image: a). Midgut normal rotation. Note the foregut is coloured green, midgut as yellow and hind gut is having red color. b). Midgut malrotation with all of the small bowel on the right side, ileocecal region in the epigastrium with Ladd’s bands across the duodenum to gall bladder and most of the large bowel on the left side of the abdomen reducing the small bowel mesentery very narrow based. c). Midgut malrotation with volvulus leading to strangulation and catastrophic loss of midgut if not being managed urgently. A, appendix; AC, ascending colon; C, cecum; DC, descending colon; D, duodenum; E, esophagus; J, jejunum; LADD’S BANDS, adhesion bands between cecum and gall bladder across the duodenum; R, rectum; S, sigmoid colon; TC, transverse colon; TI, terminal ileum.
Credit: Ramnik Vallabh Patel, Indre Zaparackaite
Gastroschisis, a congenital abdominal wall defect, has transformed from a uniformly fatal condition to one with a 95% survival rate through surgical advancements over the past six decades. The primary goal of managing gastroschisis is to mitigate fetal and postnatal risks, including damage from herniated bowel loops and ensuring effective decompression of the gastrointestinal tract during recovery. This review focuses on both preventative and corrective aspects of gastroschisis management, highlighting innovations in neonatal surgery that improve quality of life and long-term health outcomes.
Definition and Classification
Traditionally, gastroschisis is defined as a paraumbilical abdominal wall defect without a covering sac for the exposed organs. This review proposes an expanded definition, emphasizing a congenital secreto-motility disorder affecting the colorectal and hindgut, which can worsen the abdominal wall defect. The condition’s classification includes simple and complex forms and highlights rare types such as “variant gastroschisis,” which encompasses atypical presentations. The differentiation from omphalocele is emphasized, as gastroschisis typically presents with gastrointestinal complications rather than genetic anomalies often associated with omphalocele.
Embryo-pathogenesis
Although environmental factors primarily influence gastroschisis, the exact pathogenesis remains unclear. Proposed theories suggest a combination of abdominal wall defects and increased intraabdominal pressure leads to herniation. This review provides insights into intrauterine events and hindgut anomalies that can affect development, offering evidence from experimental models and prenatal monitoring to advance understanding of the condition’s origins.
Epidemiology
Risk factors for gastroschisis include maternal age under 20, substance use, stress, and micronutrient deficiencies, with the highest prevalence observed in lower socioeconomic backgrounds. Regional disparities in healthcare access contribute to higher gastroschisis rates and poorer outcomes. Preventative strategies include improving maternal nutrition, increasing awareness of risk factors, and promoting healthcare access, particularly for at-risk populations.
Antenatal and Perinatal Management
Early diagnosis via ultrasound enables detailed prenatal monitoring and the option for delivery at specialized centers. The optimal timing for delivery is around 37–38 weeks, ideally via vaginal delivery to avoid complications linked to cesarean sections. Upon birth, careful handling of exposed bowel and temperature regulation are critical to prevent further injury. The use of preformed silastic silo and a multidisciplinary approach to perinatal management have significantly improved neonatal outcomes.
Surgical and Postoperative Management
The primary aim in gastroschisis surgery is to reduce and close the defect without risking bowel ischemia due to high intra-abdominal pressure. The review describes bedside reduction and sutureless closure techniques, particularly effective for simple gastroschisis. For complex cases, gradual reduction using a silastic silo is favored. Postoperative care focuses on preventing infection, minimizing antibiotic exposure, and supporting gastrointestinal function, often through enteral feeding as soon as possible to reduce the reliance on total parenteral nutrition (TPN).
Outcomes and Prognosis
Survival rates are high, with complications primarily arising in complex cases. Long-term complications can include gastrointestinal dysfunction, TPN dependence, and growth delays. The review encourages early feeding with breast milk to reduce risks of complications like necrotizing enterocolitis and suggests targeted interventions for cases with severe intestinal resection or short bowel syndrome.
Conclusions
Through a comprehensive approach encompassing preventative, surgical, and postnatal care, outcomes for gastroschisis patients have improved markedly. This review underscores the need for continued innovation in minimally invasive techniques and patient-centered care strategies to optimize results. Future research may reveal additional insights into prevention, prenatal diagnostics, and neonatal management of gastroschisis.
Full text
https://www.xiahepublishing.com/2994-8754/JTG-2023-00092
The study was recently published in the Journal of Translational Gastroenterology.
Journal of Translational Gastroenterology (JTG) dedicates to improving clinical diagnosis and treatment, advancing understanding of the molecular mechanisms, and promoting translation from bench to bedside of gastrointestinal, hepatobiliary, and pancreatic diseases. The aim of JTG is to provide a forum for the exchange of ideas and concepts on basic, translational, and clinical aspects of gastroenterology, and promote cross-disciplinary research and collaboration.
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Journal
Journal of Translational Gastroenterology
Article Title
Innovative Approaches to the Surgical Challenges in the Management of Gastroschisis: A Narrative Review of the Literature
Article Publication Date
30-Sep-2024