Journal of Pediatric Surgery (2012) 47, 1521–1528

Contemporary 2-year outcomes of complex gastroschisis☆
Sherif Emil a,b,⁎, Noah Canvasser a , Tiffany Chen a , Esther Friedrich c , Wendy Su a,b

Division of Pediatric Surgery, University of California Irvine School of Medicine, Orange, California Department of Pediatric Surgery, Miller Children's Hospital, Long Beach, California c Division of Maternal Fetal Medicine, University of California Irvine School of Medicine, Orange, California

Received 10 October 2011; revised 20 December 2011; accepted 21 December 2011

Key words:
Gastroschisis; Complex; Atresia; Outcomes; Morbidity; Mortality

Abstract Purpose: Outcomes of gastroschisis are influenced by associated intestinal complications. We present a detailed analysis of complex gastroschisis. Methods: A retrospective study of all patients with gastroschisis treated at 2 university neonatal intensive care units between January 1, 2001, and March 31, 2007, was performed. Results: Of 83 patients, 19 (23%) had complex gastroschisis, including atresias (68%), gangrene (37%), closing gastroschisis (32%), perforation (21%), strictures (21%), and volvulus (11%). Prenatal ultrasound did not predict complications. Fifty-three percent underwent primary closure. Duration of mechanical ventilation and total parenteral nutrition (TPN) was 14.4 ± 1.9 days and 90.7 ± 9.0 days, respectively. Enteral feeds started at 35.9 ± 4.6 days. Hospital stay was 104.4 ± 9.6 days. Patients underwent a median of 3 abdominal procedures (range, 2-5) before discharge. Ninety-five percent survived to discharge; 33% and 67% were discharged on TPN and gastrostomy feeds, respectively. Two-year survival was 89%, with 82% on full oral feeding, 12% on a combination of oral and gastrostomy feeding, and 1 patient (who received a liver/bowel transplant) on a combination of enteral and parenteral nutrition. Conclusions: Complex gastroschisis continues to produce significant morbidity. However, most of the patients are TPN free by 2 years of age. © 2012 Elsevier Inc. All rights reserved.

Gastroschisis is one of the most fascinating congenital anomalies treated by pediatric surgeons. Rare enough to warrant a case report in the Annals of Surgery in 1963 [1], it is now one of the more frequently encountered neonatal surgical anomalies because of a significant increase in incidence throughout the world [2-4]. Although mortality in
☆ Poster presentation at the annual meeting of the Canadian Association of Pediatric Surgeons, Ottawa, Ontario, Canada, September 22-24, 2011. ⁎ Corresponding author. Division of Pediatric General Surgery, Montreal Children's Hospital, Montreal, Quebec, Canada, H3H 1P3. Tel.: +1 514 412 4497; fax: +1 514 412 4289. E-mail address: (S. Emil).

gastroschisis has decreased to less than 10% in most series published in the 21st century [2-10], morbidity is still significant. Efforts have been focused on identifying prenatal or perinatal predictors of outcome as well as factors that may be amenable to manipulation to improve outcomes. It has become clear over the past 2 decades that presence of 1 or more intestinal complications, such as atresia, volvulus, perforation, or necrosis, places the patient in a high-risk category and is associated with worse outcomes [5-10]. Although there is now a significant body of literature regarding this dichotomy in the spectrum of gastroschisis, very few publications have provided detailed analyses of patients with complex gastroschisis [11,12].

