HAPPY IME

Gastroschisis
Pembimbing :
dr. Shalita Dastamuar, Sp.B Sp.BA
dr. Windi Astriana, Sp.BA
EMBRYOLOGY AND ETIOLOGY
2nd week
4th week
6th week
Obliterated Rt umblicalvein
EMBRYOLOGY AND ETIOLOGY

(Gastroschisis)

• etiology for gastroschisis is less clear

• >>One theory suggests that gastroschisis results from
failure of the mesoderm to form in the anterior
abdominal wall
• >>Currently(most widely accepted), the ventral body
folds theory

• which suggests failure of migration of the lateral folds

(more frequent on the right side),
Possible causative factors

• Tobacco
• certain environmental exposures
• lower maternal age
• low socioeconomic status
GASTROSCHISIS

• 1 in 4,000 live births

• mothers younger than 21 years
• Preterm delivery (28% Vs 6%)
• maternal serum α-fetoprotein
(AFP) level (elevated in the presence of gastroschisis)
• ACHE
Diagnostic US by 20 wks
• bowel loops freely floating in the amniotic fluid
• defect in the abdominal wall to the right of a
normal umbilical cord
• Intrauterine growth retardation (IUGR)
..con
t
…cont
• Some authors advocate selective preterm delivery
based on the finding of bowel distention and thickening on
prenatal ultrasound
• Bowel dilitation from 7 to 25 mm is associated with fetal
distress and demise
…cont
. duration of amniotic fluid exposure is correlated with the
degree of the inflammatory peel and intestinal
dysmotility
. bowel atresia is the most common associated
anomaly(6.9–28%)
. cardiac, pulmonary, nervous, musculoskeletal
genitourinary systems, as well as chromosomal
abnormalities
Perinatal Care(gastris…)

. both vaginal delivery and C-section are safe

. Preterm delivery is advocated
. dysmotility and malabsorption(Damage to the
pacemaker cells and nerve plexi )
. evidence does not support elective preterm delivery for
gastroschisis
Neonatal Resuscitation
and Management
• Appropriate IV access and fluid resuscitation initiated after
birth
• Nasogastric (NG) decompression
• The bowel should be wrapped in warm saline-soaked
gauze and placed in a central position on the abdominal
wall
• positioned on the right side(prevents kinking)
..cont
• The bowel should be wrapped with plastic wrap or
the infant placed partially in a plastic bag
• gastroschisis >>>isolatedanomaly
• intestinal atresia, necrosis, or
perforation>>>complicated
• excess fluid resuscitation >>poor outcome
Surgical Management

• goal >>return the viscera to the abdominal

cavity
• In minimizing the risk of damage due to
trauma or increased intra-abdominal pressure.
Two most commonly used treatment options
I. silo + serial reductions +delayed closure,
II. primary closure
…cont
• N.B>>inspection of the bowel for obstructing bands,
perforation, or atresia>>>> before silo application or
primary closure
Primary Closure

• in neonates in whom reduction of the herniated

viscera appears possible>> it has to be done
• Is in the operating room, but some advocates primary
closure at the bedside without general anesthesia
• close the skin only and leave the fascia separated
…cont
• Prosthetic options for primary closure
• preservation of the umbilicus has
been shown to lead to an excellent cosmetic
result(against the previous view)
• Intra-abdominal pressure approximated from either the
bladder pressure or stomach pressure
…cont
. Pressures >10– 15 mmHg >>decreased renal and
intestinal perfusion>> apply silo or patch
. Pressures higher than 20 mmHg can lead to
renal failure and bowel ischemia
. CVP greater than 4 mmHg has been correlated with
the need for silo placement or patch closure
. Splanchnic perfusion pressure at least 44mmHg is
acceptable
Staged Closure

• Spring loaded silo>>> made it possible to insert the silo

in the delivery room or at the bedside
…cont
• takes 1 to 14 days with the majority being ready within
a week, depending on the condition of the bowel and
the infant
…cont
Definitive closure
• Small skin flaps around the fascia
• Closure of the fascia in vertical or horyzontal direction
• Closure of the skin in a transverse direction Vs
vertical direction(keyhole sign)
…cont
. purse-string skin closure around the umbilicus
. the umbilical cord is tailored to fill the gastroschisis defect
and is then covered with an adhesive dressing
. Residual ventral hernia rates are reported to be 60–84%
Primary vs staged closure
• Avoidance of ischemic injury
• Need for mechanical ventilator
• Early initiation of PO feeding to the
foolest
• Oxygen requirement
• Vasopressor requirement
• Effect on UOP
CLOSING SKIN
ONLY
Management of Associated
Intestinal Atresia
• Up to 10% of neonates with gastroschisis have an
associated atresia
• jejunal or ileal
• 5% small bowel atresia 5% and a large bowel atresia
IS 2%
Management of atresia(gastr..)
Options
• Resection and primary anastomosis + primary
closure
• Four to six weeks after the primary closure
• Stoma + primary anastomosis
 complicated
gastroschisis
Gastriscisis plus one of the following
• atresia,
• perforation,
• Necrosis
• Volvulus
Associated with poor prognosis
Postoperative Course

• abnormal intestinal motility and nutrient absorption,

gradually improve in most patients
• NGT decompression
• Parenteral nutrition
• Enteral feeding started when the bowel functions(wks)
…cont
• Early oral stimulation

• Prokinetic medication
•
Long-Term Outcomes

• Long-term outcomes for patients born with gastroschisis

are generally excellent( except complex disease)
• complex gastroschisis took a median of 21 days longer
to reach full enteral feedings
 Poor prognostic factors(complex
disease)
• 21 days longer to reach full enteral feedings,
• had a longer total parenteral nutrition (TPN)
use
• had almost 2 months longer length of hospitalization
twice as likely to develop intestinal failure
six times more likely to develop liver disease
…cont
. Intestinal transplantation(last resort)
. NEC (up to 18.5%)
. Most patients have some degree of intestinal
nonrotation
. Cryptorchidism(15–30%)
. If the umbilicus is sacrificed ,up to 60% of children report
psychosocial stress
Reference
1. ASCHCRAFT’S PEDIATRIC SURGERY,6TH ED.
2. PEDIATRIC SURGERY(ARNOLD G.CORAN),7TH ED.
3. OPERATIVE PEDIATRIC SURGERY,2ND ED
4. ATLAS OF PEDIATRIC SURGERY,2ND ED
5. UPTODATE 21.2
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