No free ride? The hidden costs of delayed operative management using a spring-loaded silo for gastroschisis
Jennifer D Lobo1, Anne C Kim, Ryan P Davis
1Section of Pediatric Surgery, Department of Surgery, The University of Michigan Medical School and The C.S. Mott Children's Hospital, Box 0245, Ann Arbor, MI 48109, USA.
Purpose:
The ideal management of gastroschisis (primary vs staged closure) has not yet been established. Despite the ease of silo placement, anecdotal experience shows that silos do not always offer benefit. The aim of this study was to highlight concerns regarding use of spring loaded silos and compare outcomes to primary closure.
Methods:
Thirty-seven neonates with gastroschisis treated with either primary (n = 10) or staged closure with a spring-loaded silo (n = 27) were reviewed (1998-2007). Variables included ventilator days, daily intravenous fluid, hospital days, and complication rates. SPSS (SPSS Inc, Chicago, Ill) was used to perform t test and chi(2) analyses (significance P < .05).
Results:
Survival for primary closure was 100% (10/10) compared to 89% (24/27) for staged closure (P = .548). Patients managed with silos required prolonged ventilation (16.1 +/- 4 days vs 3.6 +/- 1 days; P < or = .05) and greater intravenous fluids on days 3, 4, and 5 of life (132 +/- 25 mL/kg per day vs 104 +/- 18 mL/kg per day; P < or = .01). Although there was no difference in the complication rates between the groups, several problems were evident in the silo group: 15% (4/27) required silo replacement, 44% (12/27) required fascial defect enlargement for silo placement, and 19% (5/27) required mesh at closure. No significant differences in recovery of intestinal function were observed. Three silo patients developed ischemic complications because of vascular insufficiency at the level of the abdominal wall, leading to significant intestinal loss, ventilator and total parenteral nutrition dependence, and increased hospital stay.
Conclusions:
Patients managed with a silo had longer ventilator requirements and greater fluid needs. This Specific technical complications leading to bowel ischemia were notable in the silo group. The silo should be carefully placed to avoid bowel twisting and the funnel effect. Larger prospective studies should be performed to provide decision-making criteria for the use of a silo vs primary closure.
