Surgical treatments of infants with necrotizing enterocolitis

A retrospective cohort study of the application of Santulli enterostomy in neonatal necrotizing enterocolitis

The use of Santulli enterostomy (SE) for necrotizing enterocolitis (NEC) has been limited to a small number of studies involving a small number of patients and no control group. Our study aimed to compare the clinical safety and efficacy of Santulli enterostomy with those of single- or double-lumen enterostomy for neonatal NEC through a retrospective cohort study. One hundred ten patients who met the criteria were divided into an SE group (64 patients) and a conventional enterostomy (CE) group (46 patients). The CE group underwent single- or double-lumen enterostomy. There were no significant differences in complication rates or prognoses between the two groups after either procedure. Although the stoma was positioned higher in the SE group, the length of the unused small intestine (USI) was not significantly different. Multivariate analysis revealed that the length of the USI influenced the likelihood of malnutrition after enterostomy (OR = 1.108, P = 0.008). After stoma closure, compared with those in the CE group, the operation time, intestinal recovery time, fasting time, hospitalization time, intraoperative blood loss volume and the incidence of complications requiring surgical reintervention was significantly lower in the SE group. In conclusion, Santulli enterostomy is not only a safe treatment option for NEC but also an effective method for increasing the length of the small intestine after enterostomy, thereby improving the patient's postoperative nutritional status. In addition, the procedure is associated with good recovery and a reduced incidence of surgical reintervention after stoma closure.

Understanding necrotizing enterocolitis endotypes and acquired intestinal injury phenotypes from a historical and artificial intelligence perspective

Necrotizing enterocolitis (NEC) remains a devastating disease in preterm and term neonates. Despite significant progress made in understanding NEC pathogenesis over the last 50 years, the inability of current definitions to discriminate the various pathophysiological processes underlying NEC has led to an umbrella term that limits clinical and research progress. In this mini review, we provide a historical perspective on how NEC definitions and pathogenesis have evolved to our current understanding of NEC endotypes. We also discuss how artificial intelligence-based approaches are influencing our knowledge of risk-factors, classification and prognosis of NEC and other neonatal intestinal injury phenotypes.

A new classification for surgical NEC during exploratory laparotomy: introduction and reproducibility assessment

PURPOSE

Variability in necrosis patterns and operative techniques in surgical necrotizing enterocolitis (NEC) necessitates a standardized classification system for consistent assessment and comparison. This study introduces a novel intraoperative reporting system for surgical NEC, focusing on reliability and reproducibility.

METHODS

Analyzing surgical NEC cases from January 2018 to June 2023 at two tertiary neonatal and pediatric surgery units, a new classification system incorporating anatomical details and intestinal involvement extent was developed. Its reproducibility was quantified using kappa coefficients (κ) for interobserver and intraobserver reliability, assessed by four specialists. Furthermore, following surgery, the occurrence of mortality and enteric autonomy were evaluated on the basis of surgical decision-making of the novel intraoperative classification system for surgical NEC.

RESULTS

In total, 95 patients with surgical NEC were included in this analysis. The mean κ value of the intra-observer reliability was 0.889 (range, 0.790-0.941) for the new classification, indicating excellent agreement and the inter-observer reliability was 0.806 (range, 0.718-0.883), indicating substantial agreement.

CONCLUSION

The introduced classification system for surgical NEC shows high reliability, deepening the understanding of NEC's intraoperative exploration aspects. It promises to indicate operative strategies, enhance prognosis prediction, and substantially facilitate scholarly communication in pediatric surgery. Importantly, it explores the potential for a standardized report and may represent a step forward in classifying surgical NEC, if pediatric surgeons are open to change.

Intraperitoneal insufflation of carbon dioxide rescues intestinal damage in an experimental murine model of colitis

OBJECTIVES

Necrotizing enterocolitis (NEC) is a severe neonatal surgical condition, associated with a prolonged pro-inflammatory state, leading to high mortality and morbidity rates. Carbon dioxide (CO2 ) insufflation during laparoscopy may have an anti-inflammatory effect. We aimed to evaluate the effects of CO2 -insufflation on experimental colitis.

METHODS

Acute colitis was induced in 6-week-old Balb/c mice by the administration of 2%-dextran sulfate-sodium (DSS) during 7 days (n = 45). On Day 4, two groups received intraperitoneal insufflation (duration: 30 mn, pressure: 5 mmHg) of CO2 ("DSS+CO2 ") or air ("DSS+air"). A group received no insufflation ("DSS"). Groups were compared for clinical severity using the disease activity index (DAI-body weight loss, stool consistency, and bleeding), histological severity (histopathological activity index, colon length, and ulcerations), colonic mucosecretion, and inflammation.

RESULTS

DAI was significantly decreased in DSS+CO2 group, compared to DSS (p < 0.0001) or DSS+air (p < 0.0001) groups. Colon length was increased in DSS+CO2 treated mice compared to DSS (p = 0.0002). The histopathological activity index was lower in DSS+CO2 (vs. DSS, p = 0.0059/vs. DSS+air, p = 0.0389), with decreased ulcerations (3.77 vs. 10.7, p = 0.0306), and persistent mucosecretion with increased mucin-secreting cells.

CONCLUSIONS

CO2 -insufflation attenuates DSS-induced colitis and improves both clinical and histological scores. Laparoscopy with CO2 insufflation represents a therapeutic anti-inflammatory strategy for NEC.

A Nomogram for Predicting Surgical Timing in Neonates with Necrotizing Enterocolitis

OBJECTIVE

To explore the surgical risk variables in patients with necrotizing enterocolitis (NEC) and develop a nomogram model for predicting the surgical intervention timing of NEC.

METHODS

Infants diagnosed with NEC were enrolled in our study. We gathered information from clinical data, laboratory examinations, and radiological manifestations. Using LASSO (least absolute shrinkage and selection operator) regression analysis and multivariate logistic regression analysis, a clinical prediction model based on the logistic nomogram was developed. The performance of the nomogram model was evaluated using the receiver operating characteristic (ROC) curve, calibration curves, and decision curve analysis (DCA).

