Repair of postclosure of incisional hernia was needed in seven patients in group I and in three patients in group II.
Follow-up period ranged from 2 to 6 months in both groups (average: 3.7 months). Two patients came later with adhesive intestinal obstruction that was treated conservatively and another one with inguinal hernia.
Gastroschisis continued to be a challenging surgical emergency in neonates. The abdominal cavity may not be large enough to tolerate reduction of herniated frequently foreshortened, edematous, matted together bowel in many cases. Similarly, a prolonged ileus represents a challenge in the postoperative period.
During the past 12 years, there was a steady improvement in antenatal care at our region. Prenatal diagnosis of abdominal wall defect increased from 16.7% in group I to 31.8% in group II. All mothers were advised to continue the normal course of pregnancy instead of preterm delivery. The limited incubators equipped with advanced neonatal intensive care facilities dictated this approach.
Preterm delivery of infants with gastroschisis was recommended by some researchers to avoid the intestinal damage that may occur due to prolonged exposure to the amniotic fluid, which contain inflammatory factors that lead to intestinal ischemia or damage [17,18]. In contrary, Maramreddy et al.  reported that there is no benefit of preterm delivery in reducing the morbidities in patients with gastroschisis. In addition, preterm delivery increased complication rate in those infants with regard to sepsis, longer hospital stay, and prolonged period to establish feeding and to tolerate full feeding.
Owing to increased prenatal diagnosis, more deliveries were performed at hospitals equipped with neonatal care facilities. Earlier presentation and primary closure was noted in group II compared with group I (5 vs. 7 h). This might have contributed to the overall improvement of outcome in the second group. Stringer et al.  reported that prenatal diagnosis and transfer of patient to a specialized center is in favor of more frequent successful primary closure, less postoperative ventilation, and reduced hospital stay, because of earlier surgery and early management of patient with regard to hypothermia and hypovolemia and adequate nasogastric drainage.
The management of neonates with gastroschisis depends on several factors including the amount and status of herniated bowel, the size of abdominal cavity, the available resources at neonatal intestine care unit, and the presence or absence of other associated congenital anomalies. Operative primary reduction with closure of the abdominal defect continued to be the standard initial surgical strategy, whereas operative staged reduction is frequently used as a rescue strategy when reduction is deemed unsafe or physically impossible because of visceroabdominal disproportion .
A significant percentage of infants with gastroschisis can undergo reduction of the herniated intestinal contents and primary abdominal wall closure. Primary closure was decided whenever feasible. In 1970, pharmacologic paralysis and prolonged mechanical ventilation after aggressive attempts at primary closure were recommended .
More patients underwent primary repair in the first group (60% of cases). For fear of infection and disruption of the silo at the margin of the defect and risk of evisceration, many surgeons still prefer primary closure in many cases of gastroschisis, if at all possible. The use of intraoperative pressure manometry by measuring either intragastric central venous pressure or bladder was recommended as a guide for primary closure of the abdominal defect to avoid potential abdominal compartment syndrome, which may lead to ischemic/necrotic bowel, renal insufficiency, and respiratory distress [22–24].
Operative staged reduction has been predominantly achieved by suturing a synthetic material to the enlarged defect and delayed defect closure. Staged closure carries the risk of loss of fascial strength at the margins of the defect, the infection risk from the lack of a watertight seal, and the risk of evisceration due to disrupt suture line .
A more conservative approach toward overzealous primary closure has been adopted in our practice during the past 5 years. The availability of SLS has encouraged us to limit primary closure to cases in which this can be done safely without the need of postoperative ventilation. The use of a preformed SLS bag in infants with gastroschisis has been shown to be associated with improved facial closure rates, fewer ventilator days, more rapid return of bowel function, and fewer complications. Reduction of gastroschisis bowel has been successfully performed with and without anesthesia [26,27].
Despite the several advantages of SLS, it has potential pitfalls including ischemic complications, dislodgment, bowel twisting, and difficulties with final closure. One of the disadvantages of SLS is the progressively increased abdominal wall defect, which may be explained by the development of lateral distractive forces being applied to the abdominal wall . Another potential complication is bowel ischemia at the inferior portion of the silo during reduction through small openings that can serve as a constriction point of the bowel or mesentery ‘funnel effect’ .
Many patients with gastroschisis have associated intestinal abnormalities including atresia (mostly involving the small intestine) [4,33]. The incidence of associated atresia was 9.6% in this series. Although primary anastomosis is not recommended in such cases, this was feasible in two cases with relatively mild edematous bowel.
The outcome of patients with gastroschisis has dramatically improved in our institution and affiliated hospitals. The mortality rate was 23% during the first 7 years in this study, whereas it came down to less than 10% in the past 5 years. The improvement in outcome is related to the optimization of perinatal care, the availability of intravenous nutrition, and the use of staged closure when indicated. Late complications and mortality are related to sepsis either from an intra-abdominal or wound complication or from a central venous catheter placed for parental nutrition.
Significant changes occurred in the management philosophy of gastroschisis at our institution. The morbidity and mortality rates are steadily improving. Antenatal diagnosis is increasing. Primary closure of the abdominal wall defect is only performed if it is safe without high intra-abdominal pressure. The use of a SLS is helpful but has potential pitfalls.