0022-3468/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2011.12.023

Inc.001 .1 ± 1.2 Birth weight (g) 2560 ± 70 TPN duration (d) 30. perforation. Most of the of patients with gastroschisis were inborn.6 . During this period. Cases 9 to 13 represented ischemic complications such as stenosis. gangrene. Table 1 presents characteristics and outcomes of the 2 groups.7% survival to discharge.9 104.0 (day of life) Ventilator duration (d) 9. and perforation. despite successful abdominal closure using Alloderm (LifeCell. and outcomes. The baby boy had severely matted bowel. atresia represented the main complication.054 . between January 1. 1 patient died in hospital (case 3). Branchburg. Methods All patients treated for gastroschisis at the University of California Irvine (UCI) Medical Center. we examined outcomes of specific surgical interventions as well as patient progress up to 2 years of age. A baby boy born at 31 weeks gestation with a large defect.1 ± 2. The study was approved by the institutional review boards of both institutions (UCI 2007-5650. and March 31.2 Initiation of enteral feeds 20.001 b. 2 patients died in hospital. operative interventions. Patients were labeled as complex gastroschisis if 1 or more of the following conditions were diagnosed at birth or at any time during the initial hospitalization: intestinal atresia. and the UCI-affiliated Miller Children's Hospital.8 19 35. Table 2 presents the details of the complex gastroschisis group. TX).5 ± 2. 2.020 b. Outcomes In the simple gastroschisis group. We were not aware of any postdischarge deaths in this group. A baby girl born at 39 weeks gestation with abdominal wall agenesis died at age 76 days of protracted sepsis and multiple organ system failure. maternal information.4 ± 0. Nineteen patients met the definition of complex gastroschisis (23%). 2007. Specifically. 2001. volvulus. additional complications developed. In cases 1 to 8. as is evident in Table 2. full oral feeds.1522 We reviewed our experience with gastroschisis over a 6-year period. gastrostomy. Surgery. resulting in 96. California. In the complex gastroschisis group. etc) during the first 2 years of life on all patients with complex gastroschisis. Emil et al.1 ± 1. Memorial Health Services 439-07 CR). including necrosis of Table 1 Characteristics and outcomes of patients with simple and complex gastroschisis Simple Complex P gastroschisis gastroschisis N 64 Gestational age (wk) 36. necrosis. S. gastroenterology. medical and surgical management. However. postnatal findings. interventions. timing of operations. Student t tests were used to compare the simple and complex gastroschisis cohorts. In cases 14 to 19. including clinical findings.2.001 .9 ± 4. resulting in 94. patients were labeled as simple gastroschisis. We sought to define early gastrointestinal outcomes in this patient population. San Antonio. and severe persistent pulmonary hypertension of the newborn was withdrawn from life support on the fourth day of life per the parents' wishes. operative findings. Both units served as level III tertiary referral units for their respective counties and were housed at hospitals with large obstetric services and active maternal fetal medicine teams. NJ) and vacuum-assisted closure (Kinetic Concepts. Long Beach. severe respiratory distress syndrome. Data on prenatal ultrasound results. surgical outcomes.1. and other outpatient clinic data were available for extraction of final nutritional outcome (eg. There was no established follow-up program (other than postoperative surgical visits) for patients with simple gastroschisis. Postdischarge clinic progress notes were also reviewed to obtain data on gastrointestinal outcomes during the first 2 years. Orange. There was a preponderance of males in both groups. 2.5 2545 ± 170 90.4 ± 9.6 14. even if their gastroschisis was associated with other nonintestinal complications. and therefore. Results 2. with the goal of performing a detailed analysis of patients with complex gastroschisis.2 Hospital stay (d) 40. or closing gastroschisis. no attempt was made to formally review outpatient charts for this group. 60% in simple gastroschisis and 63% in complex gastroschisis. the 2 neonatal intensive care units had a combined capacity of approximately 90 beds. were retrospectively reviewed. but follow-up was not consistent as mentioned previously. stenosis. herniated liver. During a prolonged treatment course. 83 patients with gastroschisis were treated. as well as multiple atresias and stenoses extending from the jejunum to the rectosigmoid junction. and complications. Continuous data are presented as mean ± SEM. 1. a closing gastroschisis represented the main complication. and outcomes were extracted from the charts of patients and their mothers. Complications caused by necrotizing enterocolitis were excluded.6 ± 0.4 ± 1. California.9% survival to discharge. All operative reports and operative notes of patients with complex gastroschisis were reviewed by the senior author to obtain detailed information on indications for operations.930 b. Data were entered into an Excel spreadsheet for analysis. Patient cohort During the 75-month period analyzed. Hospital data were complete and available in all patients.0 35. If these conditions did not exist. the cases were quite heterogeneous and most often were affected by more than one complication.7 ± 9.