RESULTS

A surgical intervention risk nomogram based on hypothermia, absent bowel sounds, WBC > 20 × 10⁹/L or < 5 × 10⁹/L, CRP > 50 mg/L, pneumatosis intestinalis, and ascites was practical, had a moderate predictive value (AUC > 0.8), improved calibration, and enhanced clinical benefit.

CONCLUSIONS

This simple and reliable clinical prediction nomogram model can help physicians evaluate children with NEC in a fast and effective manner, enabling the early identification and diagnosis of children at risk for surgery. It offers clinical revolutionary value for the development of medical or surgical treatment plans for children with NEC.

The role of neutrophil extracellular traps in necrotizing enterocolitis

Necrotizing enterocolitis (NEC) continues to be one of the most common causes of mortality and morbidity in preterm infants. Although not fully elucidated, studies suggest that prematurity, formula feeding, imbalanced vascular supply, and altered bacterial colonization play major roles in the pathogenesis of NEC. NEC is characterized by increased cytokine release and leukocyte infiltration. Recent data from preterm infants and animal models of NEC suggest that neutrophil extracellular traps (NETs) are released in intestinal tissue. The contribution of NETs in the pathogenesis and/or prevention/treatment of this disease continues to be controversial. Here, we review the available data on NETs release in NEC in human patients and in different NEC models, highlighting their potential contribution to pathology and resolution of inflammation. Here, we review the available data on NETs release in NEC in human patients and the different NEC models, highlighting their potential contribution to pathology or resolution of inflammation.

Intestinal atresia and necrotizing enterocolitis: Embryology and anatomy

The primitive gut originates at week 3 of gestation from the endoderm, with posterior incorporation of the remaining embryo layers. Wnt, Notch and TLR4 pathways have been shown to play central roles in the correct development of the intestine. The classical hypothesis for intestinal atresia development consists of failure in bowel recanalization or a vascular accident with secondary bowel reabsorption. These have been challenged due to the high frequency of associated malformations, and furthermore, with the discovery of molecular pathways and genes involved in bowel formation and correlated defects producing atresia. Necrotizing enterocolitis (NEC) has a multifactorial pathogenesis with prematurity being the most important risk factor; therefore, bowel immaturity plays a central role in NEC. Some of the same molecular pathways involved in gut maturation have been found to correlate with the predisposition of the immature bowel to develop the pathological findings seen in NEC.

Incomplete resection of necrotic bowel may increase mortality in infants with necrotizing enterocolitis

BACKGROUND

Infants with advanced necrotizing enterocolitis (NEC) often need surgical resection of necrotic bowel. We hypothesized that incomplete resection of NEC lesions, signified by the detection of necrotic patches in margins of resected bowel loops, results in inferior clinical outcomes.

METHODS

We reviewed the medical records of infants with surgical NEC in the past 15 years for demographic, clinical, and histopathological data. We also developed statistical models to predict mortality and hospital stay.

RESULTS

Ninety infants with surgical NEC had a mean (±standard error) gestational age of 27.3 ± 0.4 weeks, birth weight 1008 ± 48 g, NEC onset at 25.2 ± 2.4 days, and resected bowel length of 29.2 ± 3.2 cm. Seventeen (18.9%) infants who had complete resection of the necrosed bowel had fewer (4; 23.5%) deaths and shorter lengths of hospital stay. In contrast, a group of 73 infants with some necrosis within the margins of resected bowel had significantly more (34; 46.6%) deaths and longer hospital stay. The combination of clinical and histopathological data gave better regression models for mortality and hospital stay.

CONCLUSION

In surgical NEC, incomplete resection of necrotic bowel increased mortality and the duration of hospitalization. Regression models combining clinical and histopathological data were more accurate for mortality and the length of hospital stay.

IMPACT

In infants with surgical NEC, complete resection of necrotic bowel reduced mortality and hospital stay. Regression models combining clinical and histopathological information were superior at predicting mortality and hospital stay than simpler models focusing on either of these two sets of data alone. Prediction of mortality improved with the combination of antenatal steroids, chorioamnionitis, and duration of post-operative ileus, with severity of inflammation and hemorrhages in resected intestine. Length of hospital stay was shorter in infants with higher gestational ages, but longer in those with greater depth of necrosis or needing prolonged parenteral nutrition or supervised feedings.

Nesfatin-1 ameliorates oxidative bowel injury in rats with necrotizing enterocolitis: The role of the microbiota composition and claudin-3 expression

BACKGROUND AND PURPOSE

Ongoing high mortality due to necrotizing enterocolitis (NEC) necessitates the investigation of novel treatments to improve the outcome of the affected newborns. The aim was to elucidate the potential therapeutic impact of the nesfatin-1, a peptide with anti-inflammatory and anti-apoptotic effects in several inflammatory processes, on NEC-induced newborn rats.

MATERIALS AND METHODS

Sprague-Dawley pups were separated from their mothers, fed with a hyperosmolar formula and exposed to hypoxia, while control pups had no intervention. NEC-induced pups received saline or nesfatin-1 (0.2 μg/kg/day) for 3 days, while some nesfatin-1 treated pups were injected with capsaicin (50 μg/g) for the chemical ablation of afferent neurons. On the 4th day, clinical state and macroscopic gut assessments were made. In intestines, immunohistochemical staining of cycloxygenase-2 (COX-2), nuclear factor (NF)-κB-p65 (RelA), vascular endothelial growth factor (VEGF), claudin-3 and zonula occludens-1 (ZO-1) were performed, while gene expressions of COX-2, occludin, claudin-3, NF-κB-p65 (RelA) and VEGF were determined using q-PCR. In fecal samples, relative abundance of bacteria was quantified by q-PCR. Biochemical evaluation of oxidant/antioxidant parameters was performed in both intestinal and cerebral tissues.

