Complex gastroschisis: a new indication for fetal surgery?
Gastroschisis (GS) is a congenital abdominal wall defect in which the bowel eviscerates from the abdominal cavity. It is a non-lethal isolated anomaly and its pathogenesis is hypothesized to occur as a result of two hits, i.e. primary rupture of the ‘physiological’ umbilical hernia (congenital anomaly) followed by progressive damage of the eviscerated bowel (secondary injury). This second hit is thought to be caused by a combination of mesenteric ischemia from constriction in the abdominal wall defect and prolonged amniotic fluid exposure with resultant inflammatory damage, both eventually leading to bowel dysfunction and complications. GS can be classified as either simple or complex, the latter being complicated by combinations of intestinal atresia, stenosis, perforation, volvulus, and/or necrosis.

Complex GS requires multiple neonatal surgeries and has a significantly greater postnatal morbidity and mortality than simple GS. The intra-uterine reduction of eviscerated bowel before irreversible damage and subsequent defect closure may diminish or potentially prevent the bowel and other fetal and neonatal complications and risks associated with this condition. Serial prenatal amnio-exchange has been studied but never adopted because of its unproven benefit in terms of survival, bowel, and lung function. Researchers believe that recent advances in prenatal diagnosis and fetoscopic surgery now justify reconsideration of the antenatal management of complex GS under the rubric of the criteria for fetal surgery established by the International Fetal Medicine and Surgery Society. Finally, Researchers advance a research agenda that will help overcome barriers to progress and provide a pathway toward clinical implementation.