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Hapnes NC, Stensvold HJ, Bjørnland K, Sæter T, Guthe HJT, Støen R, Moltu SJ, Rønnestad A, Klingenberg C. Surgery for intestinal injuries in very preterm infants: a Norwegian population-based study with a new approach to disease classification. BMJ Paediatr Open 2024; 8:e002722. [PMID: 39299770 PMCID: PMC11418550 DOI: 10.1136/bmjpo-2024-002722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 09/02/2024] [Indexed: 09/22/2024] Open
Abstract
OBJECTIVE To evaluate population-based data on very preterm infants (<32 weeks gestation) operated for intestinal injuries, focusing on necrotising enterocolitis (NEC) and focal intestinal perforation (FIP). DESIGN Nationwide, population-based registry cohort study. SETTING All 21 neonatal units in Norway. PARTICIPANTS All very preterm infants born from 2014 through 2021 and admitted to a neonatal unit. MAIN OUTCOME MEASURES Incidence of surgery for subgroups of intestinal injuries, medical record data on laboratory-radiology results, anatomical location of affected bowel, length of resections, number of re-operations, morbidities of prematurity and/or death before discharge. RESULTS Abdominal surgery was performed in 124/4009 (3.1%) very preterm infants and in 97/1300 (7.5%) extremely preterm infants <28 weeks. The main intestinal injuries operated were NEC (85/124; 69%), FIP (26/124; 21%) and 'other abdominal pathologies' (13/124; 10%). NEC cases were divided in (i) acute NEC, extensive disease (n=18), (ii) non-extensive disease (n=53) and (iii) NEC with surgery >3 days after disease onset (n=14). High lactate values immediately prior to surgery was predominantly seen in acute NEC-extensive disease and associated with high mortality. Other laboratory values could not discriminate between acute NEC and FIP. Timing of surgery for acute NEC and FIP overlapped. Radiological absence of portal venous gas was typical in FIP. Most infants (62.5%) underwent a stoma formation at initial surgery. The overall survival rate was 67% for NEC and 77% for FIP. CONCLUSION NEC cases have different presentation and prognosis depending on the extent of bowel affected. Revised classifications for intestinal injuries in preterm infants may improve prognostication and better guide therapy.
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MESH Headings
- Humans
- Norway/epidemiology
- Infant, Newborn
- Enterocolitis, Necrotizing/surgery
- Enterocolitis, Necrotizing/diagnosis
- Enterocolitis, Necrotizing/mortality
- Male
- Female
- Registries
- Intestinal Perforation/surgery
- Intestinal Perforation/mortality
- Intestinal Perforation/epidemiology
- Infant, Premature, Diseases/surgery
- Infant, Premature, Diseases/diagnosis
- Infant, Premature, Diseases/mortality
- Infant, Premature
- Intestines/injuries
- Intestines/surgery
- Infant, Extremely Premature
- Incidence
- Cohort Studies
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Affiliation(s)
- Nina Clare Hapnes
- Paediatric Department, Stavanger University Hospital, Stavanger, Norway
| | - Hans Jørgen Stensvold
- Neonatal Department, Oslo University Hospital Rikshospitalet, Oslo, Norway
- Faculty of Medicine, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kristin Bjørnland
- Section of Pediatric Surgery, Oslo University Hospital, Oslo, Norway
| | - Thorstein Sæter
- Department of Pediatric Surgery, St. Olav's Hospital Trondheim University Hospital, Trondheim, Norway
| | - Hans Jørgen Timm Guthe
- Department of Paediatrics and Adolescents Medicine, Haukeland Universitetssjukehus, Bergen, Norway
| | - Ragnhild Støen
- Department of Paediatrics, St. Olav's University Hospital, Trondheim, Norway
| | - Sissel Jennifer Moltu
- Department of Neonatal Intensive Care Unit, Clinic of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Arild Rønnestad
- Department of Neonatal Intensive Care, Oslo University Hospital, Oslo, Norway
- University of Oslo, Oslo, Norway
| | - Claus Klingenberg
- Department of Paediatrics, University Hospital of North Norway, Tromsø, Norway
- Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
| | - on behalf of the Norwegian Neonatal Network
- Paediatric Department, Stavanger University Hospital, Stavanger, Norway
- Neonatal Department, Oslo University Hospital Rikshospitalet, Oslo, Norway
- Faculty of Medicine, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
- Section of Pediatric Surgery, Oslo University Hospital, Oslo, Norway
- Department of Pediatric Surgery, St. Olav's Hospital Trondheim University Hospital, Trondheim, Norway
- Department of Paediatrics and Adolescents Medicine, Haukeland Universitetssjukehus, Bergen, Norway
- Department of Paediatrics, St. Olav's University Hospital, Trondheim, Norway
- Department of Neonatal Intensive Care Unit, Clinic of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Department of Neonatal Intensive Care, Oslo University Hospital, Oslo, Norway
- University of Oslo, Oslo, Norway
- Department of Paediatrics, University Hospital of North Norway, Tromsø, Norway
- Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
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Li J, Zhou J, Weng J, Jin F, Shen Y, Qi Y, Jiang M, Hei M. Rapidly progressive necrotizing enterocolitis: Risk factors and a predictive model. Pediatr Res 2024:10.1038/s41390-024-03482-z. [PMID: 39147906 DOI: 10.1038/s41390-024-03482-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 07/24/2024] [Accepted: 07/25/2024] [Indexed: 08/17/2024]
Abstract
BACKGROUND Rapidly progressive necrotizing enterocolitis (RP-NEC) is a particular subtype of NEC known for its rapid progression and high mortality rate. The objective of this study was to establish a predictive model for RP-NEC. METHODS This was a retrospective single-center cohort study. Patients were newborn infants with NEC (Bell's stage ≥ IIB) admitted from January 1, 2016 to December 31, 2023. The primary outcome was RP-NEC defined as the need for surgical intervention and/or death within 48 hours of the onset of NEC. RESULTS Totally 334 newborn infants were included, among which 82 (24.6%) were RP-NEC cases with a gestation age 34.1 (31.0, 37.0) weeks and birth weight 2100 (1413, 2800) g. Plasma sodium <135 mmol/L, C-reactive protein ≥10 mg/L, platelet count <100 × 109/L, lymphocyte count <1.5 × 109/L, pH <7.2 in blood gas, and ascites at NEC onset were identified as independent risk factors for RP-NEC. The model established presented an AUC value of 0.983 (95% CI 0.97-0.99). The calibration curve for validation was applied revealing a slope close to unity while the Hosmer-Lemeshow test yielded χ2 = 2.550 (p = 0.636). CONCLUSION The predictive model established on the above 6 items of RP-NEC is highly promising. IMPACT Currently, there is a paucity of research on this specific type of severe necrotizing enterocolitis (NEC) characterized by rapid progression. Our study was to investigate the risk factors associated with surgical intervention and/or death within 48 hours following onset in infants with NEC, establish a predictive model for infants with rapidly progressive NEC. The new data presented in this study was the ROC curve combining the above factors as well as hyponatremia.
