Postnatal outcome in gastroschisis: effect of birth weight and gestational age

Introduction

Early elective delivery of antenatally diagnosed gastroschisis has been proposed as a strategy to minimize postnatal morbidity. This hypothesis was tested by analyzing outcome in relationship to gestational age and birth weight at delivery.

Methods

Single-center retrospective review of infants born with gastroschisis over a 13-year period (January 1993-December 2005). Standard outcome measures were compared using nonparametric methods. Data are quoted as median values (range).

Results

The study population consisted of 110 infants with gastroschisis. They were divided according to gestational age (group A, <35 weeks; group B, 35-37 weeks; group C, >37 weeks) and birth weight (group D, <2 kg; group E, 2-2.5 kg; group F, >2.5 kg).Duration in hospital (P < .01) and time to full enteral feeding (P = .05) was increased in group A vs groups B and C. In comparison, duration in hospital (P < .01), days ventilated (P = .03), establishment of full feeds (P = .01), and parentral nutrition (P = .02) were all prolonged in group D vs groups E and F.Six (5%) infants died (group D, n = 3; group E, n = 3). Necrotizing enterocolitis was found in 7 infants, and confined to groups D and E (χ² for trend P = .06).

Conclusion

There is no evidence that prematurity confers an advantage in restitution of gastrointestinal function in infants with gastroschisis; indeed, the opposite appears true. Birth weight, rather than gestational age, appears a better predictor of outcome.     

Effects of intrauterine treatment on interstitial cells of Cajal in gastroschisis

Aim

An experimental study was performed to investigate the effects of amnio-allantoic fluid exchange and intrauterine bicarbonate treatment on intestinal damage and interstitial cells of Cajal (ICC) in gastroschisis.

Materials and Methods

Thirteen-day-old fertilized chick eggs were randomly allocated into 4 groups as control, gastroschisis, gastroschisis + amnio-allantoic fluid exchange, and gastroschisis + bicarbonate treatment groups. In the treatment groups, amnio-allantoic exchange and bicarbonate treatments were performed for 3 days, after creating gastroschisis. Specimens were processed for hematoxylin-eosin and c-kit immunohistochemistry on the 18th day of incubation, after macroscopic examination. The intestines were evaluated with light microscopy for the presence of mucosal congestion and muscular and serosal edema. Mean muscular thickness and density of ICC were measured.

Results

Mean muscular thickness significantly increased in the gastroschisis group when compared with control and treatment groups. Labeling intensity, morphology, and localization of the ICC were similar in all groups. Mean ICC density significantly decreased in the gastroschisis group when compared with the control group (P < .01), and it significantly increased after amnio-allantoic fluid exchange treatment (P < .01).

Conclusions

The decrease in ICC density encountered in damaged intestinal loops in gastroschisis was prevented with intrauterine treatment. The beneficial effects of amniotic exchange on intestinal motility may depend on both prevention of intestinal damage and preservation of ICC density and function. The density of ICC might be a reliable numeric parameter both to predict intestinal motility disorders in gastroschisis and to compare the effectiveness of intrauterine treatment methods.     

Gastroschisis: ward reduction compared with traditional reduction under general anesthesia

Background/Purpose

In gastroschisis it is proposed that gut reduction may be achieved without intubation or general anesthesia (GA) through ward reduction. The authors aimed to determine if ward reduction decreased morbidity and duration of treatment.

Methods

Infants born from January 1, 1995, to December 31, 2001, with gastroschisis were managed with either reduction under GA in the operating theatre (OT group)—up to September 1999, or ward reduction (when eligible) in the neonatal unit without GA/ventilation (ward reduction [WR] group)—from September 1999.

Results

Of the 37 infants, 31 were eligible for ward reduction—15 from the OT group, 16 from the WR group. All infants in the OT group had at least 1 episode of ventilation and 1 GA: 62% of infants in the WR group avoided ventilation (P = .0002) and 81% avoided GA (P < .0001). Infants who had ward reduction had significantly shorter durations of ventilation and oxygen therapy. Septicemia occurred in 31% of the WR group and 7% of the OT group (P = .17). Infants who had ward reduction left intensive care 16 days earlier (P = .02) and tended to reach full enteral feeds 8 days sooner (P = .06) and be discharged from hospital 15 days earlier (P = .05).

