Factors determining outcome in gastroschisis: clinical experience over 18 years

Abstract

Although the survival in gastroschisis has improved to more than 85%, serious morbidity with consequent long hospital stay is still very common. Alternative strategies such as planned early delivery and amniotic fluid exchange are being explored. In order to evaluate these approaches, adequate risk stratification of patients with gastroschisis is required. The aim of this study was to identify the risk factors associated with increased morbidity and mortality. A retrospective analysis of all patients with gastroschisis treated at our institution between 1988 and 2005 was conducted. Patients' data were collected from the files and compared for statistical significance with three outcome measures: (1) complicated post-operative course; (2) time to full enteral feeding (TFE); (3) length of hospital stay (LOS). SPSS was used for statistical analysis. Fifty-nine newborns with gastroschisis were admitted during the study period. Antenatal diagnosis was made in 40 cases (68%). Associated malformations (other than intestinal anomalies) were present in eight patients. One patient with trisomy 13 was excluded from the analysis. Ten patients (17%) had compromised bowel (atresia, severe ischaemia or a combination). Primary repair was successful in 47 (81%) and in 11 patients a silo was applied. Overall survival was 54/58 children (93%), four patients died. Complications associated with closure occurred in eight patients. Postoperative course was uncomplicated in 45 patients and complicated in 13. The RR for patients with compromised bowel to have a complicated post-operative course is 9 (95% CI 2-39) and the RR to die is 20 (95% CI 2-222) for these patients. Risk stratification of patients with gastroschisis appears possible based on the presence of compromised bowel before closure.

Predictors of postnatal outcome in neonates with gastroschisis

“…Of 6 patients who died, 5 were either born with closed gastroschisis with intestinal atresia or had intestinal necrosis. These results are in accordance with other studies [8,12,19,27] and could be explained by the development of SBS in 9 of our 13 patients with intestinal atresia. Those patients required continuation of PN, and in combination with episodes of septicemia, they developed IFALD, and finally, 3 died of liver failure.…”

“…Although sepsis was an independent predictor of poor outcome in our patients, the incidence of sepsis (16.5%) was lower than those reported by others, which ranged from 26% to 42% [12,14,18]. Their patients also had longer LOS and more days on PN.…”

“…Some infants with gastroschisis develop short bowel syndrome (SBS) and may require liver and/or intestinal transplantation [7]. The optimal management for neonates with gastroschisis is unclear because there are conflicting opinions in the literature regarding optimal timing, route of delivery, location of postnatal repair, primary repair vs elective secondary repair, and whether fetal bowel dilatation is a predictor of outcome [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23]. Counseling of parents during pregnancy is difficult because the postnatal outcome in the individual newborn with gastroschisis is unpredictable and there is a lack in clearly defined risk factors.…”

Prenatal Risk Factors and Outcomes in Gastroschisis: A Meta-Analysis

“…2,3 The highly variable return to functional bowel (due to chronic intestinal inflammation) and the occurrence of bowel atresia (BA; requiring intestinal surgery in ∼10%-20% of cases) are the main factors affecting length of hospital stay (LOS) as well as total parenteral nutrition (TPN) dependence and associated neonatal complications (ie, recurrent sepsis, TPN cholestasis, adhesive bowel obstruction). 2,[4][5][6] Different surgical techniques (primary vs staged closure) to repair this abdominal wall defect did not show significant differences in outcomes. 2 In developed countries, prenatal diagnosis allows a 90% detection rate of gastroschisis within the second trimester of pregnancy.…”

Profile of Newborns With Gastroschisis Diagnosis in a Public Hospital at Porto Alegre/Rs

“…However, the most appropriate mode of delivery for this condition is still controversial. Studies did not show any benefit from routine surgical delivery [19][20][21] except for the possibility of planning neonatal care together with the neonatology team. In the present study, 79.2% of infants were born by cesarean section, of which 97.6% were performed with medical indication due to gastroschisis.…”