E383 Full PDF

Download as pdf or txt
Download as pdf or txt
You are on page 1of 11

Abdominal Wall Defects

Bethany J. Slater, MD, MBA,* Ashwin Pimpalwar, MD†


*Division of Pediatric Surgery, University of Chicago Medicine, Chicago, IL

Division of Pediatric Surgery, Children’s Hospital, University of Missouri, Columbia, MO

Practice Gaps
Abdominal wall defects are a relatively common congenital anomaly
encountered in the pediatric population. These defects include 2 separate
pathologies, gastroschisis and omphalocele, with divergent pathophysiologic
origins, clinical manifestations, and management strategies. Although the
mode and timing of delivery is somewhat controversial, particularly for
gastroschisis, most of the evidence supports delivery at a high-volume tertiary
care center with immediate access to neonatal and pediatric surgical expertise.
Clinicians should be aware of a rare variant of gastroschisis, closing
gastroschisis, because early recognition and treatment may affect patient
outcomes, as well as complicated gastroschisis and giant omphalocele because
of the more challenging surgical considerations.

Abstract
The 2 most common congenital abdominal wall defects are gastroschisis and
omphalocele. Both are usually diagnosed prenatally with fetal ultrasonography,
and affected patients are treated at a center with access to high-risk obstetric
services, neonatology, and pediatric surgery. The main distinguishing features
between the 2 are that gastroschisis has no sac and the defect is to the right of
the umbilicus, whereas an omphalocele typically has a sac and the defect is at
the umbilicus. In addition, patients with an omphalocele have a high prevalence
of associated anomalies, whereas those with gastroschisis have a higher
likelihood of abnormalities related to the gastrointestinal tract, with the most
common being intestinal atresia. As such, the prognosis in patients with
omphalocele is primarily affected by the severity and number of other
anomalies and the prognosis for gastroschisis is correlated with the amount and
function of the bowel. Because of these distinctions, these defects have different
management strategies and outcomes. The goal of surgical treatment for both
conditions consists of reduction of the abdominal viscera and closure of the
abdominal wall defect; primary closure or a variety of staged approaches can be
used without injury to the intra-abdominal contents through direct injury or
AUTHOR DISCLOSURE Dr Slater is a increased intra-abdominal pressure, or abdominal compartment syndrome.
consultant for Boulder Surgical. Dr Pimpalwar Overall, the long-term outcome is generally good. The ability to stratify patients,
has no financial relationships relevant to this
article. This commentary does not contain a particularly those with gastroschisis, based on risk factors for higher morbidity
discussion of an unapproved/investigative would potentially improve counseling and outcomes.
use of a commercial product/device.

Vol. 21 No. 6 JUNE 2020 e383


Downloaded from http://neoreviews.aappublications.org/ at Indonesia:AAP Sponsored on October 13, 2020
Objectives After completing this article, readers should be able to:

1. Distinguish between gastroschisis and omphalocele.


2. Identify the major prenatal ultrasound findings of the congenital
abdominal wall defects.
3. Recognize the rare variant of gastroschisis, closing gastroschisis.
4. Describe the management and surgical techniques used for patients with
gastroschisis and omphalocele, including giant omphalocele.
5. Recognize the clinical manifestations of abdominal compartment
syndrome and its treatment.

