[Intestinal stenosis during ulceronecrotizing enterocolitis]

Characteristics, progression, management, and outcomes of NEC: a retrospective cohort study

BACKGROUND

Necrotising enterocolitis (NEC) in preterm infants is associated with high morbidity and mortality. In most neonates, it is a progressive disease from medical NEC (mNEC) to surgical NEC (sNEC); however, in some, it presents as sNEC from onset.

OBJECTIVE

To evaluate the rate, the timing of progression, different surgical approaches, and outcomes of mNEC and sNEC in preterm neonates.

DESIGN

A retrospective cohort study of preterm infants with diagnosis of NEC between 2010 and 2020 was conducted. Data on clinical presentation, NEC progression, treatment received, different surgical approaches, resource utilization, and outcomes were abstracted. Infants were classified into 3 groups: mNEC, mNEC that progressed to sNEC, and sNEC at presentation.

RESULTS

Among 208 included infants with NEC, 109 (52%) were mNEC, 66 (32%) progressed from mNEC to sNEC, and 33 (16%) presented with sNEC. Gestational age, birth weight, and postnatal age at NEC were inversely associated with the development of sNEC. mNEC progressed to sNEC occurred after a median of 2.5 (IQR 1-4.25) days. Ninety (91%) of sNEC patients underwent interventions: peritoneal drain only in 19 (21%), laparotomy in 59 (66%), or both in 12 (13%). In comparison with mNEC, those with sNEC infants had longer duration on antibiotics, inotropes, respiratory support, length of stay, and time to reaching full enteral feeds; and were more likely to have recurrent NEC episodes, BPD, and mortality.

CONCLUSION

There is a high burden of illness for sNEC cases. Insight into the expected clinical course of sNEC patients can facilitate anticipatory management and provide a window of opportunity for timely interventions that may ameliorate the course of sNEC.

Infant progressive colonic stenosis caused by antibiotic-related Clostridium difficile colitis - a case report and literature review

BACKGROUND

Colonic stenosis is a rare cause of pediatric intestinal obstruction. The root cause underlying colonic stenosis is unclear and there is no fixed operation.

CASE PRESENTATION

We reported on a male infant with progressive colonic stenosis caused by antibiotic-related colitis. The infant was admitted to our hospital with pneumonia but developed progressive abdominal distension and diarrhea following antibiotic treatment with meropenem. Initial testing of stool culture showed a Clostridium difficile infection. Additional testing with barium enema imaging showed stenosis at the junction of the sigmoid and descending colon at first and another stenosis occurred at the right half of the transverse colon 3 weeks later. Staged surgical treatment was performed with primary resections of the two parts suffering stenosis, ileostomy, and secondary intestinal anastomosis. A pathological exam then confirmed the diagnosis of colonic stenosis and the patient had an uneventful recovery and has been recovering well as evidenced by the 1-year follow-up.

CONCLUSIONS

Based on a review of the literature and our case report, we found that progressive colonic stenosis caused by colitis due to antibiotic-related Clostridium difficile infection is rare in infants. Infants with colitis and repeated abdominal distention, vomiting, and constipation should be treated with the utmost caution and screened. Despite this, clinical manifestations depended on the severity of the stenosis. Barium enema, colonoscopy, laprascopy or laparotomy and colonic biopsy are helpful for diagnosis and differential diagnosis. While both one-stage and multiple-stage operations are feasible, a staged operation should be used for multiple colonic stenoses.

Risk factors associated with postnecrotizing enterocolitis strictures in infants

INTRODUCTION

Survivors of necrotizing enterocolitis (NEC) often develop a post-NEC intestinal stricture, causing severe and prolonged morbidity.

OBJECTIVES

We first aimed to determine the incidence of post-NEC strictures. Second, we aimed to determine risk factors associated with intestinal post-NEC strictures.

MATERIALS AND METHODS

A total of 441 patients diagnosed with NEC Bell's stage ≥2 were retrospectively included in three academic pediatric surgical centers between January 2005 and January 2013. Clinical data were related to the occurrence of intestinal post-NEC strictures. Post-NEC strictures were defined as clinically relevant strictures with a radiological and/or surgical confirmation of this post-NEC stricture.

RESULTS

The median gestational age of the 337 survivors of the acute phase of NEC was 29weeks (range 24-41) and median birth weight was 1130g (range 410-4130). Of the survivors, 37 (17%) medically treated NEC patients developed a post-NEC strictures versus 27 surgically treated NEC patients (24%; p=0.001). Highest C-reactive protein (CRP) level measured during the NEC episode was associated with the development of post-NEC strictures (OR 1.20, 95% confidence interval 1.11-1.32; p=0.03). No post-NEC strictures were detected in patients with CRP levels <46mg/L.

