Gastroschisis

Gastroschisis LT. COL. ROBERT

M.

HARDAWAY, 1n, M .c ., Diplomate,

American Board of Surgery,

Fort Belvoir, Virginia From the Surgical Service, U . S . Army Hospital, Fort Belvoir, Virginia .

died. Johns,' reporting the successful treatment of an infant, found ninety-six cases in the ASTROSC141SIS is a rare congenital malformaliterature . Sixty-eight of these were stillborn tion in which the abdomen remains open, monstrosities . Nineteen were born alive but no surgical attempt at repair was made . All with viscera protruding . According to Moore and Stokes,' "the principal features of gastrospatients except one died shortly thereafter . chisis are the extraumbilical location of the Nine patients were subjected to operation, of which six survived for varying periods of time . defect and the absence of a membranous sac Most of these cases apparently were not concovering the eviscerated mass of intestines . The umbilical cord insertion into the ab- sidered authentic by Moore and Stokes . In dominal wall is normal and the umbilical cord fact it would appear that Johns' case was one of omphalocele as there was a covering memis not involved in the evisceration ." According to Bernstein,e "the absence of a sac results in brane and the umbilicus was included in the marked enlargement and thickening of the defect . intestines, with cyanosis, injections and adThe reason for the high mortality of gastroshesions, firmly matting together clusters of chisis stems from : (r) massive disproportion between the volume of the eviscerated mass bowel loops ; in fact, the entire ectopia presents and the capacity of the abdomen ; (2) infection usually as a large solid mass, consisting of due to the lack of a protective covering as densely adherent abdominal viscera with leathery consistency ." Moore and Stokes found in an omphalocele ; and (3) the poor classify congenital eviscerations as follows : condition of the bowel wall . Prompt surgical intervention and antibiotic therapy should i . Omphalocele (umbilical cord anomaly) : minimize the mortality due to the latter two Most common ; herniation of viscera into base circumstances . Disproportion between the volof umbilical cord ; covering membranous sac ume of the eviscerated mass and the abdomen or its ruptured remnants present ; umbilical cord insertion into sac ; present at birth . may prove an insurmountable difficulty . However, it may be lessened by utilizing the prinl . Intussusception of ileum through perciple recommended by Ladd and Gross' for sistent omphalomesenteric duct (omphalothe treatment of omphalocele . This consists of mesenteric duct anomaly) : Rare ; prolapse of inverted mucosa covered small intestine at reduction of the eviscerated mass and suturing umbilicus ; mass often T-shaped ; no covering over it only skin and subcutaneous tissue, leaving the other layers of the abdominal wall sac ; may be present at birth but most often unsutured . This creates a ventral hernia which occurs between one and four weeks of age ; often preceded for several days by umbilical may be dealt with at a later date . The following case is reported because it may represent a true fecal fistula . case of gastroschisis which was successfully . Gastroschisis (extraumbilical abdominal 3 wall anomaly) : Rare ; large eviscerated mass of treated by the Ladd and Gross type operation . discolored intestines of leathery consistency ; CASE REPORT intestines often embedded in a gelatinous ; normal umbilical cord insertion, the A 4 pound, 8 ounce female was born at 7 :45 matrix defect being extraumbilical ; no covering sac or P .M. on November 1, 1952 . The mother was a its ruptured remnants ; present at birth . twenty-one year old white para o, gravida r . In reviewing the literature :More and Stokes The child was delivered eleven days before the found only five authenticated cases of gastrosestimated date of confinement after an unchisis in living newborn infants . Surgery was eventful pregnancy . It was a spontaneous attempted in only three and a successful result delivery, cephalic presentation . The infant was was achieved in only one. The authors themapparently normal and vigorous except for a selves reported on two patients, both of whom circular defect 3 cm . in diameter in the ab636

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Gastroschisis

I' IC . 7 .

Flc .

