Original Article

Surgical Management of Congenital Abdominal

Wall Defects in Germany: A Population-Based
Study and Comparison with Literature Reports
Carmen Dingemann1 Janine Dietrich2 Jan Zeidler2 Jochen Blaser3 Jan Hendrik Gosemann1,4
Martin Lacher1,4 Benno Ure1

1 Department of Pediatric Surgery, Hannover Medical School, Address for correspondence Priv.-Doz. Dr. med Carmen Dingemann,
Hannover, Germany Department of Pediatric Surgery, Hannover Medical School,
2 Center for Health Economics Research Hannover (CHERH), Leibniz Carl-Neuberg-Str. 1, D-30625 Hannover, Germany
University Hannover, Hannover, Germany (e-mail: dingemann.carmen@mh-hannover.de).
3 Representative Office of Lower Saxony, Techniker Krankenkasse
(Health Insurance), Hannover, Germany
4 Department of Pediatric Surgery, University of Leipzig, Leipzig,
Germany

Eur J Pediatr Surg

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Abstract Introduction We aimed to analyze for the first time the characteristics, treatment
modalities, and outcomes in infants with congenital abdominal wall defects (CAWDs) in
Germany and to compare the results with current literature reports.
Patients and Methods Data of a health insurance covering approximately 10% of the
German population were analyzed. Patients who had undergone CAWD closure during a
period of nearly 6 years were included. Surgical approach was categorized into primary
versus secondary closure. Complications were defined as any reintervention within
1 year after initial treatment.
Results Patients with gastroschisis were treated in 24 centers, newborns with
omphalocele in 34 centers. There was no mortality, and the type of surgical approach
had no significant impact on the incidence of complications in both gastroschisis and
omphalocele. Out of 39 patients with gastroschisis, 72% had undergone primary closure
being associated with a shorter duration of ventilation (p ¼ 0.003) and hospitalization
(p < 0.001). Out of 54 patients with omphalocele, 54% had undergone secondary
closure, whereas modality of management did not affect duration of ventilation and
Keywords hospitalization. Although heterogeneous, data of the current literature were compara-
► omphalocele ble to those of this study.
► gastroschisis Conclusions Unbiased data demonstrate for the first time that the quality of the
► abdominal wall defect current surgical management of newborns with CAWD across Germany is excellent.
► neonatal There was no correlation of complications with the method of closure in gastroschisis
► pediatric surgery and omphalocele.

