Primary fascial closure versus staged closure with silo in patients with gastroschisis: a meta-analysis

Abstract

Background/purpose: Gastroschisis is the most common congenital abdominal wall defect. Despite advances in the surgical closure of gastroschisis, consensus is lacking as to which method results in the best patient outcomes. The purpose of this meta-analysis was to compare short-term outcomes associated with primary fascial closure and staged repair with a silo in patients with gastroschisis.

Methods: We reviewed Medline citations, as well as the Cochrane Database of Systematic Reviews, between January 1, 1996 and June 1, 2012. Articles were identified using the search term "gastroschisis" and [("treatment outcome" or "prognosis") or randomized controlled trials]. Case reports, reviews, letters, abstracts only, non-English abstracts, and studies that did not address at least one of the outcomes of interest were excluded from the meta-analysis. Two independent reviewers identified relevant articles for final inclusion. A standard data collection form created by the authors was used to extract study information, including study design, patient characteristics, and reported patient outcomes. The data were analyzed using standard meta-analytic techniques.

Results: Twenty studies were included in the meta-analysis. In the five studies that selected closure method randomly or as a temporal shift in practice, silo was associated with better outcomes, with a significant reduction in ventilator days (p<0.0001), time to first feed (p=0.04), and infection rates (p=0.03). When all studies were included, primary closure was associated with improved outcomes.

Conclusions: Silo closure is associated with better clinical outcomes in the studies with the least selection bias. Larger prospective studies are needed to definitively determine the best closure technique.

Figure 1

Details of included and excluded studies.

Figure 2

Forest plots for continuous variables. (A) Mean differences for studies with random or temporal allocation of patients to study group. (B) Mean differences for studies using surgeon preference to assign patients to study group. (C) Mean differences for studies in which silo closure was only used after failure of primary closure. Mean differences falling to the left of the line favor silo closure; those falling to the right of the line favor primary fascial closure.

Figure 3

Forest plots for dichotomous variables. (A) Odds ratios for studies with random or temporal allocation of patients to study group. (B) Odds ratios for studies using surgeon preference to assign patients to study group. (C) Odds ratios for studies in which silo closure was only used after failure of primary closure. Odds ratios falling to the left of the line favor silo closure; those falling to the right of the line favor primary fascial closure.