Sutureless gastroschisis tied to significant benefits but higher hernia risk

Last Updated: 2018-09-28

By Marilynn Larkin

NEW YORK (Reuters Health) - Compared to sutured closure, sutureless gastroschisis is associated with a significant reduction in pain medication requirements and mechanical ventilation duration but may increase the risk of umbilical hernia, researchers say.

"The main conclusion from the (study) is the feasibility of sutureless repair for patients with gastroschisis and potential benefits, including eliminating the need for general anesthesia and intubation, and decreased use of narcotics, which may allow this technique to be utilized at hospitals or communities with limited resources," Dr. Lan Vu of the University of California, San Francisco told Reuters Health.

"However," she said by email, "those benefits need to balanced with potential increased risk of umbilical hernia, which fortunately can be repaired at a later age."

Dr. Vu and her colleagues studied 90 consecutive infants (mean age 2.8 days; 48% girls) who underwent gastroschisis repair at their center from 2007 through 2017. Fifty-six percent underwent sutured closure and 44%, sutureless closure.

As reported online September 19 in JAMA Surgery, no statistical differences were found between the sutured and sutureless groups in length of hospital stay (mean days, 43.9 vs. 36.7), time to full enteral feeds (mean days, 31.4 vs. 27.9), total parenteral nutrition duration (mean days, 33.5 vs. 27.4), wound infection rates (14 vs. 10), and readmission rates (five vs. seven).

Compared with the sutured group, the sutureless group had substantially fewer days receiving antibiotics (mean, 7.2 vs. 12.4), being intubated (mean, 2.8 vs. 6.8), and receiving intravenous analgesia (mean, 4.2 vs. 7.1). Further, fewer patients required silo reduction (25 vs. 48).

By contrast, five sutureless closures - but none with sutures - had umbilical hernias requiring surgical repair.

"Sutureless repair of gastroschisis appears to be associated with a statistically significant reduction in mechanical ventilation duration and pain medication requirements but may increase umbilical hernia risk," the authors conclude. "Multicenter randomized clinical trials are necessary to determine the true advantages of the sutureless approach."

"A multicenter clinical trial may help determine whether there are differences in feeding outcomes between the two techniques," Dr. Vu added. "However, given the fact that the type of repair does not necessarily change the degree of inflammation of the bowel from intrauterine exposure to amniotic fluid, a clinical trial may not be able to clearly answer that question."

Dr. Peter Midulla, Surgeon in Chief at Kravis Children's Hospital of Mount Sinai Medical Center in New York City, commented, "We agree with the principal conclusions of the authors. At (our) hospital, we have also converted to the sutureless technique over the past few years."

"The primary advantage is that the procedure can typically be performed at the bedside, avoiding general anesthesia altogether, whether performed in one step, or staged with a silo," Dr. Midulla told Reuters Health by email. "It avoids intubation and ventilation completely and avoids the risks of general anesthesia on neonatal brain development, which has recently come to light as a potential concern."

"For complicated gastroschisis with intestinal blockage, the benefits of sutureless repair may not be as significant, as the neonate will end up requiring surgery and anesthesia to repair the intestine," he noted. "But even in these cases, some are candidates for sutureless closure for the first stage of their repair, reducing the number of general anesthetics."

"As the authors demonstrated, we have also seen an increase in umbilical hernias, which are universal after sutureless repair," he added. "The vast majority of these hernias close spontaneously and the few which require repair can be done at school age, when we believe the risk of anesthesia is negligible."

"We support the use of sutureless closure whenever anatomically feasible and for all uncomplicated gastroschisis cases," Dr. Midulla concluded.

SOURCE: http://bit.ly/2xJ5mHN

JAMA Surg 2018.