received © Georg Thieme Verlag KG DOI http://dx.doi.org/

April 5, 2016 Stuttgart · New York 10.1055/s-0037-1598250.
accepted after revision ISSN 0939-7248.
December 22, 2016
Surgical Management of CAWDs in Germany Dingemann et al.
Introduction
Congenital abdominal wall defects (CAWDs) can be catego-
rized into gastroschisis with an estimated incidence of 4 to
5:10,000 live births and omphalocele with an estimated
incidence of 1:4,000 live-births in Western countries.1–6
Both conditions require immediate and coordinated treat-
ment by several medical disciplines.4,6
Gastroschisis is characterized by an intact umbilical cord
and paraumbilical herniation of gastrointestinal structures
into the amniotic cavity without a membranous protective
sac.4,7,8 Omphalocele is a midline CAWD with herniation of
small intestine, liver, and other organs into the intact umbili-
cal cord, which is covered by membranes unless ruptured.4,6,8
Prognosis of gastroschisis is primarily determined by the
degree of prematurity and significant intestinal dysfunction,
whereas prognosis of omphalocele is related to the number
and severity of associated anomalies.7,9,10
The options for the correction of CAWD include primary
closure and a variety of staged approaches.7 The general
principle of surgical management of both conditions consists
of closure of the abdominal wall defect, while minimizing the
risk of injury to the abdominal viscera.7,11 Nevertheless,
repeated hospitalization and revisional surgery are often
required to achieve complete closure of the abdominal wall
and an acceptable cosmetic appearance.11,12 Recent reports
suggest that the type of defect closure correlates with the
outcome.7,11,13–24 However, due to the inconsistent results of
available studies, a conclusive recommendation for any of the
different treatment options cannot be given to date.4,6
Typically, the outcome of CAWD has been investigated
using single-center case series.12,22,25–31 These series are
subject to bias including case selection, information bias,
and inherent single-operator series bias.11 Thus, it has been
suggested to use national databases to obtain objective and
population-based data on newborns with CAWD.11,32
There are no nationwide data available describing the type
of surgical management of CAWD, the characteristics of
affected newborns, complications, and related outcomes in
Germany. Information on the contemporary application of
strategies in Germany is limited to single-center
studies.12,17,22,25–27
The aim of this study was to identify the patient character-
istics and outcomes of liveborn infants with gastroschisis and
omphalocele and to evaluate the contemporary treatment
modalities based on unbiased data of large German public
health insurance. We hypothesized that the type of surgical
management has an impact on the outcome. Moreover, we
aimed to compare the data of the German cohort with those
of literature reports.
Patients and Methods
The study was approved by the Institutional Review Board
(approval number 2533–2014). This retrospective study was
based on claims data of the German statutory health care
insurance company Techniker Krankenkasse (TK), which is
one of the largest of more than 130 German health insurances
European Journal of Pediatric Surgery
and covers approximately 10% of the German population
(10 million clients). Data from all clients who had under-
gone closure of CAWD from January 2007 to August 2012 and
who had been continuous members of the TK were analyzed.
These clients are homogeneously distributed over all German
federal states. The database provided anonymized informa-
tion on patient characteristics, associated anomalies, opera-
tive data, perioperative complications, and readmissions.
To perform a standardized analysis of each single patient,
the hospital stay for initial surgical intervention was chosen
as the index event. All diagnoses and reinterventions within
1 year after this index event were analyzed. Children with a
shorter follow-up period were excluded from the study.
Patient-specific diagnoses were encoded based on the
International Classification of Diseases in its 10th version
(ICD-10). Database was searched for the diagnoses “gastro-
schisis“ (Q79.3) and “omphalocele“ (Q79.2). All surgical pro-
cedures were encoded based on the International
Classification of Procedures in Medicine (ICPM).
With regard to initial surgical management of the CAWD,
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different ICPM codes were used. Primary closure of the
abdominal wall was clearly encoded (ICPM 5–537.0). Since
one can only speculate which types of surgical intervention
had been performed using the reported codes, all other
operations have been summarized under the term secondary
closure. This term included plastic closure (ICPM 5–537.1),
closure with allogenic material (ICPM 5–537.3), closure with
alloplastic material (ICPM 5–537.4), or staged closure using
Schuster’s technique (ICPM 5–537.5).
Postoperative complications were defined as any reinter-
vention for CAWD-related morbidity within 1 year after
initial surgical intervention including mortality.
All available ICD codes have been decoded. Thus, associat-
ed malformations were concurrently detected and listed.
Associated malformations were classified as cardiac, pulmo-
nary, gastrointestinal, anorectal, urogenital, skeletal, chro-
mosomal, or others. Duration of mechanical ventilation was
analyzed for the initial surgical intervention. Patients with
incomplete datasets were excluded.
Results were compared with the latest published national
cohorts. Clinical studies published in the English literature
were identified by Medline literature search using PubMed
(www.ncbi.nlm.nih.gov/pubmed; last accessed February 1,
2016). Only publications reporting on a study period of the
past 10 years were considered for comparison using the key
words “gastroschisis,” “omphalocele,” and “outcome.” Publi-
cations were individually reviewed, and only those studies
reporting on clinical outcome and patient characteristics
were included for further analysis.
Statistical Analysis and Software
Chi-squared test, Student’s t-test, and Wilcoxon signed-rank
sum test were used where appropriate to compare demo-
graphic characteristics of outcomes and the presence of
associated anomalies between infants with gastroschisis
and those with omphalocele. Kolmogorov–Smirnov test
was used to test for normal distribution. Data were quoted
as mean  standard deviation (SD) and/or median
 Surgical Management of CAWDs in Germany Dingemann et al.