Conclusions

Infants who had ward reduction do better in terms of avoiding GA/ventilation, establishing feeds, and going home earlier. A randomized, controlled trial comparing the 2 approaches is feasible, safe, and worthwhile.     

Does gastroschisis reduction require general anesthesia? A comparative analysis

Background

Outcome after gastroschisis repair without general anesthesia is controversial, and published conclusions are variable with no comparative studies.

Aim

The aim of this study was to present a comparative study evaluating outcome after gastroschisis repair with and without general anesthesia.

Methods

An ambispective nonrandomized study of a cohort of 51 neonates born with gastroschisis between July 1998 and December 2003 was performed. Twenty-four neonates (group 1) had conventional reduction under general anesthesia, and 27 (group 2) cotside minimal intervention reductions were without general anesthesia.

Results

Groups were comparable regarding gestational age, birth weight, and quality of eviscerated bowel. Statistical significance (P < .05) was seen between groups 1 and 2 with regard to age at reduction of gastroschisis (5.6 ± 2.5 vs 3 ± 1 hours) and time taken for completion of gastroschisis reduction (58.1 ± 15 vs 49 ± 14 minutes). No statistical significance (P > .05) was seen with respect to start of feeds (10.4 ± 3.6 vs 10.9 ± 4.1 days), duration of total parenteral nutrition (21.5 ± 7.3 vs 22.4 ± 6.8 days), and total hospital (stay 29 ± 10 vs 30 ± 13 days). Admission to the intensive care unit was required in 92% in group 1 for 1 to 6 days vs 7% in group 2 for 3 to 6 days. There was 1 death in group 1 (4%). Total hospital cost in group 1 was £12,283 ± £2438 vs £6208 ± £2120 in group 2 (P = .013).

Conclusions

Neonates with gastroschisis, whose bowel was reduced without general anesthesia, have similar outcomes to those whose bowel was reduced under general anesthesia. Both approaches appear to be safe and effective, but reduction without general anesthesia was cost-effective.     

The impact of prenatal bowel dilation on clinical outcomes in neonates with gastroschisis

Purpose

In fetuses with gastroschisis, the importance of ultrasonographic bowel dilation remains controversial. The outcome of patients with gastroschisis with and without prenatal bowel dilation is reported.

Methods

From 2000 to 2004, 27 neonates with gastroschisis were followed at a single center. Thirteen patients had prenatal ultrasonographic bowel dilation (diameter, ≥6 mm; range, 6-35 mm). Outcomes of those with and without dilation were compared using 2 sample t tests and logistic regression.

Results

Time to initiation of enteral nutrition varied significantly between groups (20.4 ± 11.7 days vs 12.5 ± 4.3 days, P < .05). A trend toward a reduced rate of primary closure was seen in those with dilation (23% vs 50%, P = .06). No significant difference was found when considering mortality, gestational age, time in the intensive care unit (ICU), time on parenteral nutrition, or length of stay. Prenatal bowel dilation, a longer ICU stay, and later gestational age independently predicted readmission for bowel obstruction (P < .001).

Conclusion

Infants with gastroschisis and prenatal bowel dilation were significantly slower to initiate enteral feeding and tended to have a reduced incidence of primary closure. This did not translate into increased mortality, time on parenteral nutrition, time in the ICU, or length of stay. However, dilation was associated with readmission for bowel obstruction.     

Outcome of gastroschisis: a 20-year case review of infants with gastroschisis born in Galveston, Texas

Background/Purpose

In the past decade, the preferred method of closure of gastroschisis at our institution has been staged reduction using a silo with repair on an elective basis (SR) rather than primary surgical closure (PC). We performed a 20-year case review of infants with gastroschisis at a university hospital to compare these shifts in management and to determine factors affecting outcome.

Methods

Seventy-two cases were reviewed from 1983 to 2003. Times to first and full feeds were outcome variables for statistical analysis.

