- Email: [email protected]
Silo formation without suturing in gastroschisis: Use of steridrape® for delayed repair
Silo Formation Without Suturing in Gastroschisis: Use of Steridrape@ for Delayed Repair By Seong-Cheol
Lee, Sung-Eun Jung, Seoul, Korea
0 Although primary repair is preferred for gastroschisis, this cannot be performed in many patients because of the visceroabdominal disproportion or other accompanying conditions. Several prosthetic materials are used for a silo or patch. When prosthetics are used, staged operations are necessary and infection is an inherent problem. However, these problems can be avoided by using Steridrape for a silo without suturing. The authors used the Steridrape to create a covering for two patients. The eviscerated bowel was irrigated and the abdominal wall was cleansed. A sheet of Steridrape was attached onto the abdominal wall and the herniated viscera was wrapped with it. A second sheet was applied over the first one. Antibiotics were administered and parenteral nutrition was sta,rted. The Steridrape covering was changed twice a week. In 1 week the edema subsided remarkably and in 2 weeks the bowel had an almost normal appearance except for hyperemic serosa. Primary repair was performed on the 19th hospital day in patient 1, the 14th day in patient 2. Oral feeding was started 7 days after repair in patient 1, and 22 days after repair in patient 2. Patient 2 developed aspiration pneumonia during transport. Discharge was on the 18th day after surgery in patient 1 and the 59th day in patient 2. The patients are now 18 months and 14 months old, respectively, and are doing well. Steridrape application in gastroschisis is economical, easy to perform, and is a better method to use when transporting the patient. It also facilitates drainage of purulent exudate, and allows the bowel to be inspected easily. This method has proved useful in treating two patients with gastroschisis. Copyright o 1997 by W. 6. Saunders Company INDEX sure.
WORDS:
Gastroschisis,
Steridrape,
silo,
delayed
clo-
P
ROSTHETIC MATERIALS1-6 are used to contain the eviscerated abdominal content in congenital abdominal wall defect with visceroabdominal disproportion. Unlike omphalocele, the visceroabdominal disparity in gastroschisis is partly caused by the edema of the bowel, as well as the decreased volume of abdominal
From the Department of Pediatric Surgery. Seoul National University Children’s Hospital, Seoul, Korea. Presented at the 29th Annual Meeting of the Pact@ Assocration of Pediatric Surgeons, Singapore, May 12-15, 1996. Supported by the Seoul National University Hospital Grant (No. 93046). Address reprint requests to Seong-Cheol Lee, MD, Department of Pediatric Surgerq: Seoul National University Children k Hospital, 28 Yongon-dong, Chongno-gu, Seoul 110-744, Korea. Copyright o 1997 by U?B. Saunders Company 0022-3468/97/3201-0018$03.00/O
66
and Woo-Ki
Kim
cavity. The eviscerated bowel can be protected until the edema subsides. Infection of the bowel is minimized before its reduction into the abdominal cavity. Steridrape (3M, St Paul, MN), a polyethylene film used to drape during operation, was used to create a covering without suturing in two patients with gastroschisis. The patients were treated uneventfully. This method does not create pressure on the viscera and allows drainage of the exudate outside the abdominal cavity.
MATERIALS
AND
METHODS
Technique of Silo Formation Under general anesthesia, the eviscerated bowel associated with gastroschisis is irrigated copiously and an attempt is made to reduce the viscera. Intragastric pressure (IGP) is measured. If the IGP is greater than 20 cm Hz0 without all viscera reduced into the abdommal cavtty, then we proceeded with delayed repair using the Steridrape covering (Fig I). After cleansing the abdominal wall, benzoin tmcture is applied. A sheet of Steridrape is attached to the abdominal wall and wrapped around the herniated viscera. A second sheet is applied over the first one. The outermost sheets are ligated. If the defect is small and compromising the mesenteric blood supply, the defect is enlarged by incising the abdominal wall about 2 cm laterally. Antibiotics are administered on arrival and parenteral nutrition is started within a few days. The Steridrapes are changed twice each week in the nursery without anesthesia. Before applying new sheets, the bowel is inspected and irrigated. Further reduction of the exposed is not attempted until the bowel wall edema is minimal. In approximately 2 weeks, the patient is returned to the operating room and the abdominal wall defect is repaired under general anesthesia. The fascia is approximated with a running 3-O Maxon suture and the skin closed wtth a continuous 4-O nylon suture.