INTRODUCTION GASTROSCHISIS

The 2 most common congenital abdominal wall defects are Clinical Aspects
gastroschisis (Fig 1A) and omphalocele (Fig 1B). Both are Gastroschisis is usually less than 4 cm in diameter, has no
typically diagnosed prenatally using fetal ultrasonography, covering membrane or sac, and generally contains only
and affected patients are treated at a center with access to small intestine, potentially with the stomach or gonad. In
high-risk obstetric services, neonatology, and pediatric sur- almost all cases, it is present to the right of the umbilical
gery. In this review, we discuss the distinguishing features, cord. (5) After birth, the bowel may appear fairly normal or
current management strategies, and outcomes of patients may be thickened, matted, and covered with a fibrinous peel.
with these defects. In contrast to patients with omphaloceles, those with gastro-
schisis do not typically have associated congenital anomalies
but are more likely to have abnormalities of the bowel,
EPIDEMIOLOGY AND PATHOPHYSIOLOGY
including atresias. Many affected patients are born preterm
The incidence of congenital abdominal wall defects has and are often small for gestational age. Those with atresia,
been increasing, primarily because of the increased inci- perforation, necrosis, or volvulus fall into a separate category
dence of gastroschisis. (1) Gastroschisis occurs in 1 in called “complicated gastroschisis.”
approximately 4,000 live births (2) with a male preponder- Gastroschisis is commonly seen on mid-second trimes-
ance and has become the most common abdominal wall ter fetal ultrasonography with characteristics of a right-sided
defect over the past 30 years. (3) A strong association with defect with free-floating bowel in the amniotic cavity. There
young maternal age has been noted. The overall incidence of are a few ultrasonographic findings that raise the concern
omphalocele is 1 to 2.5 per 5,000 live births. (4) for intestinal complications; of these intra-abdominal bowel
An omphalocele results from the failure of the bowel dilation appears to be the most reliable predictor of complex
loops to return to the abdominal cavity after the physiologic gastroschisis. (6) In addition, elevated a-fetoprotein con-
herniation through the umbilical cord that occurs between centrations in both maternal blood and amniotic fluid have
the 6th and 11th week of development. Several mechanisms been correlated with gastroschisis.
have been proposed for the pathogenesis of gastroschisis. Closing or closed gastroschisis is a rare variant of com-
One theory is that the defect arises from failure of the plicated gastroschisis in which the defect narrows in utero,
umbilical coelom to develop, leading to rupture of the resulting in strangulation and subsequent ischemia of the
elongating intestine out of the body wall to the right of herniated bowel and atresia. The most severe cases can lead
the umbilicus. An alternative explanation is that the embry- to complete loss of the midgut with short gut syndrome
onic structures fail to incorporate into the umbilical cord. (Fig 2) The patient depicted was diagnosed with closing
In addition, experts suggest that several environmental gastroschisis and initially had complete atresia and signif-
exposures and demographic risk factors contribute to its icant bowel loss (Fig 2A and 2B). After exploration 6 weeks
development. later, the bowel had grown with significant progressive

e384 NeoReviews
Downloaded from http://neoreviews.aappublications.org/ at Indonesia:AAP Sponsored on October 13, 2020
Figure 1. A. Picture of gastroschisis with no sac and the defect to the
right of the umbilicus. B. Picture of omphalocele with a sac present and
defect at the umbilicus.

development of bowel loops (Fig 2C) and anastomosis and


complete closure was achieved. This patient was discharged Figure 2. A. Picture of closing gastroschisis with a single strand of tissue
(superior mesenteric artery) and complete separation of the midgut
9 days later on full feedings. This is one of a series of 5 (atresia). B. Intraoperative exploration at birth, of the same patient as
infants treated at a single referral center for closing gastro- shown in A, demonstrating complete atresia and bowel loss. C. Same
patient 6 weeks later, demonstrating growth of small bowel left in situ.
schisis (A.P., personal communication, 2016). The defects
found in these patients ranged from 0.5 to 2 cm and all
tolerated oral intake at discharge, with 3 requiring supple- exposed bowel, but published literature has not shown a
mental nutrition. Affected patients have variable outcomes difference in outcomes in infants delivered via cesarean
that depend on the amount of bowel that is viable but versus vaginal delivery. (7) Similarly, certain centers perform
resulting in significantly higher morbidity, mortality, and early delivery of the fetus to reduce the inflammatory peel on
short bowel syndrome rates. If suspected on prenatal imag- the bowel. However, data have not shown conclusive evi-
ing, preterm delivery may be indicated. dence supporting this view, and the risks associated with
prematurity argue against this practice. (8)(9) Thus, the
Management delivery method should be at the discretion of the obstetri-
The optimal mode and timing of delivery for patients with cian and parents. Most authors and clinicians encourage
gastroschisis are controversial. Some experts have advocated delivery at a tertiary center with immediate neonatal and
the use of routine cesarean delivery to avoid injury to the pediatric surgery access. (10)(11) The Canadian Pediatric

