Improving gastroschisis outcomes: Does birth place matter? Kate B. Savoie a , Eunice Y. Huang a , Shahroz K. Aziz b , Martin L. Blakely c , Sid Dassinger d , Amanda R. Dorale e , Eileen M. Duggan c , Matthew T. Harting b , Troy A. Markel e , Stacey D. Moore-Olufemi b , Sohail R. Shah f , Shawn D. St. Peter f , Koujen Tsao b , Deidre L. Wyrick d , Regan F. Williams a, ⁎ a University of Tennessee Health Science Center, Memphis, Tennessee b University of Texas at Houston, Houston, Texas c Vanderbilt University, Nashville, Tennessee d University of Arkansas, Little Rock, Arkansas e Indiana University School of Medicine, Indianapolis, Indiana f University of Missouri-Kansas City, Kansas City, Missouri abstract article info Article history: Received 25 August 2014 Accepted 5 September 2014 Available online xxxx Key words: Gastroschisis Birthplace Birth location Regionalization Outcomes Purpose: Babies born in the hospital where they obtain definitive surgical care do not require transportation be- tween institutions and may have shorter time to surgical intervention. Whether these differences result in mean- ingful improvement in outcomes has been debated. A multi-institutional retrospective study was performed comparing outcomes based on birthplace. Methods: Six institutions within the PedSRC reviewed infants born with gastroschisis from 2008 to 2013. Birth- place, perinatal, and postoperative data were collected. Based on the P-NSQIP definition, inborn was defined as birth at the pediatric hospital where repair occurred. The primary outcome was days to full enteral nutrition (FEN; 120 kcal/kg/day). Results: 528 patients with gastroschisis were identified: 286 inborn, 242 outborn. Days to FEN, time to bowel coverage and abdominal wall closure, primary closure rate, and length of stay significantly favored inborn patients. In multivariable analysis, birthplace was not a significant predictor of time to FEN. Gestational age, pres- ence of atresia or necrosis, primary closure rate, and time to abdominal wall closure were significant predictors. Conclusions: Inborn patients had bowel coverage and definitive closure sooner with fewer days to full feeds and shorter length of stay. Birthplace appears to be important and should be considered in efforts to improve out- comes in patients with gastroschisis. © 2014 Elsevier Inc. All rights reserved. 1. Background The incidence of gastroschisis is approximately 1 in 4000 live births [1], with many studies showing an increasing worldwide incidence [2,3]. Appropriate care of these patients requires prompt surgical intervention, as some studies have shown improved outcomes with earlier definitive closure [4,5]. Recently, there has been a drive towards region- alization of care in neonates with complex congenital anomalies, such as gastroschisis [6,7]. However, the data to support a significant benefit to delivering gastroschisis neonates at institutions with immediate access to pediatric surgical providers and facilities are inconclusive [5,8–15]. Although there is literature to support the hypothesis that early definitive abdominal wall closure can improve outcomes, such as decreased time to feeding and length of stay, overly aggressive primary closure has also been associated with severe complications, such as abdominal compart- ment syndrome, respiratory failure, and intestinal compromise [16,17]. This has led some to hypothesize that birth at an institution capable of surgically treating gastroschisis may be of benefit; however, birth at a re- gional facility may be difficult without scheduling the delivery or transporting the laboring mother. Balancing the needs of the neonate with the safety of the delivering mother is paramount. To date, there have been nine single institution retrospective studies and one large national database study that have reviewed whether loca- tion of birth is associated with significant differences in outcomes, with contradictory results (Table 1). An additional multi-institutional study utilizing consistent data definitions across institutions may help further inform this discussion. In collaboration with the Pediatric Surgery Research Collaborative (PedSRC), we evaluated whether location of birth might affect time to intervention for neonates with gastroschisis, and if earlier intervention might affect outcomes and complication rates. We hypothesize that Journal of Pediatric Surgery xxx (2014) xxx–xxx ⁎ Corresponding author. E-mail addresses: ksavoie@uthsc.edu (K.B. Savoie), ehuang@uthsc.edu (E.Y. Huang), shahroz.k.aziz@uth.tmc.edu (S.K. Aziz), martin.blakely@vanderbilt.edu (M.L. Blakely), dassingermelvins@uams.edu (S. Dassinger), adorale@iupui.edu (A.R. Dorale), eileen.m.duggan@vanderbilt.edu (E.M. Duggan), matthew.t.harting@uth.tmc.edu (M.T. Harting), tmarkel@iupui.edu (T.A. Markel), stacey.d.moore-olufemi@uth.tmc.edu (S.D. Moore-Olufemi), sshah@cmh.edu (S.R. Shah), sspeter@cmh.edu (S.D. St. Peter), koujen.tsao@uth.tmc.edu (K. Tsao), dlwyrick@uams.edu (D.L. Wyrick), rfwillia@uthsc.edu (R.F. Williams). http://dx.doi.org/10.1016/j.jpedsurg.2014.09.019 0022-3468/© 2014 Elsevier Inc. All rights reserved. Contents lists available at ScienceDirect Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg Please cite this article as: Savoie KB, et al, Improving gastroschisis outcomes: Does birth place matter?, J Pediatr Surg (2014), http://dx.doi.org/ 10.1016/j.jpedsurg.2014.09.019