(interquartile range) as indicated. A p-value of 0.05 was
considered significant. Incomplete datasets were excluded
from statistical analysis. Data management and statistical
analyses were realized with Microsoft Excel 2010. All data
were analyzed in an anonymized form.
Results
In total, 93 patients with CAWD were identified, 39 encoded
as gastroschisis and 54 as omphalocele (►Table 1). A male
predominance was detected for both conditions without
reaching the level of statistical significance. Initial surgical
intervention was performed for gastroschisis in 24 surgical
centers. Patients with omphalocele underwent initial surgery
in a total of 34 surgical centers.
Prematurity (<37 weeks of gestation) was documented in 21
patients with gastroschisis (54%) and in 12 patients with ompha-
locele (22%) (►Table 1). No newborn with gastroschisis presented
with a birth weight of  1,500 g. In the group of patients with
omphalocele, three infants (6%) had a birth weight of 1,500 g.

Table 1 Characteristics and management of patients with CAWDs

CAWD Gastroschisis Omphalocele

(n ¼ 93) (n ¼ 39) (n ¼ 54)
Gender
Male 23 (59%) 35 (65%)
Female 16 (41%) 19 (35%)
At birth

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Prematurity 21 (54%) 12 (22%)
Birth weight
1,000–1,250 g 0 1 (2%)
1,250–1,500 g 0 2 (4%)
1,500–2,500 g 21 (54%) 8 (15%)
Associated anomaliesa
Cardiac 6 (15%) 22 (41%)
Pulmonary 0 2 (4%)
Gastrointestinal 8 (21%) 13 (24%)
Anorectal 0 1 (2%)
Urogenital 2 (5%) 4 (7%)
Skeletal 0 2 (4%)
Chromosomal 0 5 (9%)
Others 3 (8%) 8 (15%)
Total no. of patients 14 (36%) 34 (63%)
Surgical management
Primary closure 28 (72%) 25 (46%)
Secondary closure 11 (28%) 29 (54%)
b
Complications
Primary closure 2 (5%) 3 (6%)
Secondary closure 4 (10%) 5 (9%)
Duration of mechanical ventilation (h)c 146  200 241  688
Hospitalization
Length of initial stay (d) 41  26 33  41
No. of patients being readmitted for CAWD onlyd 6 (15%) 8 (15%)
Length of readmissions for CAWDd (d) 32 69
d
No. of readmissions for CAWD 22 43

Abbreviation: CAWD, congenital abdominal wall defects.

a
Multiple anomalies per patient are possible; figures are given in mean  standard deviation.
b
Requiring surgical intervention.
c
After initial surgical intervention.
d
Within 1 year after initial surgery.

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Surgical Management of CAWDs in Germany Dingemann et al.

Table 2 Duration of mechanical ventilation after initial surgical intervention for gastroschisis and omphalocele

Gastroschisis Omphalocele
(n ¼ 39) (n ¼ 54)
Primary closure Secondary closure p-Value Primary closure Secondary closure p-Value
(n ¼ 28) (n ¼ 11) (n ¼ 25) (n ¼ 29)
Duration of 88  93 292  308 0.003 145  430 321  851 n.s.
mechanical
ventilation (h)

Abbreviation: n.s., not significant.

Note: Figures are given in mean  standard deviation.

Associated anomalies (single or multiple) were docu-
mented in 14 patients with gastroschisis (36%) and in 34
infants with omphalocele (63%).
Predominant associated malformations in patients with
gastroschisis were intestinal atresia (8/39, 21%). In the group
of infants with omphalocele, cardiac anomalies were pre-
dominantly documented (22/54; 41%). One patient presented
treatment. One newborn underwent primary closure, and the
other newborn underwent secondary closure of the defect.
Complications have not been documented for either of them.
There was no difference in the outcome of transferred babies.
Postoperative complications were documented in six
patients with gastroschisis (15%), of whom two infants (5%)
had undergone primary closure and four infants (10%) sec-