CONCLUSION

This multicenter retrospective cohort study demonstrates an overall incidence of clinical relevant post-NEC strictures of 19%, with a higher rate (24%) in NEC cases treated surgically. Increased CRP levels during the NEC episode were associated with the development of post-NEC strictures.

Necrotizing enterocolitis (NEC) and the risk of intestinal stricture: the value of C-reactive protein

Necrotizing enterocolitis (NEC) is a severe complication frequently seen during the neonatal period associated with high mortality rate and severe and prolonged morbidity including Post-NEC intestinal stricture. The aim of this study is to define the incidence and risk factors of these post-NEC strictures, in order to better orient their medicosurgical care. Sixty cases of NEC were retrospectively reviewed from a single tertiary center with identical treatment protocols throughout the period under study, including systematic X-ray contrast study. This study reports a high rate of post-NEC intestinal stricture (n = 27/48; 57% of survivors), either in cases treated surgically (91%) and after the medical treatment of NEC (47%). A colonic localization of the strictures was more frequent in medically-treated patients than in those with NEC treated surgically (87% vs. 50%). The length of the strictures was significantly shorter in case of NEC treated medically. No deaths were attributable to the presence of post-NEC stricture. The mean hospitalization time in NICU and the median age at discontinuation of parenteral nutrition were longer in the group with stricture, but this difference was not significant. The median age at discharge was significantly higher in the group with stricture (p = 0.02). The occurrence of post-NEC stricture was significantly associated with the presence of parietal signs of inflammation and thrombopenia (<100 000 platelets/mm³). The mean maximum CRP concentration during acute phase was significantly higher in infants who developed stricture (p<0.001), as was the mean duration of the elevation of CRP levels (p<0.001). The negative predictive value of CRP levels continually <10 mg/dL for the appearance of stricture was 100% in our study. In conclusion, this retrospective and monocentric study demonstrates the correlation between the intensity of the inflammatory syndrome and the risk of secondary intestinal stricture, when systematic contrast study is performed following NEC.

Neonatal necrotizing enterocolitis: an overview

PURPOSE OF REVIEW

Necrotizing enterocolitis represents a disease entity that remains quite challenging for neonatologists all around the world, in that its aetiology has yet to be revealed, but it is the cause of death for many premature infants each year, affecting up to 28% of very low birthweight infants. This is an attempt to improve the management of affected babies and stimulate more research concerning new diagnostic tools.

RECENT FINDINGS

Current trends in the field of (early) diagnosis, such as: (1) imaging techniques, e.g. contrast radiography, portal vein ultrasonography, magnetic resonance, radionuclide scanning; (2) gastrointestinal tonometry; (3) the detection of biochemical markers, cytokines, growth factors; and (4) the determination of the mean peak hydrogen: carbon dioxide ratio excreted in breath, are only some of those mentioned. Various novel preventive techniques are also presented, among which platelet-activating factor acetyl hydrolase activity enhancement, platelet-activating factor receptor antagonists and probiotics, such as Bifidobacterium infantis and Lactobacillus acidophilus, seem quite promising. Regarding treatment, the use of oxygenated perfluorocarbon has added to the limited alternatives available. These data along with other recent discoveries concerning the risk factors and pathogenesis of this disease create a full picture of the current opinion on this topic.

SUMMARY

Keeping in mind that the key to confronting such a devastating disorder as necrotizing enterocolitis is early diagnosis and prevention, both clinically applicable and experimental advances are presented with the hope of improving the survival rates of patients affected.

Z-shaped anastomosis for the treatment of a benign rectosigmoid stricture

A girl with malrotation underwent a Ladd's operation at 35 days of age and later had an adhesiotomy at 115 days of age. After the adhesiotomy, she suffered from sepsis and subsequent disseminated intravascular coagulation (DIC). At 178 days of age, she developed an intestinal obstruction because of a rectosigmoid stricture probably caused by DIC-associated ischemia. As a result, an ileostomy was performed. At one year, 4 months of age, she underwent a resection of the proximal part of the rectosigmoid stricture and a reconstruction by means of a Z-shaped anastomosis. Based on our experience, Z-shaped anastomosis appears to be an excellent treatment not only for Hirschsprung's disease but also for benign rectosigmoid stricture.