Conservative management of exomphalos major with silver dressings: are they safe?

doi:10.1016/j.jpedsurg.2010.08.013

Journal of Pediatric Surgery

Volume 45, Issue 12, December 2010, Pages 2438-2439

https://doi.org/10.1016/j.jpedsurg.2010.08.013 Get rights and content

Abstract

Historically, some dressings used in exomphalos major were associated with toxicity. These have been abandoned in favor of safer dressings. Silver toxicity has not been described following the use of silver dressings in infants. We, however, found disconcerting serum silver levels in 2 consecutive patients during treatment with silver salt containing dressings.

Section snippets

Case 1

A baby girl with antenatally detected exomphalos major was delivered at term via elective cesarean section. She had an 8-cm hole in the sac at birth which was effectively repaired with interrupted Prolene sutures. Conservative management was carried out using daily silver sulfadiazine dressings designed to apply controlled compression to remodel the herniated liver and expand the small abdominal cavity. The serum silver level on day 21 was 73 mg/L (682 nmol/L). In response to this, dressings

Case 2

A girl with an antenatally diagnosed exomphalos major was delivered at term by elective cesarean section and was managed conservatively with daily or alternate day pressure dressings over a layer of Urgotul or Urgotul SSD. Urgotul was chosen, since we anticipated that the silver levels might be less worrisome. At 22 days, the serum silver was 20 mg/L (187 nmol/L). Urgotul and Urgotul SSD were discontinued, and dressings were carried out with Jelonet. No local or systemic manifestations of

Discussion

Silver dressings have well-recognized antimicrobial properties [5], [6]. They have been used successfully to prevent burns wound infection and sepsis. When silver sulfadiazine is applied to burns involving a large surface area, the sulfadiazine component is absorbed and may produce adverse effects [7]: these include allergic reactions, hyperosmolality, methemoglobinemia, and hemolysis caused by a lack of glucose-6-phospate dehydrogenase enzyme. Similarly, the silver component of burns dressing

References (13)

WakhluA. et al.
The management of exomphalos
J Pediatr Surg
(2000)
RussellA.D. et al.
Antimicrobial activity and action of silver
Prog Med Chem
(1994)
WrightJ.B. et al.
Efficacy of topical silver against fungal burn wound pathogens
Am J Infect Control
(1999)
LockhartS.P. et al.
Topical silver sulphadiazine: side effects and urinary excretion
Burns
(1983)
LeeS.L. et al.
Initial nonoperative management and delayed closure for treatment of giant omphaloceles
J Pediatr Surg
(2006)
ArmitageS.A. et al.
The determination of silver in whole blood and its application to biological monitoring of occupationally exposed groups
Ann Occup Hyg
(1996)

There are more references available in the full text version of this article.

Cited by (17)