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Affiliation(s)
- Jicheng Li
- Neonatal Center, Beijing Children's Hospital, Capital Medical University, Beijing, 100045, China
- National Center for Children's Health, Beijing, 100045, China
| | - Jingjing Zhou
- Neonatal Center, Beijing Children's Hospital, Capital Medical University, Beijing, 100045, China
- National Center for Children's Health, Beijing, 100045, China
| | - Jingwen Weng
- Neonatal Center, Beijing Children's Hospital, Capital Medical University, Beijing, 100045, China
- National Center for Children's Health, Beijing, 100045, China
| | - Fei Jin
- Neonatal Center, Beijing Children's Hospital, Capital Medical University, Beijing, 100045, China
- National Center for Children's Health, Beijing, 100045, China
| | - Yanhua Shen
- Neonatal Center, Beijing Children's Hospital, Capital Medical University, Beijing, 100045, China
- National Center for Children's Health, Beijing, 100045, China
| | - Yujie Qi
- Neonatal Center, Beijing Children's Hospital, Capital Medical University, Beijing, 100045, China
- National Center for Children's Health, Beijing, 100045, China
| | - Min Jiang
- Neonatal Center, Beijing Children's Hospital, Capital Medical University, Beijing, 100045, China.
- National Center for Children's Health, Beijing, 100045, China.
| | - Mingyan Hei
- Neonatal Center, Beijing Children's Hospital, Capital Medical University, Beijing, 100045, China.
- National Center for Children's Health, Beijing, 100045, China.
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Bethell GS, Jones IH, Battersby C, Knight M, Hall NJ. Methods of identifying surgical Necrotizing Enterocolitis-a systematic review and meta-analysis. Pediatr Res 2024:10.1038/s41390-024-03292-3. [PMID: 38849483 DOI: 10.1038/s41390-024-03292-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 04/02/2024] [Accepted: 05/15/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND Current data suggests potential benefit of earlier surgery for necrotizing enterocolitis (NEC) however this requires accurate prognostication early in the disease course. This study aims to identify and determine the effectiveness of previously reported methods or tests for the identification of surgical NEC. METHODS Systematic review and meta-analysis with registration on PROSPERO including articles describing a method of identifying surgical NEC. Outcomes of interest were effectiveness and repeatability of index test. RESULTS Of the 190 full-text articles screened, 90 studies were included which contained 114 methods of identifying surgical NEC in 9546 infants. Of these methods, 44 were a scoring system, 37 a single biomarker, 24 an imaging method, and 9 an invasive method. Sensitivity and specificity ranged from 12.8-100% to 13-100%, respectively. Some methods (9.6%) provided insufficient methods for repeatability within clinical practice or research. Meta-analyses were possible for only 2 methods, the metabolic derangement 7 score and abdominal ultrasound. CONCLUSIONS A range of methods for identifying surgical NEC have been identified with varying overall performance and uncertainties about reproducibility and superiority of any method. External validation in large multicentre datasets should allow direct comparison of accuracy and prospective study should evaluate impact on clinical outcomes. IMPACT Earlier identification of need for surgery in necrotizing enterocolitis (NEC) has the potential to improve the unfavourable outcomes in this condition. As such, many methods have been developed and reported to allow earlier identification of surgical NEC. This study is the first synthesis of the literature which identifies previously reported methods and the effectiveness of these. Many methods, including scoring systems and biomarkers, appear effective for prognostication in NEC and external validation is now required in multicentre datasets prior to clinical utility.
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Affiliation(s)
- George S Bethell
- University Surgical Unit, Faculty of Medicine, University of Southampton, Southampton, UK
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
| | - Ian H Jones
- Department of Paediatric Surgery and Urology, Birmingham Children's Hospital, Birmingham, UK
| | - Cheryl Battersby
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Marian Knight
- Nuffield Department of Population Health, National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Nigel J Hall
- University Surgical Unit, Faculty of Medicine, University of Southampton, Southampton, UK.
- Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK.
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Oulego-Erroz I, Rodríguez-Fanjul J, Terroba-Seara S, Sorribes-Orti C, Fernandez-Fernández D, Fuentes-Martínez S, Pou-Blázquez Á. Bedside Ultrasound for Early Diagnosis of Necrotizing Enterocolitis: A Pilot Study. Am J Perinatol 2024; 41:e630-e640. [PMID: 35973795 DOI: 10.1055/a-1925-1797] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE This study aimed to assess whether bedside ultrasound (BUS) as the first imaging modality allows an earlier diagnosis of necrotizing enterocolitis (NEC) compared with abdominal radiography. STUDY DESIGN A before-after controlled study in preterm infants with suspected NEC. The intervention group (October 2019-October 2021) received BUS as the first imaging modality and was managed accordingly to BUS findings. The control group (October 2015-September 2019) received radiography as the first imaging modality. The main outcome was NEC confirmation at the time of initial imaging. Secondary outcomes included time to diagnosis, laboratory data, and treatment requirements. RESULTS Thirty-five episodes of suspected NEC with 14 (40%) confirmed NEC cases and 49 episodes of suspected NEC with 22 (44.9%) confirmed NEC cases were included in the intervention and control groups, respectively. In the intervention group, 11 of 14 (78.6%) NEC cases were confirmed at initial evaluation compared with 5 of 22 (22.7%) in the control group (p = 0.001). Infants in the intervention group developed thrombocytopenia and coagulopathy less frequently, were exposed to less radiation, and required less days of parenteral nutrition compared with the control group (p < 0.05). CONCLUSION The use of BUS as the first imaging modality allowed an earlier diagnosis and timely treatment of NEC compared with abdominal radiography.Key Points · This is the first study that has assessed the role of BUS as the first imaging modality in NEC.. · BUS improves early diagnosis of NEC compared with abdominal radiography.. · BUS shortens time to NEC confirmation and treatment initiation which may reduce clinical severity of the NEC episode..