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with OEIS complex (omphalocele–exstrophy–imperforate
anus–spinal defects).
With regard to surgical management, the majority of
patients with gastroschisis underwent primary closure
(28/39; 72% ;►Table 1). The majority of patients with
omphalocele (29/54; 54%) underwent secondary closure of
the defect.
During follow-up, 9 patients with gastroschisis (9/39; 23%)
and 16 with omphalocele (16/54; 30%) changed the hospital.
Most of the patients underwent further interventions for
associated malformations, but not for any CAWD-related
reasons.
Immediately after birth, one infant with gastroschisis
(1/39; 3%) was transferred to another hospital for primary
defect closure. This patient also underwent closure of an
incisional hernia at the age of 4 months and did not present
with any further complications during follow-up.
Two infants with omphalocele (2/54; 4%) were also trans-
ferred to another hospital immediately after birth for surgical
ondary closure (►Table 1). In the two patients after primary
closure, the indication for surgical revision was an incisional
hernia. The four patients after secondary closure underwent
multiple revisions and reconstruction of the abdominal wall.
In patients with omphalocele, postoperative complica-
tions were identified in eight infants (15%), of whom three
(6%) had undergone primary and five (9%) secondary
closure. In the three patients after primary closure, surgical
revision was performed for reconstruction of the abdomi-
nal wall. Three of the patients after secondary closure
underwent multiple surgical revisions and reconstructions
until a definite closure of the abdominal wall was achieved.
One patient after secondary closure presented with adhe-
sive small bowel obstruction, and another patient with
intra-abdominal bleeding. Both patients underwent
laparotomy.
There was no mortality within 1 year after the index event
in both groups of patients with CAWD. The mean duration of
mechanical ventilation was 145.7  199.5 hours in patients

Table 3 Hospitalization of patients with gastroschisis and omphalocele

Hospitalization Gastroschisis Omphalocele

(n ¼ 39) (n ¼ 54)
Primary closure Secondary closure p-Valuea Primary Secondary p-Valueb
(n ¼ 28) (n ¼ 11) closure closure
(n ¼ 25) (n ¼ 29)
Length of initial stay (d) 32  16 64  32 < 0.001 27  27 38  50 n.s.
No. patients being readmitted 2 (5%) 4 (10%) n.s. 3 (6%) 5 (9%) n.s.
for CAWD onlyc
Length of readmissions for 31 3  11 n.s. 34 7  10 n.s.
CAWDc (d)
No. of readmissions for CAWDc 21 32 n.s. 31 63 n.s.

Abbreviations: CAWD, congenital abdominal wall defects; n.s., not significant.

Note: Figures are given in mean  standard deviation.
a
Gastroschisis: primary versus secondary closure.
b
Omphalocele: primary versus secondary closure.
c
Within 1 year after initial surgery.

European Journal of Pediatric Surgery

 Surgical Management of CAWDs in Germany Dingemann et al.

with gastroschisis and 240.8  688.2 hours in newborns with
omphalocele (►Table 1).
Within the gastroschisis group, primary closure was
associated with significantly shorter mean duration of
mechanical ventilation compared with secondary closure
(87.9  93.4 vs. 291.8  308.4; p ¼ 0.003) (►Table 2).
Within the group of newborns with omphalocele, primary
closure was also linked to shorter mean duration of venti-
lation, but without showing any statistical significance
(145.3  429.7 vs. 321.4  850.0; p ¼ n.s.).
The mean length of initial hospitalization was 41.2  25.6
days (median: 32 [13–142]) in patients with gastroschisis and
33.2  40.9 days (median: 16 [2–233]) for patients with
omphalocele (►Table 1).
Six patients with gastroschisis (15%) and eight with
omphalocele (15%) were readmitted at least once within
1 year after initial surgery for CAWD-related reasons. Details
of readmissions are shown in ►Table 1.
The mean length of initial hospitalization was signifi-
cantly shorter after primary closure of gastroschisis com-
pared with secondary closure of gastroschisis (32.3  15.8
vs. 63.7  32.1; p < 0.001) (►Table 3). This finding could
not be confirmed in patients with omphalocele.
Literature Review: Gastroschisis
There are numerous publications on national cohorts of
gastroschisis (►Tables 4 and 5). The vast majority of authors
subdivided their cohort based on surgical management,
risk stratification, or complexity of cases to enable compar-
ison (►Table 4). Associated anomalies were reported in 7.8
to 32.4%33–35 of cases compared with 35.9% in our series
(►Table 5). Some authors only mentioned the prevalence of
nonbowel anomalies ranging from 5.6 to 11.4%11,33,36
compared with 15.4% in our study. However, in several
studies, the prevalence of associated anomalies in patients
with gastroschisis was not reported. 20,37–40

