Surgical Treatment of Gastroschisis with Visceroabdominal Disproportion

The dissertation is dedicated to the development and clinical testing of a method for surgical treatment of gastroschisis with visceroabdominal disproportion. The study justifies the necessity of optimizing the conditions for delayed plastic repair of the anterior abdominal wall through staged reduction of eviscerated organs into an artificial temporary peritoneal cavity with subsequent aponeurosis suturing through the lumen. A device for surgical treatment of gastroschisis has been developed and tested, allowing improvement of the technical conditions for staged reduction of eviscerated organs and delayed radical plastic repair of the anterior abdominal wall using local tissues. It has been demonstrated that the proposed technology ensures prolonged decompression, early restoration of gastrointestinal motility, reduction in the number of postoperative complications, and decreased mortality compared to primary plastic repair with local tissues.

Relevance. The increase in the number of newborns with gastroschisis, high mortality, prolonged and costly hospitalization, and unresolved questions regarding optimal surgical correction define the relevance of the problem of treating this congenital malformation.

Over recent years, reports by foreign and domestic authors have noted a trend toward an increase in the number of children with gastroschisis (21, 169). The frequency of this defect has approximately doubled and currently ranges from 0.4 to 4.1 per 10,000 live births [7, 90, 111].

In leading foreign clinics, mortality in gastroschisis remains at the level of 4–10% [94, 110, 161]. According to domestic authors, it ranges from 6.5% to 45% [21, 30, 35, 39].

Hospitalization periods for this disease average 38 to 50 days; treatment requires substantial financial expenditures associated with prolonged parenteral nutrition, artificial ventilation of the lungs, administration of expensive medications, and laboratory monitoring tools [7, 94].

The most complex and important aspect of gastroschisis treatment remains the resolution of the question of optimal surgical correction. During surgical treatment, a complex of problems arises associated with visceroabdominal disproportion, peritonitis, combined malformations, prolonged intestinal ileus, and repair of the anterior abdominal wall defect [8, 13, 15, 37, 119]. The choice of surgical correction method is considered a separate problem that is constantly discussed in specialized literature [14, 22, 118, 171, 2011].

Currently, surgical treatment of gastroschisis mainly employs primary anterior abdominal wall repair and delayed plastic repair using a temporary synthetic covering [5, 21, 22, 144].

Most surgeons prefer primary plastic repair of the abdominal wall using local tissues, supplemented by manual stretching of the anterior abdominal wall [5, 3, 91]. However, when this technique is applied, radical plastic repair of the anterior abdominal wall using local tissues is possible in only 30–80% of patients with gastroschisis. In the remaining cases, the defect is closed using skin only, or patches made of various plastic materials are used [17, 39, 144, 161, 179]. Due to visceroabdominal mismatch after primary plastic repair, intra-abdominal pressure increases, leading to compression of the inferior vena cava, decreased cardiac output, severe respiratory disorders, acute renal insufficiency, mesenteric ischemia, and thrombosis [29, 85, 201]. The listed complications prolong treatment duration and are the most frequent causes of fatal outcomes [24, 39]. Therefore, some surgeons consider it more expedient to use various techniques of delayed plastic repair of the anterior abdominal wall in the treatment of gastroschisis [14, 123, 168, 197].

In world practice, the most widespread variant of delayed plastic repair is silo plastic repair [5, 89, 161]. The latter is also not devoid of drawbacks. A prolonged period of organ repositions often leads to sepsis, wound edge suppuration, suture insufficiency, disruption of intestinal motility, and intensification of the adhesive process [5, 119, 179]. Attempts to accelerate the process of organ immersion into the abdominal cavity give rise to the same problems as primary plastic repair [119]. Moreover, in patients with pronounced visceroabdominal disproportion, even silo plastic repair does not always allow radical defect closure. In such cases, after complete immersion of eviscerated organs into the abdominal cavity, the defect is closed using skin only or synthetic material [50, 119, 161, 163].

An unresolved problem in gastroschisis treatment is also the correction of combined intestinal malformations [37, 88]. Intestinal atresia and stenosis occur in 5–25% of gastroschisis cases [39, 68, 102]. Mortality in such combinations reaches 40–66% [81, 179]. It is important that in 12% of observations, due to edema and fibrotic sheath, the intestinal malformation cannot be detected during the first surgical intervention. Therefore, the necessity for repeated surgeries arises, which complicates the disease course and worsens the prognosis [60, 124].

Thus, during surgical treatment of gastroschisis, a complex of problems arises associated with visceroabdominal disproportion, repair of the anterior abdominal wall defect, diagnosis, and correction of combined intestinal malformations. In this regard, the necessity of searching for a method of surgical treatment of gastroschisis that provides effective intraoperative diagnosis of combined malformations, optimal immersion of eviscerated organs into the abdominal cavity, and performance of radical plastic repair of the anterior abdominal wall using local tissues becomes clear.

Objective of the research

To improve the results of surgical treatment of patients with gastroschisis and visceroabdominal disproportion by optimizing the conditions for performing delayed plastic repair of the anterior abdominal wall.

