Multi-institutional practice patterns and outcomes in uncomplicated gastroschisis: A report from the University of California Fetal Consortium (UCfC)

doi:10.1016/j.jpedsurg.2014.09.018

Journal of Pediatric Surgery

Volume 49, Issue 12, December 2014, Pages 1782-1786

https://doi.org/10.1016/j.jpedsurg.2014.09.018 Get rights and content

Abstract

Background/Purpose

Gastroschisis is a resource-intensive birth defect without consensus regarding optimal surgical and medical management. We sought to determine best-practice guidelines by examining differences in multi-institutional practices and outcomes.

Methods

Site-specific practice patterns were queried, and infant–maternal chart review was retrospectively performed for gastroschisis infants treated at 5 UCfC institutions (2007–2012). The primary outcome was length of stay. Univariate analysis was done to assess variation practices and outcomes by site. Multivariate models were constructed with site as an instrumental variable and with sites grouped by silo practice pattern adjusting for confounding factors.

Results

Of 191 gastroschisis infants, 164 infants were uncomplicated. Among uncomplicated patients, there were no deaths and only one case of necrotizing enterocolitis. Bivariate analysis revealed significant differences in practices and outcomes by site. Despite wide variations in practice patterns, there were no major differences in outcome among sites or by silo practice, after adjusting for confounding factors.

Conclusions

Wide variability exists in institutional practice patterns for infants with gastroschisis, but poor outcomes were not associated with expeditious silo or primary closure, avoidance of routine paralysis, or limited central line and antibiotic durations. Development of clinical pathways incorporating these practices may help standardize care and reduce health care costs.

Section snippets

Overview

This is a retrospective cohort study of infants with gastroschisis who were evaluated antenatally and born at any of the five University of California Fetal Consortium sites (UCfC: UC San Francisco, UC Davis, UC Los Angeles, UC Irvine, and UC San Diego) during the years 2007–2012. A multi-institutional review board reliance registry provided approval for the study (IRB #10-04093). Patients were identified and maternal and neonatal data were gathered by chart review at each site directly.

Cohort characteristics

We identified 191 infants born with gastroschisis within the UCfC from 2007 to 2012. Twenty-three infants were excluded for complicated gastroschisis, including 19 with bowel atresia or stricture requiring reoperation (10%), two with ischemic bowel prior to definitive closure (1%), and two with severe pulmonary hypoplasia (1%). There were three deaths in these complicated cases. All occurred within the first 9 days of life in premature infants (30–36 weeks GA). Two of the infants had evisceration

Discussion

The optimal surgical and neonatal management of gastroschisis remains an area of debate. Despite abundant literature on the subject, consensus regarding best practice has not been reached. The current study is a large, contemporary, multi-institutional report on both preferred practice patterns and outcomes for infants with uncomplicated gastroschisis. The study confirms the existence of wide variability in institutional practice patterns, but importantly demonstrates that poor outcomes were

Funding

The UCfC is supported through the UC Research Opportunity Fund through UCOP. This research has been supported NIH/NCRR/NCATS UCLA CTSI Grant Number UL1TR000124. Leslie Lusk was supported by the National Institute of Child Health and Human Development (T32 HD-07162).

Members of the UCfC Consortium

UCD: Erin Brown, MD; Nancy Field, MD; Diana Farmer, MD; Sima Parmar, MD; Francis Poulain, MD.; Laila Rhee Morris, MD; Yen Truong, MD; Nina Boe, MD; Nancy Field; Veronique Tache, MD
UCI: Megan Stephenson, MD; Cherry Uy, MD; Manny Porto, MD; Pamela Rumney, RNC; Deborah Wing, MD; Tamera Hatfield, MD; Nafiz Kiciman, MD
UCLA: Daniel DeUgarte, MD; Kara Calkins, MD; Rachel Gutkin, MD; Melanie Maykin; Dan Kahn, MD, PhD; Stephen Shew, MD; Kara Calkins, MD; Aisling Murphy, MD; Tina Nguyen, MD; Gary Satou,

Acknowledgments

We would to acknowledge David Elashoff (UCLA) for his statistical assistance and Dr. Kara Calkins (UCLA) for her thorough review of this manuscript.