RESULTS
Case I A full-term female neonate with gastroschisis (Fig 1A) was transferred to the Seoul National University Children’s Hospital. With the patient under general anesthesia, an attempt was made to reduce the exposed viscera. The IGP increased to above 20 cm HZ0 before reducing half of the exposed bowel, therefore a delayed closure using Steridrape was performed. The bowel wall edema subsided remarkably in 1 week as shown by the size of the covering Steridrape in Fig lB, and in 2 weeks the bowel had an almost normal appearance except for
Journal
ofpediatric
Surgery,
Vol32,
No 1 (January),
1997: pp 66-68
DELAYED
REPAIR OF GASTROSCHISIS
Fig 1. Photograph of patient 1. (A) At the time of first attempt to reduce the exposed viscera on the day of admission before proceeding intoadelayedclosureusingtheSteridrape covering. (B) Before changing the Steridrape a second time on the 7th day after admission in the nursery. (C)Well-formed membrane over the bowel on the lgth day after admission. (D) An almost normalappearing bowel after excising the membrane on the same day as in C. Reduction of the bowel and repair of the abdominal wall defect were performed without difficulty.
hyperemic serosa. On the 19th hospital day, the patient was returned to the operating room. The bowel was covered with well-formed membrane (Fig lC), and this was excised (Fig 1D). The viscera was reduced, and the defect was repaired without tension. After repair the IGP was 3 cm H20, and no ventilatory support was necessary. Oral feeding was started the 7th day after repair. The postoperative course was uneventful and the patient was discharged on the 18th day after repair. This girl is now 18 months old and doing well. Case 2 A full-term male neonate with gastroschisis was transferred to Seoul from a remote island. On arrival he had severe pneumonia presumably caused by aspiration during transport and required intubation. Because of his poor general condition and marked edema of the bowel we decided not to attempt immediate repair. Significant pulmonary disease kept the patient on mechanical ventilation for 21 days. The defect was closed in 2 weeks without difficulty, and the IGP after repair was 6 cm H20. Mechanical ventilation was continued for 1 week after repair. Postoperatively, oral feeding was started on the 22nd day. He was discharged on the 50th day after repair. This boy is now 14 months old and enjoying normal growth. DISCUSSION
Although primary repair is ideal in abdominal wall defects, the thickened, congested bowel in gastroschisis may make primary repair without markedly increasing intraabdominal pressure impossible.’ The high intraab-
dominal pressure results in high morbidity and mortality. A prosthetic pouch is used to contain the eviscerated bowel with less tension allowing the defect to be repaired at a later date. Prosthetic pouches may also have a problem with undue pressure on the viscera. The disparity between the abdominal cavity and the eviscerated bowel is largely caused by the edema of bowel caused by exposure to amniotic fluid. If the bowel wall edema is allowed to resolve and infection is minimized, it is then possible to return the bowel to the abdominal cavity without tension. Using Steridrape for a covering, without suturing, is easy and economical. When Steridrape is applied, the exudate drains naturally through the small gap formed after partial detachment of sheet by the exudate, thus minimizing infection. The sheet is changed twice a week in the nursery without anesthesia. Irrigation is repeated at the same time to reduce infection. The bowel can be inspected directly, which is another advantage. Also with this method, tightening of the covering is not necessary. Steridrape is cheaper than any other prosthetic material and is readily available. This method is easy to use, and can also be used during transport. A pseudomembrane forms over the bowel in 2 weeks after which it may be possible to start feeding the baby and delay repair of the defect further. The patient can be sent to home for a certain period in hope of wound contraction. Creation of a covering to contain eviscerated abdominal content without suturing is another option for management of gastroschisis. It is safe and easy to perform.