Table 4 Recent publications on national cohorts of gastroschisis: Study design

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Authors Country No. of No. of Study period Subdivision of the
patients institutions cohort
Emami et al41 Canada 565 16 2005–2011 Fascial closure vs.
flap closure; low-risk
vs. high-risk
patients
Barrett et al33 Ireland 70 n/d 2007–2011 Primary closure vs.
secondary closure
Benjamin and Wilson34 USA 1831 n/d 1999–2008 Simple cases vs.
complex cases
Corey et al35 USA 4687 348 1997–2012 None
37
Stanger et al Canada 679 17 2005–2011 Intended closure vs.
actual closure
Bradnock et al36 United Kingdom and Ireland 301 28 2006–2008 Simple cases vs.
complex cases
Owen et al11 Unite Kingdom and Ireland 393 28 2006–2008 Simple cases vs.
complex cases
Boutros et al38 Canada 192 16 2005–2007 Route of delivery
Birth weight/
gestational age
Lao et al39 USA 2490 43 2003–2008 Systemic comorbid-
ities vs.
intestinal
comorbidities
Skarsgard et al40 Canada 100 16 2005–2006 Urgent closure vs.
delayed closure
Weinsheimer et ala Canada 99 16 2005–2006 Association
between perinatal
descriptors, man-
agement variables,
and functional out-
comes
(primary closure vs.
secondary closure)
This study Germany 39 24 2007–2012 Primary closure vs.
secondary closure

Abbreviation: n/d, not defined.

a
All complicated cases excluded (severe bowel pathology or neonatal death).

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Surgical Management of CAWDs in Germany Dingemann et al.

Table 5 Recent publications on national cohorts of gastroschisis: Patient’s characteristics and outcome

Authors Associated Prematuritya Surgical management Reintervention LOS Mechanical

anomalies (d) ventilation
(d)
Emami et al41 n/d n/d Fascial closure 436 n/d Fascial closure 36 (median) 3–4 (median)
Flap closure 129 Flap closure 31 (median)
Barrett et al33 21% n/d Primary closure 40% n/d Primary closure 28 (median) n/d
(11%)b Secondary closure 60% Secondary closure 32 (median)
Benjamin and 32% n/d n/d n/d n/d n/d
Wilson34
Corey et al35 8% 65% n/d n/d 33 (median) 4 (median)
Stanger et al37 n/d n/d Primary closure 55% 11% Primary closure 57 Primary closure 7
Secondary closure 45% Secondary closure 54 Secondary closure 7
Bradnock et al36 (6%)b 46% Primary closure 46% 13% Primary closure 34 (median) n/d
Secondary closure 54% Secondary closure 38 (median)
Owen et al11 (6%)b 47% Primary closure 60% 20% n/d n/d
Secondary closure 40%
Boutros et al38 n/d n/d n/d n/d 55  56 57
39
Lao et al n/d 81% n/d n/d 35 (median) n/d
Skarsgard et al40 n/d n/d Primary closure 61% n/d Primary closure 42  31 n/d

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Secondary closure 39% Secondary closure 57  40
Weinsheimer et alc n/d 33% n/d n/d 41  28 n/d
This study 36% 54% Primary closure 72% 15% 41  26 68
(15%)b Secondary closure 28% 32 (median)d 4 (median)e

Abbreviations: LOS, length of stay; n/d, not defined.

