Prenatal repair of gastroschisis using partial carbon dioxide insufflation fetoscopy: lessons learned

ABSTRACT We report the long-term outcomes of a case of prenatal gastroschisis repair using a fully percutaneous fetoscopic approach with partial carbon dioxide insufflation. Surgery was performed as an experimental procedure before the scheduled elective birth. The fetal intestines were successfully returned to the abdominal cavity without any fetal or maternal complications. Ultrasonography performed 24 hours later revealed bowel peristalsis and no signs of fetal distress. After 48 hours, partial extrusion of the small bowel was observed, and the fetus was delivered. Gastroschisis repair was immediately performed upon delivery using the EXIT-like procedure as per our institutional protocol. The newborn did not require assisted mechanical ventilation, was discharged at 14 days of age and was then exclusively breastfed. At 3-year follow-up, the patient had no associated gastroschisis-related complications. This is the first case of prenatal repair of gastroschisis, which provides baseline knowledge for future researchers on the potential hurdles and management of prenatal repair.

Novel multidisciplinary approach to monitor and treat fetuses with gastroschisis using the Svetliza Reducibility Index and the EXIT-like procedure / Nova abordagem multidisciplinar para monitorizar e tratar fetos com gastrosquise utilizando o Svetliza Reducibility Index e o procedimento EXIT-like

ABSTRACT Objective: To describe our initial experience with a novel approach to follow-up and treat gastroschisis in "zero minute" using the EXITlike procedure. Methods: Eleven fetuses with prenatal diagnosis of gastroschisis were evaluated. The Svetliza Reductibility Index was used to prospectively evaluate five cases, and six cases were used as historical controls. The Svetliza Reductibility Index consisted in dividing the real abdominal wall defect diameter by the larger intestinal loop to be fitted in such space. The EXIT-like procedure consists in planned cesarean section, fetal analgesia and return of the herniated viscera to the abdominal cavity before the baby can fill the intestines with air. No general anesthesia or uterine relaxation is needed. Exteriorized viscera reduction is performed while umbilical cord circulation is maintained. Results: Four of the five cases were performed with the EXIT-like procedure. Successful complete closure was achieved in three infants. The other cases were planned deliveries at term and treated by construction of a Silo. The average time to return the viscera in EXIT-like Group was 5.0 minutes, and, in all cases, oximetry was maintained within normal ranges. In the perinatal period, there were significant statistical differences in ventilation days required (p = 0.0169), duration of parenteral nutrition (p=0.0104) and duration of enteral feed (p=0.0294). Conclusion: The Svetliza Reductibility Index and EXIT-like procedure could be new options to follow and treat gastroschisis, with significantly improved neonatal outcome in our unit. Further randomized studies are needed to evaluate this novel approach.

RESUMO Objetivo: Descrever a experiência inicial com a nova técnica cirúrgica EXIT-like para acompanhamento e correção de gastrosquise no "minuto zero". Métodos: Foram avaliados onze fetos com diagnóstico pré-natal de gastrosquise. O Svetliza Reducibility Index foi usado prospectivamente para avaliar cinco casos, e seis foram utilizados como controles. O índice foi calculado dividindo-se o diâmetro do defeito da parede abdominal pela maior alça intestinal que coubesse neste espaço. O procedimento EXIT-like compreendeu cesárea programada, analgesia fetal e redução da víscera herniada para a cavidade abdominal, antes da deglutição de ar pelo recém- nascido. Não são necessários anestesia geral e nem relaxamento uterino. A redução da víscera exteriorizada é realizada enquanto se mantém a circulação do cordão umbilical. Resultados: Quatro casos, dos cinco, foram submetidos ao EXIT-like. A correção foi completa em três casos. Os demais casos foram partos a termo planejados, e a correção do defeito foi feita com Silo. O tempo médio de redução da víscera foi de 5,0 minutos no grupo submetido ao procedimento EXITlike, e a oximetria foi mantida dentro dos valores de variação normal em todos os casos. No período perinatal, foram observadas diferenças estatisticamente significativas no tempo de ventilação mecânica (p=0,0169), duração da nutrição parenteral (p = 0,0104) e da nutrição enteral (p=0,0294). Conclusão: O Svetliza Reducibility Index e o procedimento EXIT-like podem ser novas opções para acompanhar e tratar gastroquise, com desfecho neonatal significativamente melhor em nossa unidade. Novos estudos randomizados são necessários para avaliar esta nova abordagem.