1. Caniano DA, Brokaw B, Ginn Pease ME. An individualized approach to the management of gastroschisis. J Pediatr Surg. 1990;25:297–300
2. Baerg J, Kaban G, Tonita J, Pahwa P, Reid D. Gastroschisis: a sixteen-year review. J Pediatr Surg. 2003;38:771–774
3. Hougland KT, Hanna AM, Meyers R, Null D. Increasing prevalence of gastroschisis in Utah. J Pediatr Surg. 2005;40:535–540
4. Owen A, Marven S, Johnson P, Kurinczuk J, Spark P, Draper ES, et al. Gastroschisis: a national cohort study to describe contemporary surgical strategies and outcomes. J Pediatr Surg. 2010;45:1808–1816
5. Fear W. Congenital extrusion of abdominal viscera: return: recovery. Br Med J. 1878;2:518–520
6. Watkins DE. Gastroschisis. Va Med. 1943;70:42–45
7. Moore TC, Stokes GE. Gastroschisis. Report of two cases treated by a modification of the gross operation for omphalocele. Surgery. 1953;33:112–120
8. Buchanan RW, Cain WL. A case of a complete omphalocele. Ann Surg. 1956;143:552–556
9. Kleinhaus S, Kaufer N, Boley SJ. Partial hepatectomy in omphalocele repair. Surgery. 1968;64:484–485
10. Izant RJ Jr, Brown F, Rothmann BF. Current embryology and treatment of gastroschisis and omphalocele. Arch Surg. 1966;93:49–53
11. Firor HV. Technical improvements in the management of omphalocele and gastroschisis. Surg Clin North Am. 1975;55:129–134
12. Schuster SR. A new method for the staged repair of large omphaloceles. Surg Gynecol Obstet. 1967;125:837–850
13. Allen RG, Wrenn EL Jr. Silon as a sac in the treatment of omphalocele and gastroschisis. J Pediatr Surg. 1969;4:3–8
14. Shermeta DW, Haller JA Jr. A new preformed transparent silo for the management of gastroschisis. J Pediatr Surg. 1975;10:973–975
15. Kidd JN, Levy MS, Wagner CW. Staged reduction of gastroschisis: a simple method. Pediatr Surg Int. 2001;17:242–244
16. Minkes RK, Langer JC, Mazziotti MV, Skinner MA, Foglia RP. Routine insertion of a silastic spring-loaded silo for infants with gastroschisis. J Pediatr Surg. 2000;35:843–846
17. Guibourdenche J, Berrebi D, Vuillard E, De Lagausie P, Aigrain Y, Oury JF, et al. Biochemical investigations of bowel inflammation in gastroschisis. Pediatr Res. 2006;60:565–568
18. Hadidi A, Subotic U, Goeppl M, Waag KL. Early elective cesarean delivery before 36 weeks versus late spontaneous delivery in infants with gastroschisis. J Pediatr Surg. 2008;43:1342–1346
19. Maramreddy H, Fisher J, Slim M, LaGamma EF, Parvez B. Delivery of gastroschisis patients before 37 weeks of gestation is associated with increased morbidities. J Pediatr Surg. 2009;44:1360–1366
20. Stringer MD, Brereton RJ, Wright VM. Controversies in the management of gastroschisis: a study of 40 patients. Arch Dis Child. 1991;66:34–36
21. Raffensperger JG, Jona JZ. Gastroschisis. Surg Gynecol Obstet. 1974;138:230–234
22. Wesley JR, Drongowski R, Coran AG. Intragastric pressure measurement: a guide for reduction and closure of the silastic chimney in omphalocele and gastroschisis. J Pediatr Surg. 1981;16:264–270
23. Lacey SR, Carris LA, Beyer AJ III, Azizkhan RG. Bladder pressure monitoring significantly enhances care of infants with abdominal wall defects: a prospective clinical study. J Pediatr Surg. 1993;28:1370–1374 discussion 1374–1375.
24. Yaster M, Scherer TL, Stone MM, Maxwell LG, Schleien CL, Wetzel RC, et al. Prediction of successful primary closure of congenital abdominal wall defects using intraoperative measurements. J Pediatr Surg. 1989;24:1217–1220
25. Stringel G. Large gastroschisis: primary repair with Gore-Tex patch. J Pediatr Surg. 1993;28:653–655
26. David AL, Tan A, Curry J. Gastroschisis: sonographic diagnosis, associations, management and outcome. Prenat Diagn. 2008;28:633–644
27. Owen A, Marven S, Jackson L, Antao B, Roberts J, Walker J, et al. Experience of bedside preformed silo staged reduction and closure for gastroschisis. J Pediatr Surg. 2006;41:1830–1835
28. Wu Y, Vogel AM, Sailhamer EA, Somme S, Santore MJ, Chwals WJ, et al. Primary insertion of a silastic spring-loaded silo for gastroschisis. Am Surg. 2003;69:1083–1086
29. Allotey J, Davenport M, Njere I, Charlesworth P, Greenough A, Ade Ajayi N, et al. Benefit of preformed silos in the management of gastroschisis. Pediatr Surg Int. 2007;23:1065–1069
30. Pastor AC, Phillips JD, Fenton SJ, Meyers RL, Lamm AW, Raval MV, et al. Routine use of a SILASTIC spring-loaded silo for infants with gastroschisis: a multicenter randomized controlled trial. J Pediatr Surg. 2008;43:1807–1812
31. Lobo JD, Kim AC, Davis RP, Segura BJ, Alpert H, Teitelbaum DH, et al. No free ride? The hidden costs of delayed operative management using a spring-loaded silo for gastroschisis. J Pediatr Surg. 2010;45:1426–1432
32. Ryckman J, Aspirot A, Laberge JM, Shaw K. Intestinal venous congestion as a complication of elective silo placement for gastroschisis. Semin Pediatr Surg. 2009;18:109–112
33. Arnold MA, Chang DC, Nabaweesi R, Colombani PM, Bathurst MA, Mon KS, et al. Risk stratification of 4344 patients with gastroschisis into simple and complex categories. J Pediatr Surg. 2007;42:1520–1525