- Email: [email protected]
Silo pouch stoma: a rescue procedure for intestinal catastrophe in gastroschisis
Journal of Pediatric Surgery (2006) 41, E13 – E14
www.elsevier.com/locate/jpedsurg
Silo pouch stoma: a rescue procedure for intestinal catastrophe in gastroschisis Anupam Lall, Michael Singh, Antonino Morabito* Neonatal Surgical Unit, St. Mary’s Hospital, M13 9WL Manchester, UK Index words: Gastroschisis; Perforation; Silo pouch
Abstract Silo pouch formation is a standard procedure to prevent compartment syndrome in gastroschisis. Intestinal complications such as perforation and volvulus can occur and their management can be perplexing. We present three such patients in which we formed a stoma through the silo pouch owing to these complications. Creation of stoma through the silo is a novel, safe temporizing technique to decompress the bowel while delayed reduction continues. Subsequently, when the baby and the bowel improve, the stoma can be closed. D 2006 Elsevier Inc. All rights reserved.
The outcome of gastroschisis, once associated with an extremely high mortality and morbidity, has improved dramatically with a survival rate exceeding 90% to 95% [1,2]. Still, considerable controversy exists in several areas of gastroschisis management, including the optimal timing, location, and mode of delivery of the infant. Intestinal atresia is estimated to occur in approximately 10% to 20% of infants with gastroschisis [3-5] and has been considered to be a significant contributor to morbidity and mortality [6]. Early intestinal perforations are well described and are thought to be associated with aggressive reduction to achieve primary closure [7]. However, most reports have focussed on their occurrence after primary or delayed closure and not while in a silo pouch.
1. Case report A retrospective review of three neonates with intestinal perforation and ischemia while in a silo pouch was * Corresponding author. Tel.: +44 161 276 6542; fax: +44 161 276 6854. E-mail address: [email protected] (A. Morabito). 0022-3468/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2005.12.058
conducted. A temporary stoma was brought out at a convenient place on the silo sheath and fixed with sutures.
1.1. Case 1 A 37-week neonate with gastroschisis and jejunal atresia underwent silo formation after failed primary reduction. Ischemia of an intestinal loop and persistent metabolic acidosis was noted 4 days later. At surgery, a volvulus of the hugely distended proximal jejunum was found. Resection was not necessary owing to improvement in the bowel condition. The two ends of the atretic bowel were brought out as a stoma on the silo sheath leaving the remaining gut inside the pouch. The baby’s condition improved and the bowel underwent successful delayed reduction. The proximal jejunal end was brought out as a stoma on abdominal wall. The stoma was then reversed after a month and a jejunocolic anastomosis was fashioned.
1.2. Cases 2 and 3 Two neonates born at 37 and 35 weeks of gestation, respectively, underwent silo formation after failed primary reduction. Meconium was noticed within the silo in both children 2 days later. At surgery, a perforation of the
E14
Fig. 1 Silo pouch stoma in patient with a perforation in the ileum.
mid-ileum was found in case 2 and terminal ileum in case 3. The perforated ileum was brought out as a divided stoma onto the silo sheath. The stomas were subsequently reversed with closure of the abdominal anomaly after 7 days.
1.3. Technique The procedure starts with the fixation of the silastic sheath to the fascia on the abdominal wall. A window is made on the sheath at a convenient site and should be of adequate size to allow the bowel to be brought through easily and without tension, angulation, or obstruction. The stoma should not be sited at the summit of the silo because it will prevent reduction by gravity. The base of the silo should also be avoided because it may predispose the stoma to detach during reduction. The cut end of the bowel is then anchored to the sheath (Fig. 1). Once complete reduction is achieved, the abdominal wall anomaly is closed. The stoma can either be reversed or a new stoma fashioned via the abdominal wall at the same time.
2. Discussion Gastroschisis is no longer a surgical emergency. The aim of management is the safe replacement of the extruded midgut into the abdominal space with minimal morbidity to the child. This is best undertaken when the newborn baby is stable and at least risk from surgery. The outcome is often determined by the quality of the bowel because other anomalies are not frequent. Intestinal atresia and perforations
A. Lall et al. are not uncommon in children with gastroschisis and are both known to increase the morbidity and mortality in these patients [3,7]. More recently, many centers have moved toward methods of closure that allow gradual reduction in the neonatal intensive care unit and subsequent closure on an elective basis [8,9]. Gastroschisis becomes a surgical emergency when there is vascular compromise of the reduced midgut. In all of our patients, primary closure was not possible owing to visceroabdominal disproportion. The presence of a transparent silo pouch in these cases helped to identify the complications at an earlier stage. A stoma on the silastic sheath has the advantages of diverting the intestinal contents outside the silo pouch, fixing the bowel and preventing retorsion, and reducing the operative time in a septic patient when creation of an abdominal stoma may be more difficult. Furthermore, it allows the bowel to be easily monitored postoperatively. We did not encounter any problem of infection, retraction, or detachment of the stoma and subsequent reversal was not hindered. It also avoids an additional abdominal scar. At the time of silo pouch stoma reversal, only the margins were trimmed, thus avoiding the loss of a longer segment of intestine that would have been unavoidable in mobilization of an abdominal wall stoma. We believe that the silo pouch stoma offers a simple and safe solution at a difficult time for the child and the surgeon. It buys time for improvement in the child’s condition and for easy monitoring of the state of the bowel. Our limited positive experience drives us to recommend this concept for further assessment by colleagues.
