Selective management of gastroschisis

Mortality of patients with gastroschisis has decreased from nearly 90% to 13% (14 of 106) during the period from 1967 to 1984. Coincident with advances in perioperative management, including parenteral nutrition and mechanical ventilation, has been the introduction of staged reduction of the viscera using prosthetic material. To assess the relative merits of primary closure, skin flap coverage, and silo reduction, operative treatment of 106 consecutive infants with gastroschisis was reviewed. Primary fascial closure was accomplished in 54 patients (52%). When fascial approximation resulted in excessive intra-abdominal presssure, the viscera were covered with lateral skin flaps in 10 infants (10%), or the defect was closed after staged reduction with a prosthetic silo in 40 infants (38%). Detailed analysis of the hospital records revealed no significant differences between the primary closure, skin flap and silo groups with regard to duration of ileus (22 ±25, 30 ± 27, 31 ± 30 days), length of hospitalization (39 ± 36, 54 ± 37, 53 ± 39 days), or mortality (6, 20,18%). Respiratory, septic, hemorrhagic, renal, and wound complications occurred in significantly fewer patients with primary closure (36%) and skin flap coverage (30%) than in those with silos (68%) (p < 0.05). Postoperative mortality was 12% (12/104) and was most often due to respiratory insufficiency (35%) or nonviable small bowel (19%). Primary fascial closure may be accomplished safely in a majority of patients with gastroschisis. However, no single operative strategy is ideal for all patients with gastroschisis, and initial treatment of individual defects should be tailored to the degree of visceroabdominal disproportion.