5. Conclusions

nutrition, and days with ventilation support. On the other hand, primary closure may cause abdominal hypertension and abdominal compartment syndrome which then could lead to an ischemia and necrosis of the bowel, renal failure, respiratory distress, and sepsis [41]. Abdominal hypertension is defined as prolonged or repeated increase in intraperitoneal pressure above 12 mmHg [42]. In fact, when the bowels are reduced into the non-sufficiently developed abdominal cavity, the raise of intraperitoneal pressure leads to compression of the blood vessels causing mesenteric ischemia and bowel necrosis. This kind of ischemia occurs very fast because the bowels in gastroschisis have got, in most cases, primarily lower perfusion than the bowels of a healthy infant [43]. Besides, an increased intra-abdominal pressure reduces the blood flow in big veins leading to diminished heart preload which then causes lower cardiac output and global hypoperfusion. This has an influence on renal blood flow making the renal hypoperfusion, anuria, and renal failure. We identified two patients in our study who received primary fascial repair and had abdominal compartment syndrome (Figure 5). So, it is very important that surgeon considers many different parameters when making the decision regarding the way of treatment of various cases of gastroschisis. In case when the primary closure without risk of abdominal compartment syndrome is not possible, surgeon should perform stage closure using a silastic bag which use becomes routine in many healthcare centers around the world. The criterion which strictly indicates that the silastic bag treatment should be performed is the presence of antenatal type of gastroschisis. Regarding to the duration of the exposure of the eviscerated bowels to amniotic fluid and the degree of abdominal cavity development, Moore classified gastroschisis into antenatal and prenatal types [44]. In antenatal type, the abdominal wall defect appears in early pregnancy so the bowels are exposed to negative influence of the aminotic fluid for a long time. Postnatally, the bowels are covered with gelatinous matrix, with a lot of adhesions and shortened mesentery. This type is also characterized by non-sufficiently developed abdominal cavity and the fascial defect which tends to become smaller and more tight during the intrauterine development. The closing of the fascial defect leads to an intrauterine bowel ischemia, which causes thickening of the intestinal wall, creating of the intestinal peel, stenosis, necrosis, and perforation. On the other hand, surgeon is not allowed to apply silastic bag if there is a possibility that tight fascial defect

242 Congenital Anomalies - From the Embryo to the Neonate

Figure 5. Massive necrosis of the bowel due to abdominal compartment syndrome.

The only factor that has been shown to predict poorer outcomes of gastroschisis is the presence of complex gastroschisis. Therefore, the strategy of surgical treatment should be focused on the management of gastroschisis-associated conditions such as perforation, necrosis, stenosis, atresia, and short bowel syndrome. Our experience confirms the safety of an early restoration of bowel continuity and primary fascial closure. We found that much better outcome is associated with this way of treatment. More researches should be focused on finding of complex gastroschisis predictors, improvement of prenatal diagnosis, and postnatal management.

Current available evidence suggests that antenatal bowel dilatation is not associated with increased risk of adverse perinatal outcome in infants with gastroschisis. Also, the absence of bowel dilatation cannot fully exclude complex patients. However, a randomized controlled trial is urgently needed.