References [1] Snyder CL. Outcome analysis of gastroschisis. J Pediatr Surg 1999; 34:1253 - 6. [2] Driver CP, Bruce J, Bianchi A, et al. The contemporary outcome of gastroschisis. J Pediatr Surg 2000;35:1719 - 23. [3] Haddock G, Davis CF, Raine PA. Gastroschisis in the decade of prenatal diagnosis: 1983-1993. Eur J Pediatr Surg 1996;6:18 - 22. [4] Nicholls EA, Ford WD, Barnes KH, et al. A decade of gastroschisis in the era of antenatal ultrasound. Aust N Z J Surg 1996;66:366 - 8. [5] Snyder CL, Miller KA, Sharp RJ, et al. Management of intestinal atresia in patients with gastroschisis. J Pediatr Surg 2001;36:1542 - 5. [6] Cusick E, Spicer RD, Beck JM. Small-bowel continuity: a crucial factor in determining survival in gastroschisis. Pediatr Surg Int 1997; 12:34 - 7. [7] Ein SH, Superina R, Bagwell C, et al. Ischemic bowel after primary closure for gastroschisis. J Pediatr Surg 1988;23:728 - 30. [8] Schlatter M, Norris K, Uitvlugt N, et al. Improved outcomes in the treatment of gastroschisis using a preformed silo and delayed repair approach. J Pediatr Surg 2003;38(3):459 - 64. [9] Minkes RK, Langer JC, Mazziotti MV, et al. Routine insertion of a silastic spring-loaded silo for infants with gastroschisis. J Pediatr Surg 2000;35:843 - 6.
www.elsevier.com/locate/jpedsurg
Silo pouch stoma: a rescue procedure for intestinal catastrophe in gastroschisis Anupam Lall, Michael Singh, Antonino Morabito* Neonatal Surgical Unit, St. Mary’s Hospital, M13 9WL Manchester, UK Index words: Gastroschisis; Perforation; Silo pouch
Abstract Silo pouch formation is a standard procedure to prevent compartment syndrome in gastroschisis. Intestinal complications such as perforation and volvulus can occur and their management can be perplexing. We present three such patients in which we formed a stoma through the silo pouch owing to these complications. Creation of stoma through the silo is a novel, safe temporizing technique to decompress the bowel while delayed reduction continues. Subsequently, when the baby and the bowel improve, the stoma can be closed. D 2006 Elsevier Inc. All rights reserved.
The outcome of gastroschisis, once associated with an extremely high mortality and morbidity, has improved dramatically with a survival rate exceeding 90% to 95% [1,2]. Still, considerable controversy exists in several areas of gastroschisis management, including the optimal timing, location, and mode of delivery of the infant. Intestinal atresia is estimated to occur in approximately 10% to 20% of infants with gastroschisis [3-5] and has been considered to be a significant contributor to morbidity and mortality [6]. Early intestinal perforations are well described and are thought to be associated with aggressive reduction to achieve primary closure [7]. However, most reports have focussed on their occurrence after primary or delayed closure and not while in a silo pouch.
1. Case report A retrospective review of three neonates with intestinal perforation and ischemia while in a silo pouch was * Corresponding author. Tel.: +44 161 276 6542; fax: +44 161 276 6854. E-mail address: [email protected] (A. Morabito). 0022-3468/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2005.12.058
conducted. A temporary stoma was brought out at a convenient place on the silo sheath and fixed with sutures.
1.1. Case 1 A 37-week neonate with gastroschisis and jejunal atresia underwent silo formation after failed primary reduction. Ischemia of an intestinal loop and persistent metabolic acidosis was noted 4 days later. At surgery, a volvulus of the hugely distended proximal jejunum was found. Resection was not necessary owing to improvement in the bowel condition. The two ends of the atretic bowel were brought out as a stoma on the silo sheath leaving the remaining gut inside the pouch. The baby’s condition improved and the bowel underwent successful delayed reduction. The proximal jejunal end was brought out as a stoma on abdominal wall. The stoma was then reversed after a month and a jejunocolic anastomosis was fashioned.
