirty-nine cases were analyzed. Simple closure could not be achieved in 28 cases. In the absence of standard silos, improvised ones were constructed from the amniotic membrane (3 cases), urine bag (4 cases), and latex gloves (9 cases) giving a total of 16 cases managed with silos. Extended right hemicolectomy was performed in 12 cases.ConclusionsGiven the peculiarities of circumstances in our region regarding human and material resources in the care of gastroschisis patients, an extended right hemicolectomy, to make it possible to close the abdomen primarily in gastroschisis is a more viable option than the use of improvised silo.Trial registrationThis trial was approved by the Ethical Committee of the University of Port Harcourt Teaching Hospital, Nigeria. Reference Number: UPTH/ADM/90/S.II/VOL XI/835. Registered 3 May 2013.

Gastroschisis: Impact of Delivery Planning on Patient Outcomes

Introduction: Success rates of gastroschisis interventions on outcome have been increasingly examined. Much of the work has focused on post-delivery management and timing of the final closure. Little data is available regarding the impact of the timing of fetal delivery on outcomes. This study aims to examine the relationships between overall outcomes of patients diagnosed with gastroschisis and timing of delivery (planned versus non-planned) and mode of delivery (cesarean section versus vaginal delivery). The primary outcome evaluated was the length of hospitalization. Methods: This work was performed as a ten-year retrospective chart analysis including patients from 2005 to 2013. Inclusion in the study required a pre-operative diagnosis and a surgical intervention for gastroschisis. We identified 29 patients of interest who were filtered based on availability of the specific timing of each intervention. Chi-square test was used to determine statistical differences amongst categorical variables and the student t-test was used to determine differences amongst continuousvariables. Results: The major factors influencing the Length of hospitalization were return of bowel function (p = 0.0213) and tolerance of full oral feeds (p = 0.0116). Further early extubation was also correlated to a shorter hospitalization (p = 0.0003). Analysis of mode of delivery, comparing vaginal delivery to Cesarean section, showed that patients delivered by Cesarean section had a reduced length of hospitalization as compared to those delivered vaginally (p = 0.0080). Mode of delivery did not significantly impact the other patient outcomes, but we did find that time to oral feeds was increased in those patients undergoing unplanned deliveries (p = 0.0176). No other outcomes were impacted by undergoing a planned versus unplanned gastroschisis delivery. Conclusion: Our data suggests that patients delivered without prior planning will have an extended time to tolerance of oral feeds. In addition, we find that patients delivered by Cesarean section will have shorter lengths of hospitalizations in the setting of poor antenatal care. Factors influencing length of stay after gastroschisis, such as return of bowel function and time to tolerance of oral feeds may be related to mode and timing of delivery. We recommend that future analysis of larger databases should focus on peri-partum factors that may influence outcomes in gastroschisis. Further greater consideration should be given to the impact of lack of antenatal services in many parts of the world and its implications on maternal fetal wellbeing in congenital malformations such as gastroschisis.

Effects of gestational age at delivery and type of labor on neonatal outcomes among infants with gastroschisis†

Objective To investigate the effect of preterm gestational age (GA) on neonatal outcomes of gastroschisis and to compare the neonatal outcomes after spontaneous labor versus iatrogenic delivery both in the preterm and early term gestational periods. Study design A retrospective study of prenatally diagnosed gastroschisis cases born at Loma Linda University Medical Center and Lucile Packard Children’s Hospital (Loma Linda, CA) between January 2009 and October 2016. A total of 194 prenatally diagnosed gastroschisis cases were identified and included in the analysis. We compared infants delivered <37 0/7 to those ≥37 0/7 weeks’ gestation. Adverse neonatal outcome was defined as any of: sepsis, short bowel syndrome, prolonged ventilation, or death. Prolonged length of stay (LOS) was defined as ≥75th percentile value. Outcomes following spontaneous versus iatrogenic delivery were compared. Analyses were performed using chi-squared test or Fisher’s exact test for categorical variables, and Student’s t-test or Wilcoxon’s rank-sum test for continuous variables. Results One hundred and six neonates were born <37 weeks and 88 at ≥37 weeks. Adverse outcome was statistically similar among those born <37 weeks compared to ≥37 weeks (48 versus 34%, p = .07). Prolonged LOS was more frequent among neonates delivered <37 weeks (p = .03). Among neonates born <37 weeks, bowel atresia was more frequent in those with spontaneous versus iatrogenic delivery (p = .04). There was no significant difference in the adverse neonatal composite outcome between those with spontaneous preterm labor versus planned iatrogenic delivery at <37 weeks (n = 30 (58%) versus n = 21 (39%), p = .08). Conclusions Neonates with gastroschisis delivered <37 weeks had prolonged LOS whereas the rate of adverse neonatal outcomes was similar between those delivered preterm versus term. Neonates born after spontaneous preterm labor had a higher rate of bowel atresia compared to those born after planned iatrogenic preterm delivery.