LEE, JUNG,
66
AND
KIM
REFERENCES 1. Caniano DA, Bmkaw B, Ginn-PeaseME: An individualized approach to the managementof gastroschisis.J Pediatr Surg 25:297-300, 1990 2. Corder0 L, Touloukian RJ, Pickett LK: Staged repair of gastroschisis with Silastic sheeting. Surgery 65:676-682, 1969 3. Stringel G: Large gastroschisis: Primary repair with Gore-Tex patch. J Pediatr Surg 28:653-655, 1993 4. Schuster SR: A new method for the staged repair of large omphaloceles. Surg Gynecol Obstet 125:837-850, 1967
5. Rubin SZ, Ein SH: Experience with 55 Silon pouches. J Pediatr Surg 11:803-807, 1976 6. Krasna BH: Is early fascial closure necessaryfor omphaloceie and gastroschisis? J Pediatr Surg 30:23-29, 1995 7. Fonkalsrud EW: Selective repair of neonatal gastroschisis based on degree of visceroabdominal disproportion. Ann Surg 191: 139- 144, 1980
Lee, Sung-Eun Jung, Seoul, Korea
0 Although primary repair is preferred for gastroschisis, this cannot be performed in many patients because of the visceroabdominal disproportion or other accompanying conditions. Several prosthetic materials are used for a silo or patch. When prosthetics are used, staged operations are necessary and infection is an inherent problem. However, these problems can be avoided by using Steridrape for a silo without suturing. The authors used the Steridrape to create a covering for two patients. The eviscerated bowel was irrigated and the abdominal wall was cleansed. A sheet of Steridrape was attached onto the abdominal wall and the herniated viscera was wrapped with it. A second sheet was applied over the first one. Antibiotics were administered and parenteral nutrition was sta,rted. The Steridrape covering was changed twice a week. In 1 week the edema subsided remarkably and in 2 weeks the bowel had an almost normal appearance except for hyperemic serosa. Primary repair was performed on the 19th hospital day in patient 1, the 14th day in patient 2. Oral feeding was started 7 days after repair in patient 1, and 22 days after repair in patient 2. Patient 2 developed aspiration pneumonia during transport. Discharge was on the 18th day after surgery in patient 1 and the 59th day in patient 2. The patients are now 18 months and 14 months old, respectively, and are doing well. Steridrape application in gastroschisis is economical, easy to perform, and is a better method to use when transporting the patient. It also facilitates drainage of purulent exudate, and allows the bowel to be inspected easily. This method has proved useful in treating two patients with gastroschisis. Copyright o 1997 by W. 6. Saunders Company INDEX sure.
WORDS:
Gastroschisis,
Steridrape,
silo,
delayed
clo-
P
ROSTHETIC MATERIALS1-6 are used to contain the eviscerated abdominal content in congenital abdominal wall defect with visceroabdominal disproportion. Unlike omphalocele, the visceroabdominal disparity in gastroschisis is partly caused by the edema of the bowel, as well as the decreased volume of abdominal
From the Department of Pediatric Surgery. Seoul National University Children’s Hospital, Seoul, Korea. Presented at the 29th Annual Meeting of the Pact@ Assocration of Pediatric Surgeons, Singapore, May 12-15, 1996. Supported by the Seoul National University Hospital Grant (No. 93046). Address reprint requests to Seong-Cheol Lee, MD, Department of Pediatric Surgerq: Seoul National University Children k Hospital, 28 Yongon-dong, Chongno-gu, Seoul 110-744, Korea. Copyright o 1997 by U?B. Saunders Company 0022-3468/97/3201-0018$03.00/O
66
and Woo-Ki
Kim
cavity. The eviscerated bowel can be protected until the edema subsides. Infection of the bowel is minimized before its reduction into the abdominal cavity. Steridrape (3M, St Paul, MN), a polyethylene film used to drape during operation, was used to create a covering without suturing in two patients with gastroschisis. The patients were treated uneventfully. This method does not create pressure on the viscera and allows drainage of the exudate outside the abdominal cavity.
MATERIALS
AND
METHODS
Technique of Silo Formation Under general anesthesia, the eviscerated bowel associated with gastroschisis is irrigated copiously and an attempt is made to reduce the viscera. Intragastric pressure (IGP) is measured. If the IGP is greater than 20 cm Hz0 without all viscera reduced into the abdommal cavtty, then we proceeded with delayed repair using the Steridrape covering (Fig I). After cleansing the abdominal wall, benzoin tmcture is applied. A sheet of Steridrape is attached to the abdominal wall and wrapped around the herniated viscera. A second sheet is applied over the first one. The outermost sheets are ligated. If the defect is small and compromising the mesenteric blood supply, the defect is enlarged by incising the abdominal wall about 2 cm laterally. Antibiotics are administered on arrival and parenteral nutrition is started within a few days. The Steridrapes are changed twice each week in the nursery without anesthesia. Before applying new sheets, the bowel is inspected and irrigated. Further reduction of the exposed is not attempted until the bowel wall edema is minimal. In approximately 2 weeks, the patient is returned to the operating room and the abdominal wall defect is repaired under general anesthesia. The fascia is approximated with a running 3-O Maxon suture and the skin closed wtth a continuous 4-O nylon suture.