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Affiliation(s)
- Ignacio Oulego-Erroz
- Pediatric Intensive Care Unit, Complejo Asistencial Universitario de León, León, Spain
| | | | - Sandra Terroba-Seara
- Pediatric Intensive Care Unit, Complejo Asistencial Universitario de León, León, Spain
| | - Clara Sorribes-Orti
- Pediatric Intensive Care Unit, Hospital Germans Trias i Pujol, Badalona, Spain
| | | | | | - Álvaro Pou-Blázquez
- Department of Pediatrics, Complejo Asistencial Universitario de León, León, Spain
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5
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Goldfarb M, Choi PM, Gollin G. Primary Anastomosis Versus Stoma for Surgical Necrotizing Enterocolitis in US Children's Hospitals. J Surg Res 2024; 295:296-301. [PMID: 38056356 DOI: 10.1016/j.jss.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/20/2023] [Accepted: 11/08/2023] [Indexed: 12/08/2023]
Abstract
INTRODUCTION Multiple studies have documented the safety of intestinal anastomosis after resection for necrotizing enterocolitis (NEC). We sought to evaluate a large population of infants with surgical NEC and assess outcomes after primary anastomosis versus enterostomy. METHODS The Pediatric Health Information System database was used to identify infants with Bell Stage 3 NEC who underwent an intestinal resection for acute disease between 2016 and 2021. Demographics and preoperative physiology were assessed, and nutritional, infectious, and surgical outcomes were analyzed. RESULTS Two hundred twenty-two infants at 38 children's hospitals were included. Thirty-five (15.8%) were managed with a primary anastomosis. Among infants who underwent a resection within 10 d of their first operative intervention and survived for at least 3 d, a primary anastomosis was used in 26 (13.7%). These patients were older but had similar weight and physiological status at the time of resection as those managed with an enterostomy. The incidence of wound and infectious complications, duration of parenteral nutrition and length of stay were similar after anastomosis or enterostomy. CONCLUSIONS In a large, geographically heterogenous population of infants with NEC, only 15.8% were managed with a primary anastomosis after intestinal resection. Survivors who underwent resection within 10 d were demographically and physiologically comparable to those who underwent enterostomy and had similar surgical outcomes. While there are clearly indications for enterostomy in some infants with NEC, these data confirm the conclusions of smaller, single-center studies that a primary anastomosis should be considered more frequently.
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Affiliation(s)
- Madeline Goldfarb
- Texas Tech Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, Texas
| | - Pamela M Choi
- Department of Surgery, Naval Medical Center San Diego, San Diego, California
| | - Gerald Gollin
- Rady Children's Hospital-San Diego, University of California San Diego School of Medicine, San Diego, California.
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Zhang G, Wang X, Zhu S, Luo L. Hyponatremia as a Marker for Predicting Surgical Intervention in Necrotizing Enterocolitis: A Retrospective Cohort Study. J Surg Res 2024; 295:364-369. [PMID: 38064977 DOI: 10.1016/j.jss.2023.11.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 10/03/2023] [Accepted: 11/12/2023] [Indexed: 02/25/2024]
Abstract
INTRODUCTION To investigate the predictive value of plasma sodium at the onset of necrotizing enterocolitis (NEC) diagnosis in distinguishing surgical NEC from medical NEC. METHODS A retrospective review of all NEC neonates treated at our hospital between 2008 and 2022. Patients were divided into two groups based on treatment methods: surgical intervention and medical treatment. Patient demographics, laboratory parameters, and outcomes were all documented. The values of laboratory parameters were collected at the onset of NEC and after treatment. To identify potential predictors of surgical NEC, multivariate logistic regression analyses were used. The receiver operating characteristic curve was applied to determine predictive factors. RESULTS Surgical treatment was performed in 111 infants (44.6%), and medical treatment in 138 cases (55.4%). Of 249 infants with NEC, 22 patients exhibited Bell stage I, 91 infants had Bell stage II, and 136 patients displayed Bell stage III. We discovered that white blood cell (WBC), C-reactive protein (CRP), fibrinogen, and sodium were independent predictors of NEC receiving surgery based on the results of the multivariate logistic regression analysis. Hyponatremia was found in 122 of the 249 patients (49%). At the onset of NEC diagnosis, hyponatremia was found in 83.8% of surgical intervention group and in 21.0% of medical treatment group (P < 0.001). Sensitivity, specificity, positive predictive value, and negative predictive value for WBC, CRP, fibrinogen, and sodium were calculated. The cutoff values were determined using receiver operating characteristic analysis. The area under the curve of hyponatremia for surgical intervention was 0.875, with 84% sensitivity, 80% specificity, 77% positive predictive value, and 86% negative predictive value, which had a greater specificity (0.80) for predicting surgical intervention than WBC (0.67), CRP (0.50), and fibrinogen (0.70). CONCLUSIONS When a surgical evaluation is necessary, hyponatremia can effectively distinguish surgical NEC from medical NEC. It could be used as a predictive marker to guide parental counseling for surgical intervention and rapid transfer of patients to tertiary centers when they have a surgical condition.
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Affiliation(s)
- Gang Zhang
- Department of Pediatric Surgery, Northwest Women's and Children's Hospital, Xi'An, Shaanxi, China
| | - Xinxin Wang
- Department of Radiation Oncology, The Third Hospital of Nanchang, Nanchang, Jiangxi, China
| | - Suyue Zhu
- Department of Pediatrics, Suqian Hospital Affiliated to Xuzhou Medical University, Suqian, Jiangsu, China
| | - Laiyue Luo
- Department of Nephrology, Anji County People's Hospital, Huzhou, Zhejiang, China.
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Davidson JR, Omran K, Chong CKL, Eaton S, Edwards AD, Yardley IE. Exploring Growth Failure in Neonates With Enterostomy. J Pediatr Surg 2024; 59:211-215. [PMID: 37940463 DOI: 10.1016/j.jpedsurg.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 10/07/2023] [Indexed: 11/10/2023]
Abstract
AIM OF THE STUDY Neonatal enterostomy is a known risk for growth failure. We hypothesized that episodes of inflammation may drive a catabolic state, exploring this by assessing serum biochemistry alongside growth trajectory in enterostomy patients. METHODS A retrospective analysis of infants with histologically confirmed NEC from 01/2012-07/2021 in a tertiary neonatal surgical centre was performed. Change in weight-for-age Z-score (ΔZ) between stoma formation and closure was calculated. Serum CRP (C-reactive protein), urea, and creatinine levels were recorded and duration of elevated levels calculated as Area Under Curve (AUC). We examined for trends of serum levels rising together using intersecting moving averages. Spearman's correlation analysis was performed, while multivariable linear regression examined factors associated with ΔZ. RESULTS 79 neonates were included. At stoma formation, median Z-score was -1.42 [range -4.73, +1.3]. Sixty-two patients (78 %) had a fall in Z-score during their time with a stoma, 16 (20 %) had a ΔZ less than -2. Urea AUC was significantly univariably correlated with ΔZ and remained statistically significant in a multivariable model (Exp(B) x 100 = -0.57[-1, -0.09]; p = 0.022). The number of biomarker peaks correlated significantly with ΔZ for urea (r = -0.25; p = 0.025) and CRP (r = -0.35; p = 0.0017) but not Creatinine (r = -0.21; p = 0.066). Analysing the number of peaks of any combination of variables coinciding was consistently significantly correlated negatively with ΔZ (r = -0.29 to -0.27; p ≤ 0.016 for all). CONCLUSION Our data shows that infants who were more severely affected by growth failure had more frequent and severe uremia while they had a stoma (suggesting a catabolic state). Disturbances in urea were commonly associated with CRP, suggesting that inflammation is a significant factor in growth failure in these infants. These findings promote aggressive management of sepsis in these infants, as well as suggesting an earlier closure of stoma to minimise their "at-risk"' period.