RESULTS

Claudin-3 and ZO-1 immunoreactivity scores were significantly elevated in the nesfatin-1 treated control pups. Nesfatin-1 reduced NEC-induced high macroscopic and clinical scores, inhibited NF-κB-65 pathway and maintained the balance of oxidant/antioxidant systems. NEC increased the abundance of Proteobacteria with a concomitant reduction in Actinobacteria and Bacteroidetes, while nesfatin-1 treatment reversed these alterations. Modulatory effects of nesfatin-1 on microbiota and oxidative injury were partially reversed by capsaicin. Immunohistochemistry demonstrated that nesfatin-1 abolished NEC-induced reduction in claudin-3. Gene expressions of COX-2, NF-κB, occludin and claudin-3 were elevated in saline-treated NEC pups, while these up-regulated mRNA levels were not further altered in nesfatin-1-treated NEC pups.

CONCLUSION

Nesfatin-1 could be regarded as a potential preventive agent for the treatment of NEC.

The Impact of Oral Sodium Chloride Supplementation on Thrive and the Intestinal Microbiome in Neonates With Small Bowel Ostomies: A Prospective Cohort Study

Background: Infants with ileostomies often suffer from sodium depletion, ultimately leading to a failure to thrive. Moreover, early-infantile microbial dysbiosis may potentially aggravate weight faltering. Given that sodium supplementation has been used to restore weight gain and feeding practices largely determine infantile microbiota, the current study investigated the effect of sodium chloride (NaCl) on weight gain and intestinal microbiome in infants with jejuno- and ileostomies.

Methods: A prospective cohort study including 24 neonates with enterostomies compared 19 subjects receiving oral NaCl (5.85%) to five subjects without supplementation with respect to postoperative changes in thrive and the intestinal microbiome.

Results: Infants receiving NaCl after enterostomy-surgery showed vastly improved weight gain and an increased abundance of Lactobacillus in fecal samples, as compared to subjects without oral supplement who displayed decreasing percentiles for weight and did not reveal a higher abundance of probiotic strains within the ostomy effluent. Contrarily, Klebsiella was equally enriched in supplemented infants, reflecting a higher susceptibility for infections in preterm neonates.

Discussion: Our findings support oral NaCl supplementation as a mainstay of postoperative treatment in infants with small bowel ostomies who are predisposed to suffer from a sodium depletion-associated failure to thrive. Not only does NaCl promote weight gain by increasing glucose resorption, but it also appears to induce microbial restoration by enhancing the abundance of health-promoting probiotic bacteria. This finding has an even greater significance when facing an elevated Klebsiella/Bifidobacteria (K/B) ratio, believed to represent an early-life microbial biomarker for development of allergic disease.

Degradation of Extracellular DNA Significantly Ameliorates Necrotizing Enterocolitis Severity in Mice

BACKGROUND

Necrotizing enterocolitis (NEC) is one of the most devastating diseases in neonates and is characterized by high morbidity and mortality. It has been suggested that neutrophils play a crucial role in NEC pathogenesis and contribute to the hyperinflammatory reaction after bacterial colonization, which ultimately induces NEC. The aim of this study was to investigate whether dissolution of neutrophil extracellular traps (NETs) by systemic DNase1 therapy reduces NEC manifestation and morbidity.

METHODS

NEC was induced in neonatal mice by gavage feeding of lipopolysaccharide mixed in Neocate, followed by hypoxia q12 h for 5d. Inactivated DNase1 and DNase1 were administered intraperitoneally twice daily in the control and treatment groups, respectively, starting on day 5 for 72 h. Survival, NEC score, intestinal damage (Chiu score, malondialdehyde [MDA], glutathione peroxidase [GPx]), inflammation (neutrophil elastase [NE], myeloperoxidase [MPO], toll-like receptor 4 [TLR4]), and NETs markers (SYTOX orange, cell-free DNA [cfDNA], DNase, citrullinated Histone 3 [H3cit]) were then assessed.

RESULTS

In total, 44 neonatal mice were used in the experiment. Mice in the treatment group demonstrated significantly reduced NEC rates (44 versus 86%, P = 0.029) and improved survival in comparison to controls (65 versus 35%, P = 0.01). Furthermore, mice treated with DNase1 showed significantly less tissue damage (cfDNA, Chiu score), oxidative stress (MDA, GPx), and inflammation (NE, MPO, H3cit, TLR4), which ultimately lead to a significant reduction in mortality.

CONCLUSIONS

The results of the study indicate that systemic DNase1 treatment leads to a significant reduction in tissue damage, NEC severity, and mortality. Therefore, after validation of our findings in human subjects, DNase1 treatment should be considered as a therapeutic option in neonates diagnosed with NEC.

Anastomotic ulcers in short bowel syndrome: New suggestions from a multidisciplinary approach

BACKGROUND AND AIMS

Anastomotic ulceration (AU) is a rare potential life-threatening complication that may occur after intestinal resection. The diagnosis is often delayed after a long-lasting history of refractory anemia. The pathogenesis remains unknown and there are no established therapies. The aim of the study was to analyze the medical history of children with short bowel syndrome (SBS) who were experiencing AU.

METHODS

Records of SBS children were retrospectively reviewed. Demographics, baseline characteristics, presentation, diagnosis and treatment of AU cases were analyzed.

RESULTS

Eight out of 114 children with SBS were identified as having AU. Mean gestational age was 32.5weeks. Underlying diseases were: 5 necrotising enterocolitis, 2 gastroschisis and 1 multiple intestinal atresia. The mean age at AU diagnosis was 6.5years (diagnosis delay of 35months). All but 2 patients had AU persistency after medical treatment. Endoscopic treatment (2 argon plasma coagulation; 1 platelet-rich fibrin instillation; 2 endoscopic hydrostatic dilations) was effective in 3 out of 5 children. Surgery was required in 3 patients.

CONCLUSIONS

Severe bowel ischemic injury, especially in preterm infant, could predispose to AU development. Medical treatment showed discouraging results. We firstly described that different endoscopic treatment could be attempted before resorting to further surgery.

LEVEL OF EVIDENCE

IV.

