Initial surgical treatment of necrotizing enterocolitis: a meta-analysis of peritoneal drainage versus laparotomy

Construction and evaluation of a risk model for adverse outcomes of necrotizing enterocolitis based on LASSO-Cox regression

Objective

This study aimed to develop a nomogram to predict adverse outcomes in neonates with necrotizing enterocolitis (NEC).

Methods

In this retrospective study on neonates with NEC, data on perinatal characteristics, clinical features, laboratory findings, and x-ray examinations were collected for the included patients. A risk model and its nomogram were developed using the least absolute shrinkage and selection operator (LASSO) Cox regression analyses.

Results

A total of 182 cases of NEC were included and divided into a training set (148 cases) and a temporal validation set (34 cases). Eight features, including weight [p = 0.471, HR = 0.99 (95% CI: 0.98-1.00)], history of congenital heart disease [p < 0.001, HR = 3.13 (95% CI:1.75-5.61)], blood transfusion before onset [p = 0.757, HR = 0.85 (95%CI:0.29-2.45)], antibiotic exposure before onset [p = 0.003, HR = 5.52 (95% CI:1.81-16.83)], C-reactive protein (CRP) at onset [p = 0.757, HR = 1.01 (95%CI:1.00-1.02)], plasma sodium at onset [p < 0.001, HR = 4.73 (95%CI:2.61-8.59)], dynamic abdominal x-ray score change [p = 0.001, HR = 4.90 (95%CI:2.69-8.93)], and antibiotic treatment regimen [p = 0.250, HR = 1.83 (0.65-5.15)], were ultimately selected for model building. The C-index for the predictive model was 0.850 (95% CI: 0.804-0.897) for the training set and 0.7880.788 (95% CI: 0.656-0.921) for the validation set. The area under the ROC curve (AUC) at 8-, 10-, and 12-days were 0.889 (95% CI: 0.822-0.956), 0.891 (95% CI: 0.829-0.953), and 0.893 (95% CI:0.832-0.954) in the training group, and 0.812 (95% CI: 0.633-0.991), 0.846 (95% CI: 0.695-0.998), and 0.798 (95%CI: 0.623-0.973) in the validation group, respectively. Calibration curves showed good concordance between the predicted and observed outcomes, and DCA demonstrated adequate clinical benefit.

Conclusions

The LASSO-Cox model effectively identifies NEC neonates at high risk of adverse outcomes across all time points. Notably, at earlier time points (such as the 8-day mark), the model also demonstrates strong predictive performance, facilitating the early prediction of adverse outcomes in infants with NEC. This early prediction can contribute to timely clinical decision-making and ultimately improve patient prognosis.

Comparison of preoperative and intraoperative surgeon diagnosis and pathologic findings in spontaneous intestinal perforation vs necrotizing enterocolitis

OBJECTIVE

To investigate the accuracy of preoperative and intraoperative diagnosis via comparison to pathologic diagnosis in spontaneous intestinal perforation (SIP) vs. necrotizing enterocolitis (NEC).

STUDY DESIGN

A retrospective review of neonates <1500 g treated for pneumoperitoneum between 07/2004-09/2022 was conducted. Patients treated for NEC medically prior to diagnosis and those treated with drain only were excluded. Fleiss' Kappa analysis assessed agreement between all three diagnoses: preoperative, intraoperative, and pathologic.

RESULT

Overall, 125 patients were included with mean birthweight 834.2 g (SD:259.2) and mean gestational age 25.8 weeks (SD:2.2). Preoperative and intraoperative diagnoses agreed in 90.3%, intraoperative and pathologic agreed in 71.1%, and preoperative and pathologic agreed in 75.2% of patients. Fleiss' Kappa was 0.55 (95% CI:0.43,0.68), indicating moderate agreement between the three diagnoses.

CONCLUSION

Our study shows moderate agreement between preoperative, intraoperative, and pathologic diagnoses. Further studies investigating the clinical characteristics of SIP and NEC are needed to improve diagnostic accuracy and management.

Perforated Meckel's Diverticulum and Adhesive Intestinal Obstruction in a Preterm Neonate: A Case Report

Perforated bowel and adhesive intestinal obstruction are common indications for emergency surgical intervention in a preterm neonate. The initial approach to managing perforation involves either peritoneal drain insertion or formal laparotomy. Once a neonate presents with complete bowel obstruction, prompt abdominal exploration becomes crucial. One prevalent cause of bowel obstruction in this population is adhesions resulting from previous surgeries. This report details the case of a preterm, extremely low birth weight neonate experiencing pneumoperitoneum, initially managed with an intraperitoneal drain. Despite temporary improvement, the infant developed recurrent pneumoperitoneum, necessitating formal exploratory laparotomy. Approximately one month post-surgery, the baby encountered complete bowel obstruction due to adhesive intestinal obstruction, requiring a second exploratory laparotomy. The child survived both surgical interventions and is thriving at follow-up. Our findings suggest that in select cases, intraperitoneal drain placement may suffice. However, there is a need for further research to improve the suspicion and diagnosis of Meckel's diverticulum perforations in neonates. Additionally, vigilant assessment and timely intervention for adhesive intestinal obstruction can enhance bowel salvage outcomes.