Examination of Prenatal Sonographic Findings: Intra-Abdominal Bowel Dilation Predicts Poor Gastroschisis Outcomes

Background: Gastroschisis is an anterior abdominal wall defect with variable outcomes. There are conflicting data regarding the prognostic value of sonographic findings. Objectives: The aim of this study was to identify prenatal ultrasonographic features associated with poor neonatal outcomes. Method: A retrospective review of 55 patients with gastroschisis from 2007 to 2017 was completed. Ultrasounds were reviewed for extra-abdominal intestinal diameter (EAID) and intra-abdominal intestinal diameter (IAID), echogenicity, visceral content within the herniation, amniotic fluid index, defect size, and abdominal circumference (AC). Ultrasound variables were correlated with full enteral feeding and the diagnosis of a complex gastroschisis. Results: Bivariate analysis demonstrated an increased time to full enteral feeds with increasing number of surgeries, EAID, and IAID. Additionally, there was a significant relationship between IAID and AC percentile with the diagnosis of complex gastroschisis. On multivariate analysis, only IAID was significant and increasing diameter had a 2.82 (95% CI 1.02–7.78) higher odds of a longer time to full enteral feeds and a 1.2 (95% CI 1.05–1.36) greater odds of the diagnosis of a complex gastroschisis. Conclusions: Based on these findings, IAID is associated with a longer time to full enteral feeding and the diagnosis of complex gastroschisis.

Predicting Morbidity and Mortality in Neonates Born With Gastroschisis

BackgroundGastroschisis is an increasingly common congenital abdominal wall defect. Due to advances in neonatal critical care and early surgical management, mortality from gastroschisis and associated complications has decreased to less than 10% in most series. However, it has been recognized that the outcome of gastroschisis has a spectrum and that the disorder affects a heterogeneous cohort of neonates. The goal of this study is to predict morbidity and mortality in neonates with gastroschisis using clinically relevant variables. MethodsA multicenter, retrospective observational study of neonates born with gastroschisis was conducted. Neonatal characteristics and outcomes were collected and compared. Prediction of morbidity and mortality was performed using multivariate clinical models. ResultsFive hundred and sixty-six neonates with gastroschisis were identified. Overall survival was 95%. Median hospital length of stay was 37 d. Sepsis was diagnosed in 107 neonates. Days on parenteral nutrition and mechanical ventilation were considerable with a median of 27 and 5 d, respectively. Complex gastroschisis (atresia, perforation, volvulus), preterm delivery (<37 wk), and very low birth weight (<1500 g) were associated with worse clinical outcomes including increased sepsis, short bowel syndrome, parenteral nutrition days, and length of stay. The composite metric of birth weight, Apgar score at 5 min, and complex gastroschisis was able to successfully predict mortality (area under the curve, 0.81). ConclusionsClinical variables can be used in gastroschisis to distinguish those who will survive from nonsurvivors. Although these findings need to be validated in other large multicenter data sets, this prognostic score may aid practitioners in the identification and management of at-risk neonates.

P4.58: Management and outcomes of Gastroschisis over the last decade: A US tertiary-center experience.

P4.58: Management and outcomes of Gastroschisis over the last decade: A US tertiary-center experience.