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Affiliation(s)
- Joseph R Davidson
- Department of Paediatric Surgery, Evelina London Children's Hospital, London, UK; Stem Cells and Regenerative Medicine Section, GOS-UCL Institute of Child Health, London, UK; Prenatal Cell and Gene Therapy, Elizabeth Garrett Anderson UCL Institute for Women's Health, London, UK
| | - Kareem Omran
- Department of Neonatology, Evelina London Children's Hospital, London, UK
| | - Clara K L Chong
- Department of Paediatric Surgery, Evelina London Children's Hospital, London, UK
| | - Simon Eaton
- Stem Cells and Regenerative Medicine Section, GOS-UCL Institute of Child Health, London, UK
| | - A David Edwards
- Department of Neonatology, Evelina London Children's Hospital, London, UK; Centre for the Developing Brain, King's College London, London, UK
| | - Iain E Yardley
- Department of Paediatric Surgery, Evelina London Children's Hospital, London, UK; Department of Neonatology, Evelina London Children's Hospital, London, UK.
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Shang S, Du L, Geng N, Li Y, Li S, Li A, Shen C, Liu L, Xu W. Neurodevelopmental impairment following surgical necrotizing enterocolitis with gestational age ≥ 28 weeks: who is at risk? Pediatr Surg Int 2024; 40:41. [PMID: 38286871 DOI: 10.1007/s00383-023-05628-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/27/2023] [Indexed: 01/31/2024]
Abstract
PURPOSE Surgical necrotizing enterocolitis (NEC) is a severe medical condition that, even after surgery, a portion of the survival infants may still have neurological sequelae. The objective of this study was to identify the risk factors associated with the development of permanent neurodevelopmental impairment (NDI) in neonates with surgical NEC. METHODS Between January 2016 and June 2022, a retrospective data collection was conducted on 98 individuals who experienced surgical NEC with gestational age ≥ 28 weeks. Among these patients, 27 patients were diagnosed with NDI, while the remaining 71 patients did not have NDI. Based on this division, the patients were categorized into the NDI group and the Non-NDI group. Demographics, comorbidities, and admission lab results were analyzed using univariate and logistic regression analyses. RESULTS Of the 98 neonates following surgical NEC, 27(27.6%) developed permanent neurodevelopmental impairment (NDI). Predictors of NDI were identified through the final multivariable logistic regression analysis, which revealed that gestational age ≤ 32 weeks (p = 0.032; odds ratio [OR], 5.673), assisted mechanical ventilation after NEC onset (p = 0.047; OR, 5.299), postoperative acute kidney injury (p = 0.040; OR, 5.106), CRP day 3 after NEC onset (p = 0.049; OR, 1.037), time from presentation to surgery (p = 0.003; OR, 1.047) were significant risk factors. CONCLUSIONS Our study identified gestational age ≤ 32 weeks, assisted mechanical ventilation after NEC onset, postoperative acute kidney injury, CRP day 3 after NEC onset, and time from presentation to surgery as significant risk factors for NDI in neonates with surgical NEC. These factors would be helpful to refine treatment modalities for better disease outcomes. We also determined the cut-off values of CRP day 3 after NEC onset and time from presentation to surgery, allowing for the individualized evaluation of NDI risk and the implementation of earlier targeted laparotomy.
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Affiliation(s)
- Shuai Shang
- Department of Pediatric Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China
- Department of Pediatric Surgery, Maternity Hospital of Shijiazhuang City Affiliated to Hebei Medical University, Shijiazhuang, 050051, Hebei, China
| | - Lijia Du
- Department of Gynecology and Obstetrics, The Fourth Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China
| | - Na Geng
- Department of Pediatric Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China
| | - Yingchao Li
- Department of Pediatric Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China
| | - Suolin Li
- Department of Pediatric Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China
| | - Ao Li
- Department of Pediatric Surgery, Maternity Hospital of Shijiazhuang City Affiliated to Hebei Medical University, Shijiazhuang, 050051, Hebei, China
| | - Cuncun Shen
- Department of Pediatric Surgery, Maternity Hospital of Shijiazhuang City Affiliated to Hebei Medical University, Shijiazhuang, 050051, Hebei, China
| | - Lintao Liu
- Department of Pediatric Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China
| | - Weili Xu
- Department of Pediatric Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China.
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Bethell GS, Hall NJ. Recent advances in our understanding of NEC diagnosis, prognosis and surgical approach. Front Pediatr 2023; 11:1229850. [PMID: 37583622 PMCID: PMC10424793 DOI: 10.3389/fped.2023.1229850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 07/21/2023] [Indexed: 08/17/2023] Open
Abstract
Necrotising enterocolitis (NEC) remains a devasting condition that has seen limited improvement in outcomes in recent years. The incidence of the disease is increasing as more extremely premature infants survive. NEC is responsible for 1 in 10 neonatal deaths and up to 61% of survivors have significant neurodevelopmental delay. The aim of this review is to highlight recent advances in diagnosis, prognosis and surgical approach in this condition. Many recent studies have reported novel methods of diagnosis of NEC with the aim of earlier and more accurate identification. These include imaging and machine learning techniques. Prognostication of NEC is particularly important to allow earlier escalation of therapy. Around 25% of infants with NEC will require surgery and recent data has shown that time from disease onset to surgery is greater in infants whose indication for surgery is failed medical management, rather than pneumoperitoneum. This indication was also associated with worse outcomes compared to pneumoperitoneum. Ongoing research has highlighted several new methods of disease prognostication which includes differentiating surgical from medical NEC. Finally, recent randomised controlled trials in surgical technique are discussed along with the implications of these for practice. Further, high quality research utilising multi-centre collaborations and high fidelity data from electronic patient records is needed to address the issues discussed and ultimately improve outcomes in NEC.