Postoperative characteristics of infants who developed necrotizing enterocolitis with different postnatal ages

Our goal was to investigate the surgical procedures, postoperative complications, and survival with regard to different onset timing of necrotizing enterocolitis (NEC).We performed a retrospective review of medical records with a diagnosis of NEC between 2005 and 2016. The cutoff was set at 10 days for early onset ≤10 days and late onset over 10 days. Propensity score matching was performed to adjust for any baseline differences. In 53 paired patients, clinical outcomes, including, mortality, postoperative complications, and length of neonatal intensive care unit (NICU) stay, were evaluated on the basis of early or late-onset NEC.Successful 1:1 matching propensity score matching was performed with 208 infants. Mortality for early-onset NEC infants was lower than that of early late NEC infants (P = .026). A lower overall postoperative complication rate, including infectious complications [19 (35.8) vs 29 (54.7); odds ratio, 0.462, confidence interval (CI) 0.212-1.008, P = .039], was noted in patients with early-onset NEC compared with infants with late-onset NEC. NICU stay and major complication were marginal different between the 2 groups. Comparison of feeding outcomes revealed that the time to achieve full enteral feeds was significantly longer for those with late-onset NEC (18.1 ± 11.5 vs 26.3 ± 15.6, P = .008).The infants who develop NEC after 10 days of life do influence postoperative outcome survival or other clinically important outcomes after laparotomy.

Surgical findings during exploratory laparotomy are closely related to mortality in premature infants with necrotising enterocolitis

AIM

This study investigated whether a correlation existed between surgical findings during the first laparotomy for necrotising enterocolitis (NEC) and death and, or, disease progression.

METHODS

We included infants admitted within one day of birth to our tertiary neonatal department at Rigshospitalet, Denmark, from 2006 to 2015, who underwent a laparotomy for acute NEC. They were classified according to the locality and extent of intestinal necrosis by a paediatric surgeon, based on the surgical findings. We correlated the surgical findings with postoperative outcomes, namely death and, or, progression of NEC.

RESULTS

The first laparotomy showed that 48 infants had NEC, including 21 who demonstrated postoperative progression. Of these, six died before undergoing another laparotomy and 14 of the 15 infants who underwent relaparotomy also died. There was a significant association between surgical findings and NEC-related mortality (p = 0.03). The association between surgical findings and the progression of NEC was also significant (p < 0.0001).

CONCLUSION

Surgical findings during laparotomy for NEC were strongly correlated with mortality, which was close to 100% after relaparotomy. Considering the discouraging outcome, further studies should focus on alternative surgical approaches, such as proximal diverting jejunostomy and the clip and drop technique for the treatment of severe NEC.

Surgical necrotizing enterocolitis

Although currently available data are variable, it appears that the incidence of surgical necrotizing enterocolitis (NEC) has not decreased significantly over the past decade. Pneumoperitoneum and clinical deterioration despite maximal medical therapy remain the most common indications for operative treatment. Robust studies linking outcomes with specific indications for operation are lacking. Promising biomarkers for severe NEC include fecal calprotectin and S100A12; serum fatty acid-binding protein; and urine biomarkers. Recent advances in ultrasonography make this imaging modality more useful in identifying surgical NEC and near-infrared spectroscopy (NIRS) is being actively studied. Another fairly recent finding is that regionalization of care for infants with NEC likely improves outcomes. The neurodevelopmental outcomes after surgical treatment are known to be poor. A randomized trial near completion will provide robust data regarding neurodevelopmental outcomes after laparotomy versus drainage as the initial operative treatment for severe NEC.

The surgical management of necrotising enterocolitis (NEC)

Necrotising enterocolitis (NEC) is a neonatal surgical emergency. At its early stages, the management of NEC is largely medical using broad-spectrum antibiotics, gut rest and total parental nutrition. The only absolute indication for surgery is an intra-abdominal perforation. There are several relative indications for surgery based on clinical, biochemical and radiological parameters. Once the decision to intervene is made, several approaches may be taken. Peritoneal lavage can be used as a salvage procedure or definitive management in some cases. The most common approach taken is bowel resection with enterostomy formation. There is a role for primary anastomosis of bowel in limited NEC. In severe, multi-focal NEC a high diverting jejunostomy or "clip and drop technique" can be used. Laparoscopy has a limited role and is not widespread. The surgical complications of NEC include stoma related morbidity, anastomotic leak/stricture and short-bowel syndrome. Long-term data on neurodevelopmental outcomes is sparse but the present literature is suggestive of a negative impact in cases of surgically managed NEC.

Timing of Optimal Surgical Intervention for Neonates with Necrotizing Enterocolitis

Up to half of all patients with necrotizing enterocolitis require acute surgical treatment. Determining when to operate on these patients can be challenging. Utilizing a combination of clinical and metabolic indicators, we sought to identify the optimal timing of surgical intervention. A retrospective chart review was conducted on patients with necrotizing enterocolitis from 2001 to 2010. Previously validated clinical (abdominal erythema, palpable abdominal mass, hypotension), radiographic (pneumoperitoneum, portal venous gas, fixed bowel loop, severe pneumatosis intestinalis), and laboratory (acidosis, bacteremia, hyponatremia, bandemia, neutropenia, thrombocytopenia) indicators were assessed for the ability to predict the need for acute surgical intervention as a simple indicator score, based on the sum of the indicators listed above. A total of 197 patients were included. One hundred and twenty-four procedures (28 peritoneal drains, 96 laparotomy) were performed on 122 patients (62%). Median indicator score was 4 (range: 0–8). Logistic regression identified abdominal erythema (odds ratio [OR] = 3.3, P = 0.001), acidosis (OR = 2.6, P = 0.004), and hypotension (OR = 1.9, P = 0.05) as independently associated with surgical intervention. A significant increase in surgical intervention was noted for patients with indicator score of 3 or more. In conclusion, if three or more indicators exist, operative intervention is very likely required. In the absence of pneumoperitoneum, abdominal erythema, acidosis, and hypotension are especially important.

Mortality associated with laparotomy-confirmed neonatal spontaneous intestinal perforation: a prospective 5-year multicenter analysis

BACKGROUND

Spontaneous intestinal perforation (SIP) has been recognized as a distinct disease entity. This study sought to quantify mortality associated with laparotomy-confirmed SIP and to compare it to mortality of laparotomy-confirmed necrotizing enterocolitis (NEC).