Vol. 21 No. 6 JUNE 2020 e385


Downloaded from http://neoreviews.aappublications.org/ at Indonesia:AAP Sponsored on October 13, 2020
Surgery Network reviewed data on infants with gastroschisis tape and the wound vacuum can be easily removed if
from 18 pediatric surgical centers and concluded that deliv- the abdominal pressure rises after closure. A randomized
ery outside a perinatal center requiring transfer was a
significant predictor of complications. (12)
Once the infant is born, fluid resuscitation and gastric
decompression should be initiated immediately. Given the
significant evaporative and heat loss these patients experi-
ence because of the exposed viscera, the bowel must be
wrapped in warm, saline-soaked gauze and the lower half of
the infant placed in a bowel bag.
The primary goal of surgical repair is to place the intes-
tine back into the abdominal cavity without trauma to the
bowel or to avoid increased intra-abdominal pressure. The
bowel should be inspected for obstructing bands, matting,
perforation, or atresia. Various options for surgical treat-
ment are available, including:
• Primary reduction with surgical fascial closure
• Silo placement with serial reductions and delayed
surgical closure of the fascia
• Primary reduction without fascial closure
• Delayed reduction without fascial closure
The last 2 surgical procedures are commonly referred to
as “sutureless” closure.
Primary reduction in the operating room involves trans-
port to the operating room, general anesthesia, division of
the umbilical vessels and urachus, and suturing of the fascia
and skin. Alternatively, surgeons may place a spring-loaded
preformed silo into the abdominal defect at the bedside (Fig
3). (13) Serial reductions are then performed daily or twice a
day with the aid of gravity until the contents have reached
the level of the fascia. This slow reduction allows the bowel
edema to be gradually reduced and allows for bowel reduc-
tion without increasing intra-abdominal pressure. It is
important that the reduction be performed over 3 to 5 days.
Any type of surgical closure or sutureless closure can then
be done.
Sutureless closure entails covering the abdominal defect
with the umbilical cord or synthetic dressing such as a self-
adherent foam dressing and allowing closure by secondary
intention. We have reported a technique of primary suture-
less closure of gastroschisis using negative pressure dress-
ing/wound vacuum (14) (Fig 4). This procedure involves
initial placement of a silo with gradual reduction of the intra-
abdominal contents. Subsequently, the defect is primarily
closed with adhesive tape and wound vacuum. This pro-
cedure can be performed at the bedside without anesthesia
and without going to the operating room. It has the advan-
tage of gentle silo reduction without increasing the intra-
abdominal pressure and causing compartment syndrome. It
Figure 3. A. Intraoperative picture of silo being placed. B. Silo placed
is also an easily reversible procedure because the adhesive and held upright for gravity to aid with reduction of bowel.

e386 NeoReviews
Downloaded from http://neoreviews.aappublications.org/ at Indonesia:AAP Sponsored on October 13, 2020
control study comparing sutureless versus sutured gastro- syndrome is suspected. Given this complication, the ap-
schisis closure found no difference in complications. (15) proach for the type of closure must be decided based on
Advantages of this method include the lack of need for conditions such as prematurity, abdominal domain, and
transport, potential avoidance of anesthesia, and improved degree of respiratory distress.
cosmetic result. Most series report a hernia rate of 60% to For patients with gastroschisis and an associated atresia
84%, of which most close spontaneously; with the wound or perforation, the management is more complex. Care of
vacuum closure, the hernia rate is much lower. (16) Non- these infants must be individualized based on their gesta-
absorbable mesh or biosynthetic patches can also be used tional age, weight, and clinical status as well as the length
for closure when primary fascial closure cannot be achieved. and condition of the bowel. The possible techniques include
Abdominal compartment syndrome can be a complica- primary anastomosis with closure if the bowel is in good
tion after reduction of the bowel. Intra-abdominal pressures condition; creation of stomas with closure; or reduction of
greater than 15 to 20 mm Hg indicate compartment syn- unrepaired bowel into the abdomen with closure and repeat
drome. This pressure can be determined with the use of surgery for establishment of bowel continuity in the future.
intragastric or intravesical catheters. Concerning signs also Postoperatively, it is common to have delayed recovery of
include increased peak or mean inspiratory pressures, need bowel function as a result of abnormal intestinal motility,
for vasopressor support, or metabolic acidosis. Immediate which is frequently observed in these patients. During this
decompressive laparotomy or release of the closure with silo period of dysmotility, gastric decompression and parenteral
placement should be undertaken if abdominal compartment nutrition should be provided until enteral feedings are

