Evolution of management of gastroschisis
Amel Abd Eltwab Hashish and Essam Elhalaby
The management protocols andoutcome of neonates with gastroschisis have improvedsignificantly during the past two decades. The purpose ofthis study was to evaluate the evolution in managementand outcome of gastroschisis in our institution.
Materials and methods
All patients treated forgastroschisis during the past 12 years were included.These patients were divided into two chronologicallydistinct groups. Group I included patients who were treatedfrom 1998 to 2005 and group II included patients whowere treated from 2005 to 2010. Each group was furthersubdivided into two subgroups according to the method ofclosure of the abdominal wall by either primary (group IAand group IIA) or delayed primary closure of the abdominalwall defect after temporary extra-abdominal hosting of thebowel using hand-sewn silastic or plastic sheets (group IB)or a spring-loaded silo (group IIB). Each patient wasevaluated with regard to time spent on ventilator, time toinitiating enteral feeds, time to discharge from the NeonatalIntensive Care Unit, and any complications.
There was no difference between the two maingroups with regard to the gestational age, sex, modeof delivery, or the percentage of associated congenitalanomalies. Primary closure was feasible in 29 patients(18 in group IA and 11 in group IIA). Staged reduction ofthe herniated bowel and delayed repair were performed in23 patients (12 in group IB and 11 in group IIB). Reductionof the herniated bowel and delayed staged reduction wereperformed earlier in group IIB than in group IB. Enteralfeeding was earlier in patients who had primary closureeither in group IA or group IIA compared with patientstreated with delayed closure in either group IB or group IIB.Enteral feeding was relatively earlier in group IIB than ingroup IB, but the difference was not significant.
The overall morbidity and mortality showedsignificant improvement in the management ofgastroschisis at our practice. The introduction of spring-loaded silo has simplified the management of patientsborn with gastroschisis who cannot be treated with primaryreduction. Primary closure continued to have betteroutcome measures compared with staged closure.
2011 Annals of Pediatric Surgery
Annals of Pediatric Surgery
Keywords: abdominal wall defect, complications, gastroschisisspring-loaded silo
Department of Pediatric Surgery, Tanta University, Tanta, EgyptCorrespondence to Amel Abd Eltwab Hashish, Department of PediatricSurgery,Tanta University Hospital, Elgish Street, Tanta, 31111, EgyptTel: 0020 40 333 5695, 20 12 331 5309; fax: 00 20 40 341 2127;e-mail:firstname.lastname@example.org
12 August 2010
25 September 2010
Gastroschisis is a full thickness defect of the abdominalwall with herniation of a variable amount of uncoveredintestinal loops through a defect immediately to the rightof a normally formed umbilicus. The intestine is fre-quently foreshortened, covered with gelatinous exudates,matted together, and/or is edematous due to its exposureto amniotic fluid and compression of the mesentericblood supply at the defect. The incidence of gastroschisisis rising over the last decade. It has been estimatedbetween one in 3000 and one in 10000 live births[1–3].The management of gastroschisis has gradually evolvedand improved over the years. The principles of manage-ment however remain the same. First, to reduce theviscera safely, second, to close the abdominal wall defectwith an acceptable cosmetic appearance and, third, pro-per nutrition support, in addition to detection and propermanagement of any associated anomalies or complications.The first surgical intervention by manual closure withfatal outcome was reported in 1878 . In 1943, Watkins reported the first successful primary closure of gastro-schisis. In 1953, Moor and Stokes  reported the useof skin flap technique to close the abdomen. However,two of their patients died because of acute respiratory insufficiency and abdominal compartmental syndrome.Historically, many surgeons used drastic measures todecrease the size of the abdominal contents and to relievesize discrepancy, such as bowel resection, splenectomy,and partial hepatectomy [8,9]. In 1966, manual stretchingof the abdominal wall was advocated by Izant
 toenlarge the abdominal cavity. However, the overzealousstretching was complicated by lateral abdominal wallhernia .The real advance in surgical management of gastroschi-sis was the introduction of staged reduction by usingsheets of Teflon as a temporary covering for the herniatedbowel by Schuster in 1967 . However
the abdomenrequired periodic reopening to perform serial reductionand staged removal of the material with risk of bowelinjury and infectious complications
The modification of Schuster’s technique by Allen and Wrenn  involvedthe use of silastic instead of Teflon, with no attemptat skin coverage to facilitate serial reduction and enablecontinuous inspection of the bowel’s condition.In 1975, Shermata and Haller  used a preformedtransparent silo sutured to the abdominal wall. The silo was
10 Original article
c2011 Annals of Pediatric Surgery DOI: 10.1097/01.XPS.0000393094.25977.48
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