surgical intervention for gastroschisis sam smith md dept. of surgery university of arkansas and...
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Surgical Intervention Surgical Intervention for Gastroschisisfor Gastroschisis
Sam Smith MDSam Smith MD
Dept. of Surgery University of Dept. of Surgery University of Arkansas and Arkansas Children’s Arkansas and Arkansas Children’s HospitalHospital
How To Pronounce the How To Pronounce the WordWord Dorland and Stedman - gas-tros’ Dorland and Stedman - gas-tros’
ki-sis (G. ki-sis (G. gastrogastro + G. + G. schisisschisis, a , a fissure)fissure)
It should be gas-tro-ski’-sis like It should be gas-tro-ski’-sis like gastroduodenoscopy, gastroduodenoscopy, gastrodynia, gastroenteritis, gastrodynia, gastroenteritis, gastroesophageal etc.gastroesophageal etc.
History and Significant History and Significant AdvancesAdvances Neonatal Neonatal
ventilationventilation The successful use The successful use
of TPN to support of TPN to support nutritionnutrition
Staged closure of Staged closure of large abdominal large abdominal wall defects with wall defects with use of silastic use of silastic sheets sewn to the sheets sewn to the abdominal wallabdominal wall
Primary Closure vs. Primary Closure vs. Staged Closure Staged Closure ProblemsProblems Primary Closure: Primary Closure:
abdominal abdominal compartment compartment syndrome with risk syndrome with risk of renal failure and of renal failure and bowel injurybowel injury
Staged Closure: Staged Closure: wound breakdown, wound breakdown, fascial separation fascial separation and infectionand infection
PurposePurpose
Clarify the Clarify the impact of a impact of a preformed silo on preformed silo on primary vs. stage primary vs. stage closure of closure of gastroschisisgastroschisis
Gastroschisis OnlyGastroschisis Only
MethodsMethods
Reviewed medical records over Reviewed medical records over past 10 years for: closure past 10 years for: closure method, duration mechanical method, duration mechanical ventilation, time to full feeds, ventilation, time to full feeds, mechanical and infectious mechanical and infectious complications, and length of staycomplications, and length of stay
Divided into 2 groups based on Divided into 2 groups based on method of closuremethod of closure
Primary and Staged Primary and Staged ClosureClosure
Preformed Silo (1997)Preformed Silo (1997)
Preformed SiloPreformed Silo
Preformed SiloPreformed Silo
ResultsResults
1993 – present, 118 patients 6 1993 – present, 118 patients 6 excluded for other lethal anomaliesexcluded for other lethal anomalies
1993-1997- 38 patients1993-1997- 38 patients– 32 primary (84.2%)32 primary (84.2%)– 6 staged (18.8%) (silastic sheeting)6 staged (18.8%) (silastic sheeting)
1997-2002 – 80 patients1997-2002 – 80 patients– 27 primary (33.8%)27 primary (33.8%)– 53 staged with preformed silo (66.2%)53 staged with preformed silo (66.2%)
Change in Frequency of Change in Frequency of Primary Vs. Staged Primary Vs. Staged Closure Closure
ResultsResults
* p<.05* p<.05 Staged or Staged or SiloSilo
PrimaryPrimary
Length of Length of Stay Stay
37.7 37.7 ++ 12 12** daysdays
29.7 29.7 ++ 18 18 daysdays
Time on Time on VentilatorVentilator
8.6 8.6 ++ 4.8 4.8** daysdays
2.5 2.5 ++ 3.6 3.6
daysdays
Days to Full Days to Full enteric feedsenteric feeds
32 32 ++ 17 17 daysdays
31 31 ++ 23 23 daysdays
Results Results
* p<.05* p<.05 Stage Stage ClosureClosure
Primary Primary ClosureClosure
InfectionsInfections 12 (20%)12 (20%) 18 (31)%18 (31)%**
Intestinal Intestinal StrictureStricture
10 (17%)10 (17%) 14 (24%) 14 (24%) **
Re-operationRe-operation 10 (16%)10 (16%) 17 (29%)17 (29%)**
DeathsDeaths 3 (3.3%)3 (3.3%) 2 (3.4%)2 (3.4%)
Re-operationsRe-operations
* p<.05* p<.05 1993-1993-1997 1997
N=38N=38 1998-1998-20022002
N=16N=16
Primary Primary 3232
Staged Staged 66
Primary Primary 2727
StageStaged 53d 53
Decomp. Decomp. Abd. Abd. compartmentcompartment
66** 00 00 00
NECNEC 77 22 00 44StrictureStricture 1212 33 22 77Reinsertion Reinsertion of CVLof CVL
55 33 00 33
ConclusionConclusion
Staged closure associated with Staged closure associated with longer hospital stay and longer hospital stay and decreased bowel dysfunction or decreased bowel dysfunction or need for re-operation need for re-operation
Lower incidence of infection and Lower incidence of infection and complications led to an increase complications led to an increase in staged closure of gastroschisis in staged closure of gastroschisis in our practicein our practice
ConclusionConclusion
Review of our Review of our results suggest results suggest that staged that staged closure is the closure is the preferred method preferred method of gastroschisis of gastroschisis closure in the closure in the majority of majority of patients.patients.