References (20)

K. Murthy et al.
The association of type of surgical closure on length of stay among infants with gastroschisis born ≥ 34 weeks’ gestation
J Pediatr Surg
(2014)
D. Banyard et al.
Method to our madness: an 18-year retrospective analysis on gastroschisis closure
J Pediatr Surg
(2010)
S.N. Kunz et al.
Primary fascial closure versus staged closure with silo in patients with gastroschisis: a meta-analysis
J Pediatr Surg
(2013)
J.D. Lobo et al.
No free ride? The hidden costs of delayed operative management using a spring-loaded silo for gastroschisis
J Pediatr Surg
(2010)
W.F. McNamara et al.
Outcome differences between gastroschisis repair methods
J Surg Res
(2011)
A. Aljahdali et al.
Effect of timing of enteral feeding on outcome in gastroschisis
J Pediatr Surg
(2013)
N. Lansdale et al.
Staged reduction of gastroschisis using preformed silos: practicalities and problems
J Pediatr Surg
(2009)
R.M. Sydorak et al.
Gastroschisis: small hole, big cost
J Pediatr Surg
(2002)
C. Keys et al.
Gastroschisis: the cost of an epidemic
J Pediatr Surg
(2008)
L. Dubois et al.
Impact of an outpatient appendectomy protocol on clinical outcomes and cost: a case–control study
J Am Coll Surg
(2010)

There are more references available in the full text version of this article.

Cited by (29)

