Advances in Pediatrics 67 (2020) 123–129

ADVANCES IN PEDIATRICS

Approaches for Closing

Gastroschisis
Charlene Dekonenko, MDa, Jason D. Fraser, MDa,b,*
a
Department of Surgery, Children’s Mercy Kansas City, 2401 Gillham Road, Kansas City, MO
64108, USA; bUniversity of Missouri Kansas City School of Medicine, 2411 Holmes Street, Kansas
City, MO 64108, USA

Keywords
 Gastroschisis  Immediate closure  Delayed closure  Sutured closure
 Sutureless closure  Silo
Key points
 The closure of gastroschisis can be performed immediately after birth or after
gradual reduction of bowel over a number of days.
 The abdominal wall defect can be closed as a sutured fascial repair or as a
sutureless repair using the umbilical cord as a biologic dressing.
 Owing to the low incidence and management variability, the optimal timing and
closure method are still debated, and long-term outcomes are yet to be
determined.

INTRODUCTION
Gastroschisis is a congenital defect of the anterior abdominal wall resulting in
evisceration of the intestines with exposure to amniotic fluid. This condition is
usually detected prenatally, and babies with gastroschisis can be born at or near
term with expected survival of more than 90%. Morbidity is mostly determined
by the severity of the bowel injury present at birth, and postnatal management
goals include reduction of the bowel back into the abdominal cavity, closure of
the abdominal wall defect, and initiation of enteral feeds. However, methods of
obtaining abdominal wall closure vary and are still debated in the literature.
Here we review and compare outcomes for the various approaches to closing
gastroschisis.

*Corresponding author. School of Medicine, University of Missouri Kansas City, 2411

Holmes Street, Kansas City, MO 64108. E-mail address: jdfraser@cmh.edu

https://doi.org/10.1016/j.yapd.2020.03.005
0065-3101/20/ª 2020 Elsevier Inc. All rights reserved.
124 DEKONENKO & FRASER

IMMEDIATE VERSUS DELAYED CLOSURE

The timing for closure of gastroschisis varies, but reduction of the bowel and
closure of the defect as soon as is feasible is optimal to prevent evaporative fluid
loss, hypothermia, infection, and continued inflammation from exposure to the
environment. However, returning the intestines to the abdominal cavity de-
pends on multiple factors, including the state of the bowel (eg, edema, matting,
ischemia) and the ability of the abdominal cavity to accommodate the viscera.
Therefore, the timing of closure can be divided into 2 categories: immediate
and delayed.
Immediate closure is performed at or shortly after birth, generally within the
first 24 hours of life. Patients able to undergo immediate closure generally do
not have significant matting or distension of intestinal loops and have enough
abdominal domain to accommodate the bowel without creating excessive intra-
abdominal pressure. Immediate closure can be performed in the operating
room or at the bedside and has a reported success rate of 50% to 83% [1,2].
Potential advantages to immediate closure include prevention of further inflam-
mation of the bowel from exposure and mechanical irritation, possible earlier
initiation of feeds, a shorter hospital length of stay (LOS), and a decreased inci-
dence of wound infection [3]. Potential disadvantages of immediate closure
include an increase in days on the ventilator and requirement for nutritional
support at discharge [3,4].
However, immediate closure is not always feasible. Patients with complex
gastroschisis (atresia, necrosis, perforation) or with very thickened, distended
bowel (matting), and little abdominal domain may require gradual reduction
of the intestines and delayed closure of the defect. This process is accomplished
using a silo technique where the eviscerated bowel is placed into a transparent,
preformed silo and the spring-loaded or pliable ring at the base of the silo is
placed into the abdomen through the defect. This procedure allows for gradual
reduction of the intestines and enhancement of abdominal domain. Delayed
closure with a premade silo obviates the need for the placement of sutures,
thereby avoiding general anesthesia and allowing performance of the proced-
ure at the bedside. Other advantages of delayed closure include a lower risk
of abdominal compartment syndrome and a decrease in days on the ventilator
[3,5]. The disadvantages of delayed closure include possible vascular compro-
mise of the mesenteric vessels at the level of the defect owing to fascial compres-
sion from the silo, enlargement of the defect from the spring when duration of
the silo is prolonged, and a longer hospital LOS [3,6,7].

SUTURED VERSUS SUTURELESS CLOSURE

The 2 common methods used to achieve abdominal wall closure are the su-
tured and sutureless methods. The traditional method is the sutured closure,
whereas the more recent advancement is the sutureless closure technique.
For a sutured closure, patients are taken to the operating room where a pri-
mary fascial repair is performed. The fascial defect, located to the right of
the umbilicus, is closed with sutures either in an interrupted, running, or
GASTROSCHISIS CLOSURE 125

