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Gastroschisis: a plea for risk categorization
K A Molik1, C A Gingalewski, K W West
1Section of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, and the James Whitcomb Riley Hospital for Children, Indianapolis, IN 46202-5200, USA.
Insights
Gastroschisis in infants can be categorized as simple or complex, with complex cases showing significantly higher complication rates and mortality. Risk stratification impacts clinical outcomes, length of stay, and costs.
Area of Science:
- Pediatric Surgery
- Neonatal Care
- Congenital Abnormalities
Background:
- Gastroschisis incidence has risen, necessitating better risk assessment.
- Clinical courses differ significantly between simple and complex gastroschisis.
- Complex gastroschisis involves atresias, perforations, or stenosis.
Purpose of the Study:
- To review risk assessment factors for gastroschisis.
- To compare clinical behavior between simple and complex gastroschisis.
- To inform parents, physicians, and insurers about risk categorization impacts.
Main Methods:
- Retrospective chart review of 103 infants with gastroschisis (1992-1997).
- Categorization into simple (71%) and complex (31%) defects.
- Analysis of gestational age, birth weight, interventions, complications, and outcomes.
Main Results:
- Complex gastroschisis infants had lower gestational age (34 vs. 37.5 weeks) and birth weight (2.0 vs. 3.0 kg).
- Complex cases required longer ventilation (22.3 vs. 6.8 days), feeding initiation (22.5 vs. 15 days), and had longer LOS (85.4 vs. 26.4 days).
- Mortality was 28% in complex cases versus 0% in simple cases; overall survival was 91%.
Conclusions:
- Gastroschisis can be stratified into low-risk (simple) and high-risk (complex) categories.
- Significant differences exist in clinical behavior, complications, LOS, and mortality between the two groups.
- Risk categorization is crucial for managing patient outcomes, resource allocation, and cost estimation.
Background:
The incidence of gastroschisis has increased in the past decade. A differing clinical course between "complex" (those with atresias, perforation, or stenosis) and "simple" cases has prompted a review of risk assessment factors.
Methods:
A retrospective chart review was conducted of 103 infants with gastroschisis over 5 years (1992 to 1997).
Results:
Of 103 infants, 52 were girls and 51 were boys. Seventy-one infants (69%) had a simple defect, and 32 (31%) were complex. The simple group had an average estimated gestational age of 37.5 weeks (range, 26 to 40), and a birth weight of 3.0 kg (range, 1.7 to 3.8). A total of 71% underwent primary repair, whereas 29% required a silo. Mechanical ventilation averaged 6.8 days (range, 1 to 19). Enteral feedings were initiated at 15 days (range, 3 to 27) with full enteral intake achieved by 22.4 days (range, 5 to 40). Three infants required home parenteral nutrition. The average length of stay (LOS) was 26.4 days (range, 10 to 57). Complications occurred in 26 infants (36%), including intravenous catheter sepsis (n = 15), pneumatosis (n = 2), pneumonia (n = 1), bowel obstruction (n = 7), wound infection (n = 5), and SVC thrombosis (n = 1). Survival rate was 100%. Thirty-two infants had complex defects; 27 patients had atresias, stenosis, or perforations; and 3 had volvulus. The average estimated gestational age was 34 weeks (range, 26 to 38), and birth weight was 2.0 kg (range, 0.9 to 4.0). Primary repair was performed in 65% and silo placement in 35%. Mechanical ventilation was required for 22.3 days (range, 2 to 14). Enteral feedings were initiated at 22.5 days (range, 6 to 56) with full feedings achieved at 50 days (range, 21 to 113). Fourteen infants required home total parenteral nutrition (TPN). The LOS was 85.4 days (range, 24 to 270). A total of 47 complications occurred in the complex group including catheter sepsis (n = 15), short bowel syndrome (n = 7), pneumatosis (n = 3), bowel obstruction (n = 4), pneumonia (n = 2), superior vena cava thrombosis (n = 1), enterocutaneous fistula (n = 1), and 9 deaths (28% mortality rate).
Conclusions:
These data indicate gastroschisis can be divided into low-risk (simple) and high-risk (complex) categories. These 2 groups have significant differences in clinical behavior, postsurgical complications, LOS, and mortality rate (0 v 28%). Although the overall survival rate was 91% (94 of 103), parents, referring physicians, and insurers must be made aware of the impact of risk categorization on the estimated cost, LOS, and outcomes.