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Delivery room repair of gastroschisis
J P Coughlin1, D E Drucker, M R Jewell
1Department of Surgery, Ochsner Clinic, New Orleans, La. 70121.
Insights
Immediate repair of gastroschisis in the delivery room improves infant outcomes. This approach leads to fewer complications and shorter hospital stays by addressing the inflammatory bowel peel early.
Area of Science:
- Neonatal surgery
- Pediatric surgery
- Abdominal wall defects
Background:
- Gastroschisis outcome is influenced by prematurity, anomalies, and the inflammatory bowel peel.
- The severity of the bowel peel, caused by amniotic fluid exposure, significantly impacts patient prognosis.
- Improving the quality of eviscerated bowel is crucial for reducing morbidity in gastroschisis patients.
Purpose of the Study:
- To evaluate the impact of immediate delivery room repair versus delayed repair on gastroschisis outcomes.
- To determine if early surgical intervention affects the inflammatory peel and subsequent patient recovery.
Main Methods:
- A cohort of 32 infants with antenatal gastroschisis diagnosis was studied between 1986 and 1991.
- Infants were divided into two groups: immediate delivery room repair (13 patients) and delayed repair within 6 hours (19 patients).
- Cesarean delivery was utilized for all patients.
Main Results:
- Immediate repair infants showed more frequent fascial repairs (73% vs 37%) and shorter hospitalizations (13.6 vs 31.3 days).
- Delivery room repair was associated with earlier extubation (2.9 vs 7.4 days) and enteral feeding (8.1 vs 22.2 days).
- Eviscerated bowel in the immediate repair group lacked the significant matted, edematous, and fibrinous peel observed in the delayed repair group.
Conclusions:
- Immediate delivery room repair of gastroschisis leads to improved outcomes, including increased fascial repairs and earlier discharge.
- Benefits such as earlier extubation and feeding are attributed to the minimal reactive peel on the bowel at birth.
- Early surgical intervention in gastroschisis can mitigate the negative effects of amniotic fluid exposure on the eviscerated bowel.
Background:
Outcome for most abdominal wall defects is related to the presence or absence of additional anomalies or prematurity. In gastroschisis, outcome is almost as closely related to the severity of the inflammatory "peel" on bowel that is thought to result from direct contact with amniotic fluid. Improving eviscerated bowel quality would be expected to reduce morbidity in these patients.
Methods:
From 1986 to 1991, 32 patients with the antenatal diagnosis of gastroschisis were treated. All were delivered by cesarean section; 13 surgical repairs were made immediately in the delivery room. Surgical repairs in 19 patients were made at less than 6 hours of age after transfer from the delivering hospital to the pediatric surgery center.
Results:
Thirty percent of infants who underwent surgical repair in delivery room and 32% of infants who underwent urgent surgical repair were either premature or had significant associated anomalies. Seventy-three percent of delivery room repair group had fascial repairs compared with 37% in the transferred group. When infants more than 34-weeks' gestation without associated anomalies are compared with transferred infants, delivery room repair group underwent more frequent fascial repair (8 of 9 vs 5 of 13, p < 0.03), were extubated sooner (2.9 vs 7.4 days, p < 0.04), tolerated enteral feedings earlier (8.1 vs 22.2 days, p < 0.009), and required fewer hospital days (13.6 vs 31.3 days, p < 0.01). Eviscerated bowel of infants who underwent immediate surgical repair lacked the characteristic matted, edematous, and fibrinous coated appearance seen in transferred patients.
Conclusions:
Immediate delivery room repair of gastroschisis results in increased fascial repairs and earlier extubation, feeding, and hospital discharge. These benefits appear to be due to the minimal reactive peel on eviscerated bowel at birth.