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Surgical Intervention for Gastroschisis

Surgical Intervention for Gastroschisis. Sam Smith MD Dept. of Surgery University of Arkansas and Arkansas Children’s Hospital. How To Pronounce the Word. Dorland and Stedman - gas-tros’ ki-sis (G. gastro + G. schisis , a fissure)

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Surgical Intervention for Gastroschisis

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  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) • It should be gas-tro-ski’-sis like gastroduodenoscopy, gastrodynia, gastroenteritis, gastroesophageal etc.

  3. History and Significant Advances • Neonatal ventilation • 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

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

  5. Purpose • 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 • Divided into 2 groups based on method of closure

  8. Primary and Staged Closure

  9. Preformed Silo (1997)

  10. Preformed Silo

  11. Preformed Silo

  12. Results • 1993 – present, 118 patients 6 excluded for other lethal anomalies • 1993-1997- 38 patients • 32 primary (84.2%) • 6 staged (18.8%) (silastic sheeting) • 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

  15. Results

  16. Re-operations

  17. Conclusion • 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

  18. Conclusion • 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 • 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

  20. Benefits of Term Delivery in Infants with Antenatally Diagnosed Gastroschisis • Data on all patients with gastroschisis seen at single institution 1991-2001 • 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) • Silo was used more often at 35-37 week • 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 • 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. • 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

  24. Comment on Huang et. Al.Roger Lenke Indianapolis (Cont.) • 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

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