gastrostomy (67) 4. colonic stricture 6 35 1972 Ileal atresia. placement of larger silo (4) 3. silo placement (1) 2. Silo placement (1) 2. Jejunal resections and 1° anastomoses (61) 3. Ileostomy takedown (38) 3. Abdominal closure. Bowel resection for segmental volvulus (81) 5. extensive lysis of adhesions (74) 1. bowel perforations. Enterectomy and 1o anastomosis × 2. Abdominal closure (1) 2. Duodenorrhaphy. Ileostomy. Ileocecal resection. and outcomes in complex gastroschisis Complication(s) Procedures before discharge (day of life) Hospital stay (d) 137 TPN on GT feeds 2-y D/C? on D/C? outcome N Y Full PO Case Gestational BW age (wk) (g) 1 38 ATRESIA 3904 Colonic atresia 2 33 2386 Ileal atresia. Repair jejunal atresia. Silo placement (5) 4. Abdominal closure with Surgisis (12) 5. ileostomy. Abdominal closure (7) 3. Silo placement (1) 2. SBS 2224 Jejunal atresia × 2 8 36 1. Silo placement (1) 2. Gastrostomy (121) 1. Jejunocolic anastomosis. Abdominal closure (13) 3. Tapering enteroplasty (164) 1. abdominal closure (7) 3. SBS 4 5 40 37 3102 Jejunal atresia 2593 Jejunal atresia. Silo placement (1) 2. abdominal closure (8) 3. Ileocolic resection and 1° anastomosis. Multiple bowel resections. Gastrostomy (92) 1. Repair jejunal atresia & tapering jejunoplasty (24) 1. Gastrostomy (140) 188 Y Y GT/PO feeds 75 Death Death 79 54 N N Y N Full PO Full PO 135 N Y Full PO 90 Y Y Death 160 N Y Full PO 9 34 ISCHEMIC COMPLICATIONS 1865 Jejunal stenosis and perforation 10 34 3445 Jejunal ischemia 1.Contemporary 2-year outcomes of complex gastrochisis Table 2 Clinical findings. severe pseudoobstruction 3 34 1851 Multiple small and large bowel atresias. Abdominal closure (1) 2. Jejunal resection and 1° anastomosis (15) 1. ileal tapering (24) 3. Midgut resection. abdominal closure (1) 2. gastrostomy (1) 2. Exploratory laparotomy. Silo placement (1) 2. Enterolysis. duodenorrhaphy. Enterorrhaphy and abdominal closure (6) 3. Attempted abdominal closure. Exploration. Ileostomy takedown (38) 4. gastrostomy (42) 1. operative interventions. colonic atresia 7 36 3880 Jejunal atresia. takedown enterocutaneous fistula (68) 56 N N Full PO 133 N N Full PO 1523 (continued on next page) . midgut volvulus and necrosis. colonic stricturoplasty (38) 1.