Figure 4. A. Picture demonstrating serial reductions with umbilical ties until at the level of the fascia. B. Complete reduction of gastroschisis. C. Adhesive
tape and wound vacuum applied to gastroschisis. D. Picture after wound vacuum removed, demonstrating closure. E. Picture of abdomen 6 weeks
after surgery.

Vol. 21 No. 6 JUNE 2020 e387


Downloaded from http://neoreviews.aappublications.org/ at Indonesia:AAP Sponsored on October 13, 2020
started. If bowel improvement is not observed after 4 to 6 during a vaginal delivery. However, neither type of delivery
weeks, imaging studies can be performed to evaluate for the has been shown to be superior.
presence of an intestinal atresia which is often difficult to Initial management involves obtaining intravenous ac-
visualize because of matted bowel. cess and initiating fluid resuscitation as well as gastric
decompression with a naso- or orogastric tube. An assess-
Prognosis ment of the neonate’s cardiopulmonary system and com-
Long-term outcomes and survival of patients with gastro- plete evaluation for associated anomalies is mandatory. As
schisis are generally excellent, with survival rates greater such, an echocardiography and abdominal ultrasonography
than 90% in large series. (17)(18) Outcomes are poorer in should be performed. In addition, a blood glucose level
patients with an associated finding such as atresia, perfo- should be checked because hypoglycemia may be an indi-
ration, necrosis, or volvulus. (19) However, a single-center cation of Beckwith-Wiedemann syndrome, which occurs in
study focusing on quality of life using a validated survey 12% of patients with an omphalocele.
demonstrated high average quality of life scores that were The management approach for infants with an ompha-
independent of severity, after the age of 2 years, which were locele depends on the defect size, birth gestational age and
comparable to published outcomes of healthy children. (20)
Potential long-term issues that can be seen in these patients
include cholestasis, recurrent, nonspecific abdominal pain,
bowel obstruction, and need for scar revision.

OMPHALOCELE

Clinical Aspects
Omphalocele is a large defect, usually greater than 4 cm,
covered by an amniotic membrane, which contains intes-
tines and other abdominal organs including the liver and
often the spleen and gonad. (5) Patients with an omphalocele
often have other congenital anomalies, chromosomal abnor-
malities, or syndromes. In addition, omphaloceles can be
combined with pentalogy of Cantrell, cloacal exstrophy, and
the rare omphalocele, exstrophy of the bladder, imperforate
anus, and spinal anomaly (OEIS) complex.
Infants with an omphalocele are typically diagnosed
prenatally. The fetal ultrasound characteristics include a
contained herniation in a membranous sac. Additional
associated anomalies may also be identified on prenatal
ultrasonography; however, up to one-third of patients with
isolated defects are found to have other abnormalities
postnatally.
A giant omphalocele contains liver and has a defect of at
least 5 to 10 cm in diameter. In addition to an underdevel-
oped abdominal wall cavity, these patients commonly have
pulmonary hypoplasia as well. Giant omphaloceles are
associated with a high morbidity and mortality rate. The
operative treatment for these patients is also challenging.
(21)

Management
Most patients with an omphalocele are born at term gesta-
tional age. Some experts advocate for cesarean delivery if Figure 5. A. Primary closure of a large omphalocele with placement of
there is an extra-abdominal liver to avoid hepatic injury mesh. B. Reduction of contents. C. Complete closure in 5 days.

