Immediate neonatal management
Prevent heat and fluid loss immediately.
Place the exposed bowel into a sterile transparent bowel bag or equivalent protective covering.
Do not tightly wrap the bowel with dry gauze.
Keep the infant warm.
Insert an orogastric tube and use continuous decompression.
Keep nil orally.
Establish IV access.
Gastroschisis causes substantial evaporative and third space losses. Provide isotonic fluid resuscitation guided by:
- Perfusion
- Heart rate
- Urine output
- Serum sodium
- Acid base status
Avoid both under resuscitation and massive unmonitored crystalloid loading.
Start perioperative broad antimicrobial coverage because the bowel is directly exposed to the environment.
A practical neonatal regimen can include:
Ampicillin 50 mg/kg IV every 8 to 12 hours, according to gestational and postnatal age
plus
Gentamicin 4 to 5 mg/kg IV, with interval adjusted for gestational age, renal function and local neonatal dosing protocol.
Discontinue prophylactic therapy after definitive closure when there is no established bowel infection or perforation.
Primary reduction and closure
Primary fascial closure is appropriate when the bowel can be returned without excessive intra abdominal pressure or physiological compromise. Contemporary evidence supports primary fascial closure when abdominal domain and haemodynamics permit.
Assess tolerance during reduction.
Stop if there is:
- Major increase in airway pressure
- Hypotension
- Reduced lower limb perfusion
- Severe venous congestion
- Markedly reduced urine output
Silo reduction
When immediate closure is too tight, place a spring loaded or constructed silo.
The silo:
- Protects bowel
- Allows oedema to decrease
- Uses gravity and gentle serial reduction
Gradually reduce the bowel over several days.
Proceed to fascial or sutureless closure once abdominal domain permits.
Do not force rapid reduction into a small abdomen.
Sutureless closure
In selected infants, the umbilical cord can be used to cover the defect after bowel reduction.
Sutureless closure is effective and can reduce the need for general anaesthesia in suitable infants.
A small residual umbilical hernia can remain and may close spontaneously or be repaired later.
Complex gastroschisis
If intestinal atresia is identified, management depends on:
- Bowel condition
- Degree of oedema
- Location of atresia
- Length of remaining bowel
Options include:
- Immediate resection and anastomosis in selected favourable bowel
- Delayed repair after oedema resolves
- Stoma where anastomosis is unsafe
Avoid sacrificing questionable but potentially viable bowel unnecessarily because short bowel syndrome can result.
Postoperative intestinal dysmotility
Prolonged ileus is expected.
Do not diagnose mechanical obstruction simply because feeding cannot begin immediately.
Continue:
- Gastric decompression
- Parenteral nutrition
until gastric aspirates decrease and bowel function returns.
Begin enteral feeds cautiously and advance according to tolerance.
Complications
Important complications include:
- Central line infection
- Cholestasis from prolonged parenteral nutrition
- Intestinal atresia
- Adhesive obstruction
- Short bowel syndrome
- Necrotising enterocolitis
- Abdominal compartment syndrome
- Ventral or umbilical hernia
Infants with simple gastroschisis generally have excellent long term survival when neonatal surgical and nutritional support are available.
