Gastroschisis and sutureless abdominal wall closure

Hey there listeners, if you haven't already, download the Stay Current in Pediatric Surgery app. There's a new version of it out now. Way more intuitive interface, a lot of interesting content. I think you guys are going to love it. But until then, enjoy the podcast. A change in surgical practice. It happens all the time, but it takes years, sometimes decades of research. Articles come out for or against something that seems pretty novel. And even when the literature feels really definitive, it could still take a lot of time for practicing surgeons to accept this change and start using it. I want to talk about one of these changes because it's happening right in front of our eyes. It all started in 2004, which feels like a lifetime ago, especially after 2020. But just to refresh everyone's memory, 2004 was the year that NASA landed a couple of rovers on Mars, let them drive around. It's the year that the Boston Red Sox broke their curse and won a World Series for the first time since 1918. It's the year Justin Timberlake and Janet Jackson had a wardrobe malfunction at the Super Bowl. But it's also the year that Tony Sandler wrote a really interesting article. I'm Rod Gerardo from Cincinnati Children's. Let's talk about gastroschisis and abdominal wall closure. In 2004, Tony Sandler published the first manuscript about suture disclosures to utilize the natural umbilical properties to closing that defect by itself. That was Dr. Jason Fraser. He is an associate professor of pediatric surgery at Children's Mercy Hospital in Kansas City. He's the program director for their pediatric surgery fellowship. And he's also a member of the Midwest Pediatric Surgery Consortium. He was talking about an article in 2004 from Tony Sandler. Well, you know who was training with Tony Sandler around that time? You guessed it. It was Todd Ponsky. I didn't know about his article. I found out about it as a fellow when he taught us how to treat gastroschisis that way. So out in D.C., Dr. Sandler is showing his trainees like Todd, hey, this hole in the abdominal wall that we've always put stitches in and you've been taught to put stitches in. Guess what? You don't have to do that. I think it's clearly been a massive change in practice. It's one of the examples of a big change that we don't actually operate on those and they can be done at the bedside. And it also is an example of something that took a while to adopt. And now most people are doing it, I think. I was explaining something to Todd and he kind of made a face at me. I made a face because the big question is this, Rod. There have been so many articles in the last few years that go back and forth. I mean, one said gastro suture list is better. One said definitely don't do suture list. So my question is now, I don't know. I almost don't read these articles anymore. So there's this back and forth and some pediatric surgeons are getting a little exhausted by it. But that takes us to the Midwest Pediatric Surgery Consortium and Dr. Fraser. Yeah, thanks, Rod. You know, I think this was a couple of years in evolution to get to the place where we finally were able to do the study. But the initial goal of this, we sought out to do a prospective randomized trial comparing suture list closure versus suture closure. And the process of working through that, it became more and more obvious that the prevalence of suture list closure at our member institutions was skyrocketing. And so it would have been very hard to kind of make that step backwards to do suture versus suture list. So they wanted to do a randomized control trial and couldn't because suture list closure was just so popular at Kansas City. That's when they pushed it over to the Midwest Pediatric Surgery Consortium. Once that became obvious, then it really became, OK, we need to just look at what we're doing as member institutions and then report that just because of our very large experience. If you haven't had a chance to yet, you're going to want to check this article out. It's titled Suture list versus sutured abdominal wall closure for gastroschisis, operative characteristics and early outcomes from the Midwest Pediatric Surgery Consortium. It was published in Journal of Pediatric Surgery. And if you're reading along or you haven't read it yet, I highly recommend checking this out. Now, when it was first published, Todd and I actually talked about it. And this was his hot take. I think anytime it's a Kansas City or an NWSPC, NWPSC. He got there eventually. Anytime it's an NWPSC article, I pay attention. Anytime it's a Kansas City article, I pay attention. But other than that, I'm tired of seeing all these gastroschisis articles. I'm waiting for someone to give me something that is really meaningful. Just to quickly summarize this article, for those of you who haven't read it yet, this is a retrospective cohort of infants born with gastroschisis between 2013 and 2016. They divided these kiddos up into two groups, sutured versus sutureless abdominal wall closures and found subsequently that they had to do a subgroup analysis because some babies got