Results

The prevalence of gastroschisis increased from 0.03% to 0.1% since 1983. Patients had low birth weights (mean = 2294 g) and were borderline premature (mean = 35.8 weeks). Only 3% of the infants were African American. There was a high rate of cesarean deliveries (57%). Ten patients (15%) had gastroschisis complicated by liver herniation, intestinal atresia(s), and/or necrosis/perforation. Most patients were managed by SR (67%). Eight percent of the infants died, 9% developed necrotizing enterocolitis, and 50% had other gastrointestinal complications. Twenty-seven percent of the infants managed with SR did not need initial mechanical ventilation. However, the patients who underwent SR were ventilated longer after birth as compared with those who underwent PC (P < .08). Infants with a complicated gastroschisis had significantly longer times to first and full feeds (P < .001). Patients managed with SR took significantly longer to reach full feeds (P = .001), and there was a trend of starting feeds later (P = .06). When patients with a complicated gastroschisis were excluded, the differences between the SR and PC groups were even greater (P = .01; P < .001).

Conclusions

In our patient population, the prevalence of gastroschisis increased by more than 400% since 1983. The defect was rare in African-American infants. Management by SR was associated with longer ventilation times and longer times to first and full feeds for both uncomplicated and complicated gastroschisis cases.     

Splanchnic perfusion pressure: a better predictor of safe primary closure than intraabdominal pressure in neonatal gastroschisis

Background/Purpose

Both measured intraabdominal pressure (IAP) and calculated splanchnic perfusion pressure (SPP) have been advocated for use in operative management of gastroschisis. We directly compared these 2 clinical indices.

Methods

Institutional review board-approved multi-institutional retrospective review from 3 centers with 112 subjects. Splanchnic perfusion pressure was recorded as mean arterial pressure-IAP. We compared the clinical utility of IAP and SPP using univariate and multivariate regression analyses.

Results

Calculated mean SPP was higher among neonates requiring silo placement compared to those without (39.0 ± 1.9 vs 33.7 mm Hg, P < .01). Measured IAP levels were similar between groups (11.5 ± 1.1 vs 10.0 ± 0.5, mm Hg, P < .4). On a receiver operating characteristic curve, the inflection point for more than 90% specificity for silo placement was at an SPP of 44. In multivariate regression analysis adjusting for all factors below, SPP was independently associated with silo placement (odds ratio 1.2, 95% confidence interval 1.1-1.3, P < .01), and IAP was not (odds ratio 1.2, 95% confidence interval <1.0-1.5, P < .1).

Conclusions

These data suggest that SPP is a stronger predictor than IAP for the ability to achieve primary closure in the management of neonatal gastroschisis. We infer from these data that intraoperative SPP of more than 43 mm Hg may obviate the need for silo placement.     

Survival of severe congenital diaphragmatic hernia has morbid consequences

Background/Purpose

Fetal tracheal occlusion (TO) was developed in an attempt to enhance prenatal lung growth and improve survival in fetuses with severe congenital diaphragmatic hernia (CDH). We conducted a randomized, controlled clinical trial in 24 fetuses with severe left CDH (liver herniated into the thorax and low lung-to-head ratio) to compare survival after endoscopic fetal TO vs standard perinatal care (control) and prospectively followed up the 16 survivors (9 control, 7 TO) to compare neurodevelopmental, respiratory, surgical, growth, and nutritional outcomes.

Methods

At 1 and 2 years old, subjects underwent evaluation consisting of medical and neurological history and physical, developmental testing, nutritional assessment, oxygen saturation and pulmonary function testing, chest radiograph, and echocardiogram. Growth and developmental measures were corrected for prematurity. Data were analyzed by Mann-Whitney rank sum test, Fisher's Exact test, and logistic and linear regression.

Results

Infants with TO were significantly more premature at birth (control vs TO, 37.4 ± 1.0 vs 31.1 ± 1.7 weeks; P < .01). Growth failure (z score for weight <2 SDs below mean) was severe in both groups at 1 year of age (control vs TO, 56% vs 86%; P = .31). There was considerable catch-up growth by age 2 years (growth failure: control vs TO, 22% vs 33%; P = .19). There were no differences in other growth parameters. There were also no differences in neurodevelopmental outcome at 1 and 2 years. Supplemental oxygen at hospital discharge was a significant predictor of worse neurodevelopmental outcome at 1 and 2 years old (P = .05 and P = .02, respectively). Hearing loss requiring amplification has been diagnosed in 44% of the group (control vs TO, 44% vs 43%; P = 1.0).