P2.41: Gastrointestinal outcomes of gastroschisis in and around Osaka, Japan

Introduction: According to the Intestinal Transplant Registry report 2018, gastroschisis was the most frequent indication (21%) for pediatric intestinal transplantation. However, in Japan, none of the pediatric intestinal transplant candidates has gastroschisis. The purpose of this study was to analyze gastrointestinal outcomes of gastroschisis in and around Osaka, Japan. Methods: One hundred and nine patients with gastroschisis were treated between January 1982 and December 2018 at our three hospitals. The patients’ gender, gestational age at birth, birth weight, Apgar Score, delivery route, fetal diagnosis, gastrointestinal complications of gastroschisis, surgical treatment, and outcomes were analyzed. Results: Mean gestational age at birth of the 109 patients (males: 57, 52%) was 36.3 ± 2.1 weeks. Mean birth weight was 2159 ± 441 g, mean Apgar Score (after 1 minute / after 5 minute) was 6.9 ± 2.3 / 8.4 ± 1.2, and 38 patients were delivered by Cesarean section. Fetal diagnosis of gastroschisis was made in 78 (72%) cases. All 109 patients were operated for gastroschisis, with primary repair in 63, silo repair in 23, and silo placement with delayed abdominal closure in 23. Eight patients (7%) had the gastrointestinal complications: seven had atresia of the intestine or colon, one had intestinal perforation. Closed gastroschisis was detected in three patients after birth. The patients with gastrointestinal complications were treated concurrently by intestinal anastomosis or enterostomy at the initial operation. Three of the eight patients underwent massive intestinal resection, resulting in short bowel syndrome (SBS), and required total parenteral nutrition (TPN) for about a year. Two of the three patients with SBS survived weaning off TPN. However, the other baby with SBS died of intestinal failure-associated liver disease. The other two patients without gastrointestinal complications died, one was an extremely low birth weight infant and the other with thrombosis in the lower extremities. Eventually, the remaining 106 (97.2 %) patients with gastroschisis have been surviving without TPN. Conclusion: Gastrointestinal complications are rare in Japanese patients with gastroschisis. One of the factors contributing to this might be the low incidence of closed gastroschisis and low prevalence of SBS and complications secondary to intestinal failure after repair of gastroschisis. Ethical approval: The hospital research ethics committee (reference number H30-36).

Fetal abdominal wall defects in an Australian tertiary setting: contemporary characteristics, ultrasound accuracy, and outcome

Purpose In this study, we aimed to comprehensively evaluate risk factors, ultrasound estimation of fetal weight, prenatal management, and pregnancy outcomes of gastroschisis and omphalocele at a metropolitan Australian hospital. Material and methods This was a retrospective single-center cohort study from 2006 to 2014 at a tertiary hospital with colocated neonatal surgical facilities. Demographic, pregnancy, ultrasound, birth and neonatal data were compared between gastroschisis and omphalocele. Correlation between routine (Hadlock 1 &2) and specific (Siemer) estimated fetal weight (EFW) estimation formulae with birth weight (BW) was made for those 50 gastroschisis cases with ≥2 third trimester scans and last scan ≤2 weeks prior to birth. Results There were 126 abdominal wall defects: 83 gastroschisis and 43 omphalocele. Consistent with international literature, the average maternal age was lower for gastroschisis and rates of smoking higher, while there were more intrauterine deaths and pregnancy terminations in omphalocele. Gastroschisis mothers were more likely living outside Sydney, had more infections in pregnancy and were followed with a larger number of antenatal visits, with a shorter period from the last visit to birth. In omphalocele pregnancies, amniocentesis was more likely performed, with more abnormal results than in gastroschisis fetuses. All EFW formulae had a good correlation between Z score for the last US and actual BW (ICC 0.693–0.815), with Hadlock 2 being the best. Siemer formula had the best correlation from first to the last scan. Gastroschisis newborns were born earlier (36.8 versus 38.2 wks p = .001), with smaller birthweight (2.52 versus 3.03 kg, p < .001), a longer request of intensive care (central line, parenteral nutrition, intubation) and second surgery, along with more multisystem complications (average 1.5 versus 0.7, p = .004) and a longer hospital stay (58.8 versus 36.8 d, p < .001). Conclusion Demographic, antenatal, and pregnancy outcome data for abdominal wall defects correlated well with the international literature. Hadlock 1–2 gave the most consistent EFW estimate, with all formulae showing good correlation.

A 25-year study of gastroschisis outcomes in a middle-income country

BackgroundSurvival of newborns with gastroschisis is significantly higher in high-income versus low and middle-income countries. We reviewed treatment and outcomes of gastroschisis in a middle-income country setting with increasing protocolized management. MethodsAll newborns with gastroschisis treated during the period 1989–2013 at a single Brazilian academic surgical service were studied retrospectively. Protocolized diagnosis, delivery, nutrition, medical interventions, and surgical interventions were introduced in 2002. Outcomes before and after protocol introduction were studied using univariate and multivariate analysis. ResultsOne hundred fifty-six newborns were treated for gastroschisis: 35 (22.4%) and 121 (77.6%) before and after 2002, respectively. When compared to the earlier cohort, patients treated after 2002 had higher rates of prenatal diagnosis (90.9% vs. 60.0%, p < 0.001), delivery at a tertiary center (90.9% vs. 62.9%, p < 0.001), early closure (65.3% vs. 33.3%, p = 0.001), primary repair (55.4% vs. 31.4%, p = 0.013), monitoring of bladder pressure (62.0% vs. 2.9%, p = 0.001), PICC placement (71.1% vs. 25.7%, p < 0.001), early initiation of enteral feeding (54.5% vs. 20.0%, p < 0.001), and lower rates of electrolyte disturbances (53.7% vs. 85.7%, p = 0.001). Mortality decreased from 34.3% before 2002 to 24.8% (p = .27) after 2002 despite an increase in the complex gastroschisis rate from 11.4% to 15.7% during the same period. ConclusionsGastroschisis outcomes in a middle-income country can be gradually improved through targeted interventions and management protocols. Type of StudyTherapeutic. Level of EvidenceIII.

