Gastroschisis revisited: role of intraoperative measurement of abdominal pressure.
BACKGROUND
Animal studies have shown that visceral circulation is well preserved when intraabdominal pressure does not exceed 20 mm Hg. Our aim was to analyze the outcomes of a series of infants with gastroschisis whose surgical management was directed by the intraoperative measurement of bladder pressure.


METHODS
Forty-two neonates with gastroschisis were surgically managed using intraoperative measurement of bladder pressure at a tertiary care center between July 31, 1992, and March 20, 2004, and their outcome was evaluated. Primary closure with or without prosthetic material was performed when pressures measured 20 mm Hg or less. Delayed closure using a silon pouch was performed when pressures measured more than 20 mm Hg. Categorical variables were analyzed including mode of delivery, associated anomalies, type of closure, complications, and mortality. Continuous variables were analyzed including gestational age, birth weight, bladder pressure, time to full feeds, and length of hospital stay. Categorical and continuous variables for both groups were compared using Fisher's Exact and Wilcoxon's rank-sum tests, respectively, and a significance level of .05 was used. Preapproval of this study was obtained from the Institutional Review Board (No. 6690).


RESULTS
Thirty-three (79%) neonates with a mean bladder pressure of 16 mm Hg underwent primary closure and 9 neonates with a mean bladder pressure of 27 mm Hg underwent delayed closure with a silon pouch that was not spring loaded ( P < .03). Patients treated with primary closure had faster return to full feeds and significantly shorter hospital length of stay compared with patients treated by delayed closure ( P = .04). Surgical morbidity and mortality was nil in patients after primary closure. One patient with total abdominal evisceration died during attempted delayed closure and another patient required reoperation for bowel necrosis after delayed closure.


CONCLUSIONS
Primary closure was safely accomplished in 100% of neonates with gastroschisis whose bladder pressure measured 20 mm Hg or less. Further, this group of patients had a faster return to full feeds and a significantly shorter hospital length of stay compared with neonates who required delayed closure.
Olesevich
Max
M
Department of Pediatric Surgery, The Children's Hospital at The Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
Alexander
Frederick
F
Khan
Mohammad
M
Cotman
Kathy
K
D000015:Abnormalities, Multiple / Q000453:epidemiology; D036861:Delivery, Obstetric; D020345:Enterocolitis, Necrotizing / Q000453:epidemiology; D020139:Gastroschisis / Q000601:surgery*; D006801:Humans; D007231:Infant, Newborn; D007902:Length of Stay / Q000706:statistics & numerical data; D016343:Monitoring, Intraoperative; D010288:Parenteral Nutrition; D011183:Postoperative Complications / Q000453:epidemiology; D011312:Pressure; D019736:Prostheses and Implants; D019919:Prosthesis Implantation; D012079:Renal Circulation; D012086:Reoperation; D012189:Retrospective Studies; D013152:Splanchnic Circulation; D013997:Time Factors; D016896:Treatment Outcome; D001743:Urinary Bladder