Impact of Bowel Coverage and Resuscitation Protocol on Gastroschisis Mortality in Low-Income Countries: Experience and Lessons From Uganda

• Published in: Journal of pediatric surgery 2024-01, Vol.59 (1), p.151-157
• Main Authors: Nimanya, Stella A., Stephens, Caroline Q., Yap, Ava, Kisa, Phyllis, Kakembo, Nasser, Wesonga, Anne, Okello, Innocent, Naluyimbazi, Rovine, Mbwali, Fiona, Kayima, Peter, Ssewanyana, Yasin, Naik-Mathuria, Bindi, Ozgediz, Doruk, Sekabira, John
• Format: Article
• Language: English
• Subjects: Capacity building; Gastroschisis; Gastroschisis - surgery; Global surgery; Health disparities; Humans; Infant; Intestines; Retrospective Studies; Treatment Outcome; Uganda - epidemiology
• ISSN: 0022-3468; 1531-5037
• DOI: 10.1016/j.jpedsurg.2023.09.015

Gastroschisis causes near complete mortality in low-income countries (LICs). This study seeks to understand the impact of bedside bowel reduction and silo placement, and protocolized resuscitation on gastroschisis outcomes in LICs. We conducted a retrospective cohort study of gastroschisis patients at a tertiary referral center in Kampala, Uganda. Multiple approaches for bedside application of bowel coverage devices and delayed closure were used: sutured urine bags (2017–2018), improvised silos using wound protectors (2020–2021), and spring-loaded silos (2022). Total parental nutrition (TPN) was not available; however, with the use of improvised silos, a protocol was implemented to include protocolized resuscitation and early enteral feeding. Risk ratios (RR) for mortality were calculated in comparison to historic controls from 2014. 368 patients were included: 42 historic controls, 7 primary closures, 81 sutured urine bags, 133 improvised silos and 105 spring-loaded silos. No differences were found in sex (p = 0.31), days to presentation (p = 0.84), and distance traveled to the tertiary hospital (p = 0.16). Following the introduction of bowel coverage methods, the proportion of infants that survived to discharge increased from 2% to 16–29%. In comparison to historic controls, the risk of mortality significantly decreased: sutured urine bags 0.65 (95%CI: 0.52–0.80), improvised silo 0.76 (0.66–0.87), and spring-loaded silo 0.65 (0.56–0.76). Bedside application of bowel coverage and protocolization decreases the risk of death for infants with gastroschisis, even in the absence of TPN. Further efforts to expand supply of low-cost silos in LICs would significantly decrease the mortality associated with gastroschisis in this setting. Treatment Study. III (Retrospective Comparative Study).