Variability in gastroschisis management: a survey of North American pediatric surgery training programs

Background: The optimal surgical management of gastroschisis has yet to be determined. We sought to define the practice patterns in the management of gastroschisis, and to ascertain the degree of variability among and within pediatric surgical training programs.

Materials and methods: An electronic survey was sent to all second-year residents in ACGME-accredited pediatric surgery programs in the United States and Canada. The questionnaire evaluated operative strategies, pain control, complications, and adherence to institutional protocols.

Results: Of the 38 pediatric surgical training programs, 27 second-year residents (71%) completed the survey. An institutional protocol was utilized in only one program, and 70% reported treatment variability among faculty. Attempted primary closure was the treatment of choice in 76% of centers, and routine silo placement at 24%. The location for routine silo placement was in the neonatal intensive care unit (77%), operating room (22%), and delivery room (1%). General anesthesia was used for all primary closures, while silos were placed using intravenous sedation at 36% of centers. The most frequent silo-related complication was dislodgement, reported by 80%. Other preformed silo complications included the inability to achieve primary fascial closure (27%) and intestinal injury (27%). When entering clinical practice, 74% of trainees stated that they would first attempt primary closure, while 22% favored routine placement of a preformed silo.

Conclusions: Protocol-driven care of infants with gastroschisis is rare in pediatric surgery training centers, leading to great variability in care between institutions, as well as among faculty within single programs. Data-driven protocols may improve care of infants with gastroschisis.