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Affiliation(s)
- George S Bethell
- University Surgical Unit, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Nigel J Hall
- University Surgical Unit, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
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Yu D, Yang H, Zhong C, Fan K, Zeng G, Zhang M, Zhao Q, Yang J, Yang L, Wu K. Pneumonia, lymphocytes and C-reactive protein are valuable tests for predicting surgical intervention in necrotizing enterocolitis. Front Pediatr 2023; 11:1231627. [PMID: 37576139 PMCID: PMC10419212 DOI: 10.3389/fped.2023.1231627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 07/14/2023] [Indexed: 08/15/2023] Open
Abstract
Background Necrotizing enterocolitis (NEC) is one of the important causes of neonatal death, and proper timing of operation is of critical significance. This study aimed to explore the high-risk factors for NEC requiring surgical intervention and to provide a reference for its clinical diagnosis and treatment. Methods Clinical and radiological evidence of NEC neonates admitted to Zhujiang Hospital of Southern Medical University and Zhongshan Boai Hospital from January 2010 to October 2022 were retrospectively analyzed. Patients were divided into surgical group and conservative group according to whether they underwent surgery or not. Univariate analysis of the clinical data of the two groups was conducted, and multivariate logistic regression analysis was then performed for statistically significant results in the univariate analysis. Results 267 infants were included in this study, of which 90 patients underwent surgical intervention for NEC and 177 conservation treatment. The univariate analysis showed that the gestational age, pneumonia, leukocytes, lymphocytes, erythrocytes, platelets, C-reactive protein, and blood glucose were statistically significant in the surgical group compared to the conservative group (All P < 0.05). Furthermore, the results of multivariate logistic regression analysis showed that compared to the conservative group, patients in the surgical group had a higher proportion of pneumonia (OR = 2.098; 95% CI: 1.030-4.272; P = 0.041), lower lymphocyte values (OR = 0.749; 95% CI: 0.588-0.954; P = 0.019), and higher C-reactive protein values (OR = 1.009; 95% CI: 1.003-1.016; P = 0.004). Conclusions Pneumonia, decreased lymphocytes, and elevated C-reactive protein are potential high-risk factors for neonates with NEC requiring surgical intervention and may have potential clinical implications for predicting surgical risk.
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Affiliation(s)
- Daiyue Yu
- Department of Pediatric Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Huirong Yang
- Department of Pediatric Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Chen Zhong
- Department of Pediatric Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, China
- Department of Pediatric Surgery, Zhongshan Boai Hospital, Zhongshan, China
| | - Kaisi Fan
- Department of Pediatric Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Guichang Zeng
- Department of Pediatric Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Mengzhen Zhang
- Department of Pediatric Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Qianyun Zhao
- Department of Pediatric Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Jiaming Yang
- Department of Pediatric Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Liucheng Yang
- Department of Pediatric Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Kai Wu
- Department of Pediatric Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, China
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11
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Garg PM, Riddick R, Ansari MAY, Pittman I, Hillegass W. Clinical impact of timing of surgery on outcomes in preterm infants with surgical necrotizing enterocolitis. RESEARCH SQUARE 2023:rs.3.rs-3084887. [PMID: 37461487 PMCID: PMC10350193 DOI: 10.21203/rs.3.rs-3084887/v1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
Background The clinical impact of the timing of surgery on outcomes in preterm infants with surgical necrotizing enterocolitis (NEC) is not well defined. Aim We sought to investigate the impact of the different timing of surgery from the day of NEC diagnosis on clinical outcomes in preterm infants with surgical NEC. Study Design Retrospective Cohort Study. Subjects Preterm 75 infants admitted between January 2013 and December 31, 2018, with an NEC (Bell stage III) diagnosis. Outcomes Comparison of clinical information by the timing of surgery at three different time points (less and more than 48 hours, 96 hours, and 168 hours) in preterm infants with surgical NEC. Results 75 infants were included in the analysis. Those who received surgery after 48 hours (n= 29/75) had lower median gestational age, lower birth weight, had less pneumoperitoneum, were out born less frequently, had higher acute kidney injury, were intubated and ventilated more frequently, and had higher hemorrhagic and reparative lesions on histopathology than those receiving surgery after 48 hours. Infants receiving surgery after 96 hours had similar trends expect had significantly lower hematocrit and more prolonged parenteral nutrition dependence than less than 96 hours group. The infants receiving surgery after one week had significantly lower birth weight and had higher reparative changes and cholestasis than those receiving surgery < 1 week.There was no significant impact of surgery timing on the length of bowel loss, surgical morbidity, Bronchopulmonary dysplasia, white matter injury, and mortality. Conclusion The infants receiving surgery later were young and smaller and received parenteral nutrition longer with no significant impact on morbidities and mortality. Our data point out that there are advantages of operating early with fewer morbidities which need further confirmation and evaluation in large multicentric prospective studies or clinical trials.
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12
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Liebe H, Lewis S, Loerke C, Golubkova A, Leiva T, Stewart K, Sarwar Z, Gin A, Porter M, Chaaban H, Hunter CJ. A Retrospective Case Control Study Examining Procalcitonin as a Biomarker for Necrotizing Enterocolitis. Surg Infect (Larchmt) 2023. [PMID: 37134209 DOI: 10.1089/sur.2022.366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023] Open
Abstract
Abstract Background: Procalcitonin (PCT) is a biomarker for sepsis, but its utility has not been investigated in necrotizing enterocolitis (NEC). Necrotizing enterocolitis is a devastating multisystem disease of infants that in severe cases requires surgical intervention. We hypothesize that an elevated PCT will be associated with surgical NEC. Patients and Methods: After obtaining Institutional Review Board (IRB) approval (#12655), we performed a single institution retrospective case control study between 2010 and 2021 of infants up to three months of age. Inclusion criteria was PCT drawn within 72 hours of NEC or sepsis diagnosis. Control infants had a PCT drawn in the absence of infectious symptoms. Recursive partitioning (RP) identified PCT cutoffs. Categorical variable associations were tested using Fisher exact or χ2 tests. Continuous variables were tested using Wilcoxon rank sum test, Student t-test, and Kruskal-Wallis test. Adjusted associations of PCT and other covariables with NEC or sepsis versus controls were obtained via multinomial logistic regression analysis. Results: We identified 49 patients with NEC, 71 with sepsis, and 523 control patients. Based on RP, we selected two PCT cutoffs: 1.4 ng/mL and 3.19 ng/ml. A PCT of ≥1.4 ng/mL was associated with surgical (n = 16) compared with medical (n = 33) NEC (87.5% vs. 39.4%; p = 0.0015). A PCT of ≥1.4 ng/mL was associated with NEC versus control (p < 0.0001) even when adjusting for prematurity and excluding stage IA/IB NEC (odds ratio [OR], 28.46; 95% confidence interval [CI], 11.27-71.88). A PCT of 1.4-3.19 ng/mL was associated with both NEC (adjusted odds ratio [aOR], 11.43; 95% CI, 2.57-50.78) and sepsis (aOR, 6.63; 95% CI, 2.66-16.55) compared with controls. Conclusions: A PCT of ≥1.4 ng/mL is associated with surgical NEC and may be a potential indicator for risk of disease progression.
