Does time to theater matter in simple gastroschisis?

Introduction

Gastroschisis is the most common congenital abdominal wall defect, estimated to affect between 3.6 and 4.4 per 10 000 live births in the UK.1 It is increasing in prevalence and has been identified by the chief medical officer of the UK as a research priority.2 3 The majority of gastroschisis is simple (85%), with excellent survival exceeding 90% in high-income countries.1 4 5 Complex gastroschisis, defined as gastroschisis with intestinal atresia, perforation or stenosis, represents a much higher risk cohort with complex clinical courses and a worse prognosis.6 Neonates with simple gastroschisis have an average length of stay (LOS) of around 1 month.7 This represents a significant cost for healthcare providers and is associated with family disruption and stress. While best care is always a clinician’s focus, with the National Health Service reporting £13.4 billion of outstanding debt at the end of the 2019/2020 tax year, service planning to facilitate high-quality delivery of care, which results in reduced LOS and thus reduces costs, is an important consideration.8

Strategies regarding the initial management and timing of intervention in simple gastroschisis are controversial. Current trends within the UK demonstrate that approximately 58% are managed by primary closure and 40% by silo.1 The silo group is inherently more heterogeneous. Some will have a preformed silo placed in a non-theater setting, some of whom would have been suitable for primary closure. Some will have a silo placed in theater when primary reduction is not possible. Multicenter UK data demonstrate that babies managed by primary closure have a shorter LOS than those managed by initial preformed silo (median 34 vs 38 days).1 9 More recent evidence suggests that expedited time to theater improves the primary closure rate to 77% with shorter time to full feeds (TFF) and shorter LOS (median 19 and 22.5 days, respectively).10

The aim of this study was to determine the relationship between time to first management (TFM) and LOS in simple gastroschisis. Although TFM was the focus of our study, other variables, including gestation, birth weight (BW), time of procedure (day 08:00–19:59 or night 20:00–07:59), primary/delayed closure and use of patch, were evaluated as possible confounding variables. The primary outcome measures were TFF, time on parenteral nutrition (TPN) and LOS.

Methods

This study was undertaken in a UK pediatric surgical tertiary center as a service evaluation of the care of children with gastroschisis and was registered with the institution. Neonates with antenatally diagnosed gastroschisis were delivered in a level III maternity and neonatal hospital and stabilized prior to transfer to the pediatric surgical center for definitive management. Preformed silo placement was performed in the maternity hospital if the neonate was unfit for transfer or if a prolonged delay to theater was expected; in this instance, the silo would be placed by a member of the pediatric surgical team, and this would be considered a delayed repair. TFM was defined as the time from delivery to the time of first management of gastroschisis, which could be time to the theater, time of bedside reduction or time of placement of bedside silo.

Inclusion criteria:

• Infants with gastroschisis admitted to the pediatric surgical center between August 2013 and August 2020, identified using the BadgerNet database and searching for ‘gastroschisis’.

• Simple gastroschisis.

• Time from birth to first management could be extracted from the notes.

Exclusion criteria:

• Complex gastroschisis. This was determined using the criteria described by Molik et al and included babies with atresia, congenital necrosis, perforation, or volvulus.6

• No documentation of the time of first management.

Data were collected retrospectively from case notes, including gestation, BW, sex, time of birth, time to first set of observations in theater, surgical procedures, vascular access and time to first feed. Outcome variables including TFF, duration of parenteral nutrition (PN) and LOS (time from birth to time of discharge, inclusive of those undergoing primary or staged/delayed closure) were recorded. When babies underwent gastroschisis management in a non-theater setting, the time of the procedure as recorded in the notes was used. Time of birth and time of procedure were coded as 0 if they occurred during ‘day-time hours’ between 08:00 and 19:59 and 1 if they occurred ‘out of hours’ between 20:00 and 07:59. In our institution, there is no standardized approach to the initiation of feeding regarding timing, volume, or rate of advancement, which is at the discretion of the clinician. Where feasible, breast feeding or expressed breast milk provision is our preference, but the family’s wishes are always respected and combination feeding is often used when available breast milk supplies do not meet the requirements of the infant.