BW indicates birth weight. Gastrostomy (53) 3161 Closing gastroschisis. colostomy and Hartman's. Jejunostomy closure (110) Hospital stay (d) 49 TPN on GT feeds 2-y D/C? on D/C? outcome N N Full PO 2155 Small bowel ischemia progressing to necrosis 12 36 2545 Ileal ischemia progressing to necrosis 93 N Y Full PO 13 33 1670 Jejunal and colonic strictures 158 N N Full PO 14 37 15 35 16 38 17 18 38 31 19 34 CLOSING GASTROSCHISIS 3415 Closing gastroschisis. Small bowel resection (22 cm). abdominal closure (1) 2. Repair jejunal stenosis (resection and 1° anastomosis). jejunocolic anastomosis. Ileostomy takedown. SBS 3. colonic volvulus and necrosis of internal bowel stricturoplasty × 2. Attempted closure. multiple ileal perforations. GT. abdominal necrotic ileum. end duodenostomy. Ileal resection. segmental ileal resection with ileostomy (19) 3. gastrostomy (59) 2780 Closing gastroschisis. Jejunal serial transverse enteroplasty procedure. . partial colectomy. Emil et al. 1. jejunal and colonic 1. jejunal atresia. atresias. Ileal resection with jejunostomy and mucus fistula ((11) 3. colonic strictures. Jejunostomy takedown.1524 Table 2 (continued) Case Gestational BW age (wk) (g) 11 37 Complication(s) Procedures before discharge (day of life) 1. Segmental jejunal resection and jejunostomy. distal jejunal atresia. jejunal atresia. Right hemicolectomy and ileocolic anastomosis (81) 4. discharge. Diverting jejunostomy. jejunal stenosis. Abdominal closure (1) atresia. abdominal closure (1) midgut necrosis. jejunal and ileal 1.jejunocolic anastomosis. gastrostomy (48) mass (jej). 1. 1. Abdominal closure (8) 1. segmental colonic resection and 1° anastomosis (48) 4. abdominal closure (1) ileal obst w/ meconium pellets 2. SBS abdominal closure (1) 2. Repair jejunocolic stricture (resection and 1° anastomosis) (84) 150 Y Y Full PO 112 Y Y GT/PO feeds 67 Y Y Full PO 65 83 N N N Y Full PO Full PO 101 Y Y GT/PO feeds TPN S. Bowel examination and silo replacement (2) 3. 1. Revision duodenoileal and ileocolic anastomoses (strictures) (107) 1715 Closing gastroschisis. Silo placement (1) 2. Ileocolic resection and jejunocolic anastomosis (20) 1455 Closing gastroschisis. SBS closure (1) 2. repair ileal perforations. Silo placement (1) 2. short bowel syndrome. SBS 2.gastrostomy (42) 3. per os. Duodenoileal anastomosis. Ileal and colonic lavage . Abdominal closure (12) 3. D/C. Jejunectomy. gastrostomy tube. Jejunostomy closure. PO. day of life. gastrostomy (50) 2305 Closing gastroschisis. silo placement (1) 2. Midgut resection and end jejunostomy. ileal sticturoplasty. silo placement (3) 4. SBS. ileal necrosis 2. DOL. gastrostomy (56) 1.

The interventions described in Table 1 were successful. The baby died 1 day after a very difficult surgical procedure to establish bowel continuity. requiring bowel resection in 2 cases and takedown of enterocutaneous fistula in 1. In 4 (31%) of 13 cases of atresia. He died at 4 years of age. entire cohort. and severe short bowel (Fig. Complications Table 3 lists the incidence of intestinal complications within the complex gastroschisis group. In 3 patients (cases 10-12). The patient with the best outcome after closing gastroschisis (case 18) was a girl born at 31 weeks gestation weighing 1455 g. Bloomington. 1525 2. Two patients (cases 2 and 15) still required continuous gastrostomy feeding at night.5 years of age after a successful bowel transplant but resumed TPN upon transplant rejection. one third were discharged on oral feeding only. 2-year survival was 89%. as well as within the Fig. One of the closing patients with gastroschisis (case 14) had volvulus and complete necrosis of the intraabdominal bowel (entire jejunum) from the duodenojejunal junction to an atresia at the exit point of the closed gastroschisis. The patient was a boy born with closing gastroschisis. With these 2 deaths. He was born with proximal jejunal atresia 20 cm distal to the ligament of Treitz and a midgut volvulus. All. intestinal perforations. A. Atresia was the most common complication of gastroschisis. 1 Case 7. A multivisceral transplant was performed at 3 years of age. the lesion was not recognized at the time of abdominal closure.3. Closing gastroschisis was present in one third of all complex cases and was responsible for 4 of the 6 cases of short bowel syndrome. with jejunal and colonic remnants. 2 Case 19. He was weaned off TPN at 2. proximal jejunal atresia 12 cm distal to the ligament of Treitz. Gastroschisis complicated by proximal jejunal atresia and necrotic midgut volvulus resulting in severe short bowel syndrome. At 2 years.Contemporary 2-year outcomes of complex gastrochisis the anterior duodenal wall. 14 (82%) of 17 surviving patients were on full oral feeding with their gastrostomies closed. and erosion of Surgisis (Cook Medical. 2). Autopsy revealed no definite etiology. He was progressing well over the first year of life but was found dead in his crib shortly after his first birthday. and the baby was discharged on total parenteral nutrition (TPN) and low-volume continuous gastrostomy feeding. Another baby boy (case 7) died at 1 year of age. Both were subsequently weaned to full oral feeding. The appendix can be seen at the lower right hand side of the picture. midgut necrosis. gastrostomy. bowel segments of questionable viability progressed to necrosis. were associated with atresia. and one third with a combination of enteral and parenteral nutrition. followed by bowel necrosis. one third on a combination of oral and gastrostomy feeding without TPN. the lowest gestational age and birth weight of the . Closing gastroschisis with necrosis of the entire extraabdominal bowel mass. B. Of the 18 discharged patients. 1). Fig. Classic findings of proximal and distal atresias at the entry and exit points of the extraabdominal bowel mass resulting in midgut loss. but 1. progressing to frank necrosis and liquefaction during the first week of life (Fig. IN) into multiple loops of bowel. and parenteral nutrition. One patient (case 19) was still on a combination of oral.

