Elsevier

Journal of Pediatric Surgery

Volume 49, Issue 12, December 2014, Pages 1771-1775
Journal of Pediatric Surgery

PAPS Paper
Improving gastroschisis outcomes: Does birth place matter?

https://doi.org/10.1016/j.jpedsurg.2014.09.019Get rights and content

Abstract

Purpose

Babies born in the hospital where they obtain definitive surgical care do not require transportation between institutions and may have shorter time to surgical intervention. Whether these differences result in meaningful improvement in outcomes has been debated. A multi-institutional retrospective study was performed comparing outcomes based on birthplace.

Methods

Six institutions within the PedSRC reviewed infants born with gastroschisis from 2008 to 2013. Birthplace, perinatal, and postoperative data were collected. Based on the P-NSQIP definition, inborn was defined as birth at the pediatric hospital where repair occurred. The primary outcome was days to full enteral nutrition (FEN; 120 kcal/kg/day).

Results

528 patients with gastroschisis were identified: 286 inborn, 242 outborn. Days to FEN, time to bowel coverage and abdominal wall closure, primary closure rate, and length of stay significantly favored inborn patients. In multivariable analysis, birthplace was not a significant predictor of time to FEN. Gestational age, presence of atresia or necrosis, primary closure rate, and time to abdominal wall closure were significant predictors.

Conclusions

Inborn patients had bowel coverage and definitive closure sooner with fewer days to full feeds and shorter length of stay. Birthplace appears to be important and should be considered in efforts to improve outcomes in patients with gastroschisis.

Section snippets

Background

The incidence of gastroschisis is approximately 1 in 4000 live births [1], with many studies showing an increasing worldwide incidence [2], [3]. Appropriate care of these patients requires prompt surgical intervention, as some studies have shown improved outcomes with earlier definitive closure [4], [5]. Recently, there has been a drive towards regionalization of care in neonates with complex congenital anomalies, such as gastroschisis [6], [7]. However, the data to support a significant

Study design

After individual institutional Internal Review Board (IRB) approval, six institutions within the Pediatric Surgery Research Collaborative (PedSRC) reviewed patients treated for gastroschisis during a five-year period between 2008 and 2013.

Patients with gastroschisis were identified by International Classification of Disease version 9 (ICD-9) codes (756.7, 756.73, and 756.79). Patients found to have omphalocele or other congenital abdominal wall defects were excluded. Additionally, patients were

Demographics

A total of 524 patients within the six participating institutions were identified that met the inclusion criteria; 285 patients were defined as inborn and 239 were outborn. The inborn and outborn populations were similar at baseline with regards to gender, birth weight, and gestational age (Table 2). Within the inborn population there was a significantly higher rate of scheduled deliveries (44% vs 27%, p = 0.0001), prenatal diagnosis (95% vs 87%, p = 0.001), and intrauterine growth retardation

Discussion

There have been several studies that have examined whether birthplace affects outcomes, with differing results (Table 1). The first to address the issue of birthplace potentially affecting outcomes was Stringer et al. in 1990; in their review, they found a trend for improved outcomes in the patients transferred prenatally with more frequent primary repairs, less ventilation, and reduced hospital stays. They were, however, unable to find any statistically significant difference between groups [8]

Acknowledgments

We would like to thank Dr. Tamekia Jones for her assistance with statistical analysis. We would also like to thank the Children’s Foundation Research Institute Biomedical Informatics Core at Le Bonheur Children’s Hospital for their help with database set up and management.

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