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Affiliation(s)
- Heather Liebe
- Division of Pediatric Surgery, Oklahoma Children's Hospital, Oklahoma City, Oklahoma, USA
| | - Samara Lewis
- Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Christopher Loerke
- University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, USA
| | - Alena Golubkova
- Division of Pediatric Surgery, Oklahoma Children's Hospital, Oklahoma City, Oklahoma, USA
| | - Tyler Leiva
- Division of Pediatric Surgery, Oklahoma Children's Hospital, Oklahoma City, Oklahoma, USA
| | - Kenneth Stewart
- Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Zoona Sarwar
- Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Amy Gin
- University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, USA
| | - Mary Porter
- University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, USA
| | - Hala Chaaban
- Division of Neonatology, Oklahoma Children's Hospital, Oklahoma City, Oklahoma, USA
| | - Catherine J Hunter
- Division of Pediatric Surgery, Oklahoma Children's Hospital, Oklahoma City, Oklahoma, USA
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13
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Montalva L, Incerti F, Qoshe L, Haffreingue A, Marsac L, Frérot A, Peycelon M, Biran V, Bonnard A. Early laparoscopic-assisted surgery is associated with decreased post-operative inflammation and intestinal strictures in infants with necrotizing enterocolitis. J Pediatr Surg 2023; 58:708-714. [PMID: 36585304 DOI: 10.1016/j.jpedsurg.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 10/12/2022] [Accepted: 11/13/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION In 2015, a protocol including early laparoscopy-assisted surgery in the treatment of necrotizing enterocolitis (NEC) was implemented at our institution. Carbon dioxide insufflation during laparoscopy may have an anti-inflammatory effect. We aimed to compare post-operative outcome after early laparoscopy-assisted surgery and classical laparotomy for NEC. MATERIAL AND METHODS Charts of premature infants undergoing surgery for NEC (2012-2021) were reviewed. Cases operated by early laparoscopy-assisted surgery (2015-2021) were compared to infants operated for NEC between 2012 and 2015 (laparotomy-NEC). Outcomes were post-operative CRP, need for reintervention, mortality, and the occurrence of post-NEC intestinal strictures. CRP was measured on the day of surgery (POD-0), 2 days (POD-2), and 7 days after surgery (POD-7). Data were compared using contingency tables for categorical variables and Student t-test or Mann-Whitney test for continuous variables. RESULTS Infants with NEC operated by early laparoscopy (n = 48) and laparotomy (n = 29) were similar in terms of perforation (60% vs 58%, p = 0.99) and POD-0 CRP (139 vs 124 mg/L, p = 0.94). Delay between first signs of NEC and surgery was shorter in the laparoscopy group (3 vs 6 days, p = 0.004). Early laparoscopy was associated with a lower CRP on POD-2 (108 vs 170, p = 0.005) and POD-7 (37 vs 68, p = 0.002), as well as a lower rate of post-operative intestinal stricture (34% vs 61%, p = 0.04). CONCLUSIONS In addition to being safe and feasible in premature infants, early laparoscopic-assisted surgery was associated with decreased NEC-related post-operative inflammation and strictures. A prospective, randomized study is needed in order to evaluate short and long-term effects of laparoscopy in infants with NEC. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Louise Montalva
- Department of Pediatric General Surgery and Urology, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; University Paris-Cité, Paris, France.
| | - Filippo Incerti
- Department of Pediatric General Surgery and Urology, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; University Paris-Cité, Paris, France
| | - Livia Qoshe
- Department of Pediatric General Surgery and Urology, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; Princeton Internships in Civic Service, Princeton University, Princeton, NJ, USA
| | - Aurore Haffreingue
- Department of Pediatric General Surgery and Urology, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Lucile Marsac
- Department of Pediatric Anesthesia, Intensive Care and Pain Management, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Alice Frérot
- Neonatal Intensive Care Unit, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Matthieu Peycelon
- Department of Pediatric General Surgery and Urology, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; University Paris-Cité, Paris, France
| | - Valérie Biran
- Neonatal Intensive Care Unit, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Arnaud Bonnard
- Department of Pediatric General Surgery and Urology, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; University Paris-Cité, Paris, France
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14
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Montalva L, Bonnard A. Reply to Letter to the Editor by Bethell and Hall. J Pediatr Surg 2023:S0022-3468(23)00167-7. [PMID: 36931939 DOI: 10.1016/j.jpedsurg.2023.02.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 02/16/2023] [Indexed: 02/24/2023]
Affiliation(s)
- Louise Montalva
- Department of Pediatric General Surgery and Urology, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; University Paris-Cité, Paris, France.
| | - Arnaud Bonnard
- Department of Pediatric General Surgery and Urology, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; University Paris-Cité, Paris, France
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15
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Bethell GS, Hall NJ. Letter to Editor in Response to: Early Laparoscopic-Assisted Surgery is Associated with Decreased Post-Operative Inflammation and Intestinal Strictures in Infants with Necrotizing Enterocolitis. J Pediatr Surg 2023:S0022-3468(23)00166-5. [PMID: 36931943 DOI: 10.1016/j.jpedsurg.2023.02.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 02/10/2023] [Indexed: 02/24/2023]
Affiliation(s)
- George S Bethell
- University Surgery Unit, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Nigel J Hall
- University Surgery Unit, Faculty of Medicine, University of Southampton, Southampton, United Kingdom.
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16
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Abstract
Necrotizing enterocolitis is a severe gastrointestinal disease of the infant. It most commonly targets those that are born prematurely. NEC has been associated with initiation of feeds and in most cases, it can be managed with antibiotics and bowel rest. However, in up to half of the cases, intestinal perforation, peritonitis, and failure of medical treatment will require surgical intervention. The following review will discuss the surgical approach to managing NEC, based on an updated review of practice patterns and recently published literature.
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17
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Garg PM, Shenberger JS. Surgical NEC, Randomized Control Trials, Missed Opportunity. J Neonatal Perinatal Med 2023; 16:193-194. [PMID: 37270818 PMCID: PMC10511036 DOI: 10.3233/npm-230048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- P M Garg
- Department of Pediatrics/Neonatology, Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - J S Shenberger
- Department of Pediatrics/Neonatology, Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston Salem, North Carolina
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18
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Duric B, Gray C, Alexander A, Naik S, Haffenden V, Yardley I. Effect of time of diagnosis to surgery on outcome, including long-term neurodevelopmental outcome, in necrotizing enterocolitis. Pediatr Surg Int 2022; 39:2. [PMID: 36434395 PMCID: PMC9700559 DOI: 10.1007/s00383-022-05283-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/16/2022] [Indexed: 11/26/2022]
Abstract
A systematic review of the PubMed and EMBASE databases was carried out to determine if time from diagnosis to surgery affects outcomes in necrotising enterocolitis. The study was registered on the PROSPERO website. Studies reporting both time to surgery and at least one clinical outcome measure in infants undergoing surgery for NEC were included. The initial search returned 1121 articles. After removing duplicates, title, and abstract screening, 49 remained for full-text review. Of these, only two reported both timing of surgery for NEC and at least one clinical outcome. The total number of neonates included was 202. Outcomes reported were death and/or parenteral nutrition use 28 days post surgery in one study and white matter brain injury in the other. No statistically significant association was found between any of the outcomes reported and timing of surgery. There were, however, significant differences associated with non-modifiable risk factors, such as age and gestation, at presentation. However, very few studies report this as a variable. Given the continuing poor outcomes and heterogeneous nature of NEC and its treatments, further large-scale prospective studies are required to examine the impact of timing of surgery, alongside other, potentially modifiable factors on outcome in NEC.