Impact of disease-specific volume and hospital transfer on outcomes in gastroschisis

BackgroundGastroschisis, a surgical condition requiring complex interdisciplinary care, may benefit from treatment at higher volume centers. Recent studies on surgical volume and outcomes have conflicting findings. MethodsData were collected prospectively on newborns ≥1500 g with gastroschisis born 2009–2015, admitted to 159 US centers, and separated into terciles based on number of annual gastroschisis repairs. Infants transferred after gastroschisis repair were excluded. ResultsThere were 4663 infants included: 307 from 53 low, 1201 from 55 medium, and 3155 from 51 high volume centers. Infants at high volume centers had higher rates of intestinal atresia (P = 0.04) and outborn status (P < 0.0001). Outborn infants (N = 1134) had higher rates of gastrostomy/jejunostomy placement (P < 0.001). Mortality was universally low (2.0% low, 2.4% medium, and 1.7% high; 2.0% outborn and 1.9% inborn). On multivariate analysis, mortality, sepsis rates, and length of stay did not differ by center volume. Outborn status was associated with longer length of stay (P = 0.001), not mortality or sepsis. ConclusionInfant characteristics and management vary based on gastroschisis surgical volume and transfer status. Center volume and early transfers were not associated with mortality. Further investigation to identify subsets of gastroschisis infants who would benefit from care at higher volume centers is warranted. Type of studyPrognosis study. Level of evidenceLevel II.

Medium and long-term outcomes of gastroschisis

As survival of gastroschisis patients has improved significantly, it has become apparent that longitudinal follow up strategies need to be developed. Problems concerning patients with gastroschisis are usually associated with gastrointestinal morbidity, but there is mounting evidence that also neurodevelopmental, cognitive, behavioral and late-onset auditory sequelae exist. The presence of associated anomalies, as well as complex features (bowel atresia, necrosis, volvulus, perforation) increase morbidity and impact long-term outcomes. Multidisciplinary follow-up is required, and the key elements of such follow-up are presented here.

Impact of societal factors and health care delivery systems on gastroschisis outcomes

Care of infants with gastroschisis is associated with a significant burden on health care delivery systems. Mortality rates in patients with gastroschisis have significantly improved over the past few decades. However, the condition is still associated with significant short-term and potentially long-term morbidity. Significant variations in clinical outcomes and resource utilization may be explained by several factors including provider and hospital experience, level of neonatal intensive care, variations in hospital regionalization of care, and differences in healthcare delivery systems. Reviewing and assessing these hospital and healthcare system related factors are paramount in addressing variations in gastroschisis care and improving outcomes for these vulnerable infants.

Closure methods in gastroschisis

The expected outcome of gastroschisis has evolved from an almost certain death of the child prior to the use of parenteral nutrition to almost certain survival. The primary goal of the surgical intervention is return of eviscerated contents into the abdominal cavity. The optimal surgical technique is dependent on the status of the intestine and the accommodation of abdominal domain. In this review, the various surgical techniques for management are discussed as they have evolved. Ironically, a minimalist surgical intervention originally practiced due to the poor expected outcome is now being adopted as a minimalist surgical approach for abdominal wall closure associated with an expected excellent outcome.

Surgical strategies in complex gastroschisis

Currently, the most important determinant of gastroschisis outcomes in high resource settings is whether the condition is associated with intestinal complications, such as atresia, necrosis, perforation, or volvulus. This form of the anomaly, known as complex gastroschisis, accounts for most of the mortality and a disproportionate burden of the morbidity from gastroschisis. There is some disagreement about what constitutes complex gastroschisis, and little consensus on the type and timing of surgical interventions. This article establishes a clear definition of complex gastroschisis. Surgical approaches to treatment of the diverse presentations of complex gastroschisis will be described and the timing of such interventions will be discussed. Contemporary outcomes of complex gastroschisis will be reviewed. Finally, a non-congenital intestinal complications that may arise in gastroschisis patients will be discussed.