Conclusions

In this group of infants with severe CDH, there were no differences in outcome at 2 years old despite significant prematurity in the TO group. Oxygen supplementation at hospital discharge identified the most vulnerable group with respect to neurodevelopmental outcome, but all infants had significant growth failure, and hearing impairment is a substantial problem in this population. Severe CDH carries significant risk of chronic morbidity.     

A contemporary analysis of parenteral nutrition-associated liver disease in surgical infants

Background/purpose

Despite advances in pediatric nutritional support and a renewed focus on management of intestinal failure, there are limited recent data regarding the risk of parenteral nutrition (PN)-associated liver disease in surgical infants. This study investigated the incidence of cholestasis from PN and risk factors for its development in this population.

Methods

A retrospective review was performed of all neonates in our institution who underwent abdominal surgery and required postoperative PN from 2001 to 2006. Cholestasis was defined as 2 conjugated bilirubin levels greater than 2 mg/dL over 14 days. Nonparametric univariate analyses and multivariate logistic regression were used to model the likelihood of developing cholestasis. Median values with range are presented.

Results

One hundred seventy-six infants met inclusion criteria, and patients received PN for 28 days (range, 2-256 days). The incidence of cholestasis was 24%. Cholestatic infants were born at an earlier gestational age (34 vs 36 weeks; P < .01), required a 3-fold longer PN duration (76 vs 21 days; P < .001), had longer inpatient stays (86 vs 29 days; P < .001), and were more likely to be discharged on PN. The median time to cholestasis was 23 days. Cholestasis was an early development; 77% of cholestatic infants developed cholestasis by 5 weeks of PN exposure. On multivariate regression, only prematurity was significantly associated with development of cholestasis (P < .05).

Conclusion

In this analysis, the development of PN-associated liver disease occurred early in the course of exposure to PN. These data help to define the time course and prognosis for PN-associated cholestasis in surgical infants.     

Recombinant activated factor VII use in critically ill infants with active hemorrhage

Introduction

Recombinant activated factor VII (rFVIIa) is infrequently used off-label in infants despite a paucity of data in this population. We report a retrospective review of rFVIIa use in infants focusing on safety and efficacy.

Method

Between 2002 and 2007, 32 critically ill nonhemophiliac infants less than 1 year old received rFVIIa at our institution. Indications of rFVIIa and post-rFVIIa venous thrombosis were reviewed. Transfusion requirements were calculated 8 hours before and after rFVIIa administration.

Results

Infants received on average 2 doses of rFVIIa at a mean dosage of 90 μg/kg. Active hemorrhage was the indication for rFVIIa in 24 infants, which included postoperative bleeding in 16 and nonsurgical bleeding in 8. The remaining 8 infants had preoperative coagulopathy. Thrombosis was noted in 4 infants (13%) and was not related to transfusion requirements, the number of doses, or dosage of rFVIIa. For infants who had active hemorrhage, rFVIIa was able to significantly reduce the requirements of packed red blood cells by 36.17 mL/kg (P < .005), platelets by 10.31 mL/kg (P < .01), and cryoprecipitates by 2.19 mL/kg (P < .05).

Conclusion

This is the first large case series demonstrating the efficacy of rFVIIa in critically ill infants with active hemorrhage by reducing their transfusion requirements. Furthermore, venous thrombosis was not associated with increase in either the number of doses or dosage of rFVIIa.     

Redefining outcomes in right congenital diaphragmatic hernia

Purpose

Available data comparing the management and outcome of right-sided (R-CDH) vs left-sided congenital diaphragmatic hernia (L-CDH) are inconsistent. Large-volume CDH studies are limited by small numbers of R-CDH or are confounded by compilations from multiple institutions with multiple treatment strategies. Consequently, they are underpowered to draw conclusions. To define the behavior and outcomes of R-CDH better, we report the largest single-institution series of R-CDH and ask if factors traditionally linked to poor prognosis in L-CDH were applicable to R-CDH.

Methods

We reviewed a single institution's experience with 267 consecutive evaluable neonates with unilateral CDH repaired from 1990 to 2006, with specific focus on R-CDH. χ² tests were performed for disease-related categorical variables. Two-tailed unpaired t tests were used for continuous variables. Factors associated with morbidity and survival were determined by univariate regression. Statistical significance was set at P < .05.