e388 NeoReviews
Downloaded from http://neoreviews.aappublications.org/ at Indonesia:AAP Sponsored on October 13, 2020
weight, and the existence of associated anomalies. In a
stable patient with a small defect, primary repair with sur-
gical closure may be possible. The sac may be removed or
inverted before fascial closure. If the sac is adherent to the
liver, some defects may need to be left in place to avoid liver
injury and hemorrhage. However, more commonly, because
of the size of the defect, loss of domain of the peritoneal
cavity, or instability of the infant, primary closure is not
possible, and various techniques are used for coverage and
closure. Staged or delayed closure (Fig 5 and Fig 6) of the
defect is typically used. Eschoratic therapy, sometimes
referred to as the “paint and wait” technique, is often used,
in which a topical agent, most commonly silver sulfadiazine,
is applied to the sac daily. It creates a gradual eschar with
subsequent epithelialization, leaving a ventral hernia. This
process takes weeks to months to complete and may be
combined with compressive dressings once the sac is thick
Figure 6. Delayed closure technique used for a large omphalocele
enough to slowly reduce the contents into the abdomen. after painting with silver sulfadiazine demonstrating complete
Later closure may involve mobilization of skin flaps, com- epilethialization after 8 months.

ponent separation, (22) use of tissue expanders, (23) or a


patch. (24) A recent report describes a series of patients FUTURE DIRECTIONS
using a serial taping method to gradually reduce the abdom-
inal contents. (25) With all of these techniques, it is impor- Future goals in the care of patients with gastroschisis are
tant to avoid kinking of the hepatic veins that may occur with mostly directed toward preventing damage to the exposed
reduction of the liver. This can lead to a metabolic acidosis bowel as a result of amniotic fluid. Amniotic fluid exchange,
and may require reoperation to reorient the position of the (30)(31)(32) nitric oxide, (33) diuretics, (34) and fetoscopic
liver. Another potential complication that can arise either surgery (35)(36)(37) have been tried in animal models with
before primary repair or while undergoing topical therapy limited success. The other areas of focus include the timing
before the eschar has completely formed is rupture of the of delivery and the role of intra-abdominal bowel dilation, as
sac. A range of methods can be used to manage a ruptured discussed herein.
sac, depending on the size of the tear and status of the
infant, and includes suture repair, skin closure, and place-
ment of a patch. American Board of Pediatrics
Neonatal-Perinatal Content
Prognosis Specification
The main determinant of prognosis for infants with an • Know the morphogenesis of the GI tract and factors that lead to
omphalocele is the association with structural or chromo- congenital malformations.
somal anomalies that may occur in as many as 80% of
affected patients. Major cardiac anomalies are seen in
approximately one-third of patients with omphaloceles.
Survival rates range from 70% to 95%, with most of the References
mortality arising from associated anomalies. (26)(27) In
1. Laughon M, Meyer R, Bose C, et al. Rising birth prevalence of
addition, a number of long-term medical problems have gastroschisis. J Perinatol. 2003;23(4):291–293
been found in patients with large omphaloceles, including 2. Baird PA, MacDonald EC. An epidemiologic study of congenital
gastroesophageal reflux disease, pulmonary insufficiency, malformations of the anterior abdominal wall in more than half a
million consecutive live births. Am J Hum Genet.
asthma, and feeding difficulties. (28)(29) Patients with
1981;33(3):470–478
giant omphaloceles have increased morbidity because
3. Baerg J, Kaban G, Tonita J, Pahwa P, Reid D. Gastroschisis: a
of an increased visceroabdominal disproportion leading sixteen-year review. J Pediatr Surg. 2003;38(5):771–774
to prolonged mechanical ventilation and a longer hospital 4. Christison-Lagay ER, Kelleher CM, Langer JC. Neonatal abdominal
stay. wall defects. Semin Fetal Neonatal Med. 2011;16(3):164–172