silos, some of them didn't. Ended up with a total of 315 patients and looking at various data points. What they ended up finding was that the kiddos who underwent a sutureless abdominal wall closure had no difference in their days on TPN or their time to goal feeds, time to initial feeds, or their length of stay. The sutureless kids actually had less antibiotic use. They had less surgical site and deep space infections. They had fewer episodes of general anesthetics. They had less ventilator use. So the thought being that there are all of these potentially positive outcomes for those who underwent a sutureless repair, and that was even considering those kids who necessitated silo use. So was this what the Kansas City team was expecting? I think it was probably what we were expecting, I think, for a couple of reasons. One, due to the heterogeneity of this disease, you know, especially with gastroschisis, a lot of the patients that were able to undergo, you know, especially a primary repair, they probably had more favorable bowel. And then those patients, you know, theoretically would have less hospital stay and theoretically feed faster and things like that. Also, too, a lot of the patients that were done with a sutureless repair, you know, probably were done in the more recent cohorts. Not always. But so some of those tended towards less interventions. Okay, that's fair. But how do you explain this difference in antibiotics? Moreover, too, if you think about just the way that we close a sutured repair, you mobilize flaps from the skin and flaps from the fascia. So there's always, you know, redness around the incision, bruising around the incision. And so, you know, even that tissue manipulation is going to put you at higher risk for a potential infection or calling it erythema infection. And so the finding of antibiotics needed after that was expected as well. As Todd alluded to previously, the pendulum kind of swings back and forth when it comes to sutureless closure for gastroschisis. So how is this going to push the pendulum further one way or another? And what are the next steps here? Yeah, that's a great question because you mean reporting your findings is one thing, but then actually changing practice and then looking back at what you're doing to make sure it's safe in the short and long term. Not only across one institution, but across multi-institutions is a really important thing. So first of all, the next phase of this study is looking at these exact patients over several years and follow up to find out how they're growing. And then also to find out what their umbilical hernia repair rate is, because it's not insignificant in the initial studies through several small studies that show that some of these sutureless patients had a high umbilical hernia repair rate, or at least a high umbilical hernia rate. And so that's this first, that's the next step of this study is where we've just completed that data and we'll be analyzing it soon and hopefully reporting it soon as well. Um, showing uh, what that actual long-term outcome of these patients is. Uh, secondarily the, the next, uh, next big leap is going to be operationalizing uh, protocolization of this, um, of this, uh, actual study in that, uh, across, you know, member institutions. Hopefully then going ahead, uh, with a, you know, more prospective, uh, study to get, uh, better, more, um, recent data and then following those patients for long-term. And so we're working, uh, within our consortium as well as some other partnerships, uh, to kind of operationalize, uh, how that might look, uh, in the future. So is this that golden ticket definitive article that Todd was looking for? I don't think so, but I think this article holds a very important place in not only the story of gastroschisis that isn't over, but the story of surgical dogma. It also shows the things that we take as dogma, the things that, you know, that we learn you have to do it this way and it only can be done this way. Um, it all, you know, those things are not always true. Uh, and those things, you know, it's good to question norms and it's good to question, um, why we do things. And especially, you know, for up and coming learners to ask those questions when you're on rounds and when you're seeing patients in the operating room is, hey, why do you do it this way? And that's the part that resonated with me. In fact, here's Todd's closing thought. Yeah, I think in general, I, I, you're right. I don't know how the pendulum is going to swing, but we are finding more and more. There are things that we don't have to operate on. So there you have it in abdominal wall defect that used to necessitate a trip to the OR that is now more like a safe bedside procedure. What do you guys do? What are your thoughts? We want to hear them. Um, download the app, stay current in pediatric surgery and leave a comment or start a discussion or leave this topic entirely to check out some guidelines, technique, videos, articles. You can do all of that in our app. So I'm Rod Gerardo from Cincinnati Children's. Thank you for listening. And remember, knowledge should be free. Thank you.