Traditional treatment of giant
omphaloceles with silo closure has been associated with
respiratory insufficiency, hemodynamic compromise, dehiscence, and inability to close the abdomen with subsequent death. To minimize such complications, initial nonoperative management with delayed closure of the defect has been used.
METHODS: Between January 1981 and December 2002, 111 patients with
omphaloceles were treated. Twenty-two patients with giant
omphaloceles (19 containing liver) underwent initial nonoperative management consisting of
silver sulfadiazine dressing changes. After pulmonary and other comorbidities stabilized, the contents were gradually reduced with a loose
elastic bandage, and delayed closure was planned at 6 to 12 months. The medical records of these 22 patients were retrospectively reviewed to determine the efficacy and safety of this technique in the setting of severe associated anomalies. Those 15 patients (n = 15) from the latter 10 years were further reviewed to determine additional end points (length of
hospital stay, length of intensive care unit stay, duration of
mechanical ventilation, time to feed, time to closure, and type of closure).
RESULTS: Of the 15 patients treated during the latter 10 years, mean gestational age and
birth weight were 38 +/- 1.4 weeks and 3.1 +/- 0.57 kg, respectively. Median
length of stay after birth was 20 days (range, 5-239 days). Median time to full diet was 8 days (range, 4-80 days). Four patients were discharged on oral feedings only, 7 with combination oral/gavage, and 4 with tube feedings. Pulmonary hypoplasia or
pulmonary hypertension was present in 11 (50%) of 22 patients. There were 11 patients with major cardiac anomalies, 14 with a
patent ductus arteriosus, and 8 with a
patent foramen ovale. Three early complications (2 ruptured sacs and 1
bleeding sac) and 1 late complication (gastric
necrosis) occurred in the initial nonoperative period. In addition, 4 patients were treated for line
sepsis, 1 patient for
acute renal insufficiency, and 1 for
aspiration pneumonia. Three patients required
tracheostomy and were discharged with home
ventilators. There were no complications associated with the use of
silver sulfadiazine. Of the 22 patients, 16 have undergone delayed repair, 2 did not require repair, 1 is awaiting repair, 2 died before closure, and 1 was lost to follow-up. Delayed closure was achieved at a median age of 14 months (range, 2-28 months) and mean weight of 8.8 +/- 3.3 kg. Four patients required implantation of mesh for definitive closure. Median postoperative
length of stay was 4 days (range, 2-21 days). Postoperative complications included prolonged
ileus, recurrent
ventral hernia, and prolonged intubation. Overall mortality rate was 9.1%. One death occurred after
diaphragmatic hernia repair, and 1 death was from overwhelming
sepsis in the patient with a late gastric perforation.
CONCLUSION: The use of
silver sulfadiazine dressing changes for initial nonoperative management of giant
omphaloceles is a safe and effective bridge to delayed closure. We recommend this method as initial nonoperative management given the high incidence of associated cardiopulmonary malformations because it may facilitate
enteral feeding, minimize respiratory compromise, and reduce morbidity and mortality.