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Affiliation(s)
- Bea Duric
- Faculty of Medicine and Life Sciences, School of Medical Education, King's College London GKT, Guy's Campus, London, SE1 1UL, UK.
| | - Cecilia Gray
- Faculty of Medicine and Life Sciences, School of Medical Education, King's College London GKT, Guy's Campus, London, SE1 1UL, UK
| | - Allen Alexander
- Faculty of Medicine and Life Sciences, School of Medical Education, King's College London GKT, Guy's Campus, London, SE1 1UL, UK
| | - Shivani Naik
- Faculty of Medicine and Life Sciences, School of Medical Education, King's College London GKT, Guy's Campus, London, SE1 1UL, UK
| | - Verity Haffenden
- Department of Pediatric Surgery, Evelina London Children's Hospital London, Guy's Campus, London, SE1 1UL, UK
| | - Iain Yardley
- Faculty of Medicine and Life Sciences, School of Medical Education, King's College London GKT, Guy's Campus, London, SE1 1UL, UK
- Department of Pediatric Surgery, Evelina London Children's Hospital London, Guy's Campus, London, SE1 1UL, UK
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Oulego-Erroz I, Rodríguez-Fanjul J, Terroba-Seara S, Sorribes-Orti C, Fernandez-Fernández D, Fuentes-Martínez S, Pou-Blázquez Á. Bedside Ultrasound for Early Diagnosis of Necrotizing Enterocolitis: A Pilot Study. Am J Perinatol 2022. [PMID: 36170862 DOI: 10.1055/s-0042-1756696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE This study aimed to assess whether bedside ultrasound (BUS) as the first imaging modality allows an earlier diagnosis of necrotizing enterocolitis (NEC) compared with abdominal radiography. STUDY DESIGN A before-after controlled study in preterm infants with suspected NEC. The intervention group (October 2019-October 2021) received BUS as the first imaging modality and was managed accordingly to BUS findings. The control group (October 2015-September 2019) received radiography as the first imaging modality. The main outcome was NEC confirmation at the time of initial imaging. Secondary outcomes included time to diagnosis, laboratory data, and treatment requirements. RESULTS Thirty-five episodes of suspected NEC with 14 (40%) confirmed NEC cases and 49 episodes of suspected NEC with 22 (44.9%) confirmed NEC cases were included in the intervention and control groups, respectively. In the intervention group, 11 of 14 (78.6%) NEC cases were confirmed at initial evaluation compared with 5 of 22 (22.7%) in the control group (p = 0.001). Infants in the intervention group developed thrombocytopenia and coagulopathy less frequently, were exposed to less radiation, and required less days of parenteral nutrition compared with the control group (p < 0.05). CONCLUSION The use of BUS as the first imaging modality allowed an earlier diagnosis and timely treatment of NEC compared with abdominal radiography.Key Points · This is the first study that has assessed the role of BUS as the first imaging modality in NEC.. · BUS improves early diagnosis of NEC compared with abdominal radiography.. · BUS shortens time to NEC confirmation and treatment initiation which may reduce clinical severity of the NEC episode..
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Affiliation(s)
- Ignacio Oulego-Erroz
- Pediatric Intensive Care Unit, Complejo Asistencial Universitario de León, León, Spain
| | | | - Sandra Terroba-Seara
- Pediatric Intensive Care Unit, Complejo Asistencial Universitario de León, León, Spain
| | - Clara Sorribes-Orti
- Pediatric Intensive Care Unit, Hospital Germans Trias i Pujol, Badalona, Spain
| | | | | | - Álvaro Pou-Blázquez
- Department of Pediatrics, Complejo Asistencial Universitario de León, León, Spain
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20
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Development of artificial neural networks for early prediction of intestinal perforation in preterm infants. Sci Rep 2022; 12:12112. [PMID: 35840701 PMCID: PMC9287325 DOI: 10.1038/s41598-022-16273-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 07/07/2022] [Indexed: 11/09/2022] Open
Abstract
Intestinal perforation (IP) in preterm infants is a life-threatening condition that may result in serious complications and increased mortality. Early Prediction of IP in infants is important, but challenging due to its multifactorial and complex nature of the disease. Thus, there are no reliable tools to predict IP in infants. In this study, we developed new machine learning (ML) models for predicting IP in very low birth weight (VLBW) infants and compared their performance to that of classic ML methods. We developed artificial neural networks (ANNs) using VLBW infant data from a nationwide cohort and prospective web-based registry. The new ANN models, which outperformed all other classic ML methods, showed an area under the receiver operating characteristic curve (AUROC) of 0.8832 for predicting IP associated with necrotizing enterocolitis (NEC-IP) and 0.8797 for spontaneous IP (SIP). We tested these algorithms using patient data from our institution, which were not included in the training dataset, and obtained an AUROC of 1.0000 for NEC-IP and 0.9364 for SIP. NEC-IP and SIP in VLBW infants can be predicted at an excellent performance level with these newly developed ML models. https://github.com/kdhRick2222/Early-Prediction-of-Intestinal-Perforation-in-Preterm-Infants.
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21
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Yu L, Liu C, Du Q, Ma L. Predictive Factors for Surgical Intervention in Neonates with Necrotizing Enterocolitis: A Retrospective Study. Front Surg 2022; 9:889321. [PMID: 36034384 PMCID: PMC9411152 DOI: 10.3389/fsurg.2022.889321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 04/25/2022] [Indexed: 12/03/2022] Open
Abstract
Background The current indications based on the clinicopathological parameters for predicting the need for surgery in neonatal necrotizing enterocolitis (NEC) are still limited. This study retrospectively analyzes the characteristics of neonatal NEC and aims to identify the risk factors for surgical intervention in NEC. Methods Data of the NEC cases from 2015 to 2019 were collected from our institution and divided into two groups: surgical group (n = 41) and conservative treatment group (n = 143). Clinical, physical, and laboratory measures were analyzed by univariate analysis and multivariate logistic regression. The diagnostic values and receiver operative characteristic (ROC) curve were used for the assessment. Results Univariate analysis identified significant differences between the surgical group and the conservative group in a series of clinical, physical, and laboratory measures (all p < 0.05). The results of multivariate logistic regression analysis showed that procalcitonin (adjusted OR: 167.1, 95% CI, 3.585–7,788.758, p = 0.009) and gestational age (adjusted OR: 0.85, 95% CI, 0.77–0.94, p = 0.001) were independent surgical indications for NEC. The results from ROC curve and diagnosis values demonstrated that procalcitonin [the area under the curve (AUC) = 0.864], CRP (AUC = 0.783) and fibrinogen (AUC = 0.720) had good predictive performance for surgical NEC. Conclusions The level of procalcitonin and gestational age were found to be independent surgical indications for neonates with NEC.
