Challenges of Improving the Evidence Base in Smaller Surgical Specialties, as Highlighted by a Systematic Review of Gastroschisis Management (original) (raw)
Related papers
Method to our madness: an 18-year retrospective analysis on gastroschisis closure
Journal of Pediatric Surgery, 2010
Background: The advent of preformed silos has facilitated routine bedside placement often without any attempt of intestinal reduction. It is unclear whether a strategy of routine silo (RS) placement with delayed fascial repair is beneficial over attempted primary repair (aPR) and silo placement only for those patients who cannot be reduced. We retrospectively compared clinical outcomes of neonates having aPR to those having RS placement to determine the impact of routine silo use and silo duration on gastroschisis care. Methods: Neonatal records from patients with gastroschisis at a single children's hospital between 1990 and 2008 were reviewed. Demographic and outcome data were recorded and subjected to statistical analyses. Documentation of attempted intestinal reduction was used as a surrogate marker for aPR. The remaining patients were placed in the RS group. Results: Two hundred forty-eight neonates with gastroschisis were identified. Thirteen were excluded for congenital or clinical issues which precluded aPR. Of the remaining 235 patients, neonates with RS had significantly more ventilator days (6.2 vs 4.4; P = .0011), more time of total parenteral nutrition (36.5 vs. 28.5; P = .0018), longer length of stay (LOS, 46.5 vs. 40.5; P = .0011), and greater hospital charges ($216,000 vs 172,000;Pb.0001)thanpatientswhohadaPR.Therewasnosignificantdifferenceobservedincomplicationsorsurvival.LinearregressionmodelingdemonstratedthattimetoclosurewassignificantlyrelatedtoLOSasanindependentvariable.Eachdaytoclosurewasassociatedwith2.2extradaysofhospitalizationandapproximately172,000; P b .0001) than patients who had aPR. There was no significant difference observed in complications or survival. Linear regression modeling demonstrated that time to closure was significantly related to LOS as an independent variable. Each day to closure was associated with 2.2 extra days of hospitalization and approximately 172,000;Pb.0001)thanpatientswhohadaPR.Therewasnosignificantdifferenceobservedincomplicationsorsurvival.LinearregressionmodelingdemonstratedthattimetoclosurewassignificantlyrelatedtoLOSasanindependentvariable.Eachdaytoclosurewasassociatedwith2.2extradaysofhospitalizationandapproximately9557 in hospital charges. Conclusion: Although limited by retrospective biases, this study demonstrates that time to closure is the most significant variable related to LOS in gastroschisis. This relationship is intuitive since longer time to closure is probably determined by the severity of gastroschisis. The method of closure, by primary Abbreviations: aPR, attempted primary repair; PR, primary repair; RS, routine silo; LOS, length of stay; NEC, necrotizing enterocolitis; NICU, neonatal intensive care unit; TPN, total parenteral nutrition.
Immediate versus silo closure for gastroschisis: Results of a large multicenter study
Journal of Pediatric Surgery, 2019
Background/Purpose: The optimal method to repair gastroschisis defects continues to be debated. The two primary methods are immediate closure (IC) or silo placement (SP). The purpose of this study was to compare outcomes between each approach using a multicenter retrospective analysis. We hypothesized that patients undergoing SP for ≤5 days would have largely equivalent outcomes compared to IC patients. Methods: Gastroschisis patient data were collected over a 7-year period. The cohort was separated into IC and SP groups. The SP group was further stratified based on time to closure (≤5 days, 6-10 days, >10 days). Characteristics and outcomes were compared between groups. Multivariate logistic regression was also performed. Results: 566 neonates with gastroschisis were identified including 224 patients in the IC group and 337 patients in the SP group. Among SP patients, 130 were closed within 5 days, 140 in 6-10 days, and 57 in >10 days. There were no significant differences in mortality, sepsis, readmission, or days to full enteral feeds between IC patients and SP patients who had a silo ≤5 days. IC patients had a significantly higher incidence of ventral hernias. Multivariate analysis revealed time to closure as a significant independent predictor of length of stay, ventilator duration, time to full enteral feeds, and TPN duration.
