Primary Closure Of Gastroschisis Research Articles

Avoidance of routine endotracheal intubation and general anesthesia for primary closure of gastroschisis: a systematic review and meta-analysis.

Over the last few decades, several articles have examined the feasibility of attempting primary reduction and closure of gastroschisis without general anesthesia (GA). We aimed to systematically evaluate the impact of forgoing routine intubation and GA during primary bedside reduction and closure of gastroschisis. The primary outcome was closure success. Secondary outcomes were mortality, time to enteral feeding, and length of hospital stay. 12 studies were included: 5 comparative studies totalling 192 patients and 7 descriptive case studies totalling 56 patients. Primary closure success was statistically equivalent between the two groups, but trended toward improved success with GA/intubation (RR = 0.86, CI 0.70-1.03, p = 0.08). Mortality was equivalent between groups (RR = 1.26, CI 0.26-6.08, p = 0.65). With respect to time to enteral feeds and length of hospital stay, outcomes were either equivalent between the two groups or favored the group that underwent primary closure without intubation and GA. There are few comparative studies examining the impact of performing primary bedside closure of gastroschisis without GA. A meta-analysis of the available data found no statistically significant difference when forgoing intubation and GA. Foregoing GA also did not negatively impact time to enteral feeds, length of hospital stay, or mortality.

Primary closure of gastroschisis aided by ileostomy: A new management approach for low resource settings

The outcome of gastroschisis largely depends on place of birth. Prognosis is excellent with >95% survival in high income countries (HIC) while mortality remains high in low-income and middle-income countries (LMIC). Gastroschisis has nearly 100% mortality rate in our country, which has made it the most frustrating condition for pediatric surgeons. Recently we attempted a different approach for gastroschisis in order to improve the outcome. This entailed creating an ileostomy on the abdominal wall defect. In this paper we describe the first two neonates managed with this method in Ethiopia. The first case was a girl that presented on the 6th hour of life and the second was a boy that arrived to our hospital on the 24th hour of life. The results were encouraging as both of the children survived. This is a new treatment strategy which has not been previously reported. Ileostomy can aid primary closure of gastroschisis with minimal bowel resection. It also promotes early bowel function and initiation of feeding which is the most important factor for survival in these neonates. We believe this is the best management option for gastroschisis in LMIC.

Tu-be or not tu-be? Is routine endotracheal intubation necessary for successful bedside reduction and primary closure of gastroschisis?

BackgroundWide practice variation exists in the management of gastroschisis. Routine endotracheal intubation for bedside closure may lead to longer duration of mechanical ventilation. MethodsThe Canadian Association of Pediatric Surgery Network gastroschisis dataset was queried for all patients undergoing attempted bedside reduction and closure. Patients with evidence of intestinal necrosis or perforation were excluded. A propensity score analysis was used to compare the rate of successful primary repair and post-operative outcomes between intubated and non-intubated patients. ResultsIn propensity score matched analysis, the successful primary repair rate did not reach statistical significance between patients who were intubated for attempted bedside closure and those who were not intubated (Odds Ratio: 2.18, 95% Confidence Interval: 0.79, 6.03). Intubated patients experienced 3.02 more ventilator days than patients who were not intubated at the time of initial attempted closure. Other post-operative parameters were similar between both groups. ConclusionsIt is reasonable to attempt primary bedside gastroschisis closure without intubation in otherwise healthy infants.

The association between gestational age at delivery, closure type and perinatal outcomes in neonates with isolated gastroschisis

