Management of Omphalocele: From Conception to Closure
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Management of Omphalocele:
From Conception to ClosureTerry L. Buchmiller, MD
Brian Labow, MD
February 13, 2013Department of Pediatric SurgeryDepartment of Plastic SurgeryAdvanced Fetal Care CenterBoston Children’s Hospital
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Conflict of Interest Disclosure
We have no financial relationships with a commercial entity producing healthcare-related products and/or services.
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Omphalocele Definition– Central abdominal wall defect– Herniation of abd contents into umbilicus– Covered by membrane/ large peritoneal sac
• Not covered by skin • Composed of fused peritoneum and
amniotic membrane• Delicate avascular wall, 1 mm thick• Occasionally intervening compartment
containing Wharton’s jelly– Umbilical cord typically inserts slightly inferior
on sac
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Embryology of Abdominal Cavity
• Celomic cavity undergoes forward expansion into umbilical cord between wk 6-10 of fetal life
• Two lateral folds form pleuroperitoneal canals; destined to fuse with cranial and caudal folds
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Embryology• Omphalocele results from
defect in migration of lateral folds very early in embryogenesis ~wk 3– Always occur at umbilicus– Rectus muscles insert
more laterally on costal margins
– Due to early event, often accompanied by other defects
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History of Omphalocele
• Described in 16th Century by Ambrose Pare in printed works
• 1802: Hey reported first successful repair
• 1887: Olshausen described skin flap coverage after removal of membrane
• 1899: Alfield described painting sac with alcohol to produce eschar, awaiting contraction and epithelialization
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History of Omphalocele
• 1953: Max Grob reported use of mercurachrome with toxic effects later described
• 1967: Schuster introduced staged reduction using prosthetic mesh as he noted abdominal cavity did not enlarge with skin flap coverage alone
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History of Omphalocele
2013: Currently no closure technique universally accepted with ingenious methods still reported
– Tissue expanders– VAC dressing– Skin grafting– Alloderm
– Partial hepatectomy– Lateral relaxing
incisions – Division of rectus
muscles– Pneumoperitoneum
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• Chief of Surgery from 1947-1968
• “The Surgery of Infancy and Childhood” • Published in 1953• Exactly 1,000
pages• “The green bible”
History of Omphalocele at BCH
Dr. Robert E. Gross
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History of Omphalocele at BCH
• Abdominal organs “directly exposed to view as if exhibited in a showcase’
• “Considerable judgment must be exercised in determining how perfect of a repair should be attempted” Dr. Robert E. Gross
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Current Demographics
– Occurs in 1 in 3,000 fetuses– 1 in 5,000 live births• Slight male predominence• No racial predilection• Risk of preterm birth 25-65%• IUGR in 6-35%
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Etiology• Several animal teratogenic models, but
none truly recapitulate omphalocele• Very rare familial occurrence, even more
rare in twins• No specific gene or environmental cause• Potential assoc with EtOH in 1st trimester;
heavy smokers (Natl Birth Defects Study)• Can occur as part of syndromes
Remains unknown
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Associated Conditions•Cardiac ~ 45%•Chromosomal defects (T18, 21) in 30-40%•Intestinal malrotation in 28%•Cryptorchidism•Increased incidence of inguinal hernias;
Meckel’s diverticulum•Pulmonary hypoplasia•Musculoskeletal/ neural tube defects rare
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Associated Syndromes
• Beckwith-Wiedemann• Donnai-Barrow• Gershoni-Baruch• Fryns’• OIES• Pentology of Cantrell
Strongly consider prenatal genetics evaluation
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Beckwith-Wiedemann Syndrome
• Macroglossia• Gigantism• Visceromegaly• Pancreatic islet cell
hyperplasia leading to hypoglycemia
• Predisposition to abdominal tumors
• Occurs in 1: 13,700
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Genetic Testing for BWS• ~85% cases are sporadic• ~15 % inherited with 50% recurrence risk• Dx by analysis of chromosome 11p15 by methylation-
specific PCR to detect methylation errors, abnormal copy number
• If negative, sequencing of CDKN1C recommended• 1-3 wk turnaround for prenatal dx on amniocytes only
• Children with features consistent with BWS, but with negative genetic test results should receive the same medical management as those with a confirmed genetic diagnosis
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Beckwith-Wiedemann Syndrome
• Tumor Screening– 10% develop
malignancy– Wilms in 5-7%
• Most prior to age 4• US screen q 3 mo• By age 8, 95% occur
– Hepatoblastoma• AFP q 6 wk until age 4• US as above
– Adrenocorticalwww.beckwith-wiedemannsyndrome.org
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Donnai-Barrow
