Does Surgical Management Alter Outcome in Necrotizing Enterocolitis?

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Key points

  • Surgical intervention is required in 30% to 50% of NEC cases, and carries a 40% to 50% mortality risk, with up to 70% morbidity.

  • Preoperative management, surgical patient selection, and operative timing vary widely across surgeons and institutions.

  • The question of peritoneal drainage versus laparotomy as both primary and definitive therapy has been investigated in two randomized controlled trials, but controversy remains.

  • Surgical NEC is associated with long-term neurodevelopmental impairment, and

Significance of surgical necrotizing enterocolitis

Although the overall incidence of NEC is approximately 1 in 1000 live births, incidence is 14% in infants weighing less than 1000 g, and is increasing as neonatal care for premature infants improves.6, 7, 8 Most cases are managed medically, but 30% to 50% of infants with NEC require surgical intervention.3, 6, 7, 9, 10, 11 The distinction between “medical NEC” and “surgical NEC” is significant. Surgical NEC carries a mortality risk of 40% to 50%,6, 8, 10, 12, 13 and a high morbidity in the

Preoperative Management

Management of NEC is determined by the severity of disease, defined by the modified Bell staging criteria.4, 6, 14, 27 Most centers have developed management protocols based on Bell staging, but these protocols are idiosyncratic and no algorithmic standard exists across institutions. The tenets of medical therapy are bowel rest and decompression, intravenous fluids and nutrition, antibiotics, and serial examinations and radiographs.4, 6, 14, 22 However, there is wide variation in antibiotic

Principles of surgery for necrotizing enterocolitis

Although the spectrum of surgical options is broad, the operative strategies share common underlying goals. There are four main principles of surgical management of NEC:

  • Early intervention to reduce contamination and sepsis

  • Resect or defunctionalize gangrenous bowel

  • Avoid or reduce multiorgan dysfunction

  • Preserve bowel length to avoid short gut syndrome

The specific approach is dictated by three factors:

  • Size of the infant

  • Extent of disease

  • Degree of metabolic derangement

Within this context, however,

Surgical options

The available surgical options depend on the extent of disease, usually classified as focal (single segment of disease), multifocal (multiple segments of disease), or panintestinal (disease affects 75% of bowel or more).11, 22 Because the extent of disease is not usually known before operation, Pierro and colleagues36 have advocated the use of laparoscopy in the intensive care unit to guide decision-making, but this approach has not been widely adopted.33 For focal disease, the standard

Management at laparotomy

At laparotomy, the full extent of disease is assessed and necrotic bowel is resected. Classically, distal bowel is defunctionalized with formation of an enterostomy, because of concern that primary anastomosis is too high-risk in the setting of metabolic derangement and systemic inflammation. However, enterostomy also carries risks of fluid and electrolyte imbalances, skin breakdown, stoma prolapse or retraction, and the need for stoma reversal, with an overall complication rate higher than 50%.

Laparotomy versus peritoneal drainage as primary operation

In the 1970s, Ein and colleagues44 reported the bedside insertion of a peritoneal drain under local anesthesia for five infants whose low weight, prematurity, and severe metabolic derangement made them too high risk for laparotomy. This strategy gained traction over the ensuing decades, although it is not in universal use (15% to 95% of surgeons use PD, depending on the practice context).31, 32, 33 Dozens of retrospective studies over the past three decades have reported variable results; some

Laparotomy versus peritoneal drainage as definitive therapy

The use of PD as definitive therapy was introduced in a retrospective series by Ein and colleagues39 in 1990, which reported that 32% of patients undergoing primary PD recovered without requiring laparotomy. Since then, other studies have shown that 30% to 70% of patients can be treated with PD alone.9, 10, 13, 51, 53, 59, 61 Even in cases of clinical deterioration after PD, several authors have questioned the benefit of laparotomy in rescuing such patients.17, 61, 62 However, not all studies

Panintestinal disease

Multifocal disease is found in about 55% of patients undergoing laparotomy, whereas panintestinal disease occurs in approximately 15%.19, 42, 63 Outcomes in cases of severe multifocal or panintestinal disease are poor. The risk of death in panintestinal disease, defined as less than 25% of total bowel remaining, is 70% or worse, and survivors are likely to have short gut syndrome and numerous ensuing complications.19, 42, 63 To preserve all possible bowel length, resection of necrotic-appearing

Postoperative management and recovery

Whether PD or laparotomy is undertaken, the overall clinical condition of the patient does not usually improve immediately.60 In fact, a systemic inflammatory response is expected postoperatively, and infants may require aggressive ventilatory and circulatory support and blood product transfusion. After clinical stabilization is achieved, aggressive support measures are weaned and enteral feeds are slowly advanced. The major early complications after surgical management of NEC are stricture,

Summary: resolving the controversies and moving forward

NEC is a complex problem, and treatment has historically been driven by retrospective experience at the surgeon or institutional level. Thus, controversies remain despite decades of experience, and include the spectrum of preoperative management, indications for surgery and patient selection, PD versus laparotomy, primary anastomosis versus enterostomy, innovative strategies for panintestinal disease, and long-term outcomes. In particular, it is important to appropriately measure and consider

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    • Surgical necrotizing enterocolitis: Association between surgical indication, timing, and outcomes

      2021, Journal of Pediatric Surgery
      Citation Excerpt :

      A final limitation is that as a UK based observational study we are unable to comment on whether these findings are applicable to other healthcare settings. Whilst the principle of surgery for NEC is early intervention to reduce contamination and sepsis without subjecting infants with non-ischaemic bowel to unnecessary surgery [10,11], the lack of agreement in indications of surgery amongst surgeons [7] suggest that these principles may be implemented with variation. As such the decision making process around the time of surgery represents a potential opportunity to influence outcome [12], something that is desperately needed for infants with NEC [2].

    View all citing articles on Scopus
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