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      Simil exit versus cierre primario de la pared abdominal en recién nacidos con gastrosquisis


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          La Gastrosquisis es una malformación congénita caracterizada por salida de vísceras a través de un defecto paraumbilical de la pared abdominal. Los órganos eviscerados permanecen en contacto con el líquido amniótico durante la vida intrauterina, sufriendo una reacción inflamatoria crónica. Objetivo: comparar los procedimientos quirúrgicos de Símil-Exit versus el cierre primario de la pared abdominal en recién nacidos. Método: En total se analizaron 9 pacientes los cuales fueron divididos en 2 grupos. El grupo A pacientes a los cuales se les realizó el procedimiento Símil-Exit (n=4). El grupo B pacientes a los cuales se les realizó cierre primario (n=5). Resultados: No hubo diferencia significativa en cuanto a tiempo de hospitalización, tiempo inicio de la vía oral y complicaciones. En la sobrevida de los pacientes si hubo diferencia significativa entre los dos procedimientos, debido a que en el grupo de Símil-Exit la sobrevida fue del 100% versus 40% en el grupo B (p<0.05). Conclusiones: La resolución de la Gastrosquisis por Símil-Exit facilita la reducción de las asas intestinales a la cavidad abdominal manteniendo la circulación feto-placentaria, sin necesidad de anestesia general, disminuye el tiempo de exposición de las asas intestinales al ambiente y obvia el uso de ventilación mecánica.

          Translated abstract

          Gastroschisis is a congenital anomaly distinguished by herniated mid-gut through a lateral umbilicus defect. The herniated organs remain in contact with the amniotic fluid during the intrauterine life suffering a chronic inflammatory reaction. Objective: To compare the surgical procedures of Simil-Exit management versus the primary closure of the abdominal walls in newborn with gastroschisis. Methods: Nine newborn with gastroschisis were studied, they were divided into 2 groups; group A included 4 patients which were managed with the Simil-Exit procedure and group B comprised of 5 patients in whom primary closure of the abdominal walls was performed. Results: There was no significant difference according to the hospitalization stay, beginning of enteral feeding nor complications. According to the survival of the patients we could observe a significant difference between the procedures, in the Simil-Exit group the survival was 100% versus 40% in group B (p<0.05). Conclusion: The Simil-Exit resolution for gastroschisis favours bowel reduction into the abdominal cavity maintaining the placental support without the need of general anesthesia, decreases the exposure of the bowel and obviates the use of mechanical ventilation.

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          Most cited references22

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          Gastroschisis: international epidemiology and public health perspectives.

          Gastroschisis offers the intriguing epidemiological situation of a pandemic, strongly associated with very low maternal age. Identifying gastroschisis, and distinguishing it from the other abdominal wall defects, is theoretically easy but difficult in practice. The baseline birth prevalence of gastroschisis before the pandemic was approximately 1 in 50,000 births and has increased since between 10- and 20-fold. In many populations worldwide, it is still increasing. Such increasing prevalence and the association with very low maternal age are well proven, but the interaction between these two findings remains unknown. Geographic gradients (decreasing prevalence from North to South) are clear in Continental Europe and suggestive in Britain and Ireland. Gastroschisis seems more frequent in Caucasians compared to African Blacks and Orientals, and in Northern compared to Southern Europeans. These observations indicate the need for investigating gene-environment interactions. Since the global human situation is marked by inequalities among as well as within countries, the medical care and public health impact of gastroschisis varies widely among regions and social strata. The postnatal benefits of prenatal diagnosis of gastroschisis include family awareness; adequate planning of delivery with alerted obstetrical, pediatric, and surgical staff; optimal risk categorization, and personalized protocol for action. The increasing prevalence of gastroschisis combined with improved medical techniques to reduce morbidity and mortality are also increasing the burden and costs of this anomaly on health systems.
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            Escape of the yolk sac: a hypothesis to explain the embryogenesis of gastroschisis.

            Gastroschisis is a significant birth defect that in many countries has shown an increased prevalence in recent decades, and the change has affected primarily younger mothers. Despite numerous epidemiological studies no other consistent associated risk factor has been identified. In this paper we review the five main theories related to the pathogenesis of this malformation and outline the reasons why we think none fully explains the embryogenesis of gastroschisis. We briefly present some clinical observations we have made that we consider germane to the pathogenesis and outline a hypothesis that we think can account for the origins of this malformation. Our proposal is that the determining defect in gastroschisis is failure of the yolk sac and related vitelline structures to be incorporated into the umbilical stalk. Otherwise, ventral closure of the lateral abdominal walls occurs normally, thus orphaning the vitelline duct and yolk sac outside both the main body stalk and the abdominal wall. Thus, in addition to the umbilicus, the abdominal wall has a separate perforation through which the midpoint of the gut is attached to the exteriorized vitelline structures. This connection through the ventral wall prevents normal egress of the gut into the umbilical cord during the second month of development and acts as the egress point for the gut resulting in gastroschisis.
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              The contemporary outcome of gastroschisis.

              The aim of this study was to evaluate the contemporary outcome in the management of gastroschisis. A retrospective analysis was conducted of 91 babies admitted over a 7-year period to a single neonatal surgical unit with a diagnosis of gastroschisis. An antenatal diagnosis was made in 89 (98%) cases. Surgical intervention occurred in 90 babies, at a mean of 5 hours (range, 0.5 to 17) postdelivery. In 72 (80%) cases, primary closure of the abdominal defect was achieved, with a silo fashioned in the remaining 18 (20%). One child died before abdominal closure. The median time to full oral feeding was 30 days (range, 5 to 160 days), and to discharge was 42 days (range, 11 to 183 days). Those children who required a silo, took longer to feed (P =.008) and stayed longer in the hospital (P =.021). The 8 (8.8%) children with an intestinal atresia, required significantly more operative procedures (P =.0001) and took significantly longer to achieve full oral feeding (P =.04), but the presence of an atresia was not an independent risk factor for mortality. There were 7 deaths (7.7%), 3 within the first 7 days. Of the deaths, 5 (71%) were caused by overwhelming sepsis. The contemporary mortality rate from gastroschisis is less than 8%, and minimizing septic complications would contribute significantly to reducing this. Strategies designed to improve morbidity must focus on optimizing management of those factors associated with a prolonged recovery, namely intestinal atresia, prematurity, and the use of a silo.

                Author and article information

                Role: ND
                Role: ND
                Role: ND
                Archivos Venezolanos de Puericultura y Pediatría
                Arch Venez Puer Ped
                Sociedad Venezolana de Puericultura y Pediatría (Caracas )
                June 2014
                : 77
                : 2
                : 65-70
                [1 ] Hospital de Clínicas Caracas Venezuela
                [2 ] Hospital Militar Carlos Arvelo Venezuela
                [3 ] Universidad Central de Venezuela Venezuela



                SciELO Venezuela

                Self URI (journal page): http://www.scielo.org.ve/scielo.php?script=sci_serial&pid=0004-0649&lng=en
                HEALTH POLICY & SERVICES

                Pediatrics,Health & Social care,Public health
                Simil-Exit,Primary Closure,Gastrosquisis,Cierre Primario,Gastroschisis


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