– Omphalocele– CDH• Absent corpus
callosum– Hypertelorism– Myopia– Sensorineural deafness– Likely autosomal
recessive; LRP2 gene
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Fryns’ Syndrome
– CDH– Coarse facies– Acral
hypoplasia– Often
omphalocele– Limited survival
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OEIS
• Caudal Fold Defect– Infraumbilical Omphalocele (usually
not containing liver)– Cloacal Exstrophy (with ileal prolapse)– Epispadias– Diastasis of pubic rami– Imperforate anus– Spinal anomalies
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Limb Body Wall Complex(Body Stalk Anomaly)
• Severe multiple congenital anomalies
• ~ 250 cases reported• Etiology remains unknown• Incompatible with survival
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Limb Body Wall Complex(Body Stalk Anomaly)
– Encephalocele– Thoraco- and/or
abdominoschisis – Limb defects – +/- Facial clefts– Short umbilical cord– Severe spinal curvature– Fetus appears “stuck”
to placenta
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Pentology of Cantrell
• “Cephalic Fold Omphalocele”– Supraumbilical abdominal wall defect
typically containing liver– Heart or ventricular diverticulum in
sac through pericardial defect– Central diaphragmatic tendon defect– Lower sternal cleft– Intracardiac anomaly
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Prenatal Assessment of Omphalocele
• Elevated AFP (serum/AF); AChE (AF)• US• MRI• ECHO• Amniocentesis / CVS
– Abnormal karyotype in 30%– More common in those with small
defects
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US Screening
• Increasing dx in 1st trimester due to nuchal translucency screening between 11-14 wks
• If seen very early in 1st trimester, repeat US in 7-10 d to assure not “physiologic”
• Stability of defect anticipated• Study of choice in prenatal
period to assess fetal growth, AF, delivery planning
13 wk US
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MRI
• Preferred at >16 wk gestation• Initial MRI exam useful in detecting
underlying syndromes• Not typically repeated unless
concern for clinical change
Estroff, Buchmiller, et al. J Radiol In press
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Giant Omphalocele MRI
Large omphalocele containing liver (L) and small bowel (SB)
Note umbilical cord (UC)inserting into inferior aspect the omphalocele
Assess hepatic vasculature? stretched
UC
L
SB
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MFM Perspective
• Kings College London• Referral Fetal Medicine Centre• Retrospective study from 1991-
2002• 445 pts• 3 cohorts formed based on
karyotype assessment, if obtained
Lakasing, Ciscero, Davenport, Patel, Nicolaides. JPS 2006
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MFM Perspective• Group A: Abnormal karyotype
– N=250 (56%)• Trisomy 18 most common in 63%• Trisomy 13 in 17%• Trisomy 21 in 4%• Turner’s syndrome in 6%• Triploidy in 5%• Rare chromosomal deletions in 5%• Additional structural anomalies in 73%
Lakasing, Ciscero, Davenport, Patel, Nicolaides. JPS 2006
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MFM Perspective
• Group A: Abnormal karyotype– 91% requested termination– 8% fetal demise– Only 2 live births (trisomy 18) with
comfort care, ultimate neonatal death
Lakasing, Ciscero, Davenport, Patel, Nicolaides. JPS 2006
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MFM Perspective
• Group B: Normal karyotype– N=135 (30%)– 54% had structural anomalies– 47% TOP (usually not isolated
anomaly)– 14% fetal demise– 31% live births– 8% lost to F/U
Lakasing, Ciscero, Davenport, Patel, Nicolaides. JPS 2006
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MFM Perspective
• Group C: Karyotype declined– N=60 (14%)– 63% structural anomalies– 55% TOP– 13 % fetal demise– 19% live births– 13% lost to F/U
Lakasing, Ciscero, Davenport, Patel, Nicolaides. JPS 2006
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MFM Perspective: Take home points
• Less than 10% of antenatal diagnosed pts came to operative repair– 55 live births– 11 died preoperatively (anencephaly,
major CHD)– 44 repaired, all survived
• Pts cared for by pediatric surgeon/ tertiary care providers are a very select group
Lakasing, Ciscero, Davenport, Patel, Nicolaides. JPS 2006
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Preparation for Delivery
• Coordinated delivery with MFM, NICU• Cognizant of travel plans should preterm
labor occur•Ave age of delivery 36.6 wks•Ave birthweight 2.9 kg
• Unclear need for C section unless defect >5 cm
• Delivery at tertiary care center essential (if not opting for comfort care)
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Delivery Room Management
• Surgical presence at delivery optimal– Observe C section– ABC’s– Is sac intact?– Place NGT– Stabilize liver in extreme cases (Kerlix
roll)– Provide moist coverage of membrane– Enable family celebration of birth
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Initial NICU Management
• Maintain temperature• Respiratory support• PE to rule out associated (midline) anomalies
– Trisomy 13, 18, 21– Beckwith-Wiedemann – Rectal exam R/O imperforate anus/ evacuate
meconium
• Protect sac with xeroform/ moist gauze, especially under warming lights.....
