Current survival rates for infants operated on due to gastroschisis are very good and exceed 90% [6]. Despite the excellent treatment results, research of the described condition needs to be maintained continuously, so that the outcomes and full recovery process after surgical treatment could be gradually improved. In order to achieve this, a lot of time and support by a multi-specialty medical team are necessary, of course. Full recovery of an infant depends not only on the extent of the opening in the abdominal wall and of the gastroschisis, but also on the patient's clinical condition as well as other associated congenital anomalies. Associated congenital anomalies occur with various frequency from 8–32% depending on publication [7, 8]. Therefore, research based on long-term analysis is particularly important.
The research carried out by the Poznan-based deparmtent involved a 20-year analysis of the therapeutic process in patients operated on due to gastroschisis with the use of primary and staged silo closure. The observations covered the period from the infant's birth and surgical treatment up to their discharge.
If gastroschisis is diagnosed prenatally, it is advisable to choose mother and child care in the highest-level health center with a neonatal intensive care unit and pediatric surgery department. It was shown that deliveries carried out in other than tertiary care centers are connected with higher frequency of complications [4].
The right time of delivery is still debatable. On one hand, it is believed that earlier delivery exposes intestines to amniotic fluid less, which minimises their atresia, necrosis and enterocolitis. On the other hand, premature delivery is connected with the risk of respiratory disorders which in turn may have repercussions during surgery and anesthesia.
Mesas Burgos et al. argue that the most appropriate stage for delivery is week 35-36.9, and for Cesarean delivery it is week 35 [9]. Baud et al. suggest week 37 [10]. Youssef et al. found that every week of intestines in utero is beneficial for the intestines and decreases the risk of complications in the form of severe bowel matting by 3.6% [11].
Nasr et al. oppose this view and argue that it is delivery after week 38 that causes increased bowel matting [12]. At our department, 94% of infants operated on were prematurely born, i.e. between weeks 31 and 39. Cesarean delivery was performed in 97% of the deliveries.
Rachel et al. carried out an analysis of birthweight of infants with gastroschisis in their publication. Based on the statistics, a significant difference was found between the birtweight of prematurely born infants with gastroschisis and full-term infants with gastroschisis [13]. Low birthweight means birthweight below 2,500 g [14]. In the material collected by our department, average birthweight of infants with gastroschisis was 2,384 g.
According to Lawrence, normal weight gain closest to WHO charts is 26–31 g daily in the period of 0–3 months (based on long-term observation) [15]. In patients treated at our department due to gastroschisis, weight gain was around 1/3 − 1/2 of the normal value. This can be easily explained by the recovery period of intestines after their insertion into the abdominal cavity, and by the necessity of gradual, moderate diet expansion.
A statistically significant correlation between APGAR scores in infants qualified for primary or staged closure was not found. These were values of 9 and 10 points respectively.
A correlation was found between the infants' birthweight centiles and the extent of gastroschisis. Infants with a considerable extent of gastroschisis with associated eventration of other organs than intestines, treated with the staged closure technique, presented birthweight of average value of 10th centile as opposed to the 50th centile in infants treated with primary or staged closure when only intestines were eventrated.
Body mass values at discharge from the hospital were referred to centile charts as well. They confirmed a similar relationship as birthweight centile values. Infants treated with primary and staged closure, but with eventration of intestines only, would achieve the 10th centile of normal body mass. Infants in which staged closure was necessary and other organs were eventrated as well would achieve the 3th body mass centile.
Similar data have not been found in available literature. The demonstrated data would constitute an evidence of a relationship between low birthweight, low body mass at discharge (difficulties in gaining weight) and the clinical condition of a patient with a highly extensive anomaly.
The performance of the analyses may be justified by the fact that birthweight centiles and body mass at discharge are identical for the specific groups.
The average postoperative analgosedation time for primary and staged silo closure was 6 and 12 days respectively, which resulted from the very specifics of surgical treatment. There are 3 categories of surgical management of gastroschisis: operative primary fascial closure, silo placement with staged reduction and delayed closure, and sutureless umbilical closure [4]. Two techniques are used at our department: operative primary fascial closure and silo placement with staged reduction and delayed closure. Silo placement with staged reduction and delayed closure consists in placing the eventrated organs into a sterile bag and attaching it to the abdominal wall. The bag volume is decreased gradually until the closure of the abdominal wall is possible [16].
Fischer et al. summed up ventilation time in their publication. For infants treated with primary closure, the ventilation time was 3–15 days, and for those treated with staged silo closure it was 5–17 days [17].
Landisch et al. determined that the frequency of generalized bacterial infection among the infants operated on is 31.6%. According to research carried out at our department, the higher incidence of infection of 37% was in patients treated with staged closure, whereas the incidence in infants treated with primary closure was 21% [13.]
According to the publication by Fischer et al., enteral feeding was implemented in the period of days 7–22 in the case of primary closure, and in the period of days 9–23 in the case of staged silo closure [17]. With reference to the presented results, the time of feeding implementation at our department was 12 days on average (5–51 days) for primary closure and 22 days on average (8–35 days) for staged closure. Nutrition for an infant with gastroschisis is a complex topic and there is not a lot of uniformity in the literature to formulate evidence-based care [18].
On the basis of our department's analyses, the time of the first natural normal bowel movement was 13 days on average for primary closure and 21 days for staged closure. Unfortunately, no reference to the provided results by other deparments was found in available literature. In our research we did not take into account bowel movements encouraged by a suppository or a coloclyster, only the patient's first natural bowel movement. Bowel movement that occured evidently earlier in an infant treated with primary closure may be related to shorter recovery time of intestines after surgery, lower exposure to intestinal inflammation during staged insertion of intestines into the abdominal cavity, and lower probability of sepsis and concretion during healing. It was proven that numerous cases of intestinal concretion are related to the organism's generalized inflammatory reaction (with incidence frequency of 37% in patients treated with staged closure) and peritoneal dehiscence which was not observed as a complication in our patients [5].
Pratheeppanyapat et al. recognise the following as normal intestinal function: presence of normal bowel sound, passage of the stool, reduction of the nasogastric content and the disappearance of the bilious content aspiration from nasogastric tube. The patients who had continuous feeding without an episode of feeding intolerance until full feeding within 21 days of life were described as successful feeding. In the mentioned publication, none of the silo-closure group had successful early enteral feeding [19].
The average hospital stay of a patient at our department was 32 days long (15 days at the shortest, 86 days at the longest) for treatment with primary closure, and 44 days (19–76 days) for treatment with staged closure. In comparison with outcomes noted by Fischer et al., it was 11–38 and 14–35 days respectively [17]. On this basis, a tendency for greater caution and prolonged hospital stays at health centers in Poland can be observed.