purse-string fashion. This skin is then closed around the umbilical stump so
that it remains in a central position [3]. Sutured closure is sometimes preferred
for patients with complex gastroschisis, because these patients may have
atresia, perforation, or necrosis necessitating operative intervention, which in-
corporates abdominal wall closure into that operation.
In 2004, the sutureless abdominal wall closure method for gastroschisis was
described. Sutureless closure allows reduction of the viscera at the bedside, at
times without intubation and general anesthesia [3,8]. Once the bowel is
reduced into the abdomen, the fascia at the site of the gastroschisis is left
open, the umbilical cord is used to cover the defect, and an occlusive dressing
is applied [9] (Fig. 1). The defect then contracts circumferentially leaving a
normal-appearing umbilicus (Fig. 2). This method minimizes the increase in
intra-abdominal pressure that occurs with fascial closure, decreasing, but
not eliminating, the risk of abdominal compartment syndrome [3]. Propo-
nents of the sutureless closure cite the avoidance of intubation and general
anesthesia, the decreased ventilator days, the cost effectiveness of avoiding
the operating room, and the enhanced cosmesis as reasons for transitioning
clinical practice to primarily sutureless closure [7,10,11]. These findings
were substantiated by a large retrospective multi-institutional study from

Fig. 1. Sutureless closure for gastroschisis.

126 DEKONENKO & FRASER

Fig. 2. Final result of sutureless closure for gastroschisis.

the Midwest Pediatric Surgery Consortium [12]. However, some investigators

report a higher incidence of umbilical hernias with sutureless closure [10].
Whether these hernias need to be repaired, and at what age, is unclear
because the long-term outcomes of this relatively new approach are yet to
be determined. Such questions will be addressed in upcoming retrospective
and prospective longitudinal studies through the Midwest Pediatric Surgery
Consortium.

DISCUSSION
As with many congenital anomalies, the low incidence of gastroschisis limits the
ability to obtain adequate data on outcomes at a single center. In contrast, vari-
ability in clinical practice among surgeons makes it difficult to interpret large,
multicenter studies. Thus, the optimal timing and closure method are still
debated and efforts to improve outcomes for these patients continue as the
management of gastroschisis evolves.
Timing of gastroschisis closure
Generally, immediate closure is performed when achievable [5]. When imme-
diate closure is not possible, delayed closure using a preformed silo is per-
formed. With the advent of the preformed, spring-loaded silo, surgeons
wondered whether it would be physiologically better to electively close the
abdomen over a period of days. Thus, several studies have attempted to eluci-
date differences in outcomes between immediate closure versus initial silo
placement and delayed closure. In a meta-analysis of studies in which random-
ization or temporal shifts in practice assigned patients to attempted primary
closure or initial silo placement, silo placement was associated with a decrease
in ventilator days, time to first feed, and rates of infection [13]. However, if
studies are included where a silo was placed after failed primary closure, pri-
mary closure was associated with a shorter LOS, shorter parenteral nutrition
GASTROSCHISIS CLOSURE 127

duration, and fewer days on the ventilator, although the inherent selection bias
toward worse clinical outcomes in those patients who failed primary closure
and required a silo is evident [13].
In a study of 627 patients from the National Surgical Quality Improvement
Program Pediatric database, delayed closure with silo placement was associated
with an increased rate of surgical site infections and LOS, but a decreased num-
ber of ventilator days and less need for nutritional support at 30 days or at
discharge [4]. In another even larger 4459 patient Pediatric Health Information
System database study, delayed closure with silo placement was also associated
with an increased LOS, and an increased duration of total parenteral nutrition
requirement [14].
A multicenter, retrospective study comparing immediate versus delayed
closure (<5 days) among 566 neonates across 8 institutions identified outcomes
that were similar between the 2 approaches [15]. Multivariate analysis demon-
strated that time to closure was an independent predictor of LOS, ventilator
duration, time to full feeds, and total parenteral nutrition duration, which sug-
gests that, whatever the approach, the sooner the defect can be closed, the bet-
ter the outcome [15].

Sutured versus sutureless gastroschisis closure

Traditionally, the fascia at the site of the gastroschisis was closed with sutures
at the time of reduction of the viscera. However, to do so requires bringing the
muscle together, which produces increased abdominal wall tension and pres-
sure. With the development of the sutureless approach, the fascia at the site
of the gastroschisis is left open. Only the umbilical stump covers the defect,
serving as the skin closure. Thus, sutureless closure of a gastroschisis is both
cosmetically pleasing, and less invasive and, as a result, does not require gen-
eral anesthesia nor the resources of an operating room. An early systematic re-
view and meta-analysis comparing sutureless with sutured fascial closure
revealed no differences in mortality, LOS, or duration of total parenteral nutri-
tion. However, sutureless closure was associated with fewer wound infections
and fewer days on the ventilator, although there was an increased risk of the
development of an umbilical hernia [10]. A more recent meta-analysis found
no difference in time to initiation of feeds, LOS, or mortality between the su-
tured and sutureless groups if they underwent immediate closure, but noted ad-
vantages to sutureless closure of gastroschisis after a silo was placed [16].
However, the authors acknowledged that the quality of the evidence reviewed
was low for all outcomes.
The only existing prospective randomized trial comparing sutured with su-
tureless closure in 39 patients with gastroschisis revealed no difference in
time to extubation, feeding complications, sepsis, or bowel operation, but an
increase in LOS and a decrease in incidence of surgical site infections in the su-
tureless group [7]. Additional multi-institutional longitudinal studies are needed
and such studies are underway to further guide optimal care of this complex
and heterogenous patient population.
128 DEKONENKO & FRASER

