Complex gastroschisis: a new indication for fetal surgery?

Abstract

Gastroschisis (GS) is a congenital abdominal wall defect, in which the bowel eviscerates from the abdominal cavity. It is a non‐lethal isolated anomaly and its pathogenesis is hypothesized to occur as a result of two hits: primary rupture of the ‘physiological’ umbilical hernia (congenital anomaly) followed by progressive damage of the eviscerated bowel (secondary injury). The second hit is thought to be caused by a combination of mesenteric ischemia from constriction in the abdominal wall defect and prolonged amniotic fluid exposure with resultant inflammatory damage, which eventually leads to bowel dysfunction and complications. GS can be classified as either simple or complex, with the latter being complicated by a combination of intestinal atresia, stenosis, perforation, volvulus and/or necrosis. Complex GS requires multiple neonatal surgeries and is associated with significantly greater postnatal morbidity and mortality than is simple GS. The intrauterine reduction of the eviscerated bowel before irreversible damage occurs and subsequent defect closure may diminish or potentially prevent the bowel damage and other fetal and neonatal complications associated with this condition. Serial prenatal amnioexchange has been studied in cases with GS as a potential intervention but never adopted because of its unproven benefit in terms of survival and bowel and lung function. We believe that recent advances in prenatal diagnosis and fetoscopic surgery justify reconsideration of the antenatal management of complex GS under the rubric of the criteria for fetal surgery established by the International Fetal Medicine and Surgery Society (IFMSS). Herein, we discuss how conditions for fetoscopic repair of complex GS might be favorable according to the IFMSS criteria, including an established natural history, an accurate prenatal diagnosis, absence of fully effective perinatal treatment due to prolonged need for neonatal intensive care, experimental evidence for fetoscopic repair and maternal and fetal safety of fetoscopy in expert fetal centers. Finally, we propose a research agenda that will help overcome barriers to progress and provide a pathway toward clinical implementation. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Improved Mortality of Patients with Gastroschisis: A Historical Literature Review of Advances in Surgery and Critical Care from 1960–2020

“…Though potential predictive factors of complex gastroschisis have been identified with the use of prenatal imaging, refinement of prenatal evaluation of complex gastroschisis is still needed [ 32 , 37 ]. Furthermore, fetal surgery has also been more recently proposed, though further data and investigation is needed regarding this innovative intervention [ 38 , 39 ].…”

Regenerative medicine: prenatal approaches

“…Finally, complex tissue engineering tissues such as fetal skin biodegradable collagen scaffolds can be used to treat full-thickness fetal skin defects 70 , and facilitate skin closure in fetuses undergoing prenatal repair in small and large animal models. The latter may become useful to treat other prenatal defects such as gastroschisis which could be treated before birth 71 .…”

Optimal timing of delivery for growth restricted fetuses with gastroschisis: A decision analysis

“…Gastroschisis is a congenital defect in which the bowel eviscerates through the paraumbilical ventral abdominal wall and is exposed to amniotic fluid 1,2 . The prevalence of gastroschisis has increased over time for reasons that are not well understood, with a 105%–137% change between 2005 and 2018 3,4 .…”

“…Gastroschisis is a congenital defect in which the bowel eviscerates through the paraumbilical ventral abdominal wall and is exposed to amniotic fluid. 1,2 The prevalence of gastroschisis has increased over time for reasons that are not well understood, with a 105%-137% change between 2005 and 2018. 3,4 Gastroschisis is an important diagnosis to identify prenatally given the risks of numerous associated complications such as FGR; preterm birth; stillbirth; and atresia, stenosis, perforation, volvulus or necrosis of the intestines.…”