Note: Figures given in mean  standard deviation or as indicated.
a
< 37 weeks of gestation.
b
Only nonbowel.
c
All complicated cases excluded (severe bowel pathology or neonatal death).
d
Additional data for primary closure (mean 32.3  15.8 days; median 29.5[13–71] days) and for secondary closure (mean 63.7  32.1 days; median
60 [28–142] days).
e
Additional data for primary closure (mean 3.7  3.9 days; median 2.6 [0–15.3] days) and for secondary closure (mean 12.2  12.9 days; median 7.7
[3.6–49.0] days).

Prematurity (<37 weeks of gestation) was documented in
32.6 to 81.3% of patients11,20,35,36,39 compared with 53.8% of
infants in our series (►Table 5).
With regard to surgical management, most studies
compared primary versus secondary closure of gastroschi-
sis.11,33,36,37,40 Methodologically, this is in line with our
study. Primary closure has been performed in 40.0 to 61.1%
11,33,36,37,40
of patients with gastroschisis compared with
71.8% of infants in our cohort. Several studies did not differ-
entiate between treatment modalities,20,34,35,38,39 and one
study reported on fascial versus flap closure.41
Most studies did not report on reinterventions for CAWD-
related morbidity.20,33–35,38–41 However, incidence of
revisional surgery is given with 10.6 to 19.7%11,36,37
compared with 15.4% in our patient collective (►Table 5).
In literature, duration of mechanical ventilation ranges
from 4 days (given as median) to 7 days (given as mean, only
secondary closure)35,37,38,41 (►Table 5). In our cohort, dura-
tion of mechanical ventilation was median 3.7 (0–49.0) days.
Subdividing the cohort according to surgical management,
duration of ventilation was median 2.6 (0–15.3) days for
primary closure only and median 7.7 (3.6–49.0) days for
secondary closure only (►Table 5).
Length of hospital stay for initial surgery has been
reported from 28 days (given as median; only primary
closure) to 57 days (given as mean; only secondary
closure).20,33,35–40 According to our data, length of hospital
stay for all patients with gastroschisis was median 32
(13–142) days. Subdividing the cohort according to surgical
management, hospital stay was median 29.5(13–71) days for

Table 6 Recent publications on national cohorts of omphalocele: Study design

Authors Country No. of patients No. of Study period Subdivision of the cohort
institutions
Benjamin and Wilson34 USA 814 n/d 1999–2008 Simple cases vs. complex cases
35
Corey et al USA 1448 348 1997–2012 None
This study Germany 54 34 2007–2012 Primary vs. secondary closure

Abbreviation: n/d, not defined.

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 Surgical Management of CAWDs in Germany Dingemann et al.

Table 7 Recent publications on national cohorts of omphalocele: Patient’s characteristics and outcome

Authors Associated Prematuritya Surgical Reintervention LOS Mechanical

anomalies management (d) ventilation
(d)
Benjamin and 80% n/d n/d n/d n/d n/d
Wilson34
Corey et al35 35% 40% n/d n/d 17 (median) 2 (median)
This study 63% 22% Primary 15% 33  41 10  29
closure 46% 16 (median) 2 (median)
Secondary
closure 54%

Abbreviations: LOS, length of stay; n/d, not defined.

Note: Figures given in mean  standard deviation or as indicated.
a
< 37 weeks of gestation.

primary closure only and median 60 (28–142) days for borns with omphalocele,7,45,46 which is consistent with our
secondary closure only (►Table 5). data. Single-center-studies suggest that the prognosis of

