M W Davies1, R M Kimble, P G Woodgate. 1. Grantley Stable Neonatal Unit, Royal Women's Hospital, Butterfield St, Herston, Brisbane, Queensland, Australia. mwdavies@ozemail.com.au
Abstract
BACKGROUND: Gastroschisis is a congenital anterior abdominal wall defect with the abdominal contents protruding through the defect. Reduction of the abdominal contents is required within hours after birth as the infant is at risk not only of water and heat loss from the exposed bowel but also of compromised gut circulation with ischaemia and infarction. To avoid the complications of general anaesthetic and mechanical ventilation it has been proposed that the reduction of abdominal contents can be achieved without endotracheal intubation or anaesthesia. OBJECTIVES: To determine which approach to the immediate surgical treatment of gastroschisis has the better outcomes: ward reduction without general anaesthetic or reduction and repair of the abdominal wall defect under general anaesthesia. SEARCH STRATEGY: Searches were made of MEDLINE from 1966 to March 2002, CINAHL from 1982 to March 2002, and the Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2002). Previous reviews including cross references, abstracts, and conference and symposia proceedings published in Pediatric Research (from 1990 to 1994) were also searched, especially for any unpublished data. SELECTION CRITERIA: Randomised, controlled trials (RCT) comparing ward reduction with reduction under general anaesthesia, for neonates with gastroschisis. Outcomes considered were: mortality, duration of total parenteral nutrition, time to full enteral feeds, need for a silo, infection, gastro-intestinal tract perforation, length of bowel lost/resected, need for a general anaesthesia, need for and duration of mechanical ventilation and respiratory support, duration of oxygen therapy, need for further operative procedure after initial reduction, duration of hospital stay, cosmetic outcome, nutritional status, and neurodevelopmental outcome. DATA COLLECTION AND ANALYSIS: No studies were found meeting the criteria for inclusion in this review. MAIN RESULTS: No studies were found meeting the criteria for inclusion in this review. REVIEWER'S CONCLUSIONS: There is no evidence from RCTs to support or refute the practice of ward reduction for the immediate management of gastroschisis. There is an urgent need for RCTs to compare ward reduction versus reduction under general anaesthesia in infants with gastroschisis. Initial trials would best be limited to those infants with uncomplicated gastroschisis (using pre-defined selection criteria excluding infants that are unstable, have gut perforation, necrosis or atresia, have other organs requiring reduction besides bowel, or are considered to need a silo prior to any reduction. Trials should use adequate pain relief and specify a pre-defined time period after which manual reduction is abandoned.
BACKGROUND: Gastroschisis is a congenital anterior abdominal wall defect with the abdominal contents protruding through the defect. Reduction of the abdominal contents is required within hours after birth as the infant is at risk not only of water and heat loss from the exposed bowel but also of compromised gut circulation with ischaemia and infarction. To avoid the complications of general anaesthetic and mechanical ventilation it has been proposed that the reduction of abdominal contents can be achieved without endotracheal intubation or anaesthesia. OBJECTIVES: To determine which approach to the immediate surgical treatment of gastroschisis has the better outcomes: ward reduction without general anaesthetic or reduction and repair of the abdominal wall defect under general anaesthesia. SEARCH STRATEGY: Searches were made of MEDLINE from 1966 to March 2002, CINAHL from 1982 to March 2002, and the Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2002). Previous reviews including cross references, abstracts, and conference and symposia proceedings published in Pediatric Research (from 1990 to 1994) were also searched, especially for any unpublished data. SELECTION CRITERIA: Randomised, controlled trials (RCT) comparing ward reduction with reduction under general anaesthesia, for neonates with gastroschisis. Outcomes considered were: mortality, duration of total parenteral nutrition, time to full enteral feeds, need for a silo, infection, gastro-intestinal tract perforation, length of bowel lost/resected, need for a general anaesthesia, need for and duration of mechanical ventilation and respiratory support, duration of oxygen therapy, need for further operative procedure after initial reduction, duration of hospital stay, cosmetic outcome, nutritional status, and neurodevelopmental outcome. DATA COLLECTION AND ANALYSIS: No studies were found meeting the criteria for inclusion in this review. MAIN RESULTS: No studies were found meeting the criteria for inclusion in this review. REVIEWER'S CONCLUSIONS: There is no evidence from RCTs to support or refute the practice of ward reduction for the immediate management of gastroschisis. There is an urgent need for RCTs to compare ward reduction versus reduction under general anaesthesia in infants with gastroschisis. Initial trials would best be limited to those infants with uncomplicated gastroschisis (using pre-defined selection criteria excluding infants that are unstable, have gut perforation, necrosis or atresia, have other organs requiring reduction besides bowel, or are considered to need a silo prior to any reduction. Trials should use adequate pain relief and specify a pre-defined time period after which manual reduction is abandoned.
Authors: Aimee C Pastor; J Duncan Phillips; Stephen J Fenton; Rebecka L Meyers; Amy W Lamm; Mehul V Raval; Elizabeth Lehman; Tracy B Karp; Paul W Wales; Jacob C Langer Journal: J Pediatr Surg Date: 2008-10 Impact factor: 2.545