Novel multidisciplinary approach to monitor and treat fetuses with gastroschisis using the Svetliza Reducibility Index and the EXIT-like procedure

Oliveira, Gustavo Henrique de; Svetliza, Javier; Vaz-Oliani, Denise Cristina Mós; Liedtke, Humberto; Oliani, Antonio Helio; Pedreira, Denise Araujo Lapa

doi:10.1590/S1679-45082017AO3979

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Original Article • EINSEinstein (São Paulo) 15 (4) • Oct-Dec 2017 • https://doi.org/10.1590/S1679-45082017AO3979 copy

Novel multidisciplinary approach to monitor and treat fetuses with gastroschisis using the Svetliza Reducibility Index and the EXIT-like procedure

Authorship SCIMAGO INSTITUTIONS RANKINGS

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.

Keywords:
Gastroschisis/surgery; Abdominal wall/abnormalities; Fetal therapies; Fetal diagnosis; Fetus/surgery

Characteristics		EXIT-like Group n (%) or mean (range) n=4	Silo Group n (%) or mean (range) n=7
Maternal age at delivery, years		21.5 (15-33)	20.14 (14-29)
Parity
	Primípara	3 (75)	5 (71.73)
	Multipara	1 (25)	2 (28.57)
Fetal sex
	Male	2 (50)	4 (57.14)
	Female	2 (50)	3 (42.86)
Gestational age at delivery, weeks		35.61 (35.00-36.43)	37.08 (35.29-38.43)
Birth weight, g		2,189.25 (1,556-2,975)	2,420 (1,700-3,480)
Time for herniated viscera reduction		5.0 minutes (4.0-5.8)	11.6 days (6.0-18.0)

Case	Gestational age at birth (weeks)	Weight at birth (g)	Mechanical ventilation (days)	Parenteral nutrition (days)	Mixed nutrition (days)	Enteral nutrition (days)	Sepsis	Reintervation	Hospital stay (days)
1	35.0	2,080	0	15	9	24	Yes	No	34
2^* * Case in which superficial laceration of the bowel loop was identified and correction was not complete with umbilical circulation.	36.71	2,975	1	18	7	25	No	No	33
3	35.29	2,146	3	14	22	36	No	No	43
4	35.71	1,556	0	14	12	26	No	No	46

Variable according to group		Median	Minimum	Maximum	Mann-Whitney test
Age at delivery, years
	Silo	19	14	29	0.9240
	EXIT-like	19	15	33
Gestational age at delivery, weeks
	Silo	37.1	35.3	38.4	0.0713
	EXIT-like	35.5	35	36.4
Weight at birth, g
	Silo	2,270	1,700	3,480	0.5083
	EXIT-like	2,113	1,556	2,975
Mechanical ventilation, days
	Silo	22	2	26	0.0169
	EXIT-like	0.5	0	3
Parenteral nutrition, days
	Silo	45	26	55	0.0104
	EXIT-like	14.5	14	18
Mixed nutrition, days
	Silo	6	5	12	0.1262
	EXIT-like	10.5	7	22
Enteral nutrition, days
	Silo	53	31	60	0.0294
	EXIT-like	25.5	24	36
Length of hospital stay, days
	Silo	67	36	83	0.726
	EXIT-like	38.5	33	46

	EXIT-like n=4	Silo n=7	Charlesworth et al.⁽¹³13. Charlesworth P Akinnola I, Hammerton C, Praveena P Desai A, Patel S, et al. Preformed silos versus traditional abdominal wall closure in gastroschisis: 163 infants at a single institution. Eur J Pediatr Surg. 2014;24(1):88-93.⁾ n=67	Charlesworth et al.⁽¹³13. Charlesworth P Akinnola I, Hammerton C, Praveena P Desai A, Patel S, et al. Preformed silos versus traditional abdominal wall closure in gastroschisis: 163 infants at a single institution. Eur J Pediatr Surg. 2014;24(1):88-93.⁾ n=89	Stanger et al.⁽¹²12. Stanger J, Mohajerani N, Skarsgard ED; Canadian Pediatric Surgery Network (CAPSNet). Practice variation in gastroschisis: factors influencing closure technique. J Pediatr Surg. 2014;49(5):720-3.⁾ n=300	Stanger et al.⁽¹²12. Stanger J, Mohajerani N, Skarsgard ED; Canadian Pediatric Surgery Network (CAPSNet). Practice variation in gastroschisis: factors influencing closure technique. J Pediatr Surg. 2014;49(5):720-3.⁾ n=379
Characteristics	“Zero minute”	Silo	Primary closure	Silo	Primary closure	Silo
Days of mechanical ventilation, mean	1	18.71	5	3.5	6.79	7.04
Days of parenteral nutrition, mean	15.25	41.29	19	24	16.5	17.7
Das of exclusive enteral nutrition, mean	27.75	48.71	24	27	44.3	43.6
Days of hospital stay, mean	39	61.86	30	24	56.6	53.8

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[1] Corresponding author: Gustavo Henrique de Oliveira - Rua Independência, 2,390 - Zip code: 15025-095 - São José do Rio Preto, SP, Brazil - Phone: (55 17) 3519-3030 - E-mail: gustavo@imrfetal.com.br