Giant omphalocele treated with simple daily dressing changes
2022, Journal of Pediatric Surgery Case Reports
Citation Excerpt :
Ahlfeld in 1899 described painting an omphalocele sac with alcohol to produce an eschar and awaiting contraction and epitheliazation. Although different local agents have been used in the past, they proved to be potentially toxic and should be avoided [2–5]. Commonly practiced and popularized technique of silo closure has been associated with hemodynamic compromise, dehiscence, and inability to close the abdomen with subsequent death due to neonatal sepsis.
Omphalocele, also called exomphalos, is an anterior abdominal wall midline defect of variable size involving the umbilical ring containing the herniated viscera into a sac made up of peritoneum, amnion and Wharton's jelly. Giant omphalocele is an extreme version of this defect management of which is challenging. Author is reporting here a case of giant omphalocele managed initially by a simple yet novel conservative technique yielding subsequently good result.
Exomphalos major: Conservative management using Manuka honey dressings and an outreach surgical nursing team
2021, Journal of Pediatric Surgery
Citation Excerpt :
Theoretical risks associated with these techniques occur because of systemic absorption; mercury compounds [5] and alcohol have now been completely abandoned. Risks of exposure to silver compounds may be associated with nephrotic syndrome or leukopaenia [6], and iodine compounds maybe associated with suppression of thyroid function [7]; these concerns have limited the enthusiasm for their use and the search for new products continued. In 2007, medical grade Manuka Honey™ was approved by the US FDA for use in wound management.
Controversy exists over the best dressing for conservative management of exomphalos major. Here we describe our experience of using Manuka Honey.
Our regimen involved covering the sac with Manuka honey (Advancis Medical™) wrapped with gauze and crepe bandage. Initially, dressings were changed 3 times a week and then twice weekly until full epithelialisation. Babies went home after reaching full feeds, with our outreach nurses continuing dressings in clinic until the parents were trained to do them alone. Only patients needing management of co-morbidities were transferred to our unit. Patients would be reviewed by video consultation. Data was prospectively collected.
From 2011–2019, 24 consecutive patients (11:13 M:F; median gestation 37 weeks, birth weight 3.1 kg) with exomphalos major were managed with honey dressings. Fourteen babies had significant associated anomalies of which 10 died of problems unrelated to the exomphalos. Time to full feeds 6 (2-58) days; time to discharge 21(7–66) days if no associated anomalies; time to epithelialisation 73 (27–199) days. Dressings were well tolerated. Definitive closure occurred at 17(11–38) months and was uneventful. No patient required fundoplication and all patients were orally fed. Only one patient developed a clinically significant infection.
This is the largest report of using Manuka honey for the management of exomphalos major. Benefits include early feeding, early discharge and a ‘normalisation’ of the neonatal period. Key to our success was the surgical outreach service supporting parents doing the dressings, first at the local hospital and then at home.
Management of narrow stalked giant omphalocele using tissue expansion, staged closure, and amnion preservation technique
2019, Journal of Pediatric Surgery Case Reports
Giant omphaloceles (GO) frequently present challenges to closure that are often influenced by patient factors, including degree of visceroabdominal disproportion, associated comorbidities (including pulmonary hypoplasia), and variation in surgeon preference for both technique and timing of abdominal wall reconstruction.
In this case report, we describe our experience with a GO that presented the unique challenge of an uncharacteristically small fascial defect through which all structures (including liver) were herniated. The challenges of the small defect, both in potentially limiting the growth of healthy neoskin and preventing any degree of visceral reduction by compression are highlighted. An innovative reconstructive solution developed in collaboration with plastic surgery is described.
Complications in neonatal surgery
2016, Seminars in Pediatric Surgery
Citation Excerpt :
Leukopenia is no longer considered a side effect. Nevertheless, excluding a report of two patients with increased serum levels of silver,337 long-term studies have not demonstrated any complications from silver sulfadiazine therapy in omphalocele.334,338 Topical povidone-iodine is an alternative antiseptic commonly available in the hospital setting.
Neonatal surgery is recognized as an independent discipline in general surgery, requiring the expertise of pediatric surgeons to optimize outcomes in infants with surgical conditions. Survival following neonatal surgery has improved dramatically in the past 60 years. Improvements in pediatric surgical outcomes are in part attributable to improved understanding of neonatal physiology, specialized pediatric anesthesia, neonatal critical care including sophisticated cardiopulmonary support, utilization of parenteral nutrition and adjustments in fluid management, refinement of surgical technique, and advances in surgical technology including minimally invasive options. Nevertheless, short and long-term complications following neonatal surgery continue to have profound and sometimes lasting effects on individual patients, families, and society.
Abdominal wall defects: Prenatal diagnosis, newborn management, and long-term outcomes
2014, Seminars in Pediatric Surgery
Citation Excerpt :
Earlier reports describing the use of mercurochrome, alcohol, and silver nitrate as eschar-producing agents were very effective but also associated with toxicity and therefore abandoned. Subsequently, there have been reports of a number of other topical agents used, including silver sulfadiazine, povidone–iodine solution, silver-impregnated dressings, neomycin, and polymyxin/bacitracin ointments.15,16 Eschar and epithelialization may take 4–10 weeks to complete, and in some cases, patients may complete the process after hospital discharge.
Omphalocele and gastroschisis represent the most frequent congenital abdominal wall defects a pediatric surgeon is called to treat. There has been an increased reported incidence in the past 10 years mainly due to the diffuse use of prenatal ultrasound. The early detection of these malformations, and related associated anomalies, allows a multidisciplinary counseling and planning of delivery in a center equipped with high-risk pregnancy assistance, pediatric surgery, and neonatology. At present times, closure of defects, even in multiple stages, is always possible as well as management of most of cardiac-, urinary-, and gastrointestinal-associated malformations. The progress, herein discussed, in the care of newborns with abdominal wall defects assures most of them survive and reach adulthood. Some aspects of transition of medical care will also be considered, including fertility and cosmesis.
Advances in Surgery for Abdominal Wall Defects. Gastroschisis and Omphalocele
2012, Clinics in Perinatology
Citation Excerpt :
Initial reports described mercurochrome, alcohol, and silver nitrate as the eschar-producing agents, which were very effective, but associated with toxicity and abandoned.20 Subsequently, there have been reports of a number of agents used, including silver sulfadiazine, povidone–iodine solution, silver impregnated dressings, neomycin, and polymixin/bacitracin ointments.20–24 The eschar and epithelialization may take over 4 to 10 weeks to complete, and in some cases, patients complete the process after discharge.

View all citing articles on Scopus

View full text

Independent case reportsConservative management of exomphalos major with silver dressings: are they safe?

Abstract

Section snippets

Case 1

Case 2

Discussion

J Pediatr Surg

Prog Med Chem

Am J Infect Control

Burns

J Pediatr Surg

Ann Occup Hyg

Independent case reports
Conservative management of exomphalos major with silver dressings: are they safe?