Gastroschisis and omphalocele are the most common abdominal wall defects. Gastroschisis is more frequent due to its sporadic origin and its association with environmental and maternal factors. Over the past 20 years, its incidence has significantly increased, reaching approximately 4 to 5 cases per 5,000 to 10,000 live births, according to various studies. In contrast, the incidence of omphalocele has remained stable, with a ratio of 1:4.5 compared to gastroschisis [1,2].

The incidence of gastroschisis is similar in both sexes. Various studies have identified potential risk factors, including motherhood in white women under the age of 20 and exposure to environments with high agricultural activity and chemical use. However, establishing a direct relationship between these factors, as well as the use of certain medications, has been challenging to prove [1,3].

Gastroschisis is described as a paraumbilical defect, generally on the right side, through which the small intestine, large intestine, and, in some cases, other structures such as the stomach, reproductive organs, or bladder protrude without any covering. In contrast, omphalocele is a midline defect covered by amnion, Wharton's jelly, and peritoneum, through which the intestines, stomach, and, in a significant percentage of patients (80%), the liver protrudes, which can make its surgical management more challenging [1-3].

Most abdominal wall defects can be detected through prenatal diagnosis by the end of the first trimester of pregnancy. However, in the second trimester, detection rates exceed 90% in both cases. Associated anomalies are less common in gastroschisis (15%) and are mostly gastrointestinal malformations, such as atresias, malrotation, and perforation [4]. In contrast, patients with omphalocele have associated malformations in 40-75% of cases. The most common include gastrointestinal anomalies (malrotation, anorectal malformation) [5-8], Cardiac anomalies (ventricular septal defects, Tetralogy of Fallot, dextrocardia), genitourinary anomalies (renal agenesis, polycystic kidneys), orofacial anomalies, and neural tube defects. Additionally, omphalocele may be associated with fetal aneuploidies, particularly trisomy 18 and trisomy 13. Therefore, the long-term prognosis is primarily determined by these associated malformations rather than the abdominal wall defect itself [9].

Regarding the optimal timing of birth, most contemporary studies have found that preterm delivery is the strongest predictor of adverse outcomes in cases of gastroschisis [10], especially when it occurs before 34 weeks [11]. Therefore, most authors suggest that scheduling a preterm birth to reduce the risk of fetal death or improve neonatal outcomes is not justified if fetal growth and fetal tests (BPP, NST) are normal. A systematic review by the Evidence-Based Practice Committee of the American Pediatric Surgical Association concluded that the optimal timing for delivery is after 37 weeks [12].

Regarding omphalocele, and in the absence of standard indications for preterm delivery, expectant management is a reasonable option until the spontaneous onset of labor or, ideally, until at least 39 weeks of gestation. Preterm birth does not provide benefits for affected newborns and, on the contrary, is associated with higher morbidity and mortality.

In a series of cases of isolated omphalocele diagnosed prenatally, the only neonatal deaths occurred due to complications related to prematurity. As in other pregnancies, the presence of non-reassuring fetal test results and/or cessation of fetal growth at term or near term are indications for ending the pregnancy, potentially justifying preterm delivery in these cases [13].

The management of these abdominal wall defects is surgical and should be performed by highly experienced surgeons, with primary closure being the ideal approach in both cases. Delayed closure with a silo is an option for very unstable patients, those with large defects, or low-birth-weight fetuses with limited abdominal domain, where compartment syndrome is an important risk. Therefore, after placing the silo, a gradual reduction of the contents should be performed until definitive closure is achieved within the first week after the initial correction to prevent complications such as fistulas, hypothermia, and dehydration.

In more complex cases, alternative strategies should be considered, such as secondary intention closure, the use of meshes or prosthetic materials, partial fascial closure with complete skin closure, and relaxation incisions [14,15].

Fetuses with abdominal wall defects should be managed in high-complexity neonatal centers to ensure comprehensive and multidisciplinary care. This approach helps achieve better outcomes by following well-defined protocols aimed at reducing morbidity and mortality [16].

Objective

This article aims to extend the sociodemographic analysis of neonates with abdominal wall defects born at a high-complexity institution in Medellín, Colombia, between 2020 and 2024. It seeks to evaluate changes in outcomes and primary closure rates following the implementation of stricter management protocols. This study serves as a follow-up to the previously published research [17].

