Experience of gastrojejunal intubation in the surgical treatment of pediatric patients with congenital abdominal wall defects in Kazakhstan

Background: Abdominal compartment syndrome (ACS) is a serious complication of congenital abdominal wall defect repair and results from a rise in intra-abdominal pressure (IAP) after the herniated viscera are reduced. Intraoperative gastrojejunal intubation (GJI), in which a tube placed through a gastrostomy decompresses the stomach, duodenum and proximal jejunum, has been used at our center to limit the postoperative rise in IAP. We describe postoperative IAP, organ dysfunction and ACS in patients treated with GJI and in a cohort treated with conventional repair at a second hospital. Method: Ambispective observational two-center cohort of infants aged 0-6 months with gastroschisis or omphalocele: 27 patients who underwent repair with GJI at a tertiary center (followed prospectively) and 30 who underwent conventional repair at a secondary-level hospital (records reviewed retrospectively via chart review). Treatment was determined by the hospital to which the patient was admitted, therefore, the effect of GJI cannot be separated from the effect of hospital, and the analysis is descriptive. ACS was considered as the primary outcome and was defined as intra-abdominal hypertension (mean IAP >10 mmHg on postoperative days 1 and 3) with the presence of at least two of three signs of organ dysfunction; alternative definitions were also considered. Secondary outcomes included in-hospital mortality, gastrointestinal recovery timing, and renal/respiratory trajectories. Categorical outcomes were compared using Fisher’s exact test, and absolute risk differences (RD) are presented with 95% confidence intervals (CI). Results: Baseline characteristics were broadly similar between cohorts, although staged closure was more frequent in the technique cohort (40.7% vs. 20.0%). ACS was observed on 5/26 evaluable technique-cohort vs. 1/26 evaluable comparison-cohort patients (RD 15.4 percentage points, 95% CI -3.1 to 34.3; p = 0.191; Firth odds ratio [OR] 4.35, 95% CI 0.63-29.98). In-hospital mortality was 5/27 vs. 0/30 (RD 18.5 percentage points, 95% CI 3.2 to 36.7; p = 0.019; Firth OR 14.91, 95% CI 0.75-298.05). The group × time interaction for IAP was significant (p = 0.018), with a slower decline in the technique cohort; interactions for creatinine, pCO2, and PIP/FiO2 trajectory were not significant. Conclusion: In this exploratory observational study, ACS and in-hospital death were more frequent in the GJI cohort than in the comparison cohort, but the CIs were wide and the differences cannot be attributed to GJI, because the procedure, the treating hospital and its case mix cannot be separated in this design. These data neither support nor exclude the benefit or harm of GJI. A single-institution study with standardized IAP monitoring and complete outcome measurement is needed.