Vol. 21 No. 6 JUNE 2020 e389


Downloaded from http://neoreviews.aappublications.org/ at Indonesia:AAP Sponsored on October 13, 2020
5. Klein MD. In: J L Grosfeld et al, eds. Congenital Defects of the surgical vs. nonoperative delayed closure. J Pediatr Surg.
Abdominal Wall. 6th ed. Philadelphia, PA: Elsevier Saunders; 2016;51(10):1725–1730
2012;1157–1171 22. van Eijck FC, de Blaauw I, Bleichrodt RP, et al. Closure of
6. Oakes MC, Porto M, Chung JH. Advances in prenatal and perinatal giant omphaloceles by the abdominal wall component
diagnosis and management of gastroschisis. Semin Pediatr Surg. separation technique in infants. J Pediatr Surg.
2018;27(5):289–299 2008;43(1):246–250
7. Segel SY, Marder SJ, Parry S, Macones GA. Fetal abdominal wall 23. De Ugarte DA, Asch MJ, Hedrick MH, Atkinson JB. The use of
defects and mode of delivery: a systematic review. Obstet Gynecol. tissue expanders in the closure of a giant omphalocele. J Pediatr
2001;98(5 pt 1):867–873 Surg. 2004;39(4):613–615
8. Landisch RM, Yin Z, Christensen M, Szabo A, Wagner AJ. 24. Siy RW, Pferdehirt RE, Izaddoost SA. Non-crosslinked porcine
Outcomes of gastroschisis early delivery: a systematic review and acellular dermal matrix in pediatric abdominal wall reconstruction:
meta-analysis. J Pediatr Surg. 2017;52(12):1962–1971 a case series. J Pediatr Surg. 2017;52(4):639–643
9. Nasr A, Wayne C, Bass J, Ryan G, Langer JC; Canadian Pediatric 25. Kogut KA, Fiore NF. Nonoperative management of giant
Surgery Network. Effect of delivery approach on outcomes in fetuses omphalocele leading to early fascial closure. J Pediatr Surg.
with gastroschisis. J Pediatr Surg. 2013;48(11):2251–2255 2018;53(12):2404–2408
10. Skarsgard ED, Claydon J, Bouchard S, et al; Canadian Pediatric 26. Marshall J, Salemi JL, Tanner JP, et al; National Birth Defects
Surgical Network. Canadian Pediatric Surgical Network: a Prevention Network. Prevalence, correlates, and outcomes of
population-based pediatric surgery network and database for omphalocele in the United States, 1995-2005. Obstet Gynecol.
analyzing surgical birth defects—the first 100 cases of gastroschisis. 2015;126(2):284–293
J Pediatr Surg. 2008;43(1):30–34, discussion 34 27. Mabogunje OA, Mahour GH. Omphalocele and gastroschisis:
11. Taylor JS, Shew SB. Impact of societal factors and health care trends in survival across two decades. Am J Surg.
delivery systems on gastroschisis outcomes. Semin Pediatr Surg. 1984;148(5):679–686
2018;27(5):316–320 28. Koivusalo A, Rintala R, Lindahl H. Gastroesophageal reflux in
12. Nasr A, Langer JC; Canadian Paediatric Surgery Network. Influence children with a congenital abdominal wall defect. J Pediatr Surg.
of location of delivery on outcome in neonates with gastroschisis. 1999;34(7):1127–1129
J Pediatr Surg. 2012;47(11):2022–2025 29. Gamba P, Midrio P. Abdominal wall defects: prenatal diagnosis,
13. Pastor AC, Phillips JD, Fenton SJ, et al. Routine use of a SILASTIC newborn management, and long-term outcomes. Semin Pediatr
