Pre-term and particularly pre-labor cesarean section to avoid complications of gastroschisis

The marked advantages and merit of pre-term and particularly pre-labor (PTP L) cesarean section (C-section) in the avoidance, and indeed, virtual elimi nation of severely disabling gastroschisis (GS) complications in infants di agnosed prior to birth by ultrasound has unfortunately remained controversi al in the 10 to 12 years since it was first reported and strongly recommend ed by numerous authors. During this period, GS has remained one of the four major causes of the short-gut syndrome (SGS) in infancy and childhood and a major cause of prolonged, costly, complicated, and hazardous neonatal int ensive care unit stays with requirements for total parenteral nutrition (TP N). The most serious and frequent complications of GS in infants born witho ut PTPL C-section are the occurrence of the "peel", which greatly enlarges and rigidifies the eviscerated gut, and of "complicated GS" (intestinal atr esia/s, stenosis, necrosis, perforations) (CGS). The "peel" occurs in 100% of these cases and CGS in approximately 20%. "Peel" enlargement and rigidif ication of eviscerated intestine in the presence of a reduced peritoneal ca vity causes great difficulty in covering the eviscerated, enlarged, and rig idified gut with abdominal wall, skin, a prosthesis, etc.,;and frequently p roduces gut ischemia from excessive pressure, which may lead to necrotizing enterocolitis (NEC) and SGS as well as prolonged hospital stays. The prese nce of a "peel" greatly complicates the hazards of dealing with cases of CG S, as resection and anastomosis are virtually impossible in the presence of a "peel." The authors report personal experience with 77 cases of GS datin g as far back as 1951; 44 of the infants were born after the onset of labor by vaginal or C-section delivery;Ind all had some degree of "peel" formati on. Of 320 cases from the literature (including some of the cases reported here), 61 (19.1%) involved CGS. Of the 33 cases born PT, and especially FL, there were no cases of "peel" and only 1 case of CGS (3.0%). This infant h ad a single atresia associated with a very small (1 cm) defect in the abdom inal wall and no labor-induced "peel," which was easily and successfully re paired by resection and anastomosis. The 6.4-fold reduction in the occurren ce of CGS by PTPL C-section (3.0% vs 19.1%) was statistically significant b y the chi-square test(P < 0.05), as was the 100% elimination of the disabli ng "peel." If the single case of CGS associated with a very small defect an d no labor or labor-associated "peel" is elimimated, the incidence of CGS i n the remaining PTPL group of 32 cases falls to 0 (0% versus 19.1%, P < 0.0 07). PT and especially PL C-section may be expected to virtually eliminate "peel" formation and CGS and to remove GS as one of the four major causes o f SGS. The findings of this report that PT labor prior to PT C-section may result in both "peel" formation and CGS further solidifies the role of labo r in the production of both the "peel" and the equally disabling CGS. Failu re to appreciate the central role of labor in GS complications has doubtles s contributed to the persistent controversy concerning the value and import ance of :PTPL C-section for gastroschisis diagnosed in utero. The pediatric surgeon has an important responsibility with the obstetrician to monitor t he possible occurrence of occult labor in the waning weeks of pregnancy and be prepared to do a prompt C-section if it occurs and there is adequate lu ng maturity. The achievement of "peel"-and CGS-free gut would greatly facil itate the use of the new Bianchi technique of gut reduction without anesthe sia. The combination of the use of epidural anesthesia for the elective PTPL C-s ection with the Bianchi approach would spare both mother and baby any untow ard effects of general anesthesia and present the potential for massive red uctions in hospital costs with minimal patient manipulation and disturbance . For infants born with labor-associated "peel," re-evaluation of the suita bility and effectiveness of surgical "peel" decortication from involved gut is strongly urged.