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Literature Review: Omphalocele
In contrast to the diverse range of recent publications on
gastroschisis, there are only few studies on national cohorts
of omphalocele meeting our inclusion criteria34,35 (►Tables 6
and 7). Associated anomalies were reported in up to 80.3% of
patients34,35 compared with 63.0% in our series (►Table 7).
Prematurity (<37 weeks of gestation) was documented in
40.2% in a study from North America35 compared with 22.2%
of patients in our series (►Table 7).
With regard to surgical management, no differentiation or
detailed description of treatment modality has been made. In
our cohort, primary closure of omphalocele has been encoded
in 46.3%, and secondary closure has been documented in
53.7% of cases. Moreover, reinterventions for CAWD-related
morbidity have not been reported by others. In our patient
collective, 14.8% underwent revisional surgery within 1 year
after initial reconstruction (►Table 7).
The length of hospital stay for initial surgery has been
reported to be a median of 17(9–36) days in North America,35
which is similar to the result of this study of a median of 16
(2–233) days. The same American study reported on a median
of 2 (0–5) days of mechanical ventilation, which is also in line
with a median of 2.2 (0–187.3) days in our cohort (►Table 7).
Discussion
Several attempts have been made to establish criteria that enable
comparison of series of patients with CAWD.42–44 However,
there are no evidence-based guidelines, and there is a large
heterogeneity regarding definitions or functional nomenclature
of CAWD, the optimal timing of intervention, and on which
patients certain techniques should be applied.6,18 Such hetero-
geneity hinders combining literature to obtain a shared consen-
sus on a unique definition and on the optimal treatment
modality of gastroschisis and omphalocele.6
Prematurity and low birth weights are reported to be more
frequent in infants with gastroschisis compared with new-
infants with gastroschisis is determined by the degree of
bowel injury, the severity of illness during the first week of
life, and the immediate postoperative recovery.47–50 Intesti-
nal atresia is the most common associated anomaly in
patients with gastroschisis, with a reported incidence of up
to 23%.51 These data are confirmed by the findings of this
study.
Omphalocele is more likely to be associated with multiple
anomalies and to have a chromosomal or genetic syndrome
etiology when compared with gastroschisis.5,8,18,21,35,46
Chromosomal anomalies are associated in 30 to 40% of
patients with omphalocele.6 We observed a relatively low
proportion of chromosomal anomalies of 9% in our cohort of
infants with omphalocele, which might be caused by incor-
rect coding. However, cardiac anomalies are present in up to
50% of omphalocele cases and gastrointestinal anomalies in
approximately 40%,5 which is in line with our results. The high
incidences of prematurity, intestinal atresia, and low birth
weight in patients with gastroschisis, as well as the high
incidence of cardiac anomalies in our patients with ompha-
locele indicate that our cohort can be considered as
representative.
There are heterogenous results in the current literature
regarding the impact of the different surgical closure strate-
gies on outcomes.5,7,13,18,22,23
Historically, primary closure of gastroschisis was advocat-
ed for all cases.7 Proponents of this approach argue that
delayed closure is associated with a higher rate of sepsis
and a myriad of other complications.52 Based on our results,
primary closure of gastroschisis is the predominant surgical
approach in Germany.
Operative staged reduction has been predominantly
achieved by using synthetic material to cover the defect
and performing delayed closure.11 More recently, other
approaches haven been considered, including primary reduc-
tion in the neonatal intensive care unit with or without
general anesthesia,7,14,19 and the nonoperative initial place-
ment of a preformed silo followed by delayed fascial