spring-loaded silo for infants with gastroschisis: a multicenter Surg. 2014;23(5):283–290
randomized controlled trial. J Pediatr Surg. 2008;43(10):1807–1812 30. Dommergues M, Ansker Y, Aubry MC, et al. Serial transabdominal
14. Hassan SF, Pimpalwar A. Primary suture-less closure of amnioinfusion in the management of gastroschisis with severe
gastroschisis using negative pressure dressing (wound vacuum). oligohydramnios. J Pediatr Surg. 1996;31(9):1297–1299
Eur J Pediatr Surg. 2011;21(5):287–291 31. Aktug T, Demir N, Akgür FM, Olguner M. Pretreatment of
15. Bruzoni M, Jaramillo JD, Dunlap JL, et al. Sutureless vs sutured gastroschisis with transabdominal amniotic fluid exchange. Obstet
gastroschisis closure: a prospective randomized controlled trial. Gynecol. 1998;91(5 Pt 2):821–823
J Am Coll Surg. 2017;224(6):1091–1096 e1 32. Luton D, de Lagausie P, Guibourdenche J, et al. Effect of
16. Islam S. Advances in surgery for abdominal wall defects: amnioinfusion on the outcome of prenatally diagnosed
gastroschisis and omphalocele. Clin Perinatol. 2012;39(2):375–386 gastroschisis. Fetal Diagn Ther. 1999;14(3):152–155
17. Youssef F, Cheong LH, Emil S; Canadian Pediatric Surgery Network 33. Gonçalves FL, Bueno MP, Schmidt AF, Figueira RL, Sbragia L.
(CAPSNet). Gastroschisis outcomes in North America: a Treatment of bowel in experimental gastroschisis with a
comparison of Canada and the United States. J Pediatr Surg. nitric oxide donor. Am J Obstet Gynecol. 2015;212(3):383.e1–383.e7
2016;51(6):891–895 34. Hakguder G, Olguner M, Gürel D, Akgür FM, Flake AW. Induction
18. Emil S, Canvasser N, Chen T, Friedrich E, Su W. Contemporary of fetal diuresis with intraamniotic furosemide injection reduces
2-year outcomes of complex gastroschisis. J Pediatr Surg. intestinal damage in a rat model of gastroschisis. Eur J Pediatr Surg.
2012;47(8):1521–1528 2011;21(3):183–187
19. Davis RP, Treadwell MC, Drongowski RA, Teitelbaum DH, 35. Kohl T, Tchatcheva K, Stressig R, Gembruch U, Kahl P. Is there a
Mychaliska GB. Risk stratification in gastroschisis: can prenatal therapeutic role for fetoscopic surgery in the prenatal treatment of
evaluation or early postnatal factors predict outcome? Pediatr Surg gastroschisis? a feasibility study in sheep. Surg Endosc.
Int. 2009;25(4):319–325 2009;23(7):1499–1505
20. Carpenter JL, Wiebe TL, Cass DL, Olutoye OO, Lee TC. Assessing 36. Bergholz R, Krebs T, Wenke K, et al. Fetoscopic management
quality of life in pediatric gastroschisis patients using the Pediatric of gastroschisis in a lamb model. Surg Endosc. 2012;26(5):
Quality of Life Inventory survey: An institutional study. J Pediatr 1412–1416
Surg. 2016;51(5):726–729 37. Stephenson JT, Pichakron KO, Vu L, et al. In utero repair of
21. Bauman B, Stephens D, Gershone H, et al. Management of gastroschisis in the sheep (Ovis aries) model. J Pediatr Surg.
giant omphaloceles: a systematic review of methods of staged 2010;45(1):65–69

