Delivery room repair of gastroschisis.

BACKGROUND: Outcome for most abdominal wall defects is related to the presence or absence of additional anomalies or prematurity. In gastroschisis, outcome is almost as closely related to the severity of the inflammatory "peel" on bowel that is thought to result from direct contact with amniotic fluid. Improving eviscerated bowel quality would be expected to reduce morbidity in these patients. METHODS: From 1986 to 1991, 32 patients with the antenatal diagnosis of gastroschisis were treated. All were delivered by cesarean section; 13 surgical repairs were made immediately in the delivery room. Surgical repairs in 19 patients were made at less than 6 hours of age after transfer from the delivering hospital to the pediatric surgery center. RESULTS: Thirty percent of infants who underwent surgical repair in delivery room and 32% of infants who underwent urgent surgical repair were either premature or had significant associated anomalies. Seventy-three percent of delivery room repair group had fascial repairs compared with 37% in the transferred group. When infants more than 34-weeks' gestation without associated anomalies are compared with transferred infants, delivery room repair group underwent more frequent fascial repair (8 of 9 vs 5 of 13, p < 0.03), were extubated sooner (2.9 vs 7.4 days, p < 0.04), tolerated enteral feedings earlier (8.1 vs 22.2 days, p < 0.009), and required fewer hospital days (13.6 vs 31.3 days, p < 0.01). Eviscerated bowel of infants who underwent immediate surgical repair lacked the characteristic matted, edematous, and fibrinous coated appearance seen in transferred patients. CONCLUSIONS: Immediate delivery room repair of gastroschisis results in increased fascial repairs and earlier extubation, feeding, and hospital discharge. These benefits appear to be due to the minimal reactive peel on eviscerated bowel at birth.

Immediate delivery room repair of fetal abdominal wall defects.

Eighteen patients with a prenatal diagnosis of fetal abdominal wall defect were delivered by cesarean section and repaired either immediately (begun within 15 min, n = 9), or by the traditional (delayed) method (n = 9, average delay = 4.4 h). Neonates repaired immediately had comparable gestational ages and birthweight, however, subjectively had less edematous bowel with less fibrous peel. These fetuses were more likely to be closed primarily (7/9 vs. 4/9), spent less time on a ventilator (8.1 vs. 17.9 days), seemed to be fed sooner (7.6 vs. 17.9 days), and discharged home earlier (14.3 vs. 24.0 days). Our results suggest that for fetuses delivered by cesarean section, early defect repair may reduce bowel edema and fibrous peel formation thus facilitating primary closure, with earlier ventilator weaning, feeding and discharge home.

Development of a program for planned cesarean delivery and immediate pediatric surgical repair of ventral wall defects.

The development of a program for timed elective delivery and immediate repair of ventral wall defects is described. Our experience with 3 cases of immediate surgical repair of gastroschisis shows that this program can be applied in tertiary care centers to shorten pre- and postoperative stay and to present the neonate to surgery in optimal condition.

Effects of 100% oxygen and a mixture of oxygen and air on oxygen saturation in the immediate postoperative period in children.

Arterial oxygen saturation during transportation of children from the operating room to the recovery room and in the recovery room was monitored in two groups of patients, one given 100% oxygen at the end of anesthesia, the other given a 50:50 mixture of oxygen and air. The oxygen-air group had a statistically significantly higher incidence of hypoxemic episodes. Preoxygenation with 100% oxygen before transfer from the operating room reduces the incidence of hypoxemia in children.

Diagnosis and management of acute epiglottitis -- report of 90 consecutive cases.

Ninety children with acute epiglottitis were admitted from 1971 - 1977. Lateral extended neck radiograph was found to be a quick, safe and reliable way to establish the diagnosis. Out of 79, 77 (97%) had blood cultures yielding Hemophilus influenzae type b. Immediate institution of airway and antibiotics were the mainstay of treatment. All patients in the series survived. For short-term airway management, as in acute epiglottitis, nasotracheal intubation under general anesthesia was found to be the airway of choice.