METHODS

Data were prospectively collected on 177,618 very-low-birth-weight (VLBW, 401-1500g) neonates born between January 2006 and December 2010 admitted to US hospitals participating in the Vermont Oxford Network (VON). SIP was defined at laparotomy as a focal perforation of the intestine without features suggestive of NEC or other intestinal abnormalities. The primary outcome was in-hospital mortality.

RESULTS

At laparotomy, 2036 (1.1%) neonates were diagnosed with SIP and 4076 (2.3%) with NEC. Neonates with laparotomy-confirmed SIP had higher mortality (19%) than infants without NEC or SIP (5%, P=0.003). However, laparotomy-confirmed SIP patients had significantly lower mortality than those with confirmed NEC (38%, P<0.0001). Mortality in both NEC and SIP groups decreased with increasing birth weight and mortality was significantly higher for NEC than SIP in each birth weight category. Indomethacin and steroid exposure were more frequent in the SIP cohort than the other two groups (P<0.001).

CONCLUSIONS

In VLBW infants, the presence of laparotomy-confirmed SIP increases mortality significantly. However, laparotomy-confirmed NEC mortality was double that of SIP. This relationship is evident regardless of birth weight. The variant mortality of laparotomy-confirmed SIP versus laparotomy-confirmed NEC highlights the importance of differentiating between these two diseases both for clinical and research purposes.

Royal Australasia of Surgeons Guest Lecture. Necrotizing enterocolitis: prevention, treatment, and outcome

Necrotizing enterocolitis (NEC) remains a very serious disease, particularly in premature infants. This review describes various aspects of the diagnosis and treatment of the disease. The pathogenesis of NEC is not completely understood, and risk factors include formula enteral feeding and bacterial involvement. Prevention of the disease is desirable, and the most robust evidence is linked to the protective effet of human milk and probiotics. The medical and surgical management has not changed significantly in the last 20 years. Insertions of peimary peritoneal drainage in comparison with laparotomy remain controversial, and this uncertainty stimulated the development of two randomized controlled trials. Neither definitely demonstrated an advantage of either periotneal drainage or laparotomy over the other. The advantage offered by a stoma compared to primary intestinal anastomosis is currently investigated in a multicenter randomized controlled trial (STAT Trial). The mortality of the disease remains high, and new therapeutic interventions are needed. Novel forms of treatment that can improve the outcome of this disease are currently under investigation. These include whole-body moderately controlled hypothermia and administration of amniotic fluid stem cells.

Emergency laparotomy for necrotising enterocolitis in a newborn with hypoplastic left heart syndrome

Necrotising enterocolitis (NEC) and congenital heart disease are two distinct disease processes, but they appear to be inter-related, particularly in patients with the congenital heart condition known as hypoplastic left heart syndrome (HLHS). Both NEC and HLHS are causes of significant morbidity and mortality in the neonatal population. As medical and surgical advances allow for the palliation and correction of complex heart lesions at an earlier gestational age and lower birth weight, the already high-risk of NEC in this population is likely to increase. In this article, we report a case of a neonate with unpalliated HLHS who underwent emergency laparotomy for NEC. We also discuss the pathophysiology of these two diseases and the perioperative care of this rare group of patients.

Long term healthcare costs of infants who survived neonatal necrotizing enterocolitis: a retrospective longitudinal study among infants enrolled in Texas Medicaid

BACKGROUND

Infants who survive advanced necrotizing enterocolitis (NEC) at the time of birth are at increased risk of having poor long term physiological and neurodevelopmental growth. The economic implications of the long term morbidity in these children have not been studied to date. This paper compares the long term healthcare costs beyond the initial hospitalization period incurred by medical and surgical NEC survivors with that of matched controls without a diagnosis of NEC during birth hospitalization.

METHODS

The longitudinal healthcare utilization claim files of infants born between January 2002 and December 2003 and enrolled in the Texas Medicaid fee-for-service program were used for this research. Propensity scoring was used to match infants diagnosed with NEC during birth hospitalization to infants without a diagnosis of NEC on the basis of gender, race, prematurity, extremely low birth weight status and presence of any major birth defects. The Medicaid paid all-inclusive healthcare costs for the period from 6 months to 3 years of age among children in the medical NEC, surgical NEC and matched control groups were evaluated descriptively, and in a generalized linear regression framework in order to model the impact of NEC over time and by birth weight.

RESULTS

Two hundred fifty NEC survivors (73 with surgical NEC) and 2,909 matched controls were available for follow-up. Medical NEC infants incurred significantly higher healthcare costs than matched controls between 6-12 months of age (mean incremental cost = US$ 5,112 per infant). No significant difference in healthcare costs between medical NEC infants and matched controls was seen after 12 months. Surgical NEC survivors incurred healthcare costs that were consistently higher than that of matched controls through 36 months of age. The mean incremental healthcare costs of surgical NEC infants compared to matched controls between 6-12, 12-24 and 24-36 months of age were US$ 18,274, 14,067 (p < 0.01) and 8,501 (p = 0.06) per infant per six month period, respectively. These incremental costs were found to vary between sub-groups of infants born with birth weight < 1,000g versus ≥ 1,000g (p < 0.05).

CONCLUSIONS

The all-inclusive healthcare costs of surgical NEC survivors continued to be substantially higher than that of matched controls through the early childhood development period. These results can have important treatment and policy implications. Further research in this topic is needed.

Primary anastomosis in necrotizing enterocolitis: the first option to consider

INTRODUCTION

Necrotizing enterocolitis (NEC) is the most frequent gastrointestinal emergency in preterm newborns. Thirty percent of all cases will require surgical intervention. Following resection of the involved segment, most patients will undergo a diverting enterostomy.

OBJECTIVE

To describe the safety and effectiveness of primary anastomosis in patients with complicated NEC.

