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Selective management of gastroschisis
Insights
Gastroschisis surgical outcomes improved significantly. Primary fascial closure and skin flap coverage showed fewer complications than silo reduction, suggesting tailored treatment is best.
Area of Science:
- Pediatric Surgery
- Neonatal Care
- Congenital Abnormalities
Background:
- Gastroschisis, a congenital abdominal wall defect, historically had high mortality rates.
- Advances in perioperative management have coincided with new surgical techniques.
- Staged reduction using prosthetic material (silos) is one such technique.
Purpose of the Study:
- To compare the effectiveness of three operative strategies for gastroschisis: primary fascial closure, skin flap coverage, and silo reduction.
- To analyze complication rates and patient outcomes associated with each method.
Main Methods:
- Retrospective review of 106 consecutive infants with gastroschisis treated between 1967 and 1984.
- Categorization of infants into primary closure, skin flap coverage, or silo reduction groups.
- Analysis of operative outcomes including duration of ileus, length of hospitalization, and mortality.
Main Results:
- No significant differences in ileus duration or hospitalization length among the three groups.
- Primary closure (52%) and skin flap coverage (10%) had significantly fewer complications (36% and 30%) compared to silo reduction (38%, 68%) (p < 0.05).
- Mortality rates were 6% (primary closure), 20% (skin flap), and 18% (silo); overall postoperative mortality was 12%.
Conclusions:
- Primary fascial closure is safe and feasible for a majority of gastroschisis patients.
- Skin flap coverage offers a viable alternative when primary closure is not possible.
- No single operative strategy is universally ideal; treatment should be individualized based on visceroabdominal disproportion.
Abstract:
Mortality of patients with gastroschisis has decreased from nearly 90% to 13% (14 of 106) during the period from 1967 to 1984. Coincident with advances in perioperative management, including parenteral nutrition and mechanical ventilation, has been the introduction of staged reduction of the viscera using prosthetic material. To assess the relative merits of primary closure, skin flap coverage, and silo reduction, operative treatment of 106 consecutive infants with gastroschisis was reviewed. Primary fascial closure was accomplished in 54 patients (52%). When fascial approximation resulted in excessive intra-abdominal pressure, the viscera were covered with lateral skin flaps in 10 infants (10%), or the defect was closed after staged reduction with a prosthetic silo in 40 infants (38%). Detailed analysis of the hospital records revealed no significant differences between the primary closure, skin flap, and silo groups with regard to duration of ileus (22 +/- 25, 30 +/- 27, 31 +/- 30 days), length of hospitalization (39 +/- 36, 54 +/- 37, 53 +/- 39 days), or mortality (6, 20, 18%). Respiratory, septic, hemorrhagic, renal, and wound complications occurred in significantly fewer patients with primary closure (36%) and skin flap coverage (30%) than in those with silos (68%) (p less than 0.05). Postoperative mortality was 12% (12/104) and was most often due to respiratory insufficiency (35%) or nonviable small bowel (19%). Primary fascial closure may be accomplished safely in a majority of patients with gastroschisis. However, no single operative strategy is ideal for all patients with gastroschisis, and initial treatment of individual defects should be tailored to the degree of visceroabdominal disproportion.