RESULTS
Case I A full-term female neonate with gastroschisis (Fig 1A) was transferred to the Seoul National University Children’s Hospital. With the patient under general anesthesia, an attempt was made to reduce the exposed viscera. The IGP increased to above 20 cm HZ0 before reducing half of the exposed bowel, therefore a delayed closure using Steridrape was performed. The bowel wall edema subsided remarkably in 1 week as shown by the size of the covering Steridrape in Fig lB, and in 2 weeks the bowel had an almost normal appearance except for
Journal
ofpediatric
Surgery,
Vol32,
No 1 (January),
1997: pp 66-68
DELAYED
REPAIR OF GASTROSCHISIS
Fig 1. Photograph of patient 1. (A) At the time of first attempt to reduce the exposed viscera on the day of admission before proceeding intoadelayedclosureusingtheSteridrape covering. (B) Before changing the Steridrape a second time on the 7th day after admission in the nursery. (C)Well-formed membrane over the bowel on the lgth day after admission. (D) An almost normalappearing bowel after excising the membrane on the same day as in C. Reduction of the bowel and repair of the abdominal wall defect were performed without difficulty.
hyperemic serosa. On the 19th hospital day, the patient was returned to the operating room. The bowel was covered with well-formed membrane (Fig lC), and this was excised (Fig 1D). The viscera was reduced, and the defect was repaired without tension. After repair the IGP was 3 cm H20, and no ventilatory support was necessary. Oral feeding was started the 7th day after repair. The postoperative course was uneventful and the patient was discharged on the 18th day after repair. This girl is now 18 months old and doing well. Case 2 A full-term male neonate with gastroschisis was transferred to Seoul from a remote island. On arrival he had severe pneumonia presumably caused by aspiration during transport and required intubation. Because of his poor general condition and marked edema of the bowel we decided not to attempt immediate repair. Significant pulmonary disease kept the patient on mechanical ventilation for 21 days. The defect was closed in 2 weeks without difficulty, and the IGP after repair was 6 cm H20. Mechanical ventilation was continued for 1 week after repair. Postoperatively, oral feeding was started on the 22nd day. He was discharged on the 50th day after repair. This boy is now 14 months old and enjoying normal growth. DISCUSSION
Although primary repair is ideal in abdominal wall defects, the thickened, congested bowel in gastroschisis may make primary repair without markedly increasing intraabdominal pressure impossible.’ The high intraab-
dominal pressure results in high morbidity and mortality. A prosthetic pouch is used to contain the eviscerated bowel with less tension allowing the defect to be repaired at a later date. Prosthetic pouches may also have a problem with undue pressure on the viscera. The disparity between the abdominal cavity and the eviscerated bowel is largely caused by the edema of bowel caused by exposure to amniotic fluid. If the bowel wall edema is allowed to resolve and infection is minimized, it is then possible to return the bowel to the abdominal cavity without tension. Using Steridrape for a covering, without suturing, is easy and economical. When Steridrape is applied, the exudate drains naturally through the small gap formed after partial detachment of sheet by the exudate, thus minimizing infection. The sheet is changed twice a week in the nursery without anesthesia. Irrigation is repeated at the same time to reduce infection. The bowel can be inspected directly, which is another advantage. Also with this method, tightening of the covering is not necessary. Steridrape is cheaper than any other prosthetic material and is readily available. This method is easy to use, and can also be used during transport. A pseudomembrane forms over the bowel in 2 weeks after which it may be possible to start feeding the baby and delay repair of the defect further. The patient can be sent to home for a certain period in hope of wound contraction. Creation of a covering to contain eviscerated abdominal content without suturing is another option for management of gastroschisis. It is safe and easy to perform.
LEE, JUNG,
66
AND
KIM
REFERENCES 1. Caniano DA, Bmkaw B, Ginn-PeaseME: An individualized approach to the managementof gastroschisis.J Pediatr Surg 25:297-300, 1990 2. Corder0 L, Touloukian RJ, Pickett LK: Staged repair of gastroschisis with Silastic sheeting. Surgery 65:676-682, 1969 3. Stringel G: Large gastroschisis: Primary repair with Gore-Tex patch. J Pediatr Surg 28:653-655, 1993 4. Schuster SR: A new method for the staged repair of large omphaloceles. Surg Gynecol Obstet 125:837-850, 1967
5. Rubin SZ, Ein SH: Experience with 55 Silon pouches. J Pediatr Surg 11:803-807, 1976 6. Krasna BH: Is early fascial closure necessaryfor omphaloceie and gastroschisis? J Pediatr Surg 30:23-29, 1995 7. Fonkalsrud EW: Selective repair of neonatal gastroschisis based on degree of visceroabdominal disproportion. Ann Surg 191: 139- 144, 1980