• No urgency for repair unless sac ruptured
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Ruptured Giant Omphalocele
Majority born prematurely
Typically fatal due to respiratory failure; sepsis
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Subsequent Management• Assess size of defect
– Small, medium, large, giant– Is the hepatic vasculature at risk?
• Reassess potential for associated conditions, even if “cleared” during fetal period– Prematurity may alter surgical closure plan– Cardiac disease– Urgent genetics consult if life threatening
association suspected
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Postnatal ECHO
• Still repeated even if prenatal study nl• Most common defect VSD• ECHO windows often compromised by
inability to visualize in substernal area
• May need surgical presence to facilitate performance of study and protect sac
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Role of Newborn US• Abd US if ? about
hepatic blood flow in giant defect
• Surgical presence paramount for effective study
• Assess in decubitus positions
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Essential ManagementDOL 1
• Continue ABC’s• Protect membrane• Assist bedside providers in
understanding positioning concerns• PICC
Operative Planning
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Historic Notes on Omphalocele Repair
• Gross noted postoperative condition after repair could be quite precarious; whenever a large portion of liver contained a grave outlook was expected
• Essential to devise a method to avoid intra-abdominal crowding of organs at first operation– Diaphragm displaced upward causing respiratory
disturbance, cyanosis, death– Pressure on IVC impedes return of blood leading
to circulatory collapse– Pressure on stomach/intestine leads to partial /
temporary obstruction (pre-PN)
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When Considering Operative Repair
“Primum non nocere”
Avoid abdominal compartment
syndrome at all costs
...........And provide a cosmetic umbilicus
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Methods to Assess Potential Abdominal Compartment
Syndrome• Saphenous vein IV that will not drip
with gravity• Bladder pressure via foley or NG
pressure > 20 mmHg
•PE•Clinical judgment
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Adjunctive Points to Consider During Closure
• Most do not recommend a Ladd procedure or appendectomy
• If testicle intraabdominal, place near ring; in most cases scrotal descent will occur by age one year; NO orchidopexy
• Consider gastrostomy if significant cardiopulmonary compromise
• Be gentle on liver; do not kink HV, PV, or rupture capsule....Budd Chiari reported
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Omphalocele Closure Options
• Primary closure• Immediate staged closure with mesh
prosthesis for serial reduction• Delayed closure
– Operative skin closure, period of waiting, later definitive closure with repair large ventral hernia
– “Paint and Wait”
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Can Fetal MRI Predict Closure?
