Coming full circle: an evidence-based definition of the timing and type of surgical management of very low-birth-weight (<1000 g) infants with signs of acute intestinal perforation

https://doi.org/10.1016/j.jpedsurg.2005.11.041Get rights and content

Abstract

Objective

Gut disruption in very low birth weight follows 1 of 3 clinical pathways: isolated perforation with sudden free air, metabolic derangement (MD) complicated by appearance of free air, or progressive metabolic deterioration without evidence of free air. To refine evidence-based indications for peritoneal drainage (PD) vs laparotomy (LAP), we hypothesized that MD acuity is the determinant of outcome and should dictate choice of PD or LAP.

Methods

Very low-birth-weight infants referred for surgical care because of free intraperitoneal air or MD associated with signs of enteritis were evaluated by univariate or multivariate logistic regression to investigate the effect on mortality of MD and initial surgical care (LAP vs PD). Metabolic derangement was scaled by assigning 1 point each for thrombocytopenia, metabolic acidosis, neutropenia, left shift of segmented neutrophils, hyponatremia, bacteremia, or hypotension. Laparotomy and PD were stratified by MD acuity, and odds of mortality were calculated for each surgical option.

Results

From October 1991 to December 2003, 65 very low-birth-weight infants with suspected gut disruption were referred for surgical care. Peritoneal drainage and LAP infants had similar birth weight and gastrointestinal age, neither of which predicted mortality. Despite a higher incidence of isolated perforation with sudden free air in PD infants, the incidence of MD and overall mortality were similar for PD and LAP. Multivariate logistic regression demonstrated MD to be the best predictor of mortality (odds ratio [OR], 4.76; confidence interval [CI], 1.41-16.13, P = .012), which significantly increased with interval between diagnosis to surgical intervention (P < .05). Infants with MD receiving PD had a 4-fold increase in mortality (OR, 4.43; CI, 1.37-14.29; P = .0126). Conversely, those without MD and sudden free air who underwent LAP had a 3-fold increase in mortality (OR, 2.915; CI, 1.107-7.692; P = .03.) Of 5, 3 failed PD were “rescued” by LAP.

Conclusions

The dramatic difference in mortality odds based on surgical option in the presence of MD defines the critical importance of a thorough assessment of physiological status to exclude MD. Absence of MD warrants consideration for PD, especially for sudden intraperitoneal free air. Overwhelming MD may limit options to PD; however, salvage of 3 of 5 infants with failed PD demonstrates the value of LAP, whenever possible, for infants with MD.

Section snippets

Methods

The neonatal research database at the University of Florida Health Science Center, Jacksonville, has been accruing clinical patient information continuously since its inception in 1991. Every neonatology patient's data is entered concurrent with care under the supervision of a single neonatologist (RS). The intensive care nursery is a regional perinatal critical care referral facility where a single, multidisciplinary faculty provides care to all admitted babies. With appropriate institutional

Results

Between October 1991 and December 2003, 65 VLBW infants with suspected gut disruption were referred for surgical care. Exclusion of the 9 babies who received both PD and LAP allowed comparison of 56 infants who received either PD or LAP as initial surgical care. Peritoneal drainage and LAP infants had similar BW and GA (Table 2). Logistic regression demonstrated MD to be the best predictor of mortality, which significantly increased with the time interval from diagnosis to surgical intervention

Discussion

Physiological stress, commonly seen in the high-risk newborn, will cause shunting of blood from the splanchnic circulation. This may produce at least transient hypoperfusion of the intestine, increasing intestinal permeability [11], [12]. This then allows bacterial translocation, which can stimulate multiple organ dysfunction. Recognizing that inappropriate operative intervention may impose additive stress and that ineffective debridement may accentuate sepsis, the decision between PD and LAP

Cited by (32)

  • Incidence of spontaneous intestinal perforations exceeds necrotizing enterocolitis in extremely low birth weight infants fed an exclusive human milk-based diet: A single center experience

    2021, Journal of Pediatric Surgery
    Citation Excerpt :

    Literature suggests that human milk's immunoprotective and gut-maturational properties may help to reduce the incidence of NEC [6,7,9,10]. In addition, standardized feeding protocols are associated with a decrease in NEC [31]. As the clinical presentation of SIP and NEC can be difficult to differentiate, this new relative incidence is an important finding for physicians to keep in mind as they try to identify a definitive diagnosis.

  • Does Surgical Management Alter Outcome in Necrotizing Enterocolitis?

    2019, Clinics in Perinatology
    Citation Excerpt :

    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).31–33 Dozens of retrospective studies over the past three decades have reported variable results; some showed comparable survival between PD and laparotomy,39,45–47 some showed higher mortality in the PD group,48–50 and others posited that severity of disease and metabolic derangement determined outcome.34,35 Over the past 20 years, several systematic reviews, meta-analyses, and prospective multicenter cohort studies have indicated that PD is associated with increased mortality,9,12,13,51,52 with the exception of a propensity-matched Kids Inpatient Database study that showed a 47% survival with PD compared with 37% survival with laparotomy as initial treatment.53

View all citing articles on Scopus

Presented at the 52nd Annual Congress of British Association of Paediatric Surgeons, Dublin, Ireland, July 12-15, 2005.

View full text