EUPSA Webinar "GIANT OMPHALOCELE II"

The non-surgical Duoderm silo technique was developed by Dr. Cristóbal Avello from Colombia approximately 20 years ago and adopted by Dr. Guelfund's team seven years ago.

In Dr. Guelfund's series of approximately 60 patients treated over seven years, 98% required only one surgery.

The silo should be placed as soon as possible after birth to prevent the amnion from drying, which facilitates reduction.

The technique uses a 20 × 20 cm (8 × 8 inch) thick hydrocolloid dressing (Duoderm GRF) shaped into a T, with the stem attached to the skin and the flaps wrapped around the omphalocele.

The apex of the omphalocele (not always the umbilical cord) should be positioned at the apex of the silo; plastic cord clamps should be replaced with suture or elastic band.

Reduction is performed every 1–2 days by 0.5 inch (1 cm), depending on the baby's respiratory tolerance.

In the first 2–3 years of using the protocol, patients were kept completely paralyzed and intubated; in the last 4–5 years, only sedation is used with paralysis reserved for silo reduction, resulting in less edema and better respiratory management.

After the silo is completely flat (typically 1–10 days), amnion inversion is performed by depressing the amnion into the cavity and securing the amniocutaneous edges with Duoderm for 1–2 days to assess tolerance before proceeding to OR closure.

In 2–3 patients, a mesh was used as reinforcement or for closure; component separation was performed in some cases, but 95% achieved primary anatomical closure.

The median silo reduction time was 5 days, amnion inversion time was 5 days, and time to closure was 12 days.

95% of patients in the series achieved anatomical closure.

Complications included one hemoperitoneum (due to delayed silo placement on day 3–4 with dry amnion), three local infections treated with antibiotics, one high intraabdominal pressure episode (resolved by retrieving reduction 1 cm), and one central line infection.

There was no mortality related to the silo technique; four deaths were related to other malformations.

The European multi-center study will collect data on primary outcomes (silo reduction time, amnion inversion time, surgical closure time) and secondary outcomes (hospital stay, mortality, complications, ventilation type/duration, antibiotic use, parenteral nutrition, enteral feeding start) via the CURRENTS platform.

ERNICA's omphalocele guideline development involves 11 PICO questions categorized into prenatal care, postnatal care, and abdominal wall closure, using evidence-based methods and expert panel consultation.

Rotterdam's first Duoderm case was a 35-week, 2400 g female with an 8 cm giant omphalocele containing liver, stomach, and small bowel, plus a cardiac defect.

The Rotterdam team encountered challenges including umbilical cord positioning, spatula migration despite tape reinforcement, uncertainty about reduction pace, and difficulty assessing bowel position through the opaque Duoderm.

Initial bladder pressure was 17 mmHg with some urine leakage; the team accepted this as acceptable pressure.

On day 5, the Duoderm was changed; the omphalocele had a yellow appearance but did not appear infected, and cultures were negative.

Enteral feeding via nasogastric tube was started on day 12 due to pressure from the team to begin feeding, despite the defect still being large.

Botox was administered on day 15 to facilitate closure.

The patient was ventilated but not paralyzed throughout treatment; CO₂ levels were consistently high (8–10 mmHg).

A Serratia infection developed on the skin/sac but the patient was not systemically ill; no antibiotics were started and the infection resolved.

Amnion inversion was attempted on days 23–30, but the patient developed leg cyanosis, tachycardia, and CO₂ rise to 12 mmHg, prompting abandonment of closure attempts.

On day 30, the team switched from Duoderm to Mepitel (silicone dressing); the patient was extubated 10 days later and is progressing on day 45 with chronic hypercapnia (CO₂ = 8) and oral feeding trials (20 mL per feed, 3 times daily).

Dr. Guelfund does not measure intraabdominal pressure directly, instead relying on clinical signs (leg color, hemodynamics, respiratory status) to guide reduction pace.

When progression stalls, complete paralysis for 7 days (24 hours/day) is used to facilitate reduction.

The Duoderm is changed every 4–5 days because it loses traction when wet; the skin is cleaned at each change, but the amnion itself is not cleaned.

Patients are not fed during silo reduction to avoid bowel distention; amnion inversion is not attempted until the silo is completely flat.

Dr. Guelfund's team is developing a protocol to use Botox from day one and is exploring in-utero Botox administration in collaboration with Dr. Avello; one patient has been treated in utero with good results.

The technique is primarily pushing (applying force into the abdomen) rather than traction to the ceiling; lateral strings stabilize the silo but do not pull.

Three patients with ruptured amnion at birth were treated by suturing the amnion and then applying the silo on top.

For narrow-neck (mushroom-shaped) defects, the technique can be trialed; if no progression occurs within 7–10 days, the approach should be changed.

Three patients underwent component separation at 2–4 weeks of age with good outcomes and no lateral hernias; the first two cases were performed with a plastic surgeon experienced in the technique.

In patients with severe pulmonary hypoplasia or cardiac conditions, the silo can be placed but reduction delayed for several days until the patient stabilizes, then progression is very slow and gentle based on patient response.