Usos de Internet en hogares con niños de entre 4 y 18 años. Control de los padres sobre este uso.Resultados de una encuesta nacional / Internet usage in households with children between 4 and 18 years old. Parent’s supervision. Results of a national survey

Introducción. Internet se ha constituido desde su nacimiento en un medio ideal para recibir información. Los niños y adolescentes lo utilizan con frecuencia y es habitual que se topen con material indebido, situación que muchas veces, es desconocida por sus padres. El objetivo del presente estudio fue evaluar la percepción familiar del uso que los niños y jóvenes hacen de Internet en el hogar. Población, material y métodos. Se realizó una encuesta coordinada por el Grupo de Informática de la Sociedad Argentina de Pediatría para ser contestada a través de Internet entre el 01/09/2007 y el 01/03/2008, que evaluaba características del hogar (número de hijos y edades) y el perfil de usuario con su patrón de navegación por Internet. Resultados. La encuesta fue completada por 857 de los 1.055 usuarios registrados. El número de niños y adolescentes abarcados fue de 1.380. El 83,5 por ciento de los encuestados provino de Argentina. El 25,8 por ciento de los niños informó a los adultos acerca de alguna experiencia desagradable que le tocó vivir durante el uso de Internet. Un 30,8 por ciento de los adultos desconocía el apodo que su hijo utiliza en la Web y sólo el 28,6 por ciento aplicaba filtros de contenidos arentales. Un 53,4 por ciento de los encuestados refirió que conversa siempre consus hijos acerca de las actividades en línea. Conclusiones. Los datos obtenidos en nuestra encuesta muestran que es frecuente que los niños tengan experiencias desagradables durante el uso de Internet y que existe poca supervisión de los padres, quienes subestiman los riesgos de acceso ala Web.

Gastrosquisis. Manejo perinatal con intervención mínima precoz. Datos preliminares / Gastroschisis. Perinatal management with minimal early intervention. Preliminary data

La gastrosquisis es un defecto congénito de la pared abdominal anterior, de uno a cinco cm, paraumbilical y generalmente a la derecha, donde el contenido abdominal sobresale a través del defecto. Su etiología no está definida. El principal objetivo del presente trabajo fue describir nuestra experiencia en el manejo de gastrosquisis. Otro de los objetivos planteados fue evaluar si se mejoran la evolución y complicaciones de esta malformación, con las nuevas estrategias de diagnóstico y tratamiento como el diagnóstico prenatal ecográfico y el tratamiento Mínimamente Invasivo Precoz en sala de partos, sin anestesia general. En los últimos años, el manejo realizado en nuestra institución ha sido reparación y cierre abdominal por medio de un silo (CS) o el cierre quirúrgico primario cuando el caso lo permitía. Nosotros hemos cambiado el CS por el manejo perinatal con Intervención Mínima en Sala de Partos, sin intubación y sin anestesia endotraqueal. No existen datos concluyentes sobre esta nueva estrategia con esta patología.

Gastroschisis is a paraumbilical congenital defect in the anterior abdominal wall, that is usually one to five centimeters thick and that is located to the right of the umbilical cord insertion site, where the abdominal content protrudes through the defect. The etiology is not defined. The main objective of this work is to describe our experience in gastroschisis management. A second objective is to determine if new diagnosis and treatment strategies, such as prenatal ultrasonic diagnosis and minimally invasive early treatment at the delivery room without general anesthesia, improve the evolution and reduce complications in this malformation. In the last few years, the management used at our institution consisted in repairing and closing the abdomen by means of a silo closure (CS) or primary surgical closing when the case allowed it. We have replaced the CS by perinatal management with minimal intervention at the delivery room, without intubation or endotracheal anesthesia in selected cases. There are no conclusive data yet on this new strategy for approaching this pathology. Key words: Gastroschisis, prenatal diagnosis, perinatal management with minimal intervention.