• N=9 (Mixed GS and omphalocele)• MRI volumetry performed; manual 3D tracing• Calculated Exteriorized Ratio= Exteriorized Viscera/Volume Abdominal Cavity• ER 1.39 in staged closure, ER 0.33 in closure• Quantifies clinical judgment • Very limited study, but increasing interest
Takada, Hamada, Kamiyama. JPS 2006
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Omphalocele Closure Options
• Primary closure• Immediate staged closure with mesh
prosthesis for serial reduction• Delayed closure
– Operative skin closure, period of waiting, later definitive closure with repair large ventral hernia
– “Paint and Wait”
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Small Omphalocele
• Occasionally small irregular liver segment in sac
• If bowel, can reduce and tie with umbilical tape if associated disease
• Genetics consult as associated syndromes more common
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Schematic of Primary Closure Dr. Gross’
• Skin edges freed• Sac removed
– Leave on liver if difficult to peel off to avoid bleeding
• Viscera reduced• Peritoneum closed• Fascia closed
– Often difficult to oppose upper rectus
• Skin closed
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Omphalocele Closure Options
• Primary closure
• Immediate staged closure with mesh prosthesis for serial reduction
• Delayed closure– Operative skin closure, period of waiting,
later definitive closure with repair large ventral hernia
– “Paint and Wait”
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Silastic Silo
• If used, suture to abd wall• Apply abx ointment at
edges• 0.007 in Dacron reinforced
Silastic alternative• Assess reduction 30 min
post procedure• Assess for tightening BID
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MEDIUM OMPHALOCELE: Schuster approach
DOL 1
DOL 2
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Omphalocele Closure Options• Primary closure• Immediate staged closure with mesh prosthesis for serial reduction
• Delayed closure–Operative skin closure, period of waiting, later definitive closure with repair large ventral hernia
– “Paint and Wait”
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First Stage Skin Closure
• Liberate skin edges• Can close skin over
sac if adherent• Never free up skin
over chest further than necessary as to not displace viscera during reduction
Dr. Gross
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“Paint and Wait”
• Can be utilized if significant cardiac disease, prematurity, chromosomal anomaly to buy time, even in small defects
• Preferred in most giant omphalocele pts
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Eschar Formation
6 wks
Occasionally, brace used for protection...
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Epithelialization
• Caloric needs often very “robust”
• Feeding tube supplementation
• Caloric needs often very “robust”
• Supplemental tube feeds often needed
3 mo
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Potions to “Paint and Wait”
• Escharotic Agents– Mercurachrome – Silver nitrate
solution– Betadine– Silvadene
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Mecurachrome
2% Merbromin solution abandoned d/t mercury poisoning
0.25% solution used in Europe BID w/o complications
Rare contemporary use
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Silver Nitrate Solution
• 0.5% solution• Bacteriostatic• Encourages
epithelialization• Hypotonic; draws Na into
dressing; monitor serum Na
• Stains linens, skin• No longer recommended
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Betadine• Promotes epithelialization and escharizaton• 10 yr review; 6 GO pts• 10% povidone-iodine used qD or qoD
– Diluted 1:4 with saline in 5, 1:10 in one
• TFT’s weekly inpt; mo as outpt• Transient elevation TSH noted, normalized by
following wk; Nl free T4, thyroxine• No thyroid replacement therapy needed• Frequency of dressing changes decreased in one• Safe, but monitoring recommended
Whitehouse, Sato, Arca. JPS 2010
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Silvadene• Bacteriostatic, used in burn sepsis prevention• May impair G6PD
– Methemoglobinemia, hemolysis, hyperosmolality
• 2 pt with toxic serum levels (x200 adult) reported by Lander JPS 2010
• No toxic sxs (incr LFT, seizures)• Consider monitoring CBC, silver levels, very
thin layer, or avoidance
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Silvadene• 20 infants with defect >10 cm• 20 gm spread over thin layer, gauze
cover qD• Mean use 5 mo at cost $1/day• Turns eschar black due to silver• Silver levels not monitored, but no
toxicity demonstrated• Routine use supported
Ein, Langer. JPS 2011
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“Paint and Wait”Dr. Gross’ observations
• Mother apt to be apprehensive about potential rupture of protruding mass; reassure her this has never happened
• Considerable distension during crying or straining
• Child may be bathed• A 4-6 inch Ace wrap serves admirably• Wait until the abdominal cavity has grown large
enough so that it can receive the organs without crowding
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Dr. Gross’ Observations
• Plan final closure when....– the sac wall can
be readily picked up between the examining fingers
– the viscera can be pushed back into the abdominal cavity
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Skin Laxity
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Epithelialized Sac Suspension
Utilized to promote visceral reduction preoperatively to lessen time of mesh; potentially decrease infection risk
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Silo Reduction
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Final Closure
• Prepare for full complement of closure techniques
• Partnership with Plastic Surgery team in select cases
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Surgical Management of Omphalocele: A Plastic Surgeon’s Perspective
Brian I. Labow, MD, FACS, FAAP
Department of Plastic SurgeryChildren’s Hospital Boston
Harvard Medical School
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• Heterogenous population and associated anomalies common
• Many approaches, techniques and tools
• No single approach will suit all patients
• Outcome data based limited by numbers and confounding variables
IntroductionIntroduction
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• General considerations• Tools/techniques • Adjuvant procedures• Summary
OutlineOutline
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• Usually not an emergency• Most cases can be
managed with “conventional approaches”
• Circumstances may mandate change in course…
General Comments
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• Medically unstable• Damage control (e.g. ruptured
membrane, silo disruptions)• Incomplete reduction • Extreme visceral-peritoneal
disproportion
Clinical Situation?