Experience of bedside preformed silo staged reduction and closure for gastroschisis
Journal of Pediatric Surgery, 2006
Aim: The purpose of this study was to assess the effectiveness of routine staged reduction and closure at the bedside, using preformed silos with no general anesthesia (PSnoGA), compared to emergency operative fascial closure (OFC) under general anesthesia for gastroschisis (GS). Methods: A retrospective matched case-control analysis of neonates with GS was performed between 1990 and 2004 inclusively. Assessment included demographics, method of closure, days on ventilator, days to first enteral feed, days to full oral feeds, days on parenteral nutrition, length of hospital stay, and complications. Results: Sixty-five patients with GS were treated in our institution between 1990 and 2004. Thirty-five underwent OFC, 4 had Bianchi ward reduction, and 26 received PSnoGA. Seventeen patients with bowel perforation, atresia, ward reduction, medical complications necessitating ventilation, or any other condition requiring urgent surgical intervention were excluded from the analysis. Patients were well matched for gestation and birth weight. Forty-eight patients (OFC = 27 and PSnoGA = 21) were compared by using Mann-Whitney U test. Median days on ventilator (4 vs 0; P V .0001) was significantly reduced, but there was no difference for days to full oral feeds (26 vs 31; P = .26), days on parenteral nutrition (25 vs 30; P = .28), and length of stay (32 vs 36; P = .32), respectively. Complications were similar for both groups. Conclusions: PSnoGA has outcomes statistically similar to OFC, although days on ventilator are significantly reduced. Slow reduction of the bowel avoids abdominal compartment syndrome and closure may be achieved without fascial sutures. PSnoGA is performed at the bedside and aims to avoid general anesthesia, a period of ventilation, and out-of-hours operating, thereby reducing costs. A prospective, multicenter, randomized control trial is needed to evaluate the effectiveness of PSnoGA. D
Is there Unity in Europe? First Survey of EUPSA Delegates on the Management of Gastroschisis
European Journal of Pediatric Surgery, 2012
Aim To report the first European survey on the current management of gastroschisis and ascertain the degree of variability between centers. Methods A 10-question survey was administered at the 2011 European Paediatric Surgeons' Association (EUPSA) Congress. Questionnaires were completed by 205 delegates from 39 countries. A total of 21 responses (10%) were incomplete and voided. The remaining 184 were divided on the basis of following region of practice: Western Europe (WE, n ¼ 102), Eastern Europe (EE, n ¼ 59), and non-European countries (n ¼ 23). Differences between WE and EE were analyzed using contingency tests. p < 0.05 was considered significant. Results A total of 15% WE and 2% EE responders work in centers where antenatal magnetic resonance imaging scans are routinely used. Nonplanned delivery is the most popular approach (WE 46%, EE 58%). Primary closure is the preferred choice (WE 92%, EE 86%), and it is achieved by operative fascial closure in the majority (WE 80%, EE 75%) rather than by Bianchi technique (WE 20%, EE 25%). Staged reduction and closure is less popular (WE 8%, EE 14%), and it is achieved by custom-made silo (WE 25%, EE 12.5%), preformed silo (PFS) followed by surgical closure (WE 63%, EE 75%), or PFS followed by sutureless closure (WE 12%, EE 12.5%). Objection to PFS in WE is mainly related to surgeons' lack of confidence in the technique (40%), whereas in EE it is due to unavailability and high cost (62%, p ¼ 0.01). In case of associated intestinal atresia, immediate resection and anastomosis is preferred by 60% of WE surgeons versus 35% of EE surgeons (p ¼ 0.03), who equally favor primary closure and delayed surgery (33%). Nutrition is preferably delivered by peripheral long line in WE (64%) and by central line inserted in the first week of life in EE (62%, p ¼ 0.003). Conclusions Primary fascial closure is currently the preferred method of gastroschisis closure across Europe. Aspects of care such as strategy for intestinal atresia and delivery of parenteral nutrition differ significantly between WE and EE.