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Surgical Management of CAWDs in Germany Dingemann et al.
closure.7,15,16,28,53 In our study, the incidence of postopera-
tive complications did not differ between primary closure and
staged repair of gastroschisis, which indicates that forced
closure may not be necessary.
This was confirmed by a retrospective review on 181
infants. The authors did not find any method of closure to
be superior.52 The results from the Canadian Pediatric
Surgeons Network (CAPSNet) database confirmed these find-
ings in 99 patients with gastroschisis.20
Bonnard et al reported on a higher number of umbilical
hernias in patients who had secondary nonsutured closure of
gastroschisis.54 In contrast, we identified the complication of
an umbilical hernia only after primary closure of a gastro-
schisis. In our series, wound-related complications or infec-
tions were not detected in patients with gastroschisis.18
Literature reports on the duration of mechanical ventilation
after closure of gastroschisis vary considerably.7,15,16,20,28,30,52–55
The only prospective randomized controlled study comparing
primary closure and the use of a preformed silo could not
demonstrate a significant difference in duration of mechanical
ventilation. Though, only uncomplicated cases of gastroschisis had
been enrolled in this trial.16 On the contrary, a recent meta-
analysis of 20 studies demonstrated that primary closure of
gastroschisis was associated with significantly shorter duration
of mechanical ventilation.56 However, recent data from the
CAPSNet database revealed that there was no difference in
ventilation days,20 which was similar to several other
reports.30,52,54,55
With regard to hospitalization, our data could show that
length of hospital stay was significantly shorter after primary
versus secondary closure of gastroschisis. These findings are
confirmed by the CAPSNet study,40 several other
studies,5,23,29,52,57,58 and a recent meta-analysis.56
Although there are a large number of methods used for closure
of omphalocele, they can broadly be broken down by the time
frame of execution: immediate or staged/delayed closure after
epithelialization.18 We could only differentiate between primary
closure, which was clearly defined by the ICPM code, and
secondary closure summarizing all other surgical techniques.
Regarding the rate of postoperative complications, we
did not detect differences between primary and secondary
closure of omphalocele. This has been confirmed by a recent
study23 and a Dutch survey, which indicated that patients
with minor and giant omphalocele report similar long-term
results and that the quality of life in both groups is
comparable to that of healthy young adults.59 Wound-
related complications or infections were not detected in
omphalocele patients of this study as reported by others. 18
Infants with large omphalocele may present with signifi-
cant respiratory insufficiency and may require substantial
ventilatory support.7,47 Nonetheless, associated malforma-
tions may have an impact on ventilator dependency,12,31,60
which may explain the higher number of ventilator days in
patients with omphalocele compared with patients with
gastroschisis in our study.
A recent study demonstrated that 13 patients after prima-
ry closure had less time on the ventilator compared with the
11 patients who underwent staged repair.31 However, only
European Journal of Pediatric Surgery
large defects had been included. According to our data, the
method of closure did not affect dependency on ventilator
and had no impact on the length of hospital stay, which is
consistent with previous findings.7,23
The data of this study were derived from one of the major
public health insurance companies in Germany, which
excludes data collection bias. In this context, it has to be
stressed that the data reflect the outcome of patients who
had been clients of the health insurance company TK only.
Therefore, only 10% of the national cohort could be analyzed.
There are other drawbacks of our study. We were not able to
describe either the size of the CAWD or the extent of involve-
ment of intra-abdominal organs. Further, we could not assess
the severity of associated malformations. Therefore, we cannot
exclude a potential selection bias due to the fact that unstable
patients or those with great intestinal damage or large defects
were more likely to undergo secondary repair. Documented
complications increase the income of the hospital in the
German health care system. Therefore, we assume that the
number of missed complications in the current study is low.
Downloaded by: Washington University. Copyrighted material.
Additionally, only diagnoses and reinterventions within 1 year
after the index event were analyzed, and data on long-term
outcome are missing. Patients with a shorter follow-up period
have been excluded from the study ab initio. This methodolog-
ical approach might result in early dropouts, and mortality and
complications might have been missed.
Other factors that might have affected the results of our
study could be excluded. In Germany, individuals freely
choose among >130 public health insurance companies. As
health insurance companies and hospitals are independent
from each other, the choice of the insurance company could
not have affected the treatment modalities. Moreover, none
of the patients of this series could have gone to hospitals with
different funding sources for further treatment including
complications. All patients included in this study remained
clients of the TK throughout the study period of 1 year after
the index event.
Conclusion
The claims database of one of the largest German public
health insurance was used in this study. Unbiased data
could demonstrate for the first time that the quality of the
current surgical management of newborns with CAWD
across Germany is excellent compared with international
reports.
Primary closure of gastroschisis is the predominant surgi-
cal approach in Germany. This approach was associated with a
significantly shorter duration of mechanical ventilation and
of hospitalization compared with secondary closure. In
patients with omphalocele, duration of ventilation and
hospitalization were not affected by the surgical strategy.
There was no correlation between method of closure and
complications for both entities of CAWD.
Funding
No funding was received from any organization.
 Surgical Management of CAWDs in Germany
Conflict of Interest
The presented material is original research. The content of
this manuscript has not been previously published or
submitted for publication elsewhere. The manuscript has
been seen and approved by all authors. The authors have
no potential conflicts of interest to disclose (financial,
professional, or personal).
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