7. A. There were no complications associated with this approach. Emil et al. In 4 of these patients (33%). and silo placement after attempted closure. 11. In 1 of these cases (case 9). Their average hospital stay was 87 days (range.10]. The rest were closed primarily. In the remainder. jejunal dilation is seen. Their average hospital stay was 124 days (range. . Excluding the single in-hospital death. Intestinal procedures were custom tailored to each patient because no 2 patients in the cohort shared exactly the same pathology. In 6 cases. Surgical procedures and their outcomes Four pediatric surgeons performed all the surgical procedures during the study period. Patient 11 underwent bowel resection. Stomas. and 12) developed bowel gangrene while in silo. with or without bowel resection. Three patients (cases 3. 3 Case 18. necessitating emergent laparotomy in patient 15. A serial transverse enteroplasty procedure was done in patient 19 to taper and lengthen the 12 cm of jejunum available but did not improve enteral feeding. a prospective Canadian database of patients with gastroschisis. 54-188 days). a perforation occurred proximal to the site of obstruction after reduction. 4. routine silo closure was performed in 47 patients (73%) with simple gastroschisis. a jejunal stenosis was clearly identified and repaired. and 6) with good results. bowel continuity was established during the first 4 weeks of life. used in 6 patients with 1 complication. B. obstructed bowel was placed intraabdominally (either knowingly or unknowingly). all 12 patients with gastroschisis underwent procedures to establish bowel continuity before discharge. Primary closure was performed after irrigating a large amount of impacted ileal meconium through the appendiceal orifice. Tapering enteroplasties was performed in 3 patients (cases 2. Primary bowel resection and anastomoses were performed in 9 patients. were 3. showed that approximately a quarter of patients with gastroschisis undergo multiple operations during their hospitalization. and placement of the anastomosis in another silo with subsequent closure and good outcome. 3). a sign of complicated Fig. the findings almost always dictated the method of closure. However. respectively [7.10]. Operative techniques and perioperative care were not standardized. 56% within the first 4 weeks of life. 2. Reviews of large national databases in Britain and the United States have shown complex gastroschisis to represent 11.9% of all cases. an incarcerated jejunal prolapse through the stoma. At birth.4. Discussion The incidence of gastroschisis has significantly increased over the past 2 decades [2-4]. During the same period. but all the bowel is viable. Method of closure was surgeon dependent with 3 favoring routine silo placement with delayed closure and 1 favoring primary closure. primary anastomosis. CAPSnet. 65-135 days).5. At 7 weeks. with no complications.1526 Table 3 Type of complication in complex gastroschisis n 13 4 7 4 2 6 6 % of complex gastroschisis 68 21 37 21 11 32 32 % of all gastroschisis 16 5 8 5 2 7 7 S. Silo placement with delayed closure was used in 7 patients (37%). in 2 patients (11%). in complex gastroschisis cases. Closing gastroschisis in a 31-week gestational age girl.5% and 10. Complication Intestinal atresia Intestinal stenoses Bowel necrosis Bowel perforation Volvulus Short bowel syndrome Closing gastroschisis entire group. The prevalence of complex gastroschisis in recent publications has been reported as 11% to 31% [4. An exit point jejunal stenosis was found without bowel loss (Fig. bowel continuity was established after 1 month of life.