Relationship between volume and outcome for gastroschisis: A systematic review
2022, Journal of Pediatric Surgery
Newborns with gastroschisis need surgery to reduce intestines into the abdominal cavity and to close the abdominal wall. Due to an existing volume-outcome relationship for other high-risk, low-volume procedures, we aimed at examining the relationship between hospital or surgeon volume and outcomes for gastroschisis.
We conducted a systematic literature search in Medline, Embase, CENTRAL, CINAHL and Biosis Previews in June 2021 and searched for additional literature. We included (cluster-) randomized controlled trials (RCTs) and prospective or retrospective cohort studies analyzing the relationship between hospital or surgeon volume and mortality, morbidity or quality of life. We assessed risk of bias of included studies using ROBINS-I and performed a systematic synthesis without meta-analysis and used GRADE for assessing the certainty of the evidence.
We included 12 cohort studies on hospital volume. Higher hospital volume may reduce in-hospital mortality of neonates with gastroschisis, while the evidence is very uncertain for other outcomes. Findings are based on a low certainty of the evidence for in-hospital mortality and a very low certainty of the evidence for all other analyzed outcomes, mainly due to risk of bias and imprecision. We did not identify any study on surgeon volume.
The evidence suggests that higher hospital volume reduces in-hospital mortality of newborns with gastroschisis. However, the magnitude of this effect seems to be heterogeneous and results should be interpreted with caution. There is no evidence on the relationship between surgeon volume and outcomes.
Implementing a standardized gastroschisis protocol significantly increases the rate of primary sutureless closure without compromising closure success or early clinical outcomes
2022, Journal of Pediatric Surgery
Citation Excerpt :
The authors noted significant variability in how patients with gastroschisis are managed both within and across centers, ultimately concluding that this high degree of variability was predominantly due to a lack of standardized practice guidelines. In 2014, Lusk et al. echoed these findings by demonstrating significant variability in the management of gastroschisis within the five hospitals comprising the University of California Fetal Consortium (UCFC) [3]. Finally, a 2017 National Surgical Quality Improvement Program (NSQIP) study found that immediate closure was associated with a shorter length of stay and fewer surgical site infections, but was simultaneously associated with increased duration of mechanical ventilation and higher rates of nutritional support at discharge [23].
Standardized protocols have been shown to improve outcomes in several pediatric surgical conditions. We implemented a multi-disciplinary gastroschisis practice bundle at our institution in 2013. We sought to evaluate its impact on closure type and early clinical outcomes.
We performed a retrospective review of uncomplicated gastroschisis patients treated at our institution between 2008–2019. Patients were divided into two groups: pre- and post-protocol implementation. Multivariate logistic regression was used to compare closure location, method, and success.
Neonates (pre-implementation n = 53, post-implementation n = 43) were similar across baseline variables. Successful immediate closure rates were comparable (75.5% vs. 72.1%, p = 0.71). The proportion of bedside closures increased significantly after protocol implementation (35.3% vs. 95.4%, p < 0.01), as did the proportion of sutureless closures (32.5% vs. 71.0%, p < 0.01). Median postoperative mechanical ventilation decreased significantly (4 days IQR [3, 5] vs. 2 days IQR [1, 3], p < 0.01). Postoperative complications and duration of parenteral nutrition were equivalent. After controlling for potential confounding, infants in the post-implementation group had a 44.0 times higher odds of undergoing bedside closure (95% CI: 9.0, 215.2, p < 0.01) and a 7.7 times higher odds of undergoing sutureless closure (95% CI: 2.3, 25.1, p < 0.01).
Implementing a standardized gastroschisis protocol significantly increased the proportion of immediate bedside sutureless closures and decreased the duration of mechanical ventilation, without increasing postoperative complications.
Level of Evidence III
Type of Study Retrospective comparative study.
Antibiotic Stewardship for the Neonatologist and Perinatologist
2021, Clinics in Perinatology
Citation Excerpt :
Importantly, preoperative antibiotic use is a notable contributor to antibiotic exposure in the NICU, particularly for infants with abdominal wall defects and congenital diaphragmatic hernias, despite low rates of infection in the early postnatal period among infants with these surgical conditions.41–43 Potential opportunities for antibiotic stewardship among neonates undergoing surgical procedures include withholding perioperative antibiotics for designated clean procedures,44 standardizing and shortening courses of postoperative antibiotics,43,45–47 and limiting preoperative antibiotics to infants with evidence of clinical illness or in whom another reason for antibiotic administration may exist.41,42 There is no clear evidence that antibiotics need to be continued beyond 24 hours postoperatively, with 1 single-center, retrospective study finding no difference in the rates of SSI within 30 days of procedure, between neonates who received 24 hours or less of postoperative antibiotics versus those who received more than 24 hours of antibiotics after abdominal surgery.47
Gastroschisis in the neonatal period: A prospective case-series in a Brazilian referral center
2020, Journal of Pediatric Surgery