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Affiliation(s)
- Lei Yu
- Children's Hospital, Capital Institute of Pediatrics, Department of Hospital Infection Administrative, Beijing, China
| | - Chao Liu
- Children's Hospital, Capital Institute of Pediatrics, Department of Neonatal General Surgery, Beijing, China
| | - Qingjing Du
- Children's Hospital, Capital Institute of Pediatrics, Department of Hospital Infection Administrative, Beijing, China
| | - Lishuang Ma
- Children's Hospital, Capital Institute of Pediatrics, Department of Neonatal General Surgery, Beijing, China
- Correspondence: Lishuang Ma
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22
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Feng W, Hou J, Die X, Sun J, Guo Z, Liu W, Wang Y. Application of coagulation parameters at the time of necrotizing enterocolitis diagnosis in surgical intervention and prognosis. BMC Pediatr 2022; 22:259. [PMID: 35538449 PMCID: PMC9086422 DOI: 10.1186/s12887-022-03333-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 05/03/2022] [Indexed: 11/10/2022] Open
Abstract
Purpose It has been shown that abnormalities of coagulation and fibrinolysis system are involved in the pathogenesis of necrotizing enterocolitis (NEC), but not well studied challenge in the context of early detection of disease progression. The present study mainly explores the predictive significance of coagulation parameters at the time of NEC diagnosis in identifying the patients who eventually received surgery and/or NEC-related deaths. Methods The retrospective study of 114 neonates with NEC was conducted with assessments of demographic data, laboratory results at the time of NEC diagnosis, treatment methods and prognosis. According to treatment methods, patients were divided into surgical intervention group and medical treatment group. Predictive factors were put forward and determined by receiver operating characteristic (ROC) curve analysis. An analysis of the surgical intervention and prognosis was performed. Results Of 114 patients, 46 (40.4%) cases received surgical intervention and 14 (12.3%) deaths. prothrombin time (PT), PT international normalized ratio, activated partial thromboplastin time (APTT), fibrinogen and platelet count at the time of NEC diagnosis were independently associated with surgical NEC. The APTT could identify patients at high risk for surgical NEC, with 67.39% sensitivity, 86.76% specificity, better than that of other serological parameters. Coagulopathy was found in 38.6% of all patients. For surgical intervention, the area under the ROC curve (AUC) of coagulopathy was 0.869 (95% confidence interval [CI]: 0.794 ~ 0.944, P < 0.001), with 82.61% sensitivity and 91.18% specificity, outperformed APTT (95% CI: 0.236 ~ 0.173, P = 0.001). Furthermore, the AUC for coagulopathy to predict mortality was 0.809 (95% CI: 0.725 ~ 0.877, P < 0.001), with 92.86% sensitivity and 69.0% specificity. Conclusion Coagulation parameters at the time of NEC diagnosis were conducive to early prediction of surgical NEC and -related deaths, which should be closely monitored in neonates at high risk of NEC and validated as a clinical decision-making tool.
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Affiliation(s)
- Wei Feng
- Department of General & Neonatal Surgery, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Jinping Hou
- Department of General & Neonatal Surgery, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Xiaohong Die
- Department of General & Neonatal Surgery, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Jing Sun
- Department of General & Neonatal Surgery, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Zhenhua Guo
- Department of General & Neonatal Surgery, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Wei Liu
- Department of General & Neonatal Surgery, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Yi Wang
- Department of General & Neonatal Surgery, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Pediatrics, Chongqing, China.
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Feng W, Hou J, Xiang C, Die X, Sun J, Guo Z, Liu W, Wang Y. Correlation of systemic immune-inflammation Index with surgical necrotizing enterocolitis. Front Pediatr 2022; 10:1044449. [PMID: 36419917 PMCID: PMC9676951 DOI: 10.3389/fped.2022.1044449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 10/18/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Systemic Immune-Inflammation Index (SII), known as an easy, economical and useful marker, correlates with the severity of inflammatory response. However, the usefulness of SII in necrotizing enterocolitis (NEC) remains unclear. Therefore, we evaluated the correlation of SII at NEC diagnosis and subsequent surgery. METHODS Retrospective review of 131 neonates with NEC in a tertiary-level pediatric referral hospital was conducted with assessments of demographic data, general blood examination results at NEC diagnosis, treatment strategies and clinical outcomes. The receiver operating characteristic (ROC) curve determined the optimal cut-off values of SII, platelet-to-lymphocyte ratio (PLR), and neutrophil-to-lymphocyte ratio. Univariate/multivariate logistic regression analysis and ROC curve were conducted to evaluate the predictive significance of SII in identifying the patients who eventually received surgery. Additionally, NEC-related deaths were assessed. RESULTS Overall, 49 (37.4%) cases received surgical intervention and mortality was 12.3% (14/131). The area under ROC curve of SII at NEC diagnosis to predict subsequent surgery was 0.833 (optimal cut-off value: 235.85). The SII value in surgical intervention group was significantly higher than that in medical treatment group (332.92 ± 158.52 vs. 158.84 ± 106.82, P < 0.001). Independent influencing factors for surgical NEC were SII (95% confidence interval [CI]: 4.568∼36.449, odds ratio [OR]:12.904, P < 0.001) and PLR (95% CI: 1.071∼7.356, OR:2.807, P = 0.036). SII ≤ 235.85 could identify patients at high risk for surgery, with 87.76% sensitivity, 73.17% specificity, outperformed PLR. Furthermore, mortality was significantly higher in patients with SII ≤ 235.85 than those with SII > 235.85 (20.0% vs. 1.5%, P < 0.001). CONCLUSION SII and PLR at NEC diagnosis were independent influencing factors for subsequent surgery. SII ≤ 235.85 may be a useful predictive marker for the identification of surgical NEC and mortality.
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Affiliation(s)
- Wei Feng
- Department of General & Neonatal Surgery, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Jinping Hou
- Department of General & Neonatal Surgery, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Chenzhu Xiang
- Department of General & Neonatal Surgery, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Xiaohong Die
- Department of General & Neonatal Surgery, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Jing Sun
- Department of General & Neonatal Surgery, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Zhenhua Guo
- Department of General & Neonatal Surgery, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Wei Liu
- Department of General & Neonatal Surgery, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Yi Wang
- Department of General & Neonatal Surgery, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
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