METHODS

This study was a retrospective chart review. The study participants were obtained from both public and private health systems between December 2004 and December 2009 in Santiago, Chile. The inclusion criteria were any patient who underwent a laparotomy for necrotizing enterocolitis. The following variables were evaluated: gestational age, birth weight, use of peritoneal drains, macroscopic features of the intestinal segment, number of anastomoses, parenteral nutrition requirements and post-surgical complications.

RESULTS

Seventy patients were identified. Sixty patients (85%) underwent primary anastomosis. The remaining 10 patients underwent a resection with enterostomy. In the primary anastomosis group (n = 60), twelve percent weighed <1,000 g and 22% weighed 1,000-1,500 g. Two anastomoses were required in 18 patients. Post-surgical complications included infection of the surgical wound in three cases and anastomotic dehiscence in only one case. Seven percent developed short bowel syndrome. Overall mortality was 11.6%, all secondary to sepsis.

CONCLUSION

In this series, primary anastomosis was a safe alternative in the management of complicated NEC, with low morbidity and mortality, independent of age, weight, intraperitoneal contamination or extent of disease.

Potential role of the detection of enterobacterial DNA in blood for the management of neonatal necrotizing enterocolitis

We present three cases of pre-term low-weight infants with suspected necrotizing enterocolitis (NEC) [one eventually recognized as a connatal cytomegalovirus (CMV) infection], microbiologically monitored using a molecular assay detecting bacterial and fungal DNA in blood. The detection of DNA from enteric pathogens in blood was interpreted as a sign of ongoing perforation, and represented a useful complement in the management of the presented cases. Moreover, these cases suggest the opportunity for larger future studies to assess the possible role of a molecular approach in the close monitoring of infants with suspected NEC or with other conditions at-risk for intestinal perforation.

Late vs early ostomy closure for necrotizing enterocolitis: analysis of adhesion formation, resource consumption, and costs

BACKGROUND

Surgeons prefer to close ostomies at least 6 weeks after the primary operation because of the anticipated postoperative abdominal adhesions. Limited data support this habit. Our aim was to evaluate adhesion formation-together with an analysis of resource consumption and costs-in patients with necrotizing enterocolitis who underwent early closure (EC), compared with a group of patients who underwent late closure (LC).

METHODS

Chart reviews and cost analyses were performed on all patients with necrotizing enterocolitis undergoing ostomy closure from 1997 to 2009. Operative reports were independently scored for adhesions by 2 surgeons.

RESULTS

Thirteen patients underwent EC (median, 39 days; range, 32-40), whereas 62 patients underwent LC (median, 94 days; range, 54-150). Adhesion formation in the EC group (10/13 patients, or 77%) was not significantly different (P = 1.000) from the LC group (47/59 patients, or 80%). No differences were found in the costs of hospital stay, surgical interventions, and outpatient clinic visits.

CONCLUSIONS

Ostomy closure within 6 weeks of the initial procedure was not associated with more adhesions or with changes in direct medical costs. Therefore, after stabilization of the patient, ostomy closure can be considered within 6 weeks during the same admission as the initial laparotomy.

Peritoneal drainage versus laparotomy for perforated necrotising enterocolitis or spontaneous intestinal perforation: a retrospective cohort study

AIM

Perforated necrotising enterocolitis (NEC) and spontaneous intestinal perforation (SIP) in preterm infants are associated with high morbidity and mortality. The optimum surgical management during the acute stage remains unclear. The aim of the study was to compare the outcomes of preterm infants (gestational age at birth <30 weeks) with perforated NEC or SIP undergoing primary peritoneal drainage (PD) versus laparotomy.

METHODS

This was a retrospective cohort study (January 2004 to February 2010). Initial search of hospital database followed by a review of the medical records was performed to identify eligible infants. Thirty-nine infants were included in the study. Information regarding the baseline characteristics and outcomes of interest were recorded using the medical charts, radiology and laboratory databases. NEC was differentiated from SIP based on radiological, operative and clinical findings retrospectively for this study.

RESULTS

Among 39 infants, 19 underwent primary PD while 20 had primary laparotomy. Gestational age and birthweight were similar between the two groups. The composite outcome of mortality before discharge or hospital stay longer than 3 months post-term was significantly worse in PD group (74% vs. 40%, P= 0.038).

CONCLUSIONS

Preterm infants undergoing PD for NEC/SIP appeared to have increased risk of adverse outcome compared with laparotomy. More randomised controlled trials are necessary to confirm these findings.

Necrotizing enterocolitis requiring surgery: outcomes by intestinal location of disease in 4371 infants

OBJECTIVE

The objective of this study was to determine whether the outcomes of infants with surgically managed necrotizing enterocolitis (NEC) differ according to whether the location of NEC is in the small bowel, large bowel, or both.

STUDY DESIGN

A retrospective analysis was performed using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample and Kids' Inpatient Database. A total of 5374 infants identified as having undergone surgical management of NEC were stratified by location of bowel affected as small bowel (SB) only, large bowel (LB) only, or both small and large bowel (SB&LB). The type of surgical operation performed was used as a proxy for the location of bowel affected.

RESULTS

Of the 5374 infants with a diagnosis of NEC, 4371 had an operation that allowed for stratification by location. The LB group (n = 963) fared the best in all outcomes. The SB group (n = 2126) had the longest length of stay and highest total hospital charges, and mortality was comparable with that of the SB&LB group (n = 1282).

CONCLUSIONS

Mortality, length of stay, and total hospital charges varied according to location of bowel affected by NEC.

Peritoneal drainage versus laparotomy as initial surgical treatment for perforated necrotizing enterocolitis or spontaneous intestinal perforation in preterm low birth weight infants

BACKGROUND

Standard surgical management of infants with perforated necrotizing enterocolitis (NEC) or spontaneous intestinal perforation (SIP) is laparotomy with the resection of the necrotic or perforated segments of the intestine. Peritoneal drainage is an alternative approach to the management of such infants.

OBJECTIVES

To evaluate the benefits and risks of peritoneal drainage compared to laparotomy as the initial surgical treatment for perforated NEC or SIP in preterm infants.

