Treatment

Gastroschisis is a surgical emergency requiring immediate closure or coverage.

The majority of cases are diagnosed by antenatal ultrasound (1).

• early delivery (around 37 weeks of gestation) is thought to be beneficial in gastroschisis - by limiting bowel damage from exposure to amniotic fluid
• there is no evidence that caesarean section improves the outcome.
• ideally these infants should be delivered in a centre where both neonatal and surgical expertise are available.

Upon delivery, these neonates should be transferred to the neonatal unit for preoperative optimization.

Neonates with gastroschisis should be nursed in an incubator to reduce heat loss and in the right lateral position with the bowel supported. Initial post delivery management include:

• fluid resuscitation
• care of herniated bowel/viscera and their blood supply;
  • to reduce heat and fluid loss, the exposed bowel covered with a waterproof cellophane bowel bag.
• bowel decompression using a nasogastric tube
• temperature regulation.

The main objective of gastroschisis management is to reduce the viscera safely and to close the abdominal wall defect with an acceptable cosmetic appearance. Two treatment options are present for gastroschisis:

The first is primary repair, and the second is delayed closure (usually utilizing a temporary silo and performing serial reduction of bowel contents).

Primary closure near birth is performed either operatively or following successful bowel reduction back into the abdominal cavity and performing sutureless gastroschisis repair. A randomized control trial evaluated primary closure versus delayed primary closure following silo reduction in which there were no differences seen between two groups in length of stay, time to enteral feeds, or ventilator time. (2)

Following reduction of the viscera and closure of the defect, total parenteral nutrition should be continued for 3 to 4 more weeks.

In those with associated intestinal atresia, a temporary enterostomy may be constructed at the time of initial abdominal wall repair and closed at a later date.

Note - one multi-institutional review has demonstrated that sutureless abdominal wall closure of neonates with gastroschisis is associated with less general anaesthetics, antibiotic use, surgical site/deep space infections, and decreased ventilator time. (3)

Reference:

1. Poddar R, Hartley L. Exomphalos and gastroschisis Crit Care Pain (2009)  9 (2): 48-51
2. Poola AS et al. Primary Closure versus Bedside Silo and Delayed Closure for Gastroschisis: A Truncated Prospective Randomized Trial. Eur J Pediatr Surg. 2019 Apr;29(2):203-208
3. Fraser JD et al. Midwest Pediatric Surgery Consortium. Sutureless vs sutured abdominal wall closure for gastroschisis: Operative characteristics and early outcomes from the Midwest Pediatric Surgery Consortium. J Pediatr Surg. 2020 Nov;55(11):2284-2288