Results

Forty right-sided (15%) and 227 (85%) left-sided cases of CDH were identified. Prenatal diagnosis was made in 20 right-sided vs 170 left-sided defects (50% vs 75%, P < .01). Survival was 22 of 40 in R-CDH compared with 175 of 227 in L-CDH (55% vs 77%, P < .01). Extracorporeal membrane oxygenation was required in 16 right-sided and 33 left-sided cases (40% vs 15%, P < .001). A diaphragmatic patch was used in 22 of 29 right-sided compared with 82 of 199 left-sided repairs (76% vs 41%, P < .01); rates of abdominal wall prosthesis were also higher in right-sided hernias (38% vs 19%, P < .05). No differences were detected in right-sided vs left-sided recurrences (14% vs 8%, P = .38), mean time from birth to operation (5.3 vs 4.8 days, P = .80), or presence of cardiac anomalies (15% vs 12%, P = .63). Morbidity persisting beyond 6 months of age was present in 16 of 22 R-CDH survivors compared with 76 of 175 L-CDH survivors (73% vs 43%, P > .05). Among R-CDHs, prenatal diagnosis was the only factor to predict survival by univariate regression (P < .01). Use of a prosthesis in the diaphragm (P < .05) for R-CDH repair correlated with morbidity.

Conclusion

Although previous reports suggest that associated anomalies, need for extracorporeal membrane oxygenation, and time to repair can influence L-CDH survival, these data do not support extrapolation to R-CDH survival. Right-sided CDH carries a disproportionately high morbidity and mortality. Prenatal diagnosis was the only factor predictive of R-CDH survival. Morbidity may correlate with use of prosthetic material for R-CDH repair. Right-sided CDH is a unique disease that may require a modified antenatal consultation.     

Outcomes of intestinal failure—a comparison between children with short bowel and dysmotile intestine

Background

We investigated whether mortality, intestinal adaptation, and liver function differ between intestinal failure (IF) patients with either short bowel (SB) or bowel dysmotility (DM).

Patients and methods

Twenty-six consecutive patients with SB (n = 20) or DM (n = 6) treated between 2000 and 2007 were retrospectively assessed. Intestinal failure was defined as less than 25% of age-adjusted small intestinal length or dependence on parenteral nutrition (PN) more than 6 months.

Results

Median age-adjusted small intestinal length (17% vs 45%) and gestational age (35 vs 40 weeks) were (P < .05) shorter, whereas proportion of the remaining colon (86% vs 0%) was (P < .05) higher in the SB group relative to the DM group. Overall survival was 92%. Median peak serum bilirubin (80 vs 25 μmol/L) and rate of cholestasis (11/20 vs 0/6) were higher (P < .05) in the SB group. Short bowel rather than DM as an etiology of IF predicted weaning off PN (RR, 39.3; 95% confidence interval [CI], 1.43-526; P < .01) and development of cholestasis (risk ration [RR], 18.3; 95% CI, 0.658-127; P < .05). Three SB children developed liver failure and two died, whereas neither of these occurred in the DM group.

Conclusions

Children with SB are more likely to wean off PN but more prone to cholestatic liver disease than those with DM as an etiology of IF.     

Evaluation of a Bayesian decision network for diagnosing pyloric stenosis

Purpose

Most infants undergoing an ultrasound to rule out pyloric stenosis will have a negative study, suggesting the low accuracy of clinical assessment. The purpose of this study was to evaluate the feasibility of using a Bayesian network to improve the accuracy of diagnosing pyloric stenosis.

Methods

Records of 118 infants undergoing an ultrasound to rule out pyloric stenosis were reviewed. Data from 88 (75%) infants were used to train a Bayesian decision network that predicted the probability of pyloric stenosis using risk factors, signs, and symptoms of the disease. The emergency department records of the remaining 28 (25%) infants were used to test the network. Two groups of pediatric surgeons and pediatric emergency medicine physicians were asked to predict the probability of pyloric stenosis in the testing set: (1) physicians using the network and (2) physicians using only emergency department records. Accuracy was evaluated using area under the ROC curve (discrimination) and Hosmer-Lemeshow (H-L) c-statistic (calibration).

