A. R. Raines1, P. C. Mantor1, T. Garwe1,2, P. Motghare2, J. Hunter3, K. Roselius4, A. Adeseye1, R. Letton1 1University Of Oklahoma College Of Medicine,Surgery,Oklahoma City, OK, USA 2University Of Oklahoma College Of Medicine,Biostatistics And Epidemiology,Oklahoma City, OK, USA 3University Of Oklahoma College Of Medicine,Oklahoma City, OK, USA 4University Of Oklahoma College Of Medicine,College Of Public Health,Oklahoma City, OK, USA
Introduction: Active debate exists regarding the use of the primary abdominal closure versus silo placement for gastroschisis treatment. In 2005, we changed our strategy from primary closure and selective silo placement to elective silo placement with delayed closure. We reviewed our experience with each strategy.
Methods: This retrospective study, evaluating infants born with gastroschisis, used data from a single children’s hospital between 1999 and 2012. Before 2005, our preferred gastroschisis treatment was primary closure with selective silo placement. After 2005, our preferred treatment was elective silo placement with delayed closure. Morbidity outcomes were evaluated based on whether treatment was received before or after 2005 (SELECTIVE SILO and ELECTIVE SILO groups, respectively). In both groups, there were patients who were not managed with the preferred standard at the time, and two analyses were performed including and excluding these patients. Morbidity outcomes of interest were total parenteral nutrition (TPN) days, ventilator days, hospital days, infectious complications, and need for unplanned re-operation.
Results: A total of 250 neonates were included (108 and 142 patients in the SELECTIVE SILO and ELECTIVE SILO groups, respectively). No significant differences (p > 0.05) were observed in gestational age, gender, birth weight, APGARs, delivery type, or rate of complicated gastroschisis (atresia, bowel necrosis, obstruction) between the two groups regardless of whether patients who did not receive the elective treatment of choice for the time period were included or excluded. The ELECTIVE SILO group had significantly (p<0.05) longer average TPN days (31 vs. 23), hospital days (41 vs. 28), and a higher rate of wound infections (18% vs. 4%) as compared to the SELECTIVE SILO group regardless of whether patients who did not receive the elective treatment of choice were included or excluded. Overall, the ELECTIVE SILO group experienced significantly (p<0.05) fewer mean ventilation days, however, excluding patients not receiving elective treatment of choice resulted in no significant mean difference. Unplanned reoperation rates between the two groups were similar, although, there was a trend toward higher reoperation rates in the ELECTIVE SILO group (15% vs 3%; p=0.0792) when excluding patients not receiving elective treatment.
Conclusion: These data suggest that the strategy of elective silo placement and delayed closure in gastroschisis patients significantly increases the total number of hospital days, TPN days, and wound infections as compared to primary closure and selective silo placement. Based on these results, primary abdominal closure should be the recommended approach in managing infants with gastroschisis. Carefully controlled prospective studies are required to further validate these conclusions.