Fine Tuning Staged Fine Tuning Staged ClosureClosure Place preformed silo in NICU with Place preformed silo in NICU with
PIC linePIC line Baby is never intubated or quickly Baby is never intubated or quickly
extubated until final closure. extubated until final closure. Now length of stay and time on Now length of stay and time on
ventilator appears equal between ventilator appears equal between staged and historic primary staged and historic primary closure patientsclosure patients
Benefits of Term Delivery Benefits of Term Delivery in Infants with in Infants with Antenatally Diagnosed Antenatally Diagnosed GastroschisisGastroschisis Data on all patients with Data on all patients with
gastroschisis seen at single gastroschisis seen at single institution 1991-2001institution 1991-2001
Patients compared based Patients compared based gestation age in weeks:gestation age in weeks:– Less than 35Less than 35– 35 – 3735 – 37– Greater than 37 weeksGreater than 37 weeks
Huang et. Al. Obstetrics & Gynecology 100:695-699, Oct. 2002
Benefits of Term Delivery in Benefits of Term Delivery in Infants with Antenatally Infants with Antenatally Diagnosed Gastroschisis Diagnosed Gastroschisis (cont.)(cont.) Age at definitive closure was Age at definitive closure was
significantly higher 35-37 (5.9 significantly higher 35-37 (5.9 ++ 4.6) than term (1.5 4.6) than term (1.5 ++ 2.3) or 2.3) or preterm (2.6 preterm (2.6 ++ 2.5) 2.5)
Silo was used more often at 35-37 Silo was used more often at 35-37 weekweek
Age at full feedings and length of Age at full feedings and length of hospitalization all significantly hospitalization all significantly longerlonger
Huang et. Al. Obstetrics & Gynecology 100:695-699, Oct. 2002
Benefits of Term Delivery in Benefits of Term Delivery in Infants with Antenatally Infants with Antenatally Diagnosed Gastroschisis Diagnosed Gastroschisis (cont.)(cont.) Term delivery results in earlier Term delivery results in earlier
closure and shorter time to full closure and shorter time to full feedingsfeedings
The benefit of early delivery The benefit of early delivery postulated by others cannot be postulated by others cannot be substantiatedsubstantiated
Comment on Huang et. Comment on Huang et. Al.Al.Roger Lenke IndianapolisRoger Lenke Indianapolis Confused concept of predictability with Confused concept of predictability with
prevention.prevention. Assume that delivery doctor had a Assume that delivery doctor had a
reason for delivering baby before termreason for delivering baby before term Thus data presented shows that Thus data presented shows that
infants with gastroschisis and no infants with gastroschisis and no indication for delivery until term did indication for delivery until term did better than those with complications better than those with complications leading to preterm deliveriesleading to preterm deliveries
Comment on Huang et. Al.Comment on Huang et. Al.Roger Lenke Indianapolis Roger Lenke Indianapolis (Cont.)(Cont.)
Two theories not yet tested. Two theories not yet tested. – Ruptured membranes and hours of Ruptured membranes and hours of
contractions add to bowel damagecontractions add to bowel damage– Longer the fetus is in utero, the more Longer the fetus is in utero, the more
likely there will be complicationslikely there will be complications Need prospective randomized Need prospective randomized
studies for early vs. late delivery studies for early vs. late delivery and elective delivery before and elective delivery before ruptured membranes-labor vs. laborruptured membranes-labor vs. labor