9 patients representing 6% of their gastroschisis cohort.16]. this is clearly a diverse condition with a wide spectrum of presentations. if a silo is necessary for a complex gastroschisis (and it often is). and hospital stay [2-10]. We encountered 2 episodes of anterior duodenal wall necrosis in patients who shared similar risk factors.5. almost 1 in 4 patients had complex gastroschisis. Previously considered quite rare and incompatible with survival. namely. ventilator duration. but delay beyond 4 weeks does not appear warranted. In others. Although the classic association with closing gastroschisis is an atresia at the proximal and distal extents of the extraabdominal bowel (Fig. did not predict complications [14]. patients with gastroschisis can manifest a severe dysmotility syndrome that results in pseudoobstruction [23].22].15]. Details of management strategies have been very scant [9. spring-loaded silos should be used with more caution in complex gastroschisis.17-19].24.4. volvulus. A third of our complex patients with gastroschisis manifested this condition. very careful bowel monitoring is required. perforation. Houben et al [11] recently published the largest series. similar to the prevalence in our series. Closing gastroschisis A special comment should be made regarding our group of patients with closing gastroschisis. In fact.13. Therefore. Prenatal ultrasounds. In some studies. On the other hand. over the past few years. the entire midgut was extraabdominal and necrotic in another patient (case 19). We also report the first case of volvulus and necrosis of the intraabdominal bowel in this condition. as well as a multicenter randomized controlled trial. Two of our patients had the primary anastomoses housed in a spring-loaded silo until closure was possible. Obstruction Atresia is the most common complication. 3. This method has had strong supporters. is not supported by our experience.20]. available for review in all but 4 of our patients. intestinal complications also predicted higher mortality. including atresia and stenosis. The method of gastroschisis closure received quite a bit of attention since Fischer et al popularized the use of the spring-loaded silo in 1995 [21]. Surgical efforts.2. may be best targeted at optimal management of conditions found in complex gastroschisis. one that is inherent to the patient. Prospectively acquired data. Although specific evolution of ultrasound findings may dictate early delivery in certain cases [11. Two other patients. therefore. and short bowel syndrome. We used it in 3 patients with good results.12]. in addition to another distal intraabdominal atresia. This is an important factor to consider during prenatal fetal consultations. which was responsible for two thirds of our cases of short bowel syndrome. In our large cohort. as in our study. 1527 occurred secondary to pressure necrosis from the silo ring. Patients with atresia are at particular risk [23]. manifested ischemic complications while the bowel was in the silo. We believe that this . such as early and/or cesarean delivery. Unfortunately. 3. necrosis. mortality did not differ significantly between simple and complex gastroschisis [6.Contemporary 2-year outcomes of complex gastrochisis disease [13]. prematurity appears to outweigh any hypothetical benefit of decreased bowel exposure to amniotic fluid and has been found to be a predictive factor for poor outcome [13. We also found early restoration of bowel continuity to be safe and associated with much earlier hospital discharge.1. Others have reported the safety of both early and late primary anastomoses for atresias associated with gastroschisis [12].3.19. Therefore. that has been consistently shown to predict poorer outcomes of this anomaly. 2). including duration of TPN.10]. Determinants of gastroschisis outcomes can be analyzed as factors that may be amenable to control by clinicians and factors inherent to the patient. The surgical impression that gastroschisis bowel is “high-risk” bowel. who underwent routine silo placement. The experience amassed through detailed review of surgical outcomes at our highvolume centers can impart several lessons in the treatment of this difficult patient population. have not shown outcome improvements with staged silo closure [15. as high as 28% [2. Dysmotility In addition to mechanical obstruction.8. prone to leakage and ischemia.7]. None of our 6 patients shared the same clinical picture. 3. Tapering enteroplasty is indicated for this syndrome [23]. have not proven of value in improving outcomes or decreasing the prevalence of complex gastroschisis [2.9. The surgeon has to exercise good judgment when deciding when to reestablish bowel continuity.25]. a well-known limitation of fetal ultrasound for this anomaly [3. a particularly devastating event because the patient then relied only on the exterior compromised bowel. the presence of simple vs complex gastroschisis is the only factor. We found primary anastomosis as a safe option. 3. as well as detractors. severe bowel ischemia and prolonged silo use. On the other end of the spectrum. a reassuring ultrasound (absence of dilated bowel) does not rule out complex gastroschisis. In our cohort. the major variables amenable to clinical manipulation.3. Most can be diagnosed at first encounter. One of our patients (case 17) had a single viable loop of extraabdominal bowel ending in an atresia. early and late mortality occurred in the 2 most severely affected patients with less than 20 cm of small intestine. Use of silos Inability to close the abdomen is not a contraindication to primary anastomosis. time to initiation of enteral feeding. it is becoming recognized with increasing frequency [11.

