[Influence of selected factors on the treatment and prognosis in newborns with gastroschisis on the basis of own experience].

AIM: The purpose of the study was to evaluate the influence of selected prognostic factors for postoperative course and prognosis in newborns with gastroschisis.

MATERIAL AND METHODS: A study of all newborns with gastroschisis treated between 2000-2010 in the Clinic of Surgery of Children and Adolescents, Institute of Mother and Child was performed. Data collected from medical documentation included the following: presence or lack of prenatal diagnosis, mode of delivery, gestational age (below or above 37 weeks), birth weight, necessity on transportation from provincial hospitals or transfer within Institute, condition of the bowel (good - little fibrinous inflammation or bad - massive inflammatory peel, necrosis, perforation, atresia), interval between delivery and operation, kind of surgery (primary repair, silo closure), complication requiring secondary operation, period of ventilatory support (PVS), time needed to achieve full enteral feeding (FEF), total length of hospital stay (TH), number and cause of death. Selected information obtained from the data of the patients were separated into two periods of time: 2000-2005 and 2006-2010 for better evaluation of the influence of individual factors on the efficiency of treatment and prognosis. Multivariate logistic regression was used to investigate the association between selected risk factors and end points (PVS,FEF,TH). Statistical analyses were performed using Stata v.10 (College Station, TX, Stata Corporation LP 2007).

RESULTS: During the study period 32 newborns with gastroschisis were treated. Prenatal diagnosis was made in 22 patients (69%) and the mean age of diagnosis was 30.7 weeks. Cesarean section was performed in 25 cases and vaginal delivery occurred in 7 cases. The mean gestational age during delivery was 35.7 weeks, mean weight was 2430 g. Twenty one newborns were delivered before 37 week of gestation, eleven after 37 week. Fifteen patients were transported from provincial obstetrics hospitals, seventeen were transferred within the Institute (from the Obstetrics Clinic to Clinic of Pediatric Surgery). A good condition of the externalized bowel was found in 18, a bad condition in 14 patients (therein necrosis with perforation in 2, atresia in 2). Mean delivery - operation interval was 6.3 hours. The operation was performed till 3rd hour after birth in 12, over 3rd hour in 20 newborns. During the first surgical intervention primary closure was possible in 29 cases, silo was used in 3 patients. Five patients required more than one surgical intervention (2 patients after silo closure and 3 patients after primary repair). For patients who survived mean PVS was 4.6, mean time FEF was 24.7 days, TH was 34.5 days. Five patients died. The reasons for death were heart tamponade in 2 and complications in the course of sepsis in 3 patients. In the period 2006-2010 versus 2000-2005 number of prenatal diagnosis significantly increased (46% and 84% respectively), mean age at delivery decreased (38.6 and 35.3 respectively), period between delivery and operation shortened from 8.8 to 3.8 hours, more patients were operated on during first three hours after birth (7.6% and 58% respectively). The condition of the bowel was assessed similarly in both periods (bad condition 38% and 47% respectively). All deaths occurred in newborns treated in the years 2000-2005. Multivariate logistic regression showed there was one independent risk factor that influenced the two end points: the period of respiratory support and the length of hospital stay, i. e. the delivery - operation interval. Patients with delivery - operation interval over 3 hours after birth had a significantly higher risk of long-standing ventilatory support or death (OR=12.4, 95%CI {1.7, 89.3}, p=0.013) and a significantly higher risk of longer total hospital stay or death (OR=12.7, 95%CI {1.7, 97.0}, p=0.014). None of the factors analyzed had statistical significance with respect to the length of time needed to achieve full enteral feeding.

CONCLUSION: The main independent risk factor having influence on the course of treatment and prognosis was the delivery - operation interval. Early repair of gastroschisis makes primary closure easier and shortens the post-operative course. Newborns with gastroschisis despite progress in prenatal diagnostics, neonatal intensive care and surgical methods remains a serious therapeutic problem requiring multidisciplinary care and long-standing hospital stay.