Tasks of the research

1. To study the results of surgical treatment of patients with gastroschisis and visceroabdominal disproportion using primary plastic repair with local tissues.

2. To develop a method and device for surgical treatment of gastroschisis with visceroabdominal disproportion that allow optimization of the technical conditions for reduction of eviscerated organs and performance of delayed radical plastic repair of the anterior abdominal wall using local tissues.

3. To evaluate the clinical effect of applying the developed device and method of staged reduction of eviscerated organs and delayed plastic repair of the anterior abdominal wall in patients with gastroschisis and visceroabdominal disproportion.

4. To conduct a comparative evaluation of the results of surgical treatment of gastroschisis with visceroabdominal disproportion using primary plastic repair and delayed plastic repair with staged reduction of eviscerated organs and aponeurosis suturing through the lumen into an artificial temporary peritoneal cavity.

Scientific novelty

A technology for surgical treatment of gastroschisis has been developed that allows staged reduction of eviscerated organs and aponeurosis suturing through the lumen into an artificial temporary peritoneal cavity.

It has been demonstrated that the developed method of surgical treatment allows improvement of intraoperative diagnosis of combined malformations of abdominal organs, effective reduction of eviscerated organs, and delayed radical plastic repair of the anterior abdominal wall using local tissues in patients with gastroschisis and visceroabdominal disproportion.

It has been established that delayed radical plastic repair performed by staged reduction of eviscerated organs and aponeurosis suturing through the lumen into an artificial peritoneal cavity is accompanied by prolonged decompression and does not cause exacerbation of respiratory insufficiency, changes in arterial blood pressure, heart rate, or diuresis in patients with gastroschisis and visceroabdominal disproportion in the early postoperative period.

It has been shown that use of the developed technology allows patients with gastroschisis and visceroabdominal disproportion to restore gastrointestinal motility earlier, reduce the number of postoperative complications associated with high intra-abdominal pressure, reduce mortality, and improve long-term surgical treatment outcomes compared to primary plastic repair with local tissues.

Practical significance

A method of staged reduction of eviscerated organs and aponeurosis suturing through the lumen into a hollow synthetic covering has been developed and clinically tested (Russian Federation Patent No. 2290098 dated May 30, 2005), allowing effective performance of delayed radical plastic repair of the anterior abdominal wall using local tissues, reducing the number of postoperative complications, and reducing mortality in patients with gastroschisis and visceroabdominal disproportion.

A device for surgical treatment of gastroschisis has been developed and clinically tested (Russian Federation Patent No. 2286100 dated May 30, 2005), allowing improvement of the technical conditions for performing staged reduction of eviscerated organs and delayed plastic repair of the anterior abdominal wall.

Implementation of research results

The main results of the research have been implemented in clinical practice of surgical department No. 2 of the State Institution "Children's City Clinical Hospital No. 5" of Kemerovo and in the educational process of the Department of Pediatric Surgical Diseases of the State Educational Institution of Higher Professional Education "Kemerovo State Medical Academy" of the Russian Academy of Education.

Main provisions submitted for defense:

1. Application of primary plastic repair of the anterior abdominal wall using local tissues in the treatment of gastroschisis with visceroabdominal disproportion often leads to the development of a high intra-abdominal pressure syndrome, which is the main cause of fatal outcomes in the early postoperative period.

2. Staged reduction of eviscerated organs and aponeurosis suturing through the lumen into an artificial peritoneal cavity in patients with gastroschisis and visceroabdominal disproportion allows improvement of intraoperative diagnosis of concomitant diseases of abdominal organs and effective performance of delayed radical plastic repair of the anterior abdominal wall using local tissues.

3. Use of delayed plastic repair with staged reduction of eviscerated organs and aponeurosis suturing through the lumen into an artificial peritoneal cavity is accompanied by prolonged decompression, allows earlier restoration of gastrointestinal motility, reduces the number of complications associated with high intra-abdominal pressure, and reduces mortality in patients with gastroschisis and visceroabdominal disproportion compared to primary plastic repair with local tissues.

Presentation of the work

The main provisions of the dissertation were reported and discussed at a meeting of the Kemerovo Society of Pediatric Surgeons (Kemerovo, 2001), the All-Russian Scientific and Practical Conference "Present and Future of Technological Medicine" (Leninsk-Kuznetsky, 2002), the International Scientific and Practical Conference "Healthy Child — Healthy Nation" (Kemerovo, 2003), the IV Russian Congress "Modern Technologies in Pediatrics and Pediatric Surgery" (Moscow, 2005).

Publications

Based on the dissertation materials, publications have been made, including 2 in leading peer-reviewed scientific journals recommended by the Higher Attestation Commission for publication of the main scientific results of dissertations for the degree of Doctor and Candidate of Sciences. Two Russian Federation patents for inventions have been obtained.

Volume and structure of the dissertation

The dissertation is presented on 128 pages of typed text, illustrated with 21 tables and 25 figures, and consists of an introduction, an analytical literature review, three chapters containing the results of original research, conclusion, findings, and practical recommendations. The bibliography includes 201 items (39 domestic and 162 foreign authors).