[size=6]A term infant weighing 2.5kg is born with a giant omphalocele measuring 6cm in diameter and containing 65% of the total liver volume. Other than a small muscular ventricular septal defect, there are no other associated anomalies. The amnion is still intact, but the defect is too large to be closed primarily. After a case conference to discuss staged closure options, a decision is made to gradually reduce the herniated contents with a silo created from an adhesive, hydrocolloid dressing (e.g. DuodermTM). The main advantage of this technique is?

 

a Reduced risk of central line associated infections

 

b Reduced risk of amniotic membrane rupture

 

c Reduced time to definitive closure

 

d Reduced exposure to anesthesia[/size]

[size=6]A term infant weighing 2.5kg is born with a giant omphalocele measuring 6cm in diameter and containing 65% of the total liver volume. Other than a small muscular ventricular septal defect, there are no other associated anomalies. The amnion is still intact, but the defect is too large to be closed primarily. After a case conference to discuss staged closure options, a decision is made to gradually reduce the herniated contents with a silo created from an adhesive, hydrocolloid dressing (e.g. DuodermTM). The main advantage of this technique is?

 

a Reduced risk of central line associated infections

 

b Reduced risk of amniotic membrane rupture

 

c Reduced time to definitive closure

 

d Reduced exposure to anesthesia[/size]

C

C

correct answer

c Reduced time to definitive closure

 

The management challenge in giant omphalocele (GO) is the protection of the herniated contents by preventing amnion breakdown, and to encourage coverage of the defect. A staged repair is often required for GO and many different techniques have been described. These include non-operative escharization (i.e. “paint and wait”) of the amniotic membranes, as well as operative options such as skin flaps, biologic and synthetic mesh, dermal matrix coverage and even skin grafts. While non-operative techniques offer the advantage of preventing potential repeated anesthetic exposure associated with operative options, almost all of these techniques require several weeks, to months and even years, before definitive repair can be entertained.

 

In their seminal series of 41 infants with giant omphalocele between 1994 and 2019, Abello et al., described their long-term experience with this technique. Silo construction occurred at the bedside without anesthesia and utilized a widely available and relatively inexpensive hydrocolloid dressing that not only protected the fragile amnion but also helped with gradual omphalocele reduction due to the adhesive nature of the dressing. The authors felt the success of their technique related to the application of force vectors (Phase 1 vertical and phase 2 horizontal) which accelerated the normalization of the abdomino-visceral disproportion seen in these patients. In their study, definitive repair was achieved between 6-35 days, much faster than other techniques described in the literature. Moreover, this technique could also be employed in the context of a ruptured omphalocele in which the amniotic membrane was repaired with suture prior to silo application. The complications reported in this series included a silo infection rate of 7.5%, lower than reported with other techniques. The authors felt their elevated central line associated blood stream infections rate was not related to the technique but rather to the lack of care bundles in the NICU. The authors identified 4 patients (9.75%) who developed bleeding complications, 3 of whom developed a liver capsule hematoma during reduction but did not require transfusion. The other patient, who required transfusion, was referred from an outside institution, after disruption of the hepatic capsule.