This study is a descriptive observational analysis of neonates with abdominal wall defects (gastroschisis and omphalocele) born at Clínica Universitaria Bolivariana in Medellín, Colombia, between 2020 and 2024. Data were collected from medical records, considering variables such as gestational age, birth weight, type of defect, sex, associated malformations, time from birth to intubation, time to surgical intervention, likelihood of primary closure, complications, time to enteral feeding restoration, and mortality.

Eligibility Criteria

Medical records of mothers and neonates diagnosed with omphalocele or gastroschisis treated at the institution between 2020 and 2024 were reviewed and included. Neonates who died before surgical intervention and records with incomplete or inadequately documented data were excluded from the study.

Data Analysis

A database was created in Excel for the systematization and collection of variables. The analysis was conducted using SPSS software, version 25, applying statistical methods based on the category and measurement level of each variable. Absolute and relative frequencies were calculated for categorical variables, while continuous variables without normal distribution were analyzed using medians and interquartile ranges. The Chi-square and Fisher's exact tests were used to assess the association between variables and primary closure.

A total of 35 medical records of neonates with abdominal wall defects were collected during the defined period. However, two records were excluded for not meeting the inclusion criteria, leaving a total of 33 cases for analysis (Figure 1).

Figure 1: Patient flowchart.

Clinical And Sociodemographic Aspects

Among the analyzed population, 60.6% were female and 30.3% were male. Regarding the distribution of abdominal wall defects, 27 patients (81.8%) were diagnosed with gastroschisis, while 6 patients (18.18%) had omphalocele (Figure 2).

Figure 2: Distribution of abdominal wall defects in the study.

Among the patients, 60.6% were preterm newborns, with a mean gestational age at birth of 35+6 weeks. The patient with the lowest gestational age was born at 27+2 weeks. Additionally, 13 patients (39.3%) were classified as small for gestational age, all of whom belonged to the gastroschisis group.

A total of 39.3% of the studied population had associated malformations, which were more prevalent in the omphalocele group (5 out of 6 patients). These included hydronephrosis, severe pulmonary hypertension, ventricular dysfunction, right ventricular hypertrophy, hypoplastic thorax, and hemivertebra. In contrast, only 6 patients out of 27 with gastroschisis had associated malformations, including right ventricular dilation and hypertrophy, severe pulmonary hypertension, and intestinal atresia in 3 cases, the latter making up 50% of the associated malformations in this group.

As part of the institution’s updated management protocols in recent years, early intubation (defined as intubation within the first 3 hours after birth) was successfully implemented in 66.6% (N=18) of patients in the gastroschisis group, resulting in favorable outcomes.

Regarding patient progression, the omphalocele group achieved a much faster return to enteral feeding, with an average of 13.4 days, compared to gastroschisis patients, who experienced a high incidence of postoperative ileus and had an average enteral feeding restoration time of 35 days. This delay may be attributed to multiple factors, including bowel inflammation and edema, surgical handling of the intestines, and the frequent use of opioid analgesics postoperatively.

Complications were observed in 18 patients (54%), as detailed in Figure 3.

Figure 3: Distribution of complications in the study.

In our population, 9 cases of mortality (27.7%) were recorded, with 66.6% occurring within the first 72 hours of life and 33.4% at a later stage. Upon analyzing the causes of death, it was found that in three patients, a decision was made to redirect therapeutic efforts due to extensive necrosis and perforation deemed incompatible with life, identified during the surgical procedure. One of these cases involved the patient born at 27+2 weeks of gestation.

Another death occurred in a patient with a giant omphalocele who developed a ruptured subcapsular hematoma with severe bleeding during cesarean section delivery, leading to secondary hypovolemic shock. Additionally, one patient died due to a misdiagnosis of bladder exstrophy, which was not detected prenatally, resulting in inadequate management and multiple subsequent complications

The remaining four patients died due to sepsis, cardiogenic shock, severe electrolyte imbalance, and endocarditis.

Below, Table 1 presents a comparison of patients with primary vs. Delayed closure, along with associated demographic and clinical variables.

Table 1: Primary Closure.

IUGR: Intrautering growth restriction, Early intubation: Less than 3hours after delivery.

The data analysis revealed a higher proportion of primary closure in male patients (80%). Additionally, no direct relationship was found between prematurity, low birth weight, or intrauterine growth restriction (IUGR) and the inability to achieve primary closure.

Among all gastroschisis cases in this study, primary closure was achieved in 89.4% of patients. Notably, in a previous study conducted at our institution on abdominal wall defects, before the implementation of current management protocols, primary closure was achieved in only 44% of cases.