43:2213-5. J Pediatr Surg 2008.12]. J Pediatr Surg 1995. et al. route. Walker K. Emil S. Gastroschisis: a simple technique for staged silo closure. Closing gastroschisis: diagnosis. [13] Boutros J. J Pediatr Surg 2009.25:319-25.38:771-4. Hunter CJ.39:742-5. Greenough A. At 2 years of age. et al. the closing gastroschisis patient with the best prognosis was a baby girl born premature at 31 weeks.1528 Interestingly. Emil et al. Closed gastroschisis: antenatal and postnatal features. Early restoration of bowel continuity. Gingalewski CA. J Pediatr Surg 2008. J Pediatr Surg 2007.158:263-9. [24] Davenport M. J Pediatr Surg 2010. Fenton SJ. West KW. et al. et al.43:30-4 [discussion 4].24. Bruce J. Petrosyan M. Chen T. Ann Surg 1963. A significant decrease in long-term morbidity and mortality. Haugen S. Tonita J. The significance of intrauterine growth restriction is different from prematurity for the outcome of infants with gastroschisis. Bianchi A. et al. as recommended here. all but 1 patient were off TPN. et al. S. Estrada et al suggested “parking” the extraabdominal bowel in this condition to preserve bowel length [25]. et al. Raval MV. We used this method in 4 of our 6 patients with good results. Thornton JG.36:51-5. Predicting the outcome of newborns with gastroschisis. management. [17] Logghe HL. Canvasser N. Acknowledgment Dr Noah Canvasser and Dr Tiffany Chen were supported as medical students participating in this research study by a research grant from the University of California. et al. Sour grapes: ultrasound abnormalities spurred delivery and neonatal surgery. [6] Driver CP. Regier M. Canadian Pediatric Surgical Network: a population-based pediatric surgery network and database for analyzing surgical birth defects. 201:332.26:871-8.41:1103-8. Risk stratification of 4344 patients with gastroschisis into simple and complex categories. Claydon J. Malloy MH. [14] Friedrich E. Kaban G. J Pediatr Surg 2004. A randomized controlled trial of elective preterm delivery of fetuses with gastroschisis. We certainly agree with this recommendation if the bowel is even marginally viable. Phillips JD.25].5. Assel B. J Pediatr Surg 2001. Norton C. J Pediatr Surg 2001. et al. J Pediatr Surg 2008. References [1] Moore T. Janvier A.7. Ergun FS. [16] Chung JH. Texas. [23] Phillips JD. coupled to a decrease in the volume of the extraabdominal bowel mass. Routine cesarean delivery does not improve the outcome of infants with gastroschisis. All our patients survived to discharge with 1 late death caused by severe short bowel syndrome. [18] Puligandla PS. J Pediatr Surg 2009. The timing of delivery of infants with gastroschisis influences outcome.40: 424-8. Flageole H. Gastroschisis. [10] Owen A. et al. Ade-Ajayi N. Pediatr Surg Int 2010. has been found [2. [8] Payne NR. are very suggestive of this condition and may be one of the few indications for early delivery in gastroschisis [11]. J Pediatr Surg 2006. The contemporary outcome of gastroschisis. and early delivery of suspected closing gastroschisis. J Pediatr Surg 2005. birth weight. Redden