Results

Physicians using the Bayesian decision network better predicted the probability of pyloric stenosis among infants in the testing set than those not using the network (ROC 0.973 vs 0.882; H-L c-statistic 3.9 [P > .05] vs 24.3 [P < .05]). Physicians using the network would have ordered 22% fewer ultrasounds and missed no cases of pyloric stenosis.

Conclusions

The use of a Bayesian decision network may improve the accuracy of physicians diagnosing infants with possible pyloric stenosis. Use of this decision tool may safely reduce the need for imaging among infants with suspected pyloric stenosis.     

Renal transplantation in old recipients from expanded criteria donors selected by kidney biopsy

Background

In Spain, the number of ideal kidney transplant donors has fallen, with at the same time an increase in the number of older recipients on the waiting list.

Aim

To analyze the results of expanded criteria cadaveric donor kidney transplants into older recipients using grafts selected by kidney biopsy.

Patients and methods

We studied 360 kidney transplant recipients who had been followed to December 2009: 180 in the study group and 180 in a control group composed of younger patients who received grafts from non-expanded criteria donors between 1999 and 2006. A paraffin-embedded kidney biopsy was evaluated by the percentages of sclerosed glomeruli, arteriolar hyalinosis, intimal wall thickening, interstitial fibrosis, and tubular atrophy.

Results

Significant differences were observed in donor age (63.50 ± 5.46 vs 31.90 ± 13.29 years; P < .001) and recipient age (58.40 ± 8.80 vs 40.71 ± 13.23 years; P < .001). Donor renal function was significantly worse among the expanded criteria group (90.80 vs 108.11 mL/min/1.73 m²; P = .006), remaining so over time in the recipient (at 1 year: 42.08 vs 63.71 [P < .001]; at 3 years: 41.25 vs 62.31 [P < .001], and at 7 years: 38.17 vs 64.18 [P < .001]). Censored 7-year graft survivals were 73% versus 87% (P < .001) with similar patient survivals (90.5% vs 95%; P = .39).

Conclusions

Selection of expanded criteria donors by kidney biopsy resulted in good renal function as well as graft and patient survivals at 7 years in older recipients.     

The impact of advanced age on trauma triage decisions and outcomes: A statewide analysis

Background

Physiologic variables used in trauma triage criteria may be significantly affected by age, decreasing their predictive value in geriatric trauma.

Methods

The study population was all adult patients in the Washington State Trauma Registry from 2000 to 2004. Elderly patients were defined as those aged >65 years. Multivariate analyses were conducted to evaluate the relationship between age and trauma triage decisions, need for emergent interventions, and outcomes.

Results

Of 51,227 trauma admissions, 13,820 (27%) were for elderly patients. Elderly patients were significantly less likely to have trauma team activation (14% vs 29%, P <.01), despite a similar percentage of severe injuries (injury severity score > 15), and more often required urgent craniotomy (10% vs 6%, P <.01) and orthopedic procedures (67% vs 51%, P <.01). Heart rate and blood pressure were not predictive of severe injury for those aged >65 years. Undertriaged elderly patients had 4 times the mortality rate and discharge disability of younger patients (both P values <.001).

Conclusions

Elderly trauma victims are less likely to undergo rapid trauma evaluation and have significantly worse outcomes compared with younger patients. Standard physiologic triage variables may not identify severe injury in older patients.     

Extracorporeal membrane oxygenation in infants with meconium aspiration syndrome: a decade of experience with venovenous ECMO

Background

Despite the emergence of new therapies for respiratory failure of the newborn with meconium aspiration syndrome (MAS), extracorporeal membrane oxygenation (ECMO) has a significant role as a rescue modality in these infants. Our objective was to compare the use of venovenous (VV) vs venoarterial (VA) ECMO in newborns with MAS who need ECMO and to ascertain the impact of new therapies in these infants during the last decade. We also evaluated how disease severity or time of ECMO initiation affected mortality and morbidity.

Methods

A report of 12 years experience (1990-2002) of a single center, comparing VV and VA ECMO, is given. Venovenous ECMO was the preferred rescue modality for respiratory failure unresponsive to maximal medical therapy. Venoarterial ECMO was used only when the placement of a VV ECMO 14-F catheter was not possible; 128 patients met ECMO criteria, 114 were treated with VV ECMO, and 12 with VA ECMO. Two patients were converted from VV to VA ECMO.