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Tools and TechniquesTools and Techniques
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• NPWT/VAC™ hopefully not necessary!
• Decrease edema and bacterial colonization accelerate granulation
• Used with absorbable mesh, biological fascial substitute
• Bridge to definitive reconstruction (Kilbride et al. J Ped Surg (2006) 41, 212–215)
Negative-Pressure Wound Therapy Negative-Pressure Wound Therapy
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• Mechanical process to increase surface area of adjacent tissues
• Examples: Growth, Silo, External Skin closure devices
• Adjunct to flap transfer• Progressive process takes time
Tissue-ExpansionTissue-Expansion
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• Tissue expanders require a clean field with minimal inflammation
• Epidermis thickens, dermis and fat atrophy, muscle thins, angiogenesis
• Multiple expanders, small, frequent fillings
Tissue-ExpandersTissue-Expanders
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• Subcutaneous, submuscular and intraperitoneal placement all reported
• Small case series, longest follow-up 3 yrs
Tissue-ExpandersTissue-Expanders
(Tanenbaum et al. Plas Rec Surg (2007)120,1564–7)
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• Useful in a subset of patients• Additional GA, time and good local
tissue conditions required• Judgment in rate of expansion• Extrusion and infection most
frequent complications
Tissue-ExpandersTissue-Expanders
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• Relaxing incision(s) separating rectus sheath from ext obliq aponeurosis
• Autologous tissue, 1-stage• Skin deficit?• Large experience in adults
Component SeparationComponent Separation
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• 1 series of 10 consecutive omphalocele patients (mean age 6.5 months) Van Eijck et al. J Ped Surg (2008)
• Mean defect size 8 cm• Required temporary prosthetic in 1 case• Complications in 3 patients (skin necrosis,
hematoma, infection)• Mean follow-up 2 years, no hernias
Component SeparationComponent Separation
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• Usually a lifeboat• Allows egress of fluid,
visualization of bowel• Used with NPWT • Lasts 3-4
months….hernia• Cost Vicryl™ 15x 15”
$1800*
Absorbable MeshAbsorbable Mesh
* BCH list price 2013
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• Allows tissue ingrowth, stronger
• Higher rate of enterocutaneous fistulae
• Onlay support• Cost e.g. Marlex™
10x14” $500
Non-absorbable, MeshedNon-absorbable, Meshed
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• Temporary use silo construction (e.g. Silastic™)
• No ingrowth, minimal adhesions
• Permanent use (e.g. Goretex™) higher hernia rate?
