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Josephine

Abdominal wall defect- Gastroschisis

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bimalc    24

Surgical or medical management?  I am not a pediatric surgeon, but I am sure there is a literature on timing of closure.

I think of several medical management issues when there is a baby with this problem in my ICU:

 

- Delivery room: sterile bowel bag is a must.  Avoid umbilical catheterization if possible.  We obtain cultures and start antibiotics for all gastroschesis because of the exposed bowel and risk of contamination despite best efforts at sterility.

- Fluids: surgeons may be worried excessive fluids will cause edematous bowel and make closure more difficult, but even with a silo there are lots of insensible losses and fluid needs will be great.  Track urine output and heart rate closely as well as electrolytes.

- Pain control/sedation/meds both for the abdomen and the fact that patient is likely to be intubated but also you may need to provide anesthesia for bedside closure.  We use high dose fentanyl and rocuronium +/- benzodiazepine.  Need to have code medications & fluid drawn up and nurse dedicated to administering medication.

- Having enough access - you can try to use a PICC, but many of these patients will need longer term access anyway, so surgeons may place tunneled line for you.

- Biggest issue with success in my experience is not the surgery itself, but re-establishing feeding afterwards.  It pays to be patient and accept slower advancement if it ultimately means less time on TPN and less central line days.

 

Are there specific issues/questions you have for your practice setting?

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Josephine    10

Thanks Bimalc for the input,very important.

We have done that,but our success rates are very poor in our setup.The oedematous bowel becomes gangrenous and post operatively they don't do well

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@Josephine you might find this article helpful or as a starting point for further literature review: https://www.ncbi.nlm.nih.gov/pubmed/27032610

Quote

J Pediatr Surg. 2016 Aug;51(8):1262-7. doi: 10.1016/j.jpedsurg.2016.02.090. Epub 
2016 Mar 12.

Gastroschisis: Bellwether for neonatal surgery capacity in low resource settings?

Ford K(1), Poenaru D(2), Moulot O(3), Tavener K(4), Bradley S(5), Bankole R(3),
Tshifularo N(6), Ameh E(7), Alema N(8), Borgstein E(9), Hickey A(4), Ade-Ajayi
N(10).

Author information: 
(1)King's Centre for Global Health, London, UK; King's College Hospital, London, 
UK.
(2)MyungSung Christian Medical center, Addis Ababa, Ethiopia.
(3)Centre Hospitalier Universitairee, Treichville, Cote D'Ivorie.
(4)King's College Hospital, London, UK.
(5)St George's Hospital, London, UK.
(6)George Mukhari Academic Hospital, Pretoria, South Africa.
(7)National Hospital, Abujah, Nigeria.
(8)St Mary's, Lacor, Uganda.
(9)Queen Elizabeth Hospital, Blantyre, Malawi.
(10)King's Centre for Global Health, London, UK; King's College Hospital, London,
UK. Electronic address: adeajayi@doctors.org.uk.

INTRODUCTION: Economic disadvantage may adversely influence the outcomes of
infants with gastroschisis (GS). Gastroschisis International (GiT) is a network
of seven paediatric surgical centres, spanning two continents, evaluating GS
treatment and outcomes.
MATERIAL AND METHODS: A 2-year retrospective review of GS infants at GiT centres.
Primary outcome was mortality. Sites were classified into high, middle and low
income country (HIC, MIC, and LIC). MIC and LIC were sometimes combined for
analysis (LMIC). Disability adjusted life years (DALYs) were calculated and
centres with the highest mortality underwent a needs assessment.
RESULTS: Mortality was higher in the LICs and LMICs: 100% in Uganda and Cote
d'Ivoire, 75% in Nigeria and 60% in Malawi. 29% and 0% mortality was reported in 
South Africa and the UK, respectively. Septicaemia was the commonest cause of
death. Averted and non-avertable DALYs were nil in Uganda and Cote d'Ivoire (no
survivors). In the UK (100% survival) averted DALYs (met need) was highest,
representing death and disability prevented by surgical intervention. Performance
improvement measures were agreed: a prospectively maintained GS register;
clarification of the key team members of a GS team and management pathway.
CONCLUSIONS: We propose the use of GS as a bellwether condition for assessing
institutional capacity to deliver newborn surgical care. Early access to care,
efficient multidisciplinary team working, appropriate resuscitation, avoidance of
abdominal compartment syndrome, stabilization prior to formal closure and
proactive nutritional interventions may reduce GS-associated burden of disease in
low resource settings.

 

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How are you managing their GUTS after birth. We deliver between 12-15 an year have not had a death due to the gut being an issue ever. The one problem is leaving them to go post term. The defect starts closing causing the bowel to become ischemic. Most of ours will get induced around 38 weeks. We use silos in 90% of cases

 

Alok

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