title: Challenges of improving the evidence base in smaller surgical specialties, as highlighted by a systematic review of gastroschisis management.
abstract: OBJECTIVE
  To identify methods of improving the evidence base in smaller surgical specialties, using a systematic review of gastroschisis management as an example.
  
  
  BACKGROUND
  Operative primary fascial closure (OPFC), and silo placement with staged reduction and delayed closure (SR) are the most commonly used methods of gastroschisis closure. Relative merits of each are unclear.
  
  
  METHODS
  A systematic review and meta-analysis was performed comparing outcomes following OPFC and SR in infants with simple gastroschisis. Primary outcomes of interest were mortality, length of hospitalization and time to full enteral feeding.
  
  
  RESULTS
  751 unique articles were identified. Eight met the inclusion criteria. None were randomized controlled trials. 488 infants underwent OPFC and 316 underwent SR. Multiple studies were excluded because they included heterogeneous populations and mixed intervention groups. Length of stay was significantly longer in the SR group (mean difference 8.97 days, 95% CI 2.14-15.80 days), as was number of post-operative days to complete enteral feeding (mean difference 7.19 days, 95%CI 2.01-12.36 days). Mortality was not statistically significantly different, although the odds of death were raised in the SR group (OR 1.96, 95%CI 0.71-5.35).
  
  
  CONCLUSIONS
  Despite showing some benefit of OPFC over SR, our results are tempered by the low quality of the available studies, which were small and variably reported. Coordinating research through a National Paediatric Surgical Trials Unit could alleviate many of these problems. A similar national approach could be used in other smaller surgical specialties.
authors.affiliation: National Perinatal Epidemiology Unit, Oxford, United Kingdom; Department of Paediatric Surgery, Oxford Radcliffe University Hospital, Oxford, United Kingdom.
authors.forename: Benjamin S R
authors.initials: BS
authors.lastname: Allin
authors.affiliation: National Perinatal Epidemiology Unit, Oxford, United Kingdom.
authors.forename: Win Hou W
authors.initials: WH
authors.lastname: Tse
authors.affiliation: Sheffield Children's Hospital, Sheffield, United Kingdom.
authors.forename: Sean
authors.initials: S
authors.lastname: Marven
authors.affiliation: Department of Paediatric Surgery, Oxford Radcliffe University Hospital, Oxford, United Kingdom.
authors.forename: Paul R V
authors.initials: PR
authors.lastname: Johnson
authors.affiliation: National Perinatal Epidemiology Unit, Oxford, United Kingdom.
authors.forename: Marian
authors.initials: M
authors.lastname: Knight
mesh_terms: D019468:Disease Management; D055317:Evidence-Based Practice; D020139:Gastroschisis / Q000601:surgery*; D006801:Humans; D058996:Quality Improvement; D013518:Surgery, Plastic; D016896:Treatment Outcome