Article

Risk stratification in gastroschisis: can prenatal evaluation or early postnatal factors predict outcome?

Section of Pediatric Surgery, Department of Surgery, University of Michigan Hospitals, Mott Children's Hospital F3970, Box 0245, Ann Arbor, MI 48109, USA.
Pediatric Surgery International (impact factor: 1.25). 04/2009; 25(4):319-25. DOI:10.1007/s00383-009-2342-x pp.319-25
Source: PubMed

ABSTRACT The prenatal or postnatal factors that predict complex gastroschisis in patients (atresia, volvulus, necrotic bowel and bowel perforation) remain controversial. We evaluated the prognostic value of prenatal ultrasonographic parameters and early postnatal factors in predicting clinical outcomes.
We analyzed maternal and neonatal records of 46 gastroschisis patients treated from 1998 to 2007. Information regarding demographics, prenatal ultrasound data when available, intrapartum and postnatal course was abstracted from medical records. Outcome variables included survival, ventilator days, TPN days, time to full enteral feeds, complications and length of stay. Univariate or multivariate analysis was used, with P < 0.05 considered as significant.
A total of 75% of complex patients were categorized within 1 week of life. Interestingly, prenatal bowel dilation (>17 mm) and thickness (>3 mm) did not correlate with outcome or risk stratification into simple versus complex (P < 0.05). Complex patients had increased morbidity compared to simple patients (sepsis 58 versus 18%; P = 0.021, NEC 42 versus 9%; P = 0.020, short bowel syndrome 58 versus 3%; P = 0.0001, ventilator days 24 versus 10; P = 0.021; TPN days 178 versus 38; P = 0.0001 and days to full feeds 171 versus 31; P = 0.0001; and length of stay 90 versus 39 days, P = 0.0001).
Prenatal bowel wall dilation and/or thickness did not predict complex patients or adverse outcome. Complex gastroschisis patients can be identified postnatally and have substantial morbidity.

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    Article: The gastroschisis prognostic score: reliable outcome prediction in gastroschisis.
    Kyle N Cowan, Pramod S Puligandla, Jean-Martin Laberge, Erik D Skarsgard, Sarah Bouchard, Natalie Yanchar, Peter Kim, Shoo Lee, Douglas McMillan, Peter von Dadelszen
    [show abstract] [hide abstract]
    ABSTRACT: Disease-specific outcome predictors are required for gastroschisis. We derived and validated a gastroschisis prognostic score (GPS) based on bowel appearance after birth. Visual scoring of bowel matting, necrosis, atresia, and perforation generated a novel gastroschisis bowel injury score recorded in a national database. Reweighting of score components by regression analysis led to assessments of model calibration and goodness of fit. The GPS was validated in subsequent cases. Records from 225 infants were used for model derivation. Only intestinal necrosis independently predicted mortality by regression analysis (odds ratio, 11.5; 95% confidence interval, 4.2-31.4). Model recalibration identified that a GPS of 4 or more predicted mortality in 75% of nonsurvivors and 99% of survivors (P = .0001). A GPS of 2 or more demonstrated significantly worse survival outcomes compared with scores of 0 or 1 (length of stay: P = .011, days to first enteral feed: P = .013, days on total parenteral nutrition: P = .006). Model validation with 184 new patients yielded continued high-quality discrimination of outcomes. The GPS demonstrated "near-perfect" interobserver reliability between 2 surgeons (κ ≥ 0.86). The GPS allows the accurate and reliable identification of high-risk groups for mortality and morbidity based on bowel appearance at birth. This information can drive discussions regarding family counseling, resource allocation, and new therapies for these patients.
    Journal of Pediatric Surgery 06/2012; 47(6):1111-7. · 1.45 Impact Factor
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Keywords

1 week
 
46 gastroschisis patients
 
Complex gastroschisis patients
 
complex patients
 
medical records
 
neonatal records
 
postnatal course
 
postnatal factors
 
postnatally
 
predict complex gastroschisis
 
prenatal
 
prenatal bowel dilation
 
Prenatal bowel wall dilation
 
prenatal ultrasonographic parameters
 
prenatal ultrasound data
 
risk stratification
 
short bowel syndrome 58
 
simple patients
 
TPN days
 
ventilator days 24
 

Ryan P Davis