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

2. How To Pronounce the Word Dorland and Stedman - gas-tros’ ki-sis (G. gastro + G. schisis, a fissure) Dorland and Stedman - gas-tros’ ki-sis (G. gastro + G. schisis, a fissure) It should be gas-tro-ski’-sis like gastroduodenoscopy, gastrodynia, gastroenteritis, gastroesophageal etc. It should be gas-tro-ski’-sis like gastroduodenoscopy, gastrodynia, gastroenteritis, gastroesophageal etc.

3. History and Significant Advances Neonatal ventilation Neonatal ventilation The successful use of TPN to support nutrition The successful use of TPN to support nutrition Staged closure of large abdominal wall defects with use of silastic sheets sewn to the abdominal wall Staged closure of large abdominal wall defects with use of silastic sheets sewn to the abdominal wall

4. Primary Closure vs. Staged Closure Problems Primary Closure: abdominal compartment syndrome with risk of renal failure and bowel injury Primary Closure: abdominal compartment syndrome with risk of renal failure and bowel injury Staged Closure: wound breakdown, fascial separation and infection Staged Closure: wound breakdown, fascial separation and infection

5. Purpose Clarify the impact of a preformed silo on primary vs. stage closure of gastroschisis Clarify the impact of a preformed silo on primary vs. stage closure of gastroschisis

6. Gastroschisis Only

7. Methods Reviewed medical records over past 10 years for: closure method, duration mechanical ventilation, time to full feeds, mechanical and infectious complications, and length of stay Reviewed medical records over past 10 years for: closure method, duration mechanical ventilation, time to full feeds, mechanical and infectious complications, and length of stay Divided into 2 groups based on method of closure Divided into 2 groups based on method of closure

8. Primary and Staged Closure

9. Preformed Silo (1997)

10. Preformed Silo

12. Results 1993 – present, 118 patients 6 excluded for other lethal anomalies 1993 – present, 118 patients 6 excluded for other lethal anomalies 1993-1997- 38 patients 1993-1997- 38 patients –32 primary (84.2%) –6 staged (18.8%) (silastic sheeting) 1997-2002 – 80 patients 1997-2002 – 80 patients –27 primary (33.8%) –53 staged with preformed silo (66.2%)

13. Change in Frequency of Primary Vs. Staged Closure

14. Results * p<.05 Staged or Silo Primary Length of Stay 37.7 + 12* days 29.7 + 18 days Time on Ventilator 8.6 + 4.8* days 2.5 + 3.6 days Days to Full enteric feeds 32 + 17 days 31 + 23 days

15. Results * p<.05 Stage Closure Primary Closure Infections 12 (20%) 18 (31)%* Intestinal Stricture 10 (17%) 14 (24%) * Re-operation 10 (16%) 17 (29%)* Deaths 3 (3.3%) 2 (3.4%)

16. Re-operations * p<.05 1993- 1997 N=38 1998- 2002 N=16 Primary 32 Staged 6 Primary 27 Staged 53 Decomp. Abd. compartment 6*6*6*6*000 NEC7204 Stricture12327 Reinsertion of CVL 5303

17. Conclusion Staged closure associated with longer hospital stay and decreased bowel dysfunction or need for re-operation Staged closure associated with longer hospital stay and decreased bowel dysfunction or need for re-operation Lower incidence of infection and complications led to an increase in staged closure of gastroschisis in our practice Lower incidence of infection and complications led to an increase in staged closure of gastroschisis in our practice

18. Conclusion Review of our results suggest that staged closure is the preferred method of gastroschisis closure in the majority of patients. Review of our results suggest that staged closure is the preferred method of gastroschisis closure in the majority of patients.

19. Fine Tuning Staged Closure Place preformed silo in NICU with PIC line Place preformed silo in NICU with PIC line Baby is never intubated or quickly extubated until final closure. Baby is never intubated or quickly extubated until final closure. Now length of stay and time on ventilator appears equal between staged and historic primary closure patients Now length of stay and time on ventilator appears equal between staged and historic primary closure patients

20. Benefits of Term Delivery in Infants with Antenatally Diagnosed Gastroschisis Data on all patients with gastroschisis seen at single institution 1991-2001 Data on all patients with gastroschisis seen at single institution 1991-2001 Patients compared based gestation age in weeks: Patients compared based gestation age in weeks: –Less than 35 –35 – 37 –Greater than 37 weeks Huang et. Al. Obstetrics & Gynecology 100:695-699, Oct. 2002

21. Benefits of Term Delivery in Infants with Antenatally Diagnosed Gastroschisis (cont.) Age at definitive closure was significantly higher 35-37 (5.9 + 4.6) than term (1.5 + 2.3) or preterm (2.6 + 2.5) Age at definitive closure was significantly higher 35-37 (5.9 + 4.6) than term (1.5 + 2.3) or preterm (2.6 + 2.5) Silo was used more often at 35-37 week Silo was used more often at 35-37 week Age at full feedings and length of hospitalization all significantly longer Age at full feedings and length of hospitalization all significantly longer Huang et. Al. Obstetrics & Gynecology 100:695-699, Oct. 2002

22. Benefits of Term Delivery in Infants with Antenatally Diagnosed Gastroschisis (cont.) Term delivery results in earlier closure and shorter time to full feedings Term delivery results in earlier closure and shorter time to full feedings The benefit of early delivery postulated by others cannot be substantiated The benefit of early delivery postulated by others cannot be substantiated

23. Comment on Huang et. Al. Roger Lenke Indianapolis Confused concept of predictability with prevention. Confused concept of predictability with prevention. Assume that delivery doctor had a reason for delivering baby before term Assume that delivery doctor had a reason for delivering baby before term Thus data presented shows that infants with gastroschisis and no indication for delivery until term did better than those with complications leading to preterm deliveries Thus data presented shows that infants with gastroschisis and no indication for delivery until term did better than those with complications leading to preterm deliveries

24. Comment on Huang et. Al. Roger Lenke Indianapolis (Cont.) Two theories not yet tested. Two theories not yet tested. –Ruptured membranes and hours of contractions add to bowel damage –Longer the fetus is in utero, the more likely there will be complications Need prospective randomized studies for early vs. late delivery and elective delivery before ruptured membranes- labor vs. labor Need prospective randomized studies for early vs. late delivery and elective delivery before ruptured membranes- labor vs. labor