1.2. Cases 2 and 3 Two neonates born at 37 and 35 weeks of gestation, respectively, underwent silo formation after failed primary reduction. Meconium was noticed within the silo in both children 2 days later. At surgery, a perforation of the
E14
Fig. 1 Silo pouch stoma in patient with a perforation in the ileum.
mid-ileum was found in case 2 and terminal ileum in case 3. The perforated ileum was brought out as a divided stoma onto the silo sheath. The stomas were subsequently reversed with closure of the abdominal anomaly after 7 days.
1.3. Technique The procedure starts with the fixation of the silastic sheath to the fascia on the abdominal wall. A window is made on the sheath at a convenient site and should be of adequate size to allow the bowel to be brought through easily and without tension, angulation, or obstruction. The stoma should not be sited at the summit of the silo because it will prevent reduction by gravity. The base of the silo should also be avoided because it may predispose the stoma to detach during reduction. The cut end of the bowel is then anchored to the sheath (Fig. 1). Once complete reduction is achieved, the abdominal wall anomaly is closed. The stoma can either be reversed or a new stoma fashioned via the abdominal wall at the same time.
2. Discussion Gastroschisis is no longer a surgical emergency. The aim of management is the safe replacement of the extruded midgut into the abdominal space with minimal morbidity to the child. This is best undertaken when the newborn baby is stable and at least risk from surgery. The outcome is often determined by the quality of the bowel because other anomalies are not frequent. Intestinal atresia and perforations
A. Lall et al. are not uncommon in children with gastroschisis and are both known to increase the morbidity and mortality in these patients [3,7]. More recently, many centers have moved toward methods of closure that allow gradual reduction in the neonatal intensive care unit and subsequent closure on an elective basis [8,9]. Gastroschisis becomes a surgical emergency when there is vascular compromise of the reduced midgut. In all of our patients, primary closure was not possible owing to visceroabdominal disproportion. The presence of a transparent silo pouch in these cases helped to identify the complications at an earlier stage. A stoma on the silastic sheath has the advantages of diverting the intestinal contents outside the silo pouch, fixing the bowel and preventing retorsion, and reducing the operative time in a septic patient when creation of an abdominal stoma may be more difficult. Furthermore, it allows the bowel to be easily monitored postoperatively. We did not encounter any problem of infection, retraction, or detachment of the stoma and subsequent reversal was not hindered. It also avoids an additional abdominal scar. At the time of silo pouch stoma reversal, only the margins were trimmed, thus avoiding the loss of a longer segment of intestine that would have been unavoidable in mobilization of an abdominal wall stoma. We believe that the silo pouch stoma offers a simple and safe solution at a difficult time for the child and the surgeon. It buys time for improvement in the child’s condition and for easy monitoring of the state of the bowel. Our limited positive experience drives us to recommend this concept for further assessment by colleagues.
References [1] Snyder CL. Outcome analysis of gastroschisis. J Pediatr Surg 1999; 34:1253 - 6. [2] Driver CP, Bruce J, Bianchi A, et al. The contemporary outcome of gastroschisis. J Pediatr Surg 2000;35:1719 - 23. [3] Haddock G, Davis CF, Raine PA. Gastroschisis in the decade of prenatal diagnosis: 1983-1993. Eur J Pediatr Surg 1996;6:18 - 22. [4] Nicholls EA, Ford WD, Barnes KH, et al. A decade of gastroschisis in the era of antenatal ultrasound. Aust N Z J Surg 1996;66:366 - 8. [5] Snyder CL, Miller KA, Sharp RJ, et al. Management of intestinal atresia in patients with gastroschisis. J Pediatr Surg 2001;36:1542 - 5. [6] Cusick E, Spicer RD, Beck JM. Small-bowel continuity: a crucial factor in determining survival in gastroschisis. Pediatr Surg Int 1997; 12:34 - 7. [7] Ein SH, Superina R, Bagwell C, et al. Ischemic bowel after primary closure for gastroschisis. J Pediatr Surg 1988;23:728 - 30. [8] Schlatter M, Norris K, Uitvlugt N, et al. Improved outcomes in the treatment of gastroschisis using a preformed silo and delayed repair approach. J Pediatr Surg 2003;38(3):459 - 64. [9] Minkes RK, Langer JC, Mazziotti MV, et al. Routine insertion of a silastic spring-loaded silo for infants with gastroschisis. J Pediatr Surg 2000;35:843 - 6.