Journal of Pediatric Surgery, 2008
Purpose: Outcomes studies for gastroschisis are constrained by small numbers, prolonged accrual, and nonstandardized data collection. The aim of this study is to create a national pediatric surgical network and database for gastroschisis (GS) that tracks cases from diagnosis to hospital discharge. Methods: The 16-center network serves a population of 32 million. Gastroschisis cases are ascertained at prenatal diagnosis. Perinatal data include maternal risk and fetal ultrasound variables, delivery plan and outcome, a postnatal bowel injury score, intended and actual surgical treatment, and neonatal outcomes. Institutional review board-approved data collection conforms to regional privacy legislation. Deidentified data are centralized and accessible for research through the network steering committee. Results: To date, 114 cases of pre-and/or postnatal gastroschisis have been uploaded. Of 106 liveborn infants (40 [38%] by cesarean delivery), 100 had complete records, and overall survival to discharge was 96%, with a mean survivor length of stay (LOS) of 46 days. Infants treated with attempted urgent closure (61%) had significantly shorter LOS (42 vs 57days; P = .048) but
Journal of Pediatric Surgery, 2014
Background/Purpose: The optimal surgical approach in infants with gastroschisis (GS) is unknown. The purpose of this study was to estimate the association between staged closure and length of stay (LOS) in infants with GS. Design/Methods: We used the Children's Hospital Neonatal Database to identify surviving infants with GS born ≥ 34 weeks' gestation referred to participating NICUs. Infants with complex GS, bowel atresia, or referred after 2 days of age were excluded. The primary outcome was LOS; multivariable linear regression was used to quantify the relationship between staged closure and LOS. Results: Among 442 eligible infants, staged closure occurred in 68.1% and was associated with an increased median LOS relative to odds ration (OR):primary closure (37 vs. 28 days, p b 0.001). This association persisted in the multivariable equation (β = 1.35, 95% CI: 1.21, 1.52, p b 0.001) after adjusting for the presence of necrotizing enterocolitis, short bowel syndrome, and central-line associated bloodstream infections. Conclusions: In this large, multicenter cohort of infants with GS, staged closure was independently associated with increased LOS. These data can be used to enhance antenatal and pre-operative counseling and also suggest that some infants who receive staged closure may benefit from primary repair.
Surgical Practice: Evidence or Anecdote
Journal of Surgical Education, 2009
OBJECTIVES: Our objective is to highlight a few surgical practices that are not based on evidence but are still taught in surgical education, and to assess our experience with these practices. DESIGN: We identified 3 practices (clamping of nasogastric tubes before removal, bowel preparation before elective colon resection, and elective sigmoid colectomy following 2 bouts of diverticulitis), identified the data supporting each practice, and administered a survey to faculty and residents at our institution.
Journal of Pediatric Surgery, 2010
Purpose: The ideal management of gastroschisis (primary vs staged closure) has not yet been established. Despite the ease of silo placement, anecdotal experience shows that silos do not always offer benefit. The aim of this study was to highlight concerns regarding use of spring loaded silos and compare outcomes to primary closure. Methods: Thirty-seven neonates with gastroschisis treated with either primary (n = 10) or staged closure with a spring-loaded silo (n = 27) were reviewed (1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007). Variables included ventilator days, daily intravenous fluid, hospital days, and complication rates. SPSS (SPSS Inc, Chicago, Ill) was used to perform t test and χ 2 analyses (significance P b .05). Results: Survival for primary closure was 100% (10/10) compared to 89% (24/27) for staged closure (P = .548). Patients managed with silos required prolonged ventilation (16.1 ± 4 days vs 3.6 ± 1 days; P ≤ .05) and greater intravenous fluids on days 3, 4, and 5 of life (132 ± 25 mL/kg per day vs 104 ± 18 mL/kg per day; P ≤ .01). Although there was no difference in the complication rates between the groups, several problems were evident in the silo group: 15% (4/27) required silo replacement, 44% (12/27) required fascial defect enlargement for silo placement, and 19% (5/27) required mesh at closure. No significant differences in recovery of intestinal function were observed. Three silo patients developed ischemic complications because of vascular insufficiency at the level of the abdominal wall, leading to significant intestinal loss, ventilator and total parenteral nutrition dependence, and increased hospital stay. Conclusions: Patients managed with a silo had longer ventilator requirements and greater fluid needs. This Specific technical complications leading to bowel ischemia were notable in the silo group. The silo should be carefully placed to avoid bowel twisting and the funnel effect. Larger prospective studies should be performed to provide decision-making criteria for the use of a silo vs primary closure.