SUMMARY
The timing of closure for gastroschisis can be performed within hours of birth
or delayed for several days using a preformed silo for gradual reduction of
abdominal contents. However, the ability to perform immediate closure largely
depends on the status of the bowel and the adequacy of abdominal domain.
The necessity to delay closure in some patients with gastroschisis has contrib-
uted to the evolution of the preformed silo that allows bedside reduction
without the need for an operation and general anesthesia. Naturally, studies
have sought to compare outcomes in immediate versus delayed closure. The
overarching consensus in the current literature suggests that outcomes in pa-
tients who undergo early closure, either immediate or within 5 days, are
improved compared with those whose closure is delayed for longer periods
of time. Evidence for the superiority of closure method, either sutured or su-
tureless, is less clear. Existing retrospective studies suggest fewer ventilator
days, less anesthetic use, and fewer surgical site infections in patients managed
with the sutureless approach. However, the only existing prospective random-
ized trial only detected a difference in wound infection rates favoring sutureless
repair and LOS favoring the sutured approach. These conflicting data are likely
due to heterogeneity in study populations, variability in clinical practice, and
continual evolution in postnatal management of gastroschisis. With the rising
incidence of gastroschisis, efforts should be focused on standardization of post-
natal care to better study this unique population and improve outcomes.

Disclosure
No disclosures.

References
[1] Henrich K, Huemmer HP, Reingruber B, et al. Gastroschisis and omphalocele: treatments
and long-term outcomes. Pediatr Surg Int 2008;24:167–73.
[2] Driver CP, Bruce J, Bianchi A, et al. The contemporary outcome of gastroschisis. J Pediatr
Surg 2000;35:1719–23.
[3] Petrosyan M, Sandler AD. Closure methods in gastroschisis. Semin Pediatr Surg 2018;27:
304–8.
[4] Gurien LA, Dassinger MS, Burford JM, et al. Does timing of gastroschisis repair matter? A
comparison using the ACS NSQIP pediatric database. J Pediatr Surg 2017;52:1751–4.
[5] Skarsgard ED. Management of gastroschisis. Curr Opin Pediatr 2016;28:363–9.
[6] Ryckman J, Aspirot A, Laberge JM, et al. Intestinal venous congestion as a complication of
elective silo placement for gastroschisis. Semin Pediatr Surg 2009;18:109–12.
[7] Bruzoni M, Jaramillo JD, Dunlap JL, et al. Sutureless vs sutured gastroschisis closure: a pro-
spective randomized controlled trial. J Am Coll Surg 2017;224:1091–6.
[8] Pet GE, Stark RA, Meehan JJ, et al. Outcomes of bedside sutureless umbilical closure without
endotracheal intubation for gastroschisis repair in surgical infants. Am J Surg 2017;213:
958–62.
[9] Sandler A, Lawrence J, Meehan J, et al. A ‘‘plastic’’ sutureless abdominal wall closure in gas-
troschisis. J Pediatr Surg 2004;39:738–41.
[10] Youssef F, Gorgy A, Arbash G, et al. Flap versus fascial closure for gastroschisis: a system-
atic review and meta-analysis. J Pediatr Surg 2016;51:718–25.
[11] Grabski DF, Hu Y, Vavolizza RD, et al. Sutureless closure: a versatile treatment for the diverse
presentations of gastroschisis. J Perinatol 2019;39:666–72.
GASTROSCHISIS CLOSURE 129

[12] Fraser JD, Deans KJ, Fallat ME. Midwest Pediatric Surgery Consortium. Sutureless vs sutured
abdominal wall closure for gastroschisis: Operative characteristics and early outcomes from
the Midwest Pediatric Surgery Consortium. J Pediatr Surg 2020; https://doi.org/10.
1016/j.jpedsurg.2020.02.017. [Epub ahead of print].
[13] Kunz SN, Tieder JS, Whitlock K, et al. Primary fascial closure versus staged closure with silo
in patients with gastroschisis: a meta-analysis. J Pediatr Surg 2013;48:845–57.
[14] Gonzalez DO, Cooper JN, St. Peter SD, et al. Variability in outcomes after gastroschisis
closure across U.S. children’s hospitals. J Pediatr Surg 2018;53:513–20.
[15] Hawkins RB, Raymond SL, St. Peter SD, et al. Immediate versus silo closure for gastroschisis:
results of a large multicenter study. J Pediatr Surg 2019 [pii:S0022-3468(19)30509-3].
[16] Miyake H, Seo S, O’Connell JS, et al. Safety and usefulness of plastic closure in infants with
gastroschisis: a systematic review and meta-analysis. Pediatr Surg Int 2019;35:107–16.