Elsevier

Journal of Surgical Research

Volume 245, January 2020, Pages 217-224
Journal of Surgical Research

Pediatric/Congenital/Developmental
Predicting Morbidity and Mortality in Neonates Born With Gastroschisis

https://doi.org/10.1016/j.jss.2019.07.065Get rights and content

Abstract

Background

Gastroschisis is an increasingly common congenital abdominal wall defect. Due to advances in neonatal critical care and early surgical management, mortality from gastroschisis and associated complications has decreased to less than 10% in most series. However, it has been recognized that the outcome of gastroschisis has a spectrum and that the disorder affects a heterogeneous cohort of neonates. The goal of this study is to predict morbidity and mortality in neonates with gastroschisis using clinically relevant variables.

Methods

A multicenter, retrospective observational study of neonates born with gastroschisis was conducted. Neonatal characteristics and outcomes were collected and compared. Prediction of morbidity and mortality was performed using multivariate clinical models.

Results

Five hundred and sixty-six neonates with gastroschisis were identified. Overall survival was 95%. Median hospital length of stay was 37 d. Sepsis was diagnosed in 107 neonates. Days on parenteral nutrition and mechanical ventilation were considerable with a median of 27 and 5 d, respectively. Complex gastroschisis (atresia, perforation, volvulus), preterm delivery (<37 wk), and very low birth weight (<1500 g) were associated with worse clinical outcomes including increased sepsis, short bowel syndrome, parenteral nutrition days, and length of stay. The composite metric of birth weight, Apgar score at 5 min, and complex gastroschisis was able to successfully predict mortality (area under the curve, 0.81).

Conclusions

Clinical variables can be used in gastroschisis to distinguish those who will survive from nonsurvivors. Although these findings need to be validated in other large multicenter data sets, this prognostic score may aid practitioners in the identification and management of at-risk neonates.

Introduction

Gastroschisis is an increasingly common congenital abdominal wall defect with a rising incidence over the last several years.1 Due to advances in neonatal critical care, along with prenatal recognition and early surgical management, mortality from gastroschisis and its associated complications has decreased to less than 10% in most series.2, 3, 4, 5 However, it has been recognized that the outcome of gastroschisis has a spectrum and that the disorder affects a heterogeneous cohort of neonates with varying rates of morbidity and mortality. Differentiation between simple, isolated gastroschisis and complex gastroschisis with the presence of atresia, perforation, or volvulus is important in that neonates with complex gastroschisis have markedly higher hospital costs, length of stay (LOS), mortality, and complication rates.6, 7

Accurate stratification of patients with gastroschisis can lead to improved understanding about a given patient's prognosis and expected outcomes. The purpose of this study was to evaluate clinical variables to predict adverse outcomes among neonates born with gastroschisis in a large, multicenter clinical series. We hypothesize that a specific set of variables can be used to aid in the identification of neonates who are most at risk of poor clinical outcomes.

Section snippets

Study design

A retrospective observational study was conducted at eight tertiary, academic medical centers in the United States. The study was approved by the Institutional Review Board at each institution before initiation. Patients included in the study were live born neonates between January 2005 and January 2013 with a diagnosis of gastroschisis. Cases were identified using the ICD-9-CM code 756.7, and the clinical chart was evaluated to confirm diagnosis. Patients were managed by a team of boarded

Patient demographics and management

Five hundred sixty-six neonates with gastroschisis were included in the study, and overall cohort demographics are provided in Table 1. Most neonates were diagnosed with gastroschisis prenatally (68%) and approximately a third of the cohort was delivered vaginally. Median maternal age was 21 y. There was a statistically significant predominance of male neonates in the cohort (54%). Gestational age at delivery ranged from 28 to 40 wk with a median gestational age of 36 wk. Fifty-six percent of

Discussion

This study demonstrates the substantial impact that the presence of complex gastroschisis has on neonatal outcomes. Overall study survival to hospital discharge was 95% with lower survival among those with complex gastroschisis and those with VLBW (less than 1500 g). Previous studies have reported similar overall survival in neonates with gastroschisis.6, 8, 9, 10 Neonates with complex gastroschisis had a greater incidence of multiple markers of morbidity, consistent with a previous

Conclusions

This study demonstrates that multivariate models are able to successfully identify clinically recognizable sets of variables most suggestive of increased risk of mortality, sepsis, short bowel syndrome, and readmissions in neonates with gastroschisis. Although these findings will need to be validated in other large multicenter data sets, this gastroschisis prognostic score may aid practitioners in the identification and management of at-risk neonates in the future.

Acknowledgment

Authors' contributions: S.L.R. and R.B.H. carried out the initial analyses, drafted the initial manuscript, and reviewed and revised the manuscript. S.D.S.P., C.D.D., F.G.Q., E.R., and P.D.D. conceptualized and designed the study, coordinated and supervised data collection, and reviewed and revised the manuscript. S.I. conceptualized and designed the study, coordinated and supervised data collection, carried out the initial analyses, drafted the initial manuscript, and reviewed and revised the

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