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Surgical Intervention Surgical Intervention for Gastroschisis for Gastroschisis Sam Smith MD Sam Smith MD Dept. of Surgery University Dept. of Surgery University of Arkansas and Arkansas of Arkansas and Arkansas Children’s Hospital Children’s Hospital

Surgical Intervention for Gastroschisis Sam Smith MD Dept. of Surgery University of Arkansas and Arkansas Children’s Hospital

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Page 1: Surgical Intervention for Gastroschisis Sam Smith MD Dept. of Surgery University of Arkansas and Arkansas Children’s Hospital

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

Page 2: Surgical Intervention for Gastroschisis Sam Smith MD Dept. of Surgery University of Arkansas and Arkansas Children’s Hospital

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.

Page 3: Surgical Intervention for Gastroschisis Sam Smith MD Dept. of Surgery University of Arkansas and Arkansas Children’s Hospital

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

Page 4: Surgical Intervention for Gastroschisis Sam Smith MD Dept. of Surgery University of Arkansas and Arkansas Children’s Hospital

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

Page 5: Surgical Intervention for Gastroschisis Sam Smith MD Dept. of Surgery University of Arkansas and Arkansas Children’s Hospital

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

Page 6: Surgical Intervention for Gastroschisis Sam Smith MD Dept. of Surgery University of Arkansas and Arkansas Children’s Hospital

Gastroschisis OnlyGastroschisis Only

Page 7: Surgical Intervention for Gastroschisis Sam Smith MD Dept. of Surgery University of Arkansas and Arkansas Children’s Hospital

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

Page 8: Surgical Intervention for Gastroschisis Sam Smith MD Dept. of Surgery University of Arkansas and Arkansas Children’s Hospital

Primary and Staged Primary and Staged ClosureClosure

Page 9: Surgical Intervention for Gastroschisis Sam Smith MD Dept. of Surgery University of Arkansas and Arkansas Children’s Hospital

Preformed Silo (1997)Preformed Silo (1997)

Page 10: Surgical Intervention for Gastroschisis Sam Smith MD Dept. of Surgery University of Arkansas and Arkansas Children’s Hospital

Preformed SiloPreformed Silo

Page 11: Surgical Intervention for Gastroschisis Sam Smith MD Dept. of Surgery University of Arkansas and Arkansas Children’s Hospital

Preformed SiloPreformed Silo

Page 12: Surgical Intervention for Gastroschisis Sam Smith MD Dept. of Surgery University of Arkansas and Arkansas Children’s Hospital

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%)

Page 13: Surgical Intervention for Gastroschisis Sam Smith MD Dept. of Surgery University of Arkansas and Arkansas Children’s Hospital

Change in Frequency of Change in Frequency of Primary Vs. Staged Primary Vs. Staged Closure Closure

Page 14: Surgical Intervention for Gastroschisis Sam Smith MD Dept. of Surgery University of Arkansas and Arkansas Children’s Hospital

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

Page 15: Surgical Intervention for Gastroschisis Sam Smith MD Dept. of Surgery University of Arkansas and Arkansas Children’s Hospital

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%)

Page 16: Surgical Intervention for Gastroschisis Sam Smith MD Dept. of Surgery University of Arkansas and Arkansas Children’s Hospital

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

Page 17: Surgical Intervention for Gastroschisis Sam Smith MD Dept. of Surgery University of Arkansas and Arkansas Children’s Hospital

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

Page 18: Surgical Intervention for Gastroschisis Sam Smith MD Dept. of Surgery University of Arkansas and Arkansas Children’s Hospital

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.

Page 19: Surgical Intervention for Gastroschisis Sam Smith MD Dept. of Surgery University of Arkansas and Arkansas Children’s Hospital

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

Page 20: Surgical Intervention for Gastroschisis Sam Smith MD Dept. of Surgery University of Arkansas and Arkansas Children’s Hospital

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

Page 21: Surgical Intervention for Gastroschisis Sam Smith MD Dept. of Surgery University of Arkansas and Arkansas Children’s Hospital

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

Page 22: Surgical Intervention for Gastroschisis Sam Smith MD Dept. of Surgery University of Arkansas and Arkansas Children’s Hospital

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

Page 23: Surgical Intervention for Gastroschisis Sam Smith MD Dept. of Surgery University of Arkansas and Arkansas Children’s Hospital

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

Page 24: Surgical Intervention for Gastroschisis Sam Smith MD Dept. of Surgery University of Arkansas and Arkansas Children’s Hospital

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