Intro music/video clip
Let’s start out with a textbook image of gastroschisis. If you’re listening to the audio version of this podcast, scroll down under the media player and we’ll give you the link to this and every other image that Dr. Lim will discuss.
Don’t worry, we’ll get further into the details later. Now let's take a look at Omphalocele!!!So Gastroschisis is a full thickness abdominal wall defect just to the right of the umbilicus in which peritoneal contents – most often intestines – protrude thru the abdomen without any membranous cover. Let’s compare that to the next image which shows omphalocele.
Show still image from slides at 15:00
The obvious difference is the membrane covering the herniated contents but another difference . . .
So prenatal diagnosis is an important factor in identifying these conditions. But are the warning signs we should be looking for obvious ?
Dr Lim !!! What about imaging!The AFP is a great screening test but you need ultrasound imaging to definitely diagnose these abdominal wall defects.
Because these patients may also have other associated anomalies. Now, lLuckily, once we get the imaging, we can then follow a protocol to follow it up. As you can see here, we track their fetal growth monthly because there is concern for significant growth restriction.
/30:5331:14 - 31:18/
Ok wait, why do we need to do biophysical profile and non stress testing?
/31.19 - 31.2640/
So if the surveillance imaging becomes worrisome enough that you’re converned about intrauterine fetal demise, the mother and fetus need to be admitted for continuous monitoring or deliver the fetus emergently. Let’s change gears and talk about epidemiology. Gastroschisis affects approximately 1 in every 2 live births. But which babies are at highest risk for gastroschisis?
Unfortunately, Inrauterine growth restriction is another big concern with more than 90% of these infants born less than 25 grams in weight. Are there any other proposed risk factors for gastroschisis that we should know about?There are other identified risk factors including some common over the counter medications.
And then there are other risk factors like B vitamin deficiencies, drug use, and some genetic predispositions. Alright, similarlynow, Let's talk about risk factors for Omphalocele which are seemingly opposite to those risk factors for gastroschisis.
You can see there are a lot less risk factors than the previous slide but one that sticks out is trisomy 18 – over 90% of patients with omphalocele also have trisomy 18.
Now that we’re caught up on the basicsprenatal diagnosis, anatomy, and epidemiology, let’s do a case. So we are outside of a tertiary pediatric center and we come across a congenital wall defect. What crucial procedures do we have to take ?
These babies can have a significant acidosis, could be complicated by pulmonary hypertension, the severity at birth can range widely so it’s key to take these initial non operative steps before movin on to the closure.
Now primary and staged closure are known procedures in these abdominal wall congenital defects. Dr. Lim, in which patients do you consider primary closure?
So if the bowel appears pristine – we could potentially do a primary closure. In fact these bottom two images show how small the abdominal wall defects look over time following primary closure. But what about staged closure?
Ok so both seem like good optionsOk so if the bowel looks perfect, you could consider primary closure. If the defect is too large, consider a staged approach. but how are things done at CCH ?
I still remember learning about sutureless closure from Dr. Tony Sandler when I was in fellowship! Dr. Lim, walk us through how the CCH team does it.
Wow that was great, now let’s talk about another challenging scenario. What do you do if you encounter an atretic bowel?
So we have a primary closure, a staged closure, and a sutureless closure. But what if we have a baby with omphalocele and NO significant respiratory issues? What’s the best option here?
You’ve probably already heard about the pitcher clamp procedure and many of you may have even done it, but at CCH it's not quite the same
So they sequentially reduce the bowel with plastic clips until the baby is ready for the last step.
Thanks Dr. Lim, congenital abdominal wall defects management is not an easy topic to grasp. If you like this episode, be sure to follow us on social media, subscribe to our YouTube channel, and download the StayCurrent in Pediatric Surgery app – it’s in the Apple app store and the Google Play store. But until next time, remember, knowledge should be free
***Alternative ending if Todd wants to say it: Wherever you are – Good morning, good afternoon, good evening, or goodnight!