Primary fascial closure versus staged closure with silo in patients with gastroschisis: a meta-analysis
Sarah N Kunz1, Joel S Tieder, Kathryn Whitlock
1Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA.
Insights
Staged repair with a silo for gastroschisis (a common birth defect) showed better outcomes in unbiased studies. Primary closure appeared better overall, but more research is needed to confirm the best gastroschisis treatment.
Area of Science:
- Pediatric Surgery
- Neonatal Care
- Congenital Anomalies
Background:
- Gastroschisis is a frequent congenital abdominal wall defect.
- Optimal surgical closure methods for gastroschisis lack consensus.
- Short-term outcomes vary between primary fascial closure and silo repair.
Purpose of the Study:
- To compare short-term outcomes of primary fascial closure versus staged repair with a silo for gastroschisis.
- To evaluate the efficacy of different gastroschisis closure techniques.
Main Methods:
- Systematic review of Medline and Cochrane Database (1996-2012).
- Included studies focused on gastroschisis treatment outcomes or were randomized controlled trials.
- Meta-analysis of data from 20 selected studies.
Main Results:
- In studies with low selection bias, silo repair significantly reduced ventilator days, time to first feed, and infection rates.
- When all studies were considered, primary closure demonstrated improved outcomes.
- Significant differences noted for ventilator days (p<0.0001), time to first feed (p=0.04), and infection rates (p=0.03) favoring silo in unbiased studies.
Conclusions:
- Silo closure appears to yield better clinical outcomes in gastroschisis patients, particularly in studies minimizing selection bias.
- Further large-scale prospective studies are necessary to establish definitive evidence for the optimal gastroschisis closure technique.
Background/Purpose:
Gastroschisis is the most common congenital abdominal wall defect. Despite advances in the surgical closure of gastroschisis, consensus is lacking as to which method results in the best patient outcomes. The purpose of this meta-analysis was to compare short-term outcomes associated with primary fascial closure and staged repair with a silo in patients with gastroschisis.
Methods:
We reviewed Medline citations, as well as the Cochrane Database of Systematic Reviews, between January 1, 1996 and June 1, 2012. Articles were identified using the search term "gastroschisis" and [("treatment outcome" or "prognosis") or randomized controlled trials]. Case reports, reviews, letters, abstracts only, non-English abstracts, and studies that did not address at least one of the outcomes of interest were excluded from the meta-analysis. Two independent reviewers identified relevant articles for final inclusion. A standard data collection form created by the authors was used to extract study information, including study design, patient characteristics, and reported patient outcomes. The data were analyzed using standard meta-analytic techniques.
Results:
Twenty studies were included in the meta-analysis. In the five studies that selected closure method randomly or as a temporal shift in practice, silo was associated with better outcomes, with a significant reduction in ventilator days (p<0.0001), time to first feed (p=0.04), and infection rates (p=0.03). When all studies were included, primary closure was associated with improved outcomes.
Conclusions:
Silo closure is associated with better clinical outcomes in the studies with the least selection bias. Larger prospective studies are needed to definitively determine the best closure technique.