e390 NeoReviews
Downloaded from http://neoreviews.aappublications.org/ at Indonesia:AAP Sponsored on October 13, 2020
NeoReviews Quiz
Individual CME quizzes are available via the blue CME link in the Table of Contents of any issue.
To learn how to claim MOC points, go to: http://www.aappublications.org/content/moc-credit.

1. A woman presents for antenatal ultrasonography at 20 weeks’ gestation. The fetus is noted REQUIREMENTS: Learners
to have probable gastroschisis. Which of the following statements concerning can take NeoReviews
gastroschisis is correct? quizzes and claim credit
A. It is more common in girls. online only at: http://
B. It usually presents with an intact peritoneal sac at this gestational age. neoreviews.org/.
C. The defect typically occurs to the left of the umbilicus. To successfully complete
D. The incidence is approximately 1 in 4,000 live births and has become the most 2020 NeoReviews articles for
common abdominal wall defect. AMA PRA Category 1
E. In the current era, it is almost always associated with either marijuana or heavy CreditTM, learners must
tobacco use during the first trimester. demonstrate a minimum
2. A female neonate with gastroschisis is born after the mother has preterm labor at 29 performance level of
weeks’ gestation. Which of the following is most likely to be seen in a neonate with 60% or higher on this
gastroschisis? assessment. If you score
A. Large for gestational age. less than 60% on the
B. Congenital anomalies of the heart and brain. assessment, you will be
C. A defect that is almost always larger than 10 cm. given additional
D. Abnormalities of the bowel such as an atresia. opportunities to answer
E. Vocal cord paralysis. questions until an overall
60% or greater score is
3. Your team is planning the delivery and postdelivery care for a patient with gastroschisis.
achieved.
Which of the following practices is an appropriate component of the routine care for
gastroschisis? This journal-based CME
A. Cesarean delivery, regardless of labor status. activity is available through
B. Delivery before 32 weeks of gestation. Dec. 31, 2022, however,
C. Avoidance of nasogastric tube insertion. credit will be recorded in
D. Immediate nasal continuous positive airway pressure administration. the year in which the
E. Placement of the bowel in warm, saline-soaked gauze and the lower half of the learner completes the quiz.
body in a bowel bag.
4. A woman undergoes antenatal ultrasound evaluation and the fetus is noted to have
omphalocele. Which of the following statements concerning omphalocele is correct?
A. The defect is usually greater than 4 cm and covered by an amniotic membrane.
B. It is almost always an isolated defect, with no other anomalies present. 2020 NeoReviews is
C. A “giant” omphalocele refers to the condition in which the entire intestinal tract is approved for a total of 10
located outside the body. Maintenance of
D. It is associated with high rates of very preterm birth. Certification (MOC) Part 2
E. There is definitive evidence that cesarean delivery improves outcomes for both the credits by the American
mother and neonate. Board of Pediatrics (ABP)
5. An infant born at term gestational age has been treated in the NICU for gastroschisis for through the AAP MOC
several weeks. The patient has been able to work up to full enteral feedings. Arrangements Portfolio Program.
are being made for transition to the home. Which of the following is the main determinant NeoReviews subscribers can
of prognosis? claim up to 10 ABP MOC
A. Race/ethnicity. Part 2 points upon passing
B. Presence of structural or chromosomal anomaly. 10 quizzes (and claiming
C. Presence or absence of intraventricular hemorrhage. full credit for each quiz) per
D. Sex. year. Subscribers can start
E. Receipt of antenatal or postnatal steroids. claiming MOC credits as
early as May 2020. To
learn how to claim MOC
points, go to: https://
www.aappublications.org/
content/moc-credit.

Vol. 21 No. 6 JUNE 2020 e391


Downloaded from http://neoreviews.aappublications.org/ at Indonesia:AAP Sponsored on October 13, 2020
Abdominal Wall Defects
Bethany J. Slater and Ashwin Pimpalwar
NeoReviews 2020;21;e383
DOI: 10.1542/neo.21-6-e383

Updated Information & including high resolution figures, can be found at:
Services http://neoreviews.aappublications.org/content/21/6/e383
References This article cites 36 articles, 0 of which you can access for free at:
http://neoreviews.aappublications.org/content/21/6/e383.full#ref-list-
1
Subspecialty Collections This article, along with others on similar topics, appears in the
following collection(s):
Pediatric Drug Labeling Update
http://classic.neoreviews.aappublications.org/cgi/collection/pediatric
_drug_labeling_update
Permissions & Licensing Information about reproducing this article in parts (figures, tables) or
in its entirety can be found online at:
https://shop.aap.org/licensing-permissions/
Reprints Information about ordering reprints can be found online:
http://classic.neoreviews.aappublications.org/content/reprints

Downloaded from http://neoreviews.aappublications.org/ at Indonesia:AAP Sponsored on October 13, 2020


Abdominal Wall Defects
Bethany J. Slater and Ashwin Pimpalwar
NeoReviews 2020;21;e383
DOI: 10.1542/neo.21-6-e383

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://neoreviews.aappublications.org/content/21/6/e383

Neoreviews is the official journal of the American Academy of Pediatrics. A monthly publication,
it has been published continuously since 2000. Neoreviews is owned, published, and trademarked
by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village,
Illinois, 60007. Copyright © 2020 by the American Academy of Pediatrics. All rights reserved.
Online ISSN: 1526-9906.

Downloaded from http://neoreviews.aappublications.org/ at Indonesia:AAP Sponsored on October 13, 2020

You might also like