SEARCH STRATEGY

Cochrane Central Register of Controlled Trials (CENTRAL), (The Cochrane Library 2010, Issue 3), MEDLINE (1966 to July 2010), EMBASE (1980 to July 2010), CINAHL (1982 to July 2010), previous reviews and cross-references were searched. Abstracts of paediatric academic society meetings were also searched (online: 2000 to 2009; handsearching Pediatric Research: 1995 to 2000).

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials in preterm (< 37 weeks gestation), low birth weight (< 2500 g) infants with perforated NEC or SIP allocated to peritoneal drainage or laparotomy as initial surgical treatment.

DATA COLLECTION AND ANALYSIS

Data were excerpted from the trial reports and analysed according to the standards of the Cochrane Neonatal Review Group.

MAIN RESULTS

Only two randomised controlled trials (RCT) met the eligibility criteria. Overall, no significant differences were seen between the peritoneal drainage and laparotomy groups regarding the incidence of mortality within 28 days of the primary procedure (28/90 versus 30/95; typical relative risk (RR) 0.99, 95% CI 0.64 to 1.52; N = 185, two trials); mortality by 90 days after the primary procedure (typical RR 1.05, 95% CI 0.71 to 1.55; N = 185, two trials) and the number of infants needing total parenteral nutrition for more than 90 days (typical RR 1.18, 95% CI 0.72 to 1.95; N = 116, two trials). Nearly 50% of the infants in the peritoneal drainage group could avoid the need for laparotomy during the study period (44/90 versus 95/96; typical RR 0.49, 95% CI 0.39 to 0.61; N = 186, two trials). One study found that the time to attain full enteral feeds in infants ≤ 1000 g was prolonged in the peritoneal drainage group (mean difference (MD) 20.77, 95% CI 3.62 to 37.92).

AUTHORS' CONCLUSIONS

Evidence from two RCTs suggests no significant benefits or harms of peritoneal drainage over laparotomy. However, due to the very small sample size, clinically significant differences may have easily been missed. No firm recommendations can be made for clinicians. Large multicentre randomised controlled trials are needed to address this question definitively.

The role of surgery in management of necrotizing enterocolitis

OBJECTIVE

Necrotizing enterocolitis (NEC) has become the most common gastrointestinal emergency among neonates and preterms admitted to the intensive care units. The aim of this study is to evaluate the surgical management of NEC as well as their outcome.

PATIENTS AND METHODS

Thirty five cases were included in this prospective study (10 full terms, 15 preterm and 10 infants) with the diagnosis of NEC. The severity of NEC episodes were determined according to Bells classification into group A (stage I 10 cases), Group B (stage II 17 cases) and group C (stage III 8 cases). Full history and clinical examination were taken. Radiological studies (abdominal plain X-ray and ultrasound), blood and stool cultures were done.

RESULTS

All risk factors such as sepsis, hypoxia, premature rupture of membrane (PROM) and eclampsia were statistically significantly higher among group C than group A. The commonest presenting symptom was abdominal distension followed by vomiting. All positive radiological signs were statistically significantly higher among both groups B&C than group A except for pneumopritonium sign. Medical treatment was started and complete clinical improvement was achieved in all cases of group A and in 2 cases from group B. The remaining 23 cases (15 cases from group B and the 8 cases of group C) failed to respond to the medical treatment and were operated upon. Resection anastomosis was done for 12 cases from group B while resection with stoma formation was done for 3 cases from group B and 8 cases from group C. The over all mortality was 11 cases out of 35 (31.4%). 5 cases from group B and 6 cases from group C.

CONCLUSIONS

Early diagnosis and intensive medical and surgical treatment with laparotomy and resection of the affected bowel were mandatory to minimize both morbidity and mortality from NEC. Primary anastomosis is the procedure of choice as long as the condition of the remaining bowel is satisfactory.

Urinary intestinal fatty acid-binding protein concentration predicts extent of disease in necrotizing enterocolitis

PURPOSE

Urinary intestinal fatty acid-binding protein (i-FABP), a marker of intestinal mucosal cell damage, has recently been proposed as a clinically useful measure in the early detection of necrotizing enterocolitis (NEC). However, there are no data on urinary i-FABP in more advanced (Bell stage II /III) NEC. The aim of this study was to test the use of urinary i-FABP in surgical NEC.

METHODS

Urine was collected every 24 hours from infants with Bell stage II/III NEC admitted to a surgical Neonatal Intensive Care Unit. Clinical, laboratory, and surgical data were collected concurrently. Urinary i-FABP was quantified by enzyme-linked immunosorbent assay and expressed as picograms per nanomole creatinine (median [range]). Results are presented as median (range) and compared by Mann-Whitney test and by linear regression.

RESULTS

There was a trend toward an increase in i-FABP:Cr in infants with NEC (controls, 1.0 [0.4-1.3], vs NEC, 2.1 [0.39-35.1], P = .055). Urinary i-FABP:Cr was significantly higher in infants with extensive disease (7.4 pg/mmol [2.1-35.0 pg/mmol]) than in those with focal disease (1.1 pg/mmol [0.3-1.7 pg/mmol]), P = .002. In addition, i-FABP:Cr was less than the previously suggested 2 pg/mmol cutoff in 6 of 16 infants with NEC, 5 of whom had focal disease. Urinary i-FABP:Cr decreased during both successful nonoperative management (P < .0001) and after surgery in the operated group.

CONCLUSIONS

In this pilot study, urinary i-FABP was associated with extensive disease in infants with NEC requiring surgery. Further work, in a larger number of patients, is required to investigate the applicability of urinary i-FABP as a marker of intestinal damage and as an adjunct to current indications for surgical intervention in infants with NEC.

Can we cut the incidence of necrotizing enterocolitis in half--today?