C. Gastroschisis: a national cohort study to describe contemporary surgical strategies and outcomes.44:343-7. [4] Eggink BH. use of primary anastomoses. Preservation of extracorporeal tissue in closing gastroschisis augments intestinal length. Gastroschisis: an update. [22] Pastor AC. Sonographic findings of progressive intraabdominal bowel dilation. atresia. given recent advances in the care of patients with short bowel syndrome. Davenport M. Am J Obstet Gynecol 2009. [5] Molik KA.43:2208-12.e1-2. when compared with several large previously reported series. Chun K. which will likely continue to improve.44:918-23. Drongowski RA. Risk stratification in gastroschisis: can prenatal evaluation or early postnatal factors predict outcome? Pediatr Surg Int 2009. Complicated gastroschisis: can prenatal ultrasound predict outcome. However. [7] Arnold MA. Mason GC.40:1726-73.39:1200-4. [12] Kronfli R. . It is likely that premature birth in this condition does prevent the catastrophic sequel of bowel strangulation. J Pediatr Surg 2008. and outcomes. 2008. et al. et al. In line with the most recently published results [11. J Pediatr Surg 2000. J Pediatr Surg 2009. USA. Irvine Department of Surgery.30:843-6. and intent of delivery on outcome in gastroschisis. [25] Estrada JJ.26:891-4. [2] Baerg J. et al. Gastroschisis with antenatal evisceration of intestines and urinary bladder. Intestinal atresia in association with gastroschisis: a 26-year review. Marven S. Flageole H. Sabharwal A. et al. Barksdale E. et al. 18th World Congress on Ultrasound in Obstetrics and Gynecology. Chicago. Johnson P.9. Badawi N. The first 100 cases of gastroschisis. Gastroschisis: a plea for risk categorization. [9] Davis RP. J Pediatric Surg 2005. We have presented the first detailed review of surgical interventions in complex gastroschisis as well as the first report on outcomes beyond discharge in this patient population. dysmotility: surgical treatment strategies for a distinct clinical entity. et al.35:1719-23. [11] Houben C. Bouchard S. as was the case in 2 of our patients. [3] Holland AJA. et al.43:1807-12. Pediatr Surg Int 2010. may further optimize outcomes. Pfleghaar K. Janvier A. et al. Skarsgard ED. the outcome of this severe complication has also improved dramatically.42:1520-5. Nabaweesi R. et al. [20] Puligandla PS. [15] Skarsgard ED. J Pediatr Surg 2003. it should be resected at birth with proximal diversion or primary anastomoses as appropriate. Bradnock TJ. Is timing everything? The influence of gestational age. Outcome of gastroschisis: a 20-year case review of infants with gastroschisis born in Galveston.44:912-7.45:1808-16. Routine use of a SILASTIC spring-loaded silo for infants with gastroschisis: a multicenter randomized controlled trial. if the extraabdominal bowel is grossly necrotic. and most were on full oral nutrition. J Pediatr Surg 2004. [19] Ergun O. Treadwell MC. Moores DC. Chang DC. Richardson CJ.36:1834-7. [21] Fischer JD. Gastroschisis: a sixteen-year review. et al.

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