Results

Venovenous and VA ECMO patients had comparable birth weight (mean ± SEM, 3.48 ± 0.05 vs 3.35 ± 0.15 kg) and gestational age (40.3 ± 0.1 vs 40.7 ± 0.3 weeks). Before ECMO, there was no difference between VV and VA ECMO patients in oxygenation index (60 ± 3 vs 63 ± 8), mean airway pressure (19.5 ± 0.4 vs 20.8 ± 1.5 cm H₂O), alveolar-arterial O₂ gradient (630 ± 2 vs 632 ± 4 torr), ECMO cannulation age (median [25th-75th percentiles], 23 [14-47] vs 26 [14-123] hours), or in the % of patients who needed vasopressors/inotropes (98% vs 100%). From November 1994, inhaled nitric oxide (NO) was available. Before VV ECMO, 67% of the patients received NO, 24% received surfactant, and 48% were treated with high-frequency ventilation (HFV). There was no significant difference between VV and VA ECMO patients in survival rate (94% vs 92%), ECMO duration (88 [64-116] vs 94 [55-130] hours), time of extubation (9 [7-11] vs 14 [9-15] days), age at discharge (23 [18-30] vs 27 [15-41] days), or incidence of short-term intracranial complications (5.3% vs 16.7%). For the total cohort of 126 infants, indices of disease severity (oxygenation index, alveolar-arterial O₂ gradient, mean airway pressure) did not correlate with outcome measures. Delay in ECMO initiation (>96 hours) was associated with prolonged mechanical ventilation and hospitalization (P < .01). New therapies (NO, HFV, surfactant) in the second part of the decade were associated with a longer ECMO duration (98 [80-131] vs 87 [60-116] hours; P < .05), no delay in ECMO initiation time (23 [10-40] vs 24 [14-52] hours), and no significant change in survival (97% vs 92.5%). No patient was treated with VA ECMO after 1994.

Conclusions

Venovenous ECMO is as reliable as VA ECMO in newborns with MAS in severe respiratory failure who need ECMO. Delay in ECMO initiation may result in prolonged mechanical ventilation and increased length of hospital stay. The emergence of new conventional therapies (NO, HFV, surfactant) and particularly increased experience enable sole use of VV ECMO with no significant change in survival in infants with MAS.     

Outcomes of sutureless gastroschisis closure

Introduction

A new technique of gastroschisis closure in which the defect is covered with sterile dressings and allowed to granulate without suture repair was first described in 2004. Little is known about the outcomes of this technique. This study evaluated short-term outcomes from the largest series of sutureless gastroschisis closures.

Methods and Patients

A retrospective case control study of 26 patients undergoing sutureless closure between 2006 and 2008 was compared to a historical control group of 20 patients with suture closure of the abdominal fascia between 2004 and 2006. Four major outcomes were assessed: (1) time spent on ventilator, (2) time to initiating enteral feeds, (3) time to discharge from the neonatal intensive care unit, and (4) rate of complications.

Results

In multivariate analysis, sutureless closure of gastroschisis defects independently reduced the time to extubation as compared to traditional closure (5.0 vs 12.1 days, P = .025). There was no difference in time to full enteral feeds (16.8 vs 21.4 days, P = .15) or time to discharge (34.8 vs 49.7 days, P = .22) with sutureless closure. The need for silo reduction independently increased the time to extubation (odds ratio, 4.2; P = .002) and time to enteral feeds (odds ratio, 5.2; P < .001). Small umbilical hernias were seen in all patients.

Conclusion

Sutureless closure of uncomplicated gastroschisis is a safe technique that reduces length of intubation and does not significantly alter the time required to reach full enteral feeds or hospital discharge.     

Impact of corticosteroid on intestinal injury in a gastroschisis rat model: morphometric analysis

Background/Purpose

The goal in the treatment of gastroschisis is to prevent intestinal injury. Corticosteroids are known by their effects at the inflammatory response and by the improvement on the intestinal maturity. The authors evaluated the effects of maternal corticosteroid administration on the intestines of rats that underwent fetal gastroschisis.