Objective: The objective of this study was to examine the association between gestational age at delivery and closure type for neonates with gastroschisis. In addition, we compared perinatal outcomes among the cases of gastroschisis based on the following two factors: gestational age at delivery and abdominal wall closure technique.Methods: This was a retrospective cohort study of all fetuses with isolated gastroschisis that were diagnosed prenatally and delivered between September 2000 and January 2017, in a single tertiary care center. Neonates were compared based on the gestational age at the time of delivery: early preterm (less than 350/7 weeks), late preterm (350/7 – 366/7 weeks), and early term (370/6 – 386/7 weeks), using bivariate and multivariate analyses. The primary outcome was the type of abdominal wall closure: primary surgical closure or delayed closure using spring-loaded silo. Secondary outcomes included length of ventilatory support, length of parenteral nutrition, and length of hospital stay.Results: The analysis included 206 pregnancies complicated by gastroschisis. In univariate analysis, no differences were detected in primary closure rates of gastroschisis among the gestational age at delivery groups (67.4%, at <35 weeks, 70.8% at 350/7–366/7 weeks, 73.7% at 370/6–386/7 weeks, p = .865). However, for every additional 100 grams of neonatal live birth weight there was an associated 9% increased odds of primary closure (OR 1.09, 95% CI 1.14–1.19, p = .04). Delivery in the early preterm period compared to the other two groups, was associated with longer duration of ventilation support and longer dependence on the parenteral nutrition. Neonates who underwent primary closure had shorter ventilation support, shorter time to initiation of enteral feeds and to discontinue parenteral nutrition, and shorter length of stay. In multivariate analyses, controlling for gestational age at delivery and presence of bowel atresia, primary closure continued to be associated with the shorter duration of ventilation (by 5 days), earlier initiation of enteral feeds (by 7 days), shorter hospital stay (by 17 days) and lower odds of wound infection (OR = 0.37, 95% CI 0.15–0.97).Conclusions: Our study did not find an association between gestational age at delivery and the rates of primary closure of the abdominal wall defect; however later gestational age at delivery was associated with shorter duration of ventilatory support and parenteral nutrition dependence. In addition, we found that primary closure of gastroschisis, compared with delayed closure technique, was associated with improved neonatal outcomes, including shorter time to initiate enteral feeds and discontinue parenteral nutrition, shorter hospital stay, and lower risk of surgical wound infection. Therefore, postponing delivery of fetuses with gastroschisis until 37 weeks may be considered. Other factors besides the gestational age at delivery should be explored as predictors of primary closure in neonates with gastroschisis.

Intestinal venous congestion as a complication of elective silo placement for gastroschisis

Use of a spring-loaded silastic silo has been advocated as a means of gentle reduction of the herniated bowel, while avoiding the possible complications of primary closure of gastroschisis. We recently encountered intestinal venous congestion during elective silo reduction of gastroschisis. Two babies with gastroschisis were treated postdelivery with a spring-loaded silo placed under the fascial defect and the eviscerated bowel suspended within the silo. Patient #1 had no bowel matting. On day of life 2, the bowel within the silo was noted to be dusky. The silo was removed, and the bowel was indeed congested, but viable. Complete reduction with a modified Bianchi closure was performed at the bedside. Patient #2 had severe matting of the bowel and did not require intubation for silo placement. As daily reductions progressed, the bowel was noted to be congested on day 2. On day 3, removal of the silo revealed frank bowel necrosis with impending perforation. Two-thirds of the small bowel required resection, leaving the child with short bowel. Venous congestion within a silo should be given prompt attention, including removal of the silo, as bowel infarction may result.

Ischemic bowel after primary closure for gastroschisis

Between 1983 and 1986, four newborns who had primary closure of gastroschisis had postoperative ischemic bowel. Suspicion was raised almost immediately after closure that something was wrong inside the abdomen when there was persistent acidosis, sepsis, abdominal wall redness, and a generalized worsening condition. All four neonates were re-explored. Necrotic bowel was found, and three required silon pouch closure. The two survivors were left with a temporary short gut. Whether the cause of the bowel ischemia in the four babies was due to excessive intraabdominal pressure, volvulus, or the intestines being too vigorously manipulated, is speculative. Therefore, excessive manipulation and compression of gastroschisis contents seem unwise; if such a newborn has persistence of the above signs and symptoms, immediate reoperation and decompression are warranted.

Pneumatic reduction bag for treatment of gastroschisis and omphalocele. A 10-year experience.

In 1975, a new Silastic device was developed by the authors to be used in the staged reduction of viscera in newborns with giant gastroschisis or omphalocele. That device and their early experience were described in 1977. This article reports the results of use of this device over the past 10 years. Primary closure of gastroschisis and omphalocele is accomplished, if possible. If tension of the closure is too great, the pneumatic bag is attached and staged reduction accomplished over 7-8 days. The advantages of this device are: it is preformed and easily sterilized by autoclaving; it is strong enough to elevate the abdominal wall; the pneumatic sac eliminates bulky ligatures; when it is pulled through a slotted rod, the edges of the defect are opposed; and it is available in two sizes.

Ventilatory support and primary closure of gastroschisis: R. J. Bower, M. J. Bell, J. L. Ternberg, et al. Surgery 90:52–55, (January), 1982

Ventilatory support and primary closure of gastroschisis: R. J. Bower, M. J. Bell, J. L. Ternberg, et al. Surgery 90:52–55, (January), 1982