THE PIVOTAL ROLE OF THE SURGEON IN THE RESULTS ACHIEVED IN GASTROSCHISIS

A single neonatal surgical unit treated 42 cases of gastroschisis over a 12-year period (1981-1993). The surgical management of each case wa s individualised, but every attempt was made to perform a primary repa ir when possible, based on the premise that this strategy gave the bes t outcome. The eviscerated intestine was evaluated with the patient un der general anaesthesia. Serosal peel was not removed and intestinal a tresias were not repaired. Gang renous intestine was resected. The con tents of the bowel were emptied proximally via a large naso-gastric tu be and distally via the anus with warm saline lavage. The anterior abd ominal wall was stretched and then reduction of the prolapse attempted . Following maximal enlargement of the peritoneal cavity, it was left to the operator to decide whether primary repair was possible and, ind eed, permissible in each instance. Staged repairs necessitated the use of silastic pouches. Respiratory and intestinal insufficiency were ma naged by intermittent positive-pressure ventilation and total parenter al nutrition (TPN). Over one-half of the cases (24 of 42) were under 2 .5 kg at birth. Intra-uterine growth retardation was unusual. Ten babi es were delivered for obstetrical indications by Caesarean section; 50 % were pre-term and in 4 pre-natal diagnosis of a ventral abdominal wa ll anomaly had been made. The transmural defects were all sited at the umbilicus and were to the right of a consolidated cord in 41 instance s. Midgut necrosis due to torsion was encountered in I case; 3 further cases with intestinal atresia occurred. Primary closure was obtained in 30 (71%) of the cases reviewed. A prosthetic pouch was used in 12 p atients for on average 10 days in 10 uncomplicated cases. The average length of time in days of tertiary care given to 25 uncomplicated case s treated by primary fascial closure was: ventilatory support 4; inten sive care treatment 8; and nutritional source TPN 20. There were 5 dea ths (12%): 1 was unpreventable due to prenatal intestinal infarction; 2 were due to abdominal compartment syndrome with renal failure, and, intestinal ischaemia complicating primary and planned staged repairs; 1 caused by intestinal infarction due to torsion of bowel in a pouch; and 1 due to invasive infection. The role played by the strategy taken by the surgeon in the management of gastroschisis is crucial to the o utcome. The creation of a compartment-like syndrome produced uncorrect able complications in this series of cases in both primary and staged abdominal wall closures. Minor degrees of this complication proved to be reversible in some patients, which was the reason for the wait-and- see attitude adopted in the management of this problem, often with fat al outcome. Where intra-peritoneal pressure monitoring is not used, th e operating surgeon relies on unscientific observations for decision-m aking at the operating table. The time from birth to operation in 25 o f the reviewed cases was on average 5 1/2 h. Of this group, 20 were ou tborn babies. This is unsatisfactory, but as shown by this review, eve n in the absence of prenatal management, which should ensure prompt re pair, satisfactory results are still possible.