Methods

A Correia-Pinto-modified gastroschisis rat model was used. Two groups were assessed: the control group (group 1) and the dexamethasone group (group 2). Each group was composed of control and sham fetuses, and fetuses with gastroschisis. Fetal body weight, intestinal weight, intestinal length, and protein were assessed. Histologic analysis involved measures of intestinal loop diameter, total intestinal wall, mucosa and submucosa, both circular and longitudinal muscle layers, and serosal thicknesses. Differences between groups and subgroups were tested by the analysis of variance method with a significant P value less than .05.

Results

Dexamethasone decreased in all the morphometric data except in the intestinal length. Dexamethasone increased the intestinal protein content in fetuses with gastroschisis, and control and sham fetuses. In both groups, all histologic parameters were increased in fetuses with gastroschisis (P < .0001).

Conclusions

Dexamethasone caused a substantial decrease in intestinal weight in GFs, increased the intestinal protein content, and it may be useful in decreasing the intestinal damage of gastroschisis.     

Improved survival outcome for hepatoblastoma based on an optimal chemotherapeutic regimen--a report from the study group for pediatric solid malignant tumors in the Kyushu area

Background/purpose

The survival outcome for patients with hepatoblastoma normally depends on the resectability of the tumor. In Japan, the pre and/or postoperative chemotherapy protocol using a combination of cisplatin (CDDP) and tetrahydropyranyl-Adriamycin (THP-ADR) has been the standard treatment since 1991. This study aims to assess exactly what influence the establishment of this chemotherapy protocol has had on both the tumor resectability and the outcome of patients with hepatoblastoma.

Methods

From 1982 to 1997, 60 patients with hepatoblatoma were treated in the Kyushu area, Japan. Based on the pretreatment extent of disease (PRETEXT), the outcome and tumor resectability were compared between group A (1982 to 1990, n = 27, PRETEXT I:5, II:8, III:6, IV:8) and group B (1991 to 1997, n = 33, PRETEXT I:9, II:9, III:5, IV:10).

Results

The 5-year survival rates (group A and group B) were 33% and 73% for all cases (P < .01), 100% and 89% for PRETEXT I, 38% and 89% for II (P < .05), 17% and 80% for III (P < .01), and 0% and 40% for IV (P < .01), respectively. The 5-year survival rates for patients with metastases were 0% for group A (n = 5) and 57% for group B (n = 7; P < .01). The rates of a complete resection of primary tumor were 48% for group A and 67% for group B. In particular, a significant difference was found regarding the complete resection rate between groups A and B in the patients with PRETEXT III (17% for group A and 80% for group B; P < .01). In the patients with an incomplete tumor resection (14 for group A, 11 for group B), the 5-year survival rates were 0% for group A and 45% for group B (P < .01).

Conclusions

The optimal chemotherapeutic regimen of CDDP and THP-ADR was thus found to greatly contribute to the improved survival rate of hepatoblastoma patients. Preoperative chemotherapy resulted in an increased resectability of the tumor, whereas postoperative chemotherapy played an important role in the increased cure rate of cases with either an incomplete tumor resection or metastasis. However, refractory cases with PRETEXT IV or metastasis may still require the development of an even more effective treatment modality, including the use of blood stem cell transplantation.     

Antenatal diagnosis of bowel dilatation in gastroschisis is predictive of poor postnatal outcome

Purpose

Although gastroschisis infants usually have a good outcome, there remains a cohort of babies who fare poorly. We inquired whether the presence of bowel dilatation in utero is predictive of postnatal course in infants with gastroschisis.

Methods

We compared the clinical course of infants who had bowel dilatation with those who did not. Bowel dilatation was defined as more than 20 mm in cross-sectional diameter on ultrasound at any gestational age. Outcome measures used were length of time of parenteral nutrition, death, and surgery for intestinal failure.

Results

A review of 170 infants with gastroschisis identified 74 who had dilatation of more than 20 mm (43.5%). There was no significant difference in the incidence of intestinal atresia in those with bowel dilatation and those without (P = .07). Those with bowel dilatation spent a longer period on parenteral nutrition. There were significantly more deaths in the group with bowel dilatation (P = .01). There was no significant difference in the number of infants requiring surgery for intestinal failure between the 2 groups (P = .47).

Conclusions

We found that sonographically detected bowel dilatation more than 20 mm in utero in fetuses with gastroschisis may have value in predicting clinically significant adverse postnatal outcomes.