Elective delayed reduction and no anesthesia: 'minimal intervention management' for gastrochisis.

PURPOSE

In a pilot study of 14 children, born when the authors were on a 1:5 "on take" for neonatal referrals, a policy evolved of elective delayed midgut reduction without anaesthesia or sedation in the incubator on the neonatal surgical unit. There was no other form of selection, and it was fortunate that the authors did not encountered any adverse criteria in this small series.

METHODS

Bowel reduction, which was pain free, was undertaken conventionally with the same attention and with no greater difficulty than under general anesthesia. Delaying midgut reduction for more than 4 hours led to more stable cardiovascular, respiratory, and renal parameters. Moderate lower limb congestion cleared rapidly.

RESULTS

At the end of the procedure, all children were conscious, and 12 were alert and indistinguishable from normal babies. A mild periumbilical infection developed in two patients. Eleven of the 12 surviving children established enteral nutrition within 11 to 32 days, eight within 18 days. Another child with ileal atresia and bowel dilatation required bowel tailoring and lengthening (LILT) to allow enteral nutrition. All are physically and developmentally normal, and none has required umbilical herniorrhaphy or umbilicoplasty. All except one have a "scarless" abdomen and an aesthetically normal umbilicus. In marked comparison, two children immediately and obviously were unwell with abdominal pain, tachycardia, and metabolic acidosis. Abdominal wall cellulitis rapidly developed in both. At laparotomy one had a midgut volvulus and died at 22 months of short bowel syndrome (SBS) and the other with a perforated segmental ileal atresia died at 7 months of Enterobacter cloacae septicaemia.

CONCLUSIONS

Our small study suggests that delayed midgut reduction without anaesthesia appears safe, carrying no additional morbidity or mortality. It helps avoid anaesthesia, muscle relaxants, and ventilation and has obvious resource benefits. The conscious child is a safety asset, and any postreduction deviation from a "normal, well-perfused, comfortable, and painfree" child is an indication for urgent laparotomy. This "minimal intervention management," when applicable, has become our preferred first option for children with gastroschisis. Further extension of this study will determine those not eligible for this technique and establish "exclusion criteria."