Outcome Reporting in Interventional Necrotizing Enterocolitis Studies: A Systematic Review

BACKGROUND

Despite an increasing necrotizing enterocolitis (NEC) incidence, treatment strategies have failed to make major advancements towards improved NEC outcomes. Heterogeneity in outcome reporting and a lack of treatment efficacy studies potentially hamper these advancements. We aimed to analyze outcome reporting in recent interventional NEC studies.

METHODS

We performed a systematic review identifying interventional studies on NEC between 1st of January 2016 and 1st of June 2023 in MEDLINE, Embase, CENTRAL and Cochrane reviews. Systematic reviews, clinical trials and change-in-practice cohort studies reporting any therapeutic intervention for NEC patients (Bell's stage ≥ IIa) were eligible. We excluded studies on NEC diagnostics or prevention and non-English publications. Outcomes were categorized into five core areas and presented descriptively. The review was registered with PROSPERO (CRD42022302712).

RESULTS

Out of 1.642 screened records, 65 were eligible for full-text review and 15 were finally included for data extraction. Median number of reported outcomes per article was six (range 1-19). We identified 66 unique outcomes, which were mapped to 53 outcome terms. Thirty-four out of the 53 of the outcome terms (64%) were only reported in a single article. Mortality was the most reported outcome (11/15 articles, 73%). Core area 'Adverse outcomes' contained the most outcome terms (n = 19), whereas 'Life impact' contained the least outcome terms (n = 4) and was represented in 3 articles (20%).

CONCLUSIONS

Considerable heterogeneity in outcome reporting and a paucity of outcomes concerning 'Life impact' exist in interventional NEC studies. Development of a NEC core outcome set may improve consistency and patient-relevance in outcome reporting.

STUDY TYPE

Systematic Review and Meta-Analyses.

LEVEL OF EVIDENCE

III.

Factors Influencing Neonatal Gut Microbiome and Health with a Focus on Necrotizing Enterocolitis

Maturational changes in the gut start in utero and rapidly progress after birth, with some functions becoming fully developed several months or years post birth including the acquisition of a full gut microbiome, which is made up of trillions of bacteria of thousands of species. Many factors influence the normal development of the neonatal and infantile microbiome, resulting in dysbiosis, which is associated with various interventions used for neonatal morbidities and survival. Extremely low gestational age neonates (<28 weeks' gestation) frequently experience recurring arterial oxygen desaturations, or apneas, during the first few weeks of life. Apnea, or the cessation of breathing lasting 15-20 s or more, occurs due to immature respiratory control and is commonly associated with intermittent hypoxia (IH). Chronic IH induces oxygen radical diseases of the neonate, including necrotizing enterocolitis (NEC), the most common and devastating gastrointestinal disease in preterm infants. NEC is associated with an immature intestinal structure and function and involves dysbiosis of the gut microbiome, inflammation, and necrosis of the intestinal mucosal layer. This review describes the factors that influence the neonatal gut microbiome and dysbiosis, which predispose preterm infants to NEC. Current and future management and therapies, including the avoidance of dysbiosis, the use of a human milk diet, probiotics, prebiotics, synbiotics, restricted antibiotics, and fecal transplantation, for the prevention of NEC and the promotion of a healthy gut microbiome are also reviewed. Interventions directed at boosting endogenous and/or exogenous antioxidant supplementation may not only help with prevention, but may also lessen the severity or shorten the course of the disease.

Laparotomy versus Peritoneal Drainage as Primary Treatment for Surgical Necrotizing Enterocolitis or Spontaneous Intestinal Perforation in Preterm Neonates: A Systematic Review and Meta-Analysis

AIM

to systematically review and meta-analyze the impact on morbidity and mortality of peritoneal drainage (PD) compared to laparotomy (LAP) in preterm neonates with surgical NEC (sNEC) or spontaneous intestinal perforation (SIP).

METHODS

Medical databases were searched until June 2022 for studies comparing PD and LAP as primary surgical treatment of preterm neonates with sNEC or SIP. The primary outcome was survival during hospitalization; predefined secondary outcomes included need for parenteral nutrition at 90 days, time to reach full enteral feeds, need for subsequent laparotomy, duration of hospitalization and complications.

RESULTS

Three RCTs (N = 493) and 49 observational studies (N = 19,447) were included. No differences were found in the primary outcome for RCTs, but pooled observational data showed that, compared to LAP, infants with sNEC/SIP who underwent PD had lower survival [48 studies; N = 19,416; RR 0.85; 95% CI 0.79-0.90; GRADE: low]. Observational studies also showed that the subgroup of infants with sNEC had increased survival in the LAP group (30 studies; N = 9370; RR = 0.82; 95% CI 0.72-0.91; GRADE: low).

CONCLUSIONS

Compared to LAP, PD as primary surgical treatment for sNEC or SIP has similar survival rates when analyzing data from RCTs. PD was associated with lower survival rates in observational studies.