Revisión de la Biliografía: Gastrosquisis
With Dr. Alberto Torres
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What the experts said
Prenatal surveillance permits detection of abrupt deterioration of the bowel or thickening of the intestinal wall, including perforation.
The debate exists between elective early delivery versus expectant management to find the equilibrium point between the benefit of early intervention versus leaving the baby in utero longer.
A silo can be placed with a ring that has some flexibility for fixation to mobilize the ring, and the bowel can be reduced step by step.
A sleeve-like silo with a ring can be used, and the intestines can be reduced gradually by compressing and reducing step by step.
A modification from Brazil (Bahia) involves a malleable silo that allows the intestine to be easily reduced and the cord to be closed.
In the first 24 hours postoperatively, patients who had primary closure had better outcomes and fewer complications compared to those who had silo placement.
When the intestine is very inflamed and the silo is reduced, there can be a report of atresia, practically congenital, or an inclusive capsule gastroschisis.
The most important thing is not to rush closure; the intestine needs time to accommodate and reduce edema, otherwise it harms the patient.
The patient can be managed without anesthesia; when placing the silo, it is done step by step, reducing tranquilly in the neonatal unit without taking the baby to the operating room.
A small amount of intramuscular ketamine can be given to permit better suturing and closure, but without general anesthesia, as the defect is small and the baby is relaxed.
The approach involves performing exploration and evaluation in the delivery room, with treatment beginning immediately rather than in the operating room.
The bowel should be handled very gently, constituting and standing, without forcing, and if something is not going well, do not apply force.
If the bowel does not reduce easily, wait a little time, irrigate with saline solution, compress the meconium, and try again.
Patients with complicated gastroschisis who required intubation were managed either immediately in the delivery room or in the neonatal unit.
What crosses the line is the dilated intestine; what crosses the line is the possibility of a different reduction in the intensive care unit.
Depending on the diameter of the ileum and how the silo is closed, if the defect is smaller (less than a centimeter), primary closure with a purse-string suture is preferred.
The umbilical cord can be used as part of the closure: wrap it around, tie it, and use a subcuticular suture, tying it to the cord to close without even needing anesthesia.
Isolation with saline completely covers and is part of the protocol for closure in the delivery room.
The skin-to-skin approach with the mother is preferred when possible.
Primary closure can be performed without complications such as necrosis or ischemia.
Closure can be performed without anesthesia in the neonatal unit when the baby is born without anesthesia in the delivery room.
In a particular paper, there was no benefit found in reduction for uncomplicated cases.
Closure can be performed without anesthesia using simple suturing.
A paper comparing size did not reach a conclusion when comparing outcomes.