Infant just prior to surgery .

dominal wall lust to the right of the umbilical cord insertion . The umbilical cord was attached normally to the abdominal wall . No skin was present between the cord and the defect but connective tissue separated the cord structures from the defect . Through this defect protruded the intestine from duodenum to rectum . No other viscera were involved . (Fig . I .) Most of the bowel was edematous, cyanotic, stiff, friable and covered with an exudate . Other loops were in better condition and probably were more recently extruded . It was not possible to stimulate peristalsis . There was no membrane covering the bowel nor was there a remnant of such a membrane . The child was otherwise normal and no evidence of malrotation was seen other than the unrotated portion of the bowel as it lay on the abdomen . She was quite vigorous,

2.

Infant just after surgery .

each side for several centimeters and then sutured over the defect with interrupted vertical mattress sutures of No . 8o cotton . The peritoneum, muscle and fascia were left open widely beneath the skin . (Fig . 2 .) The infant was placed in an incubator, with oxygen . Continual nasal Wangenstcen suction was instituted . She seemed exceptionally strong and had an excellent cry . No peristalsis was present at that time. She was given parenteral feedings of glucose and water, and small amounts of glucose and saline to maintain fluid and electrolyte balance . Penicillin and streptomycin therapy was continued . On November 3rd a small meconium stool was passed but no bowel sounds were heard . By the following day bowel sounds were present and several small stools had been passed . Wangensteen suction was discontinued . Small oral feedings werec started, although some of these were vomited . Her con-

had a strong cry and seemed in exceptionally good condition except for the abdominal defect . It was decided that surgery should be performed at once and she was operated upon at to P .-Ni . that same evening (two hours, fifteen minutes after deliver) , ) . The opening of the defect was extended superiorly and inferiorly about F cm . The insertion of the umbilical cord and intervening tissue were excised . The

dition continued to improve and she was started on Ofac formula on November loth . A milk stool was passed on November 12th . Sutures were removed on the eighth postoperative day, the wound having healed primarily . The patient was discharged on November 30th, weighing 5 pounds, 6 ounces . Since that

bowel was then gently replaced into the abdominal cavity with some difficulty and under moderate tension . Penicillin, roo,ooo units, and streptomycin, gm ., were implanted into

time she has continued to thrive, has an excellent appetite and is apparently normal in all respects . At two and a half months of age she weighed to pounds, z ounces . (Fig . 3 .) There

the peritoneal cavity . The skin and subcutaneous tissue were undermined laterally on

was only a small ventral hernia which was decreasing in extent . At six months she

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Gastroschisis

3

FIG . 3 . FIG . 4.

Infant at two and a half months. Note relatively small ventral hernia . Infant at six months . Note the ventral hernia is almost indiscernible .

weighed 15 pounds, 12 ounces, and the hernia vigorous condition of the infant ; (3) the lack was almost unnoticeable . (Fig . 4.) At eight of any other congenital defect ; (4) immediate months there was no evidence of any hernia operation ; (5) antibiotics ; and (6) utilization and the abdominal wall appeared normal of undermined skin flaps to cover the defect except for the scar . No further surgery is without any attempt to approximate the other contemplated . layers of the abdominal wall . SUMMARY REFERENCES

A case is presented which is thought to be one of true gastroschisis in a 4, pound infant . 2 . The infant was treated by immediate surgery, with successful outcome . Success is attributed to : (I) the relatively small disproportion in this case between the eviscerated mass and the size of the abdomen ; (2) the i .

r

Mgooae, T . C. and STOKES, G . E. Gastroschisis .

Surgery, 33 : 112-120, 1953 . 2 . BERNSTEIN, P. Gastroschisis, rare teratological condition in the newborn . Arch . Pediat ., 57 : 505, 1940. 3 . JOHNS, F . S . Congenital defect in the abdominal wall in the newborn . Ann . Sure., 123 : 886 - 899, 1946 . 4 . LAnD, W . E . and GROSS, R. E . Abdominal Surgery

of Infancy and Childhood, p . 321 . Philadelphia, 194r . W . B . Saunders Co .

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