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The effect of initial operative repair on the recovery of intestinal function in gastroschisis
M S Bryant1, J J Tepas, D L Mollitt
1Department of Surgery, University of Florida College of Medicine, University Hospital of Jacksonville.
Insights
Gastroschisis repair outcomes show that the method of initial fascial closure does not impact gastrointestinal recovery. Aggressive primary closure may increase risks for newborns with gastroschisis.
Area of Science:
- Pediatric Surgery
- Neonatal Care
- Congenital Abnormalities
Background:
- Gastroschisis is a congenital defect requiring surgical repair.
- Previous reports suggested primary closure offers better outcomes for gastroschisis infants.
Purpose of the Study:
- To compare outcomes of staged versus primary fascial closure in gastroschisis treatment.
- To evaluate the impact of surgical approach on gastrointestinal function recovery and infant survival.
Main Methods:
- Retrospective review of 30 infants with gastroschisis over 4 years.
- Comparison of infants undergoing staged closure (silastic or cutaneous silo) versus primary fascial closure.
- Analysis of time to fascial closure, enteral feeding initiation, and complications.
Main Results:
- Gastrointestinal recovery and time to full oral alimentation were similar between staged and primary closure groups (43 vs. 46 days).
- Primary closure group experienced higher perioperative mortality (3/21) due to sepsis and renal failure, and complications like necrotizing enterocolitis.
- Staged closure infants achieved fascial closure in 8-15 days, with enteral feeds starting at 23 days.
Conclusions:
- The method of initial fascial closure for gastroschisis does not significantly affect gastrointestinal recovery.
- Aggressive primary closure may increase risks of intestinal compromise, mortality, and morbidity in neonates with gastroschisis.
- Staged closure is a viable alternative, with outcomes comparable to primary closure regarding GI function restoration.
Abstract:
Recent reports concerning the treatment of gastroschisis suggest that primary closure results in more rapid return of gastrointestinal function, a shortened hospitalization, diminished perinatal complications, and improved long-term survival. A 4-year retrospective review of infants treated for gastroschisis at the University of Florida yielded 30 infants requiring repair of this abdominal wall defect. The series included 19 males and 11 females, and the average abdominal wall defect measured 4 cm in its greatest dimension. Nine infants (mean weight, 2,275 gm) were repaired using a staged closure using a silastic (six) or cutaneous (three) silo. Complete fascial closure was accomplished in an average of 8 days in the silastic group and 15 days in the infants with skin flaps. Mean age at start of enteral feeds was 23 days, with complete oral feedings at 43 days. Twenty-one infants (mean weight, 2,127 gm) underwent primary fascial closure. Three deaths occurred in the perioperative period: one from acute renal failure and two from sepsis secondary to a segment of necrotic intestine. An additional infant developed postoperative necrotizing entercolitis but recovered. Two infants in this group also had jejuno-ileal atresia requiring extensive small bowel resection. In the remaining 15 infants, oral alimentation was initiated for an average of 23 days, with full oral alimentation at 46 days. The data suggest that the recovery of the gastrointestinal system, adequate enough to support total oral alimentation, is unrelated to the initial surgical procedure chosen to obtain fascial closure in the newborn with gastroschisis. In addition, vigorous attempts at primary fascial closure may jeopardize intestinal viability, diminish ventilatory function, and result in unnecessary morbidity and mortality.