Results

Multivariate analysis of factors that may influence the duration of PN, TFF and LOS

Multivariate linear regression analysis (table 2) demonstrates a persistent significant association between achieving primary closure and a reduced TFF and a reduced duration of PN compared with those undergoing delayed closure when the model is adjusted for all other variables. However, an association with LOS was not demonstrated in this analysis. The TFM of an infant with gastroschisis is not associated with a significant reduction in the TFF, duration of PN or LOS.

Table 2

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Multivariate linear regression analysis of variables found to be associated with the outcomes of time to full feeds, duration of parenteral nutrition and length of stay in univariate regression analysis

Earlier administration of the first feed is associated with a reduced LOS but is not associated with a reduced time to achieving full feeds or a reduced duration of PN. Figure 1 demonstrates a significant correlation between the days to first feed and the LOS in infants undergoing primary closure but not for infants undergoing delayed closure.

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Figure 1

Association between the days to first feed and length of stay (LOS) for infants undergoing primary closure (A) and delayed closure (B). A line of best fit and 95% CIs are shown. CI, confidential interval.

For infants undergoing primary closure, the median TFF was 17 days (IQR=13–22 days), the duration of PN was 16 days (IQR=13–22 days) and the LOS was 21 days (IQR=16–29 days). No significant association was demonstrated between TFM and TFF and LOS (figure 2A,B).

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Figure 2

Association between the time to first management and the outcomes of time to full feeds (A), and length of stay (LOS) (B). A line of best fit and 95% CIs are shown. No significant association is demonstrated. CI, confidential interval.

Discussion

The incidence of gastroschisis has increased threefold over the last decade, with the estimated cost of gastroschisis care rising from 3.6 million in 1996 to 15 million by 2005.11 In addition to the economic impact, parents of infants who require long stays in neonatal intensive care units experience negative psychological effects, including issues pertaining to attachment and the development of their parenting role.12 For these reasons, it is vital as clinicians that we consider how we can safely limit the time neonates spend in the hospital.

It is demonstrated that younger gestation and lower BW infants have a longer LOS, but this does not significantly impact their TPN or their TFF. Standardized care and enhanced recovery protocols have been shown to improve outcomes across a wide range of pediatric surgical conditions.13 14 Several studies have highlighted that protocolized care in institutional ‘care bundles’ may positively impact mechanical ventilation and rates of primary closure.15–17 While Joharifard’s group did not demonstrate a reduction in the duration of TPN or LOS, they did achieve a 95% rate of TFM <6 hours after delivery with a median duration of TPN of 20 days (vs 25 in our cohort). This again supports the potential impact of time to first intervention. Early first feed has been previously suggested to improve outcomes from gastroschisis,18 19 and the results shown here suggest that early feeds may be associated with a reduction in LOS, particularly in infants undergoing primary closure. However, early feeding has not been shown to have a significant association with a reduction in TPN or the TFF, in keeping with previous research.18

It is accepted that primary closure is associated with reduced LOS in infants with gastroschisis, a finding strongly supported by the data within this study.20 21 Infants undergoing primary closure had a significantly lower rate of further laparotomies than infants undergoing delayed closure. Aprahamian’s group was the first to consider the impact of expedited theater to improve rates of primary closure. They described combining immediate attempted reduction and primary closure along with mucolytic bowel irrigation, resulting in rates of primary closure of 77%.10 This is substantially higher than the 59% receiving primary closure in this group. The findings of our study do not demonstrate that earlier intervention results in a higher likelihood of achieving primary closure. However, in Aprahamian’s group, the median time to theater was 1.8 hours compared with a median time to theater of 7.9 hours in this study. To achieve this fourfold reduction in time to theater, there must be colocated maternity services and a dedicated pediatric theater.

Aprahamian proposes that for every 1-hour delay in time to theater, there is a 5.5% increase in LOS for those undergoing primary closure. Within this study, no correlation was demonstrated between TFM and TFF, duration on PN or LOS in the group as a whole or in the group achieving primary closure. Furthermore, the TFF and LOS are comparable in those undergoing primary closure in Aprahamian’s group (19 and 22.5 days) and within this series (17 and 21 days).