Chi-square and Fisher’s exact tests were used to assess the association between variables and primary closure (Table 2).

Table 2: Statistical analysis.

IUGR: Intrauterine growth restriction, Early intubation: Less tan 3 hours after delivery.

The analysis did not find a statistically significant association between primary closure and the examined variables, likely due to the limited number of patients included in the study. However, when comparing our results with data from previous years at our institution, specifically regarding gastroschisis, the rate of primary closure was significantly higher in this study (89.4%) compared to the previous study (44%).

This improvement may be attributed to the implementation of standardized management protocols at the institution, with the most critical factors being early intubation and timely surgical intervention (ideally within the first 6 to 8 hours of life). In this study, the average time from birth to surgical intervention for gastroschisis patients was 4.2 hours, compared to 18 hours in previous years when continuous pediatric surgical availability was not ensured.

In the literature, gastroschisis is described as the most common abdominal wall defect, which aligns with our findings, where gastroschisis accounted for 81.8% of cases. Among these, 74% were preterm newborns, a percentage significantly higher than international reports, which indicate an association between gastroschisis and preterm birth at approximately 53% [18].

In the omphalocele group, none of the patients were preterm or had low birth weight, a finding consistent with reports from other authors as well as our previous study [17,19,20].

Success rates for primary closure in gastroschisis have been reported as high as 80% in some studies. In our study, conducted over the past four years, we found a similar success rate of 89.4%. However, when compared to our previous data, there was a significant improvement, as the earlier study reported a success rate of only 44% [17]. This increase is likely associated with the implementation of stricter management protocols, including early intubation (<3 hours after birth) and timely surgery (within 6-8 hours postnatally). Additionally, in recent years, early intubation was successfully implemented in 66.6% of patients, and the average time from birth to surgical intervention was reduced to 4.2 hours [21].

In our previous publication, prematurity and low birth weight had a negative impact on primary closure. However, in the current study, these variables did not show an association with primary closure, as 69.2% of low-birth-weight patients and 70% of preterm patients successfully underwent primary closure. Additionally, IUGR was included as an additional variable, which also did not show a direct impact on this outcome. This difference may be explained by improvements in the initial management standards for these patients [17].

The complication rate in our population was 54%, which is lower than the 76.4% complication rate reported by other reference centers in Medellín. When comparing the types of complications, we found that in our study, the most prevalent were respiratory complications (atelectasis and pleural effusion) at 29.1%, followed by cardiogenic shock at 19.4%, and infectious complications (bacteremia and endocarditis) at 12.9%. In contrast, other studies reported sepsis as the most common complication (43.3%), followed by ileus (25.9%) and surgical site infections (SSI) at 13%. It is worth noting that no cases of SSI were observed in our population [22,23]. (See Figure 3).

At last, when comparing the mortality rate reported in other studies, such as that of Mendez and Martinez et al., which was 26%, we found a similar rate in our study, with a mortality rate of 27% [24]. However, there was an increase in mortality compared to our previous study, where the rate was only 10% [17]. This difference may be attributed to the smaller sample size and the greater complexity of recent cases, where three patients had extensive necrosis and perforation at birth, making a fatal outcome highly likely and leading to a decision to redirect therapeutic efforts. Additionally, one patient had an undiagnosed prenatal gastroschisis, which resulted in an inadequate postnatal approach and a misdiagnosis of bladder exstrophy, leading to delays in management, complications, and subsequent death.

Due to the low incidence of these conditions, despite having medical records from a reference center, we collected a limited patient sample, which did not allow us to achieve the initially proposed analytical scope. However, this study enabled us to make specific comparisons with our previous data and draw new conclusions that contribute to the development of knowledge.

Gastroschisis and omphalocele are the most common abdominal defects encountered by pediatric surgeons and should be managed in high-complexity centers with a multidisciplinary perinatal approach. Surgical management presents a significant challenge, with the ideal goal being primary closure during the first intervention. However, this is not always achievable.

Although our study did not find a statistically significant relationship between the various variables and the likelihood of primary closure, we observed that, following the implementation of more standardized management protocols at our institution, the primary closure success rate increased (89.4% vs. 44%). This improvement coincided with the introduction of early intubation and surgical intervention within the first 6 to 8 hours in gastroschisis patients. Further studies are needed to clarify this association.

The authors declare no conflicts of interest.

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