Gastroschisis is increasing in incidence and has low mortality and high morbidity. We describe the clinical and surgical characteristics of gastroschisis patients in a Brazilian referral center.
Single-center prospective case series of gastroschisis patients. The following two groups were formed depending on the intestinal characteristics: simple and complex patients.
In total, 79 patients were enrolled, 89% of whom were classified as simple and 11% as complex. The baseline characteristics were similar between the groups, with the exception of the illness severity score. The complex group had a significantly smaller defect size, more reoperations and worse clinical outcomes than the simple group, with the initiation of feeding taking 1.5 times longer, the duration of total parenteral nutrition taking twice as long, and the length of hospitalization being 2.5 times longer; the complex group also included all the deaths that occurred. Overall, the survival rate was 96%. Patients who underwent the sutureless technique had significantly fewer wound infections and a decreased duration of mechanical ventilation than sutured patients.
This study provides a comprehensive picture of gastroschisis during the neonatal period in a Brazilian referral center, emphasizing the significantly higher risk for morbidity and mortality among complex patients than among simple patients and the few advantages of the sutureless technique over the sutured technique in terms of closing the defect.
Prognostic.
IV
Assessment of gastroschisis risk factors in Egypt
2020, Journal of Pediatric Surgery
Mortality in infants born with gastroschisis (GS) in low-to-middle-income countries (LMICs) is high. This study aimed to assess factors which might affect outcome in Egypt in order to improve survival.
A prospective study over a 15-month duration was completed. Variables assessed covered patient, maternal, antenatal, treatment, and complications. The Gastroschisis Prognostic Score (GPS) was used to predict outcome. A validated questionnaire was used to assess socioeconomic status. The main outcome was mortality.
Twenty-four cases were studied. Median gestational age was 37 (26–40) weeks, and 9 (38%) were preterm. Mortality occurred in 15 (62%) infants. Median transfer time was 8 (1.5–35) hours, and 64% survived if transferred before 8 h. Median maternal age was 20 (16–27) years. All families were of a low or very-low socioeconomic level. Only 25% had antenatal scans. Most cases were simple GS, and only 3 (12.5%) were complex GS. Median length of stay was 14 (1–52) days, TPN duration was 12 (0–49) days, and days to full feeds was 5 (3–11) days. The GPS score ranged from 0 to 6 in the studied cases and negatively correlated with outcome (r_S = − 0.98; p = 0.03).
The mortality of GS in Egypt is very high, mainly due to sepsis and prematurity. Young maternal age and poor socioeconomic status are linked to GS. The GPS is a good indicator of morbidity and mortality in a LMIC setting. Survival improved with better resuscitation and strict management protocols. More effort is needed to improve antenatal detection, and transfer time should be ideally below 8 h.
Level IV.
Adherence to and outcomes of a University-Consortium gastroschisis pathway
2020, Journal of Pediatric Surgery
Citation Excerpt :
Our multi-institutional consortium developed a clinical pathway (i.e. clinical practice guidelines) for management of gastroschisis based on retrospective review of practices and outcomes [12].
Our multi-institutional university consortium implemented a gastroschisis pathway in 2015 to standardize and improve care by promoting avoidance of routine intubation and paralysis during silo placement, expeditious abdominal wall closure, discontinuation of antibiotics/narcotics within 48 h of closure, and early initiation/advancement of feeds.
Adherence to the gastroschisis pathway was prospectively monitored. Outcomes for the contemporary cohort (2015–2018) were compared with a historical cohort (2007–2012).
Good adherence to the pathway was observed for 70 cases of inborn uncomplicated gastroschisis. The contemporary cohort had significantly lower median mechanical ventilator days (2 versus 5; p < 0.01) and antibiotic days (5.5 versus 9; p < 0.01) as well as earlier days to initiation of feeds (12 versus 15; p < 0.01). However, no differences were observed in length of stay (28 versus 29 days; p = 0.70). A skin closure technique was performed in 66% of the patients, of which 46% were performed at bedside without intubation, the assistance of an operating-room team, or general anesthesia.
In this study, adherence to a clinical pathway for gastroschisis across different facilities was feasible and led to reduction in exposure to mechanical ventilation and antibiotics. The adoption of a bedside skin closure technique appears to facilitate compliance with the pathway.
Level II/III
Prospective comparative study with historical cohort

View all citing articles on Scopus

^☆: Presented at the Pacific Association of Pediatric Surgeons Association 47th Annual Meeting on May 28, 2014.

View full text

PPS PapersMulti-institutional practice patterns and outcomes in uncomplicated gastroschisis: A report from the University of California Fetal Consortium (UCfC)☆

Abstract

Background/Purpose

Methods

Results

Conclusions

Section snippets

Overview

Cohort characteristics

Discussion

Funding

Members of the UCfC Consortium

Acknowledgments

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Surg Res

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Am Coll Surg

PPS Papers
Multi-institutional practice patterns and outcomes in uncomplicated gastroschisis: A report from the University of California Fetal Consortium (UCfC)☆