• Cost* $600 for 10x15”Goretex™
Non-absorbable, Non-meshedNon-absorbable, Non-meshed
* BCH list price 2013
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• Variety of freeze-dried, acellular dermal or intestinal products (e.g. Alloderm™, Surgisis™)
• Inlay graft or onlay above fascia
• Neovascularized, tissues replaced by native cellular ingrowth
Biological MaterialsBiological Materials
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• Small series/case reports in pediatric literature (Alaish et al. J Ped Surg (2006) 41, E37–E39)
• Variable reports in adult abdominal wall reconstruction literature
• Cost has come down, 5x10” sheet of Alloderm™ ~$1800*
Biological MaterialsBiological Materials
* BCH list price 2013
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• Local tissues usually sufficient
• Mobilization wide undermining
• Can be facilitated with relaxing incisions
FlapsFlaps
Zama et al. Br Assoc Plas Surg (2004) 57, 749–753
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FlapsFlaps
Br Assoc Plas Surg (2004) 57, 749–753
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• Skin closure: secondary but important part of reconstruction
• Umbilicoplasty if possible
• Secondary procedures: hernias, bulges, hypertophic/depressed scar
Adjunctive ProceduresAdjunctive Procedures
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Adjunctive ProceduresAdjunctive Procedures
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Long-Term Follow Up
• Postnatal survival rates 70-95%• Mortality related to associated cardiac
and chromosomal anomalies
Rijwani, Davenport, Dawrnat. et al. J Pediatr Surg 2005
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Incidence of Bowel Obstruction
• 170 abd wall defects; 111 w/ omphalocele
• 10 yr median F/U• 12/92 (13%) incidence of adhesive SBO• 85% occurred in 1st yr• 88% underwent laparotomy• Sepsis and fascial dehiscence risk
factors in entire cohort
Van Eijck, Wijnen, van Goor. JPS 2008
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Neurodevelopmental
• Cohort from CHOP with GO• 31 pts• Overall survival 81%• 20 survivors enrolled in
prospective F/U• Age > 6m, had Bayley (BSID-II,-III)
Danzer, Flake, Adzick, Hedrick. JPS 2010
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Neurodevelopmental
Median age at evaluation 12 mo• Motor skills:
– Normal 40%– Mildly delayed 13%– Severely delayed
47%
• Cognitive/Language skills:– Ave 40%– Mildly delayed 13%– Severely delayed 40%
Danzer, Flake, Adzick, Hedrick. JPS 2010
Of 6 with severe delays:2 autism4 tracheostomy1 Williams syndrome
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Pulmonary Hypoplasia
• Definition nebulous, often based on clinical course
• Require long-term vent support• ? “permanently limited” reserve• High postoperative mortality 30-
60%
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Assessment of Early Pulmonary Function in GO
• N=14, mean age 19 mo• PFT’s
– Spirometry– Fractional lung volume assessment– Bronchodilator responsiveness– Passive respiratory mechanics
Danzer, Hedrick, Panitch. JPS 2012
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Assessment of Early Pulmonary Function in GO
• FVC, mean Forced Exp Vol, TLC • FRC normal• Restrictive pattern demonstrated• responsiveness to bronchodilators• Reduced lung compliance• Undetermined clinical significance
Danzer, Hedrick, Panitch. JPS 2012
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Can Pulmonary Function be Predicted Prenatally?
• Fetal MRI assessed at ~26 wks (N=17)
• Observed/Expected TLV calculated vs. age-matched fetal nomograms
• Mean O/E TLV 52% (+/- 17%)• Age at delivery 37 wk• Survival 94%
Danzer, Victoria,Hedrick. JPS 2012
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Can Pulmonary Function be Predicted Prenatally?
• 88% staged reduction• Infants <50% O/E TLV
– Lower Apgar scores– Prolonged ventilatory support– Delayed oral intake– Longer hospitalization
Fetal MRI predictive of postnatal morbidityNumbers small, but.....a start
Danzer, Victoria,Hedrick. JPS 2012
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QOL Studies
• Tunell series of mixed abd wall defects• 88% reported good health; 80% good
QOL• 40% concerned about height,
inadequate in sporting/ social activities• Educational levels equal to general
population• Many report absence of umbilicus
caused psychologic distress
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Long Term F/U Challenges
• Most case reports, small series, single center F/U
• Typically includes gastroschisis• Definition of giant omphalocele
diverse• Are defects containing the whole
liver/all viscera different?
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Parental Perspective
“People turn to social media for answers which can be greatly helpful, but also dangerous as parents generalize their experience and their child's condition in counseling other parents.
I think the world, is in need of some really
good long term follow up on these kids to change the perspective surrounding survival and short/long term complication statistics.”
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Long-Term F/U Needed
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• No single “right way” to manage but optimistic outcome in absence of severe congenital heart disease/chromosomal anomalies
• Situation dependent• Numerous tools/techniques available• Outcome data needed
Summary
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Thank You!