#A.M.M.B.A.  Olavarr?a, and * La Esperanza Clinic, Buenos Aires, Argentina

This 15-year-old G₁P₀  had an ultrasound at 23 weeks. The male fetus has a right-sided gastroschisis. No other anomalies were identified.

Reexamination at 28 weeks revealed no changes. The abdominal perimeter was 199 mm. (equivalent to the size of a 24-25 week fetus). Only bowel were herniated and again no other anomalies could be detected.

A third examination at 38 weeks (35-36 weeks by biometry) demonstrated a dilated loop.

The mother was referred to a tertiary care center, where the baby (2400 g) was delivered at 4 days later by C section (Apgar 9). Dr. Daniel Doudtchitzky  (pediatric surgeon) found an adhesion that restricted the loop.

The adhesion was resected and after a delay of 6 hours, to verify the reduction of the edema, all the bowel were  replaced inside the abdomen (first by sliding the jejunal loop and progressing to the descendent colon. This was possible without anesthesia. (Bianchi technique, see abstract below)

The newborn a week after the procedure.

The baby 3 months later:

Elective delayed reduction and no anesthesia: "minimal intervention management" for gastrochisis.

Bianchi A, Dickson AP.

Neonatal Surgical Unit, St Mary"s Hospital, Manchester, England.

PURPOSE: In a pilot study of 14 children, born when the authors were on a 1:5 "on take" for neonatal referrals, a policy evolved of elective delayed midgut reduction without anaesthesia or sedation in the incubator on the neonatal surgical unit. There was no other form of selection, and it was fortunate that the authors did not encountered any adverse criteria in this small series. METHODS: Bowel reduction, which was pain free, was undertaken conventionally with the same attention and with no greater difficulty than under general anesthesia. Delaying midgut reduction for more than 4 hours led to more stable cardiovascular, respiratory, and renal parameters. Moderate lower limb congestion cleared rapidly. RESULTS: At the end of the procedure, all children were conscious, and 12 were alert and indistinguishable from normal babies. A mild periumbilical infection developed in two patients. Eleven of the 12 surviving children established enteral nutrition within 11 to 32 days, eight within 18 days. Another child with ileal atresia and bowel dilatation required bowel tailoring and lengthening (LILT) to allow enteral nutrition. All are physically and developmentally normal, and none has required umbilical herniorrhaphy or umbilicoplasty. All except one have a "scarless" abdomen and an aesthetically normal umbilicus. In marked comparison, two children immediately and obviously were unwell with abdominal pain, tachycardia, and metabolic acidosis. Abdominal wall cellulitis rapidly developed in both. At laparotomy one had a midgut volvulus and died at 22 months of short bowel syndrome (SBS) and the other with a perforated segmental ileal atresia died at 7 months of Enterobacter cloacae septicaemia. CONCLUSIONS: Our small study suggests that delayed midgut reduction without anaesthesia appears safe, carrying no additional morbidity or mortality. It helps avoid anaesthesia, muscle relaxants, and ventilation and has obvious resource benefits. The conscious child is a safety asset, and any postreduction deviation from a "normal, well-perfused, comfortable, and painfree" child is an indication for urgent laparotomy. This "minimal intervention management," when applicable, has become our preferred first option for children with gastroschisis. Further extension of this study will determine those not eligible for this technique and establish "exclusion criteria."