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Objective: To evaluate the impact of the use of a bedside- teral feeds, time of hyperalimentation requirement, and
placed spring-loaded silo (SLS) on practice patterns and length of hospital stay.
on outcomes for infants with gastroschisis.
Results: The rate of immediate fascial closure was lower
Design: Retrospective review comparing neonates with in the postimplementation group (58% before vs 20% af-
gastroschisis treated before and after the implementa- ter implementation, P⬍.001). Overall length of stay, time
tion of selective SLS placement. to enteral feeding, and infection rates were not signifi-
cantly different between the 2 groups.
Setting: Tertiary referral center.
Conclusions: The use of an SLS placed at the bedside
has resulted in lower immediate fascial closure rates for
Patients: Of 91 consecutive neonates admitted for ini- infants with gastroschisis without significant detrimen-
tial treatment of gastroschisis between January 1998 and tal clinical outcome. The main benefit of using the bedside-
August 2007, 45 were admitted before and 46 were ad- placed SLS is the avoidance of urgent surgical interven-
mitted after implementation of the SLS. tion. For patients undergoing delayed fascial closure, use
of the bedside SLS resulted in shorter times to definitive
Main Outcome Measures: Immediate fascial closure fascial closure.
rate, infection rate, time to fascial closure, time to ini-
tiation of enteral feeding, time to achievement of full en- Arch Surg. 2009;144(6):516-519
G
ASTROSCHISIS IS A CONGEN- son of selected cases of intermittent SLS
ital anomaly of the ab- placement3,4 or routine SLS placement2,5 vs
dominal wall that has his- urgent surgical treatment.
torically been treated on The choice of immediate surgical
an emergency basis by therapy or bedside-placed SLS in our in-
primary closure or, in the case of abdomi- stitution has been determined in most cases
novisceral disproportion, by surgical silo by surgeon discretion. Therefore, direct
placement. Ongoing controversy exists re- comparison of SLS with traditional treat-
garding the optimal surgical treatment of ment is subject to selection bias, and the
this anomaly. Bedside placement of a impact of the SLS is most appropriately
spring-loaded silo (SLS) (Ventral Wall De- evaluated within the context of overall pa-
fect Silo Bags; Bentec Medical, Woodland, tient outcomes with selective use. To our
California; Figure 1) was first described knowledge, there are no data regarding the
in 1995 and was implemented at our insti-
impact of the availability of this device on
tution in January 2004.1 Proposed ben-
practice patterns or on patient outcomes be-
efits of this device have included fewer days
in need of ventilatory support, decreased cause previous study designs do not ac-
incidence of pulmonary barotrauma, count for potential selection bias in treat-
shorter time to enteral feeding, improved ment modality. The objective of this study
Author Affiliations: tissue perfusion, improved cosmetic out- was to investigate changes in practice pat-
Department of Surgery, come, decreased incidence of infectious terns and potential changes in patient
University of Washington outcomes related to the availability and se-
complications, avoidance of emergency sur-
School of Medicine, Seattle
gical intervention, and lowered hospital lective use of the SLS in our institution.
(Drs Jensen, Waldhausen, and
Kim); and Division of General charges owing to shorter stay and fewer Therefore, comparisons are made between
and Thoracic Surgery, Seattle complications.1-5 Several studies have de- overall patient outcomes, regardless of treat-
Children’s Hospital, Seattle scribed an initial experience with this de- ment modality, before and after selective
(Drs Waldhausen and Kim). vice,1,6 including a retrospective compari- implementation of the SLS.
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PATIENT POPULATION
DEFINITIONS
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12
enteral feeding
10 Time to achievement of 37.5 (16-120) 34 (19-87) .53
8 full enteral feeds
Time to advance enteral 21.5 (4-110) 16 (9-62) .40
6
feeding to goal rate
4 Time of hyperalimentation 32 (13-114) 29 (11-76) .58
2 requirement
0 a Summary data and comparisons exclude patients with significant
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Year confounding factors (see “Study Design” subsection of the “Methods”
section).
b Mann-Whitney test.
Figure 2. Initial surgical treatment of patients with gastroschisis by year
(1998-2007).
Infectious complications were not significantly dif-
ferent between groups, but a possible trend was noted
RESULTS for decreased overall infectious complications in the
postimplementation group (Table 2). No significant dif-
Baseline patient characteristics were similar in the 2 groups ferences were seen in length of stay, time to initiation of
(Table 1). Overall mortality was 1%. One neonate in the enteral feeding, time to achievement of full enteral feeds,
postimplementation group died of sepsis at 4 days of life time to advance enteral feeding to goal rate (as calcu-
and was excluded from all analyses. Primary closure rates lated by the interval between initiation of enteral feed-
weresignificantlylowerafterimplementationoftheSLS(58% ing and achievement of full feeds), or time of hyperali-
vs 20%, P⬍.001) (Figure 2). Abdominal compartment mentation requirement (Table 3).
syndromewasnotobservedineithergroup.Intra-abdominal
pressure at time of closure was similar in the 2 groups (mean, COMMENT
10 vs 11 mm Hg for the preimplementation group vs the
postimplementation group; P=.37). Time to fascial closure This study is the first to our knowledge to demonstrate
was not significantly different between groups (mean, 5.3 the impact of the selective implementation of an SLS on
vs 5.7 days; P=.30). Among patients treated with bedside- practice patterns and subsequent clinical outcomes. A sig-
placed SLS, successful fascial closure was achieved in 90% nificant decrease was seen in immediate fascial closure
(19 of 21) of patients on the first attempt. Two patients re- rate, but clinical outcomes, including length of stay and
quired conversion to a formal sutured silo owing to persis- time to enteral feeding, were not negatively affected. It
tent abdominovisceral disproportion; 1 of the 2 eventually is difficult to make a definitive statement about infec-
required closure with bioprosthetic mesh. Among patients tious complications other than that the demonstrated
undergoing SLS placement in the operating room, closure postimplementation wound infection rate is consistent
was successful in 75% (6 of 8) of the subsequent operating with that reported in the literature. The lack of signifi-
room trips. Reasons for failure to achieve fascial closure in- cance in overall infection rate may represent a type II er-
cluded elevated IAP and perforated atresia. ror due to small numbers or may be due to difficulty in
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