Necrotizing enterocolitis (NEC) is a common gastrointestinal emergency of neonates. Population studies estimate the incidence of NEC at between 0.3 and 2.4 per 1000 live births in the United States, with a predominance of cases among preterm neonates born at the earliest gestational ages. The disease burden of NEC includes an overall disease-specific mortality rate of 15-20%, with yet higher rates in those of earliest gestations. The NEC burden also includes an increase in hospital costs approximating $100,000/case, as well as severe late sequellae including parenteral nutrition-associated liver disease and short bowel syndrome. Differentiating NEC from other forms of acquired neonatal intestinal disease is critical to assessing the success of NEC prevention strategies. Promising new prevention strategies are now being tested; one such is prophylactic heparin-binding epidermal growth factor-like growth factor (HB-EGF) administration. However, two prevention strategies have already been shown in meta-analyses to reduce the incidence of NEC, but we speculate that these are not being fully utilized. They are; 1) implementing a written set of feeding guidelines (also called standardized feeding regimens) for newborn intensive care unit (NICU) patients, and 2) implementing programs to increase the availability of human milk for patients at risk of developing NEC.

Is mortality rate influenced by the site of involvement in neonates undergoing laparotomy for necrotizing enterocolitis?

PURPOSE

The aim of the study was to evaluate the effect of disease site on the mortality rate of newborns with necrotizing enterocolitis (NEC) undergoing exploratory laparotomy.

METHODS

The study used prospective cohort of 141 consecutive newborns with NEC who underwent laparotomy from November 1991 to December 2005.

RESULTS

One hundred nineteen (84.4%) newborns were premature. Small for gestational age was observed in 57 (40.4%). Sixty-eight (48.2%) infants died. Bivariate analysis revealed that involvement of the jejunum and ileum was associated with high mortality rates (20 deaths; 76.9%; odds ratio [OR], 20; 95% confidence interval [CI], 4.6-96.3; P < .001) and that coinvolvement of the jejunum was associated with greater disease extent. After controlling for individual variables, logistic regression showed that the mortality associated with jejunum and ileum involvement (OR, 0.61; 95% CI, 0.06-6.14; P = .68) did not differ from that associated with large bowel involvement (OR, 2.91; 95% CI, 0.81-10.50; P = .10). When the jejunum was involved with the disease, the percentage of involvement of the entire intestine was 72%, and the mortality rate was 85.1%. When the other bowel segments were involved, the global percentage of disease extent ranged from 42% to 49%, and the mortality rate from 51.9% to 71.8%. After multivariable adjustment disease site, jejunal involvement appeared to be only a surrogate marker of disease extent.

CONCLUSIONS

The NEC-related mortality in newborns undergoing laparotomy was not influenced by disease site (small or large bowel). However, jejunum coinvolvement was a marker of greater disease extent and therefore of poor prognosis.

A new method to close an intestinal wall defect using fibrin glue and polyglycolic acid felt sealant

PURPOSE

This study aimed to propose an alternative method of suture closure for an intestinal wall defect using 2 absorbable materials.

METHODS

An oval intestinal wall defect was created in the duodenum, ileum, or colon of rabbits. The defect was first covered by polyglycolic felt, which was then completely covered by fibrin glue to make a fibrin glue and polyglycolic acid felt (FGPAF) sealant without any suture procedures. The rabbits with a simple suture closure for the defect were used as controls. The bursting pressure of the treated intestine was measured, and macro- and microscopic observations were carried out for 6 months.

RESULTS

Seven rabbits treated with the FGPAF sealant used in each of the 3 operated regions survived without any signs of peritonitis or intestinal obstruction, similar to the controls. The mean bursting pressure of the segment with wall defect closed by single layer sutures and the segment with FGPAF sealant was 69.7 mm Hg (n = 6) and 70.6 mm Hg (n = 7), respectively. A histologic study at 1 week after operation revealed that the FGPAF circumferentially adhered to the edge of the defect with fibrous tissue extension into the sealant; whereas when performing a laparotomy at 1 month after operation, a round mass consisting of the remnant FGPAF mixed with plant residues of daily chows was found loosely attached to the serousal surface.

CONCLUSION

These results suggest that the present technique may be useful for the new technique of intestinal wall closure.

Comparative study between window and conventional enterostomies in preterm neonates with small bowel perforations

OBJECTIVES

Small bowel perforations in the neonatal period can be secondary to necrotizing enterocolitis (NEC), ischemic necrosis, or occlusive anomalies of the small bowel; furthermore, they may be of no discernible cause. Depending on the clinical condition of the infant and the extent of the disease, a number of surgical options are available; one of which is exteriorization. To reduce the morbidity of stoma among patients, we adopted a technique called window enterostomy (WEnt). The objectives of this study were to describe the technique and to compare WEnt with conventional enterostomy (CEnt) in preterm infants undergoing surgery for focal NEC or isolated small bowel perforation (ISBP).

METHODS

We reviewed all cases of NEC and ISBP between January 1996 and March 2006 from our institution. Patients with focal NEC or ISBP who required a surgical intervention were included and categorized into the WEnt and the CEnt groups. We collected multiple data as study variables: demographics; site of perforation; operative time; need for a second operation; postoperative morbidity; duration of total parenteral nutrition; and postoperative weight gain.

RESULTS

Twenty-four neonates met the criteria for study inclusion. Of these, 14 underwent CEnt and 10 underwent WEnt. The median gestational age and birth weight of the neonates were 25.4 weeks (SD = 1.4) and 814.4 g (SD = 195.1), respectively. In comparing the 2 groups, we found statistically significant differences in the operative time for the primary and secondary procedures, duration of total parenteral nutrition, time to full oral feeding, and weekly postoperative weight gain. The rate of postoperative complications was higher among the infants from the CEnt group.

CONCLUSION

Our results suggest that WEnt is a quick and workable technique with minimal morbidity for preterm neonates with focal NEC or ISBP.

Neurodevelopmental outcomes of neonates with medically and surgically treated necrotizing enterocolitis

OBJECTIVES

(1) To characterise neurodevelopmental outcome of neonates with necrotizing enterocolitis (NEC); (2) to define whether NEC increases risk of neurodevelopmental impairment in very low birth weight neonates; (3) to investigate whether stage of disease or need for surgery increase risk of poor outcome.

DESIGN

A systematic review was performed. Searches identified 182 relevant papers. Ten studies compared extremely low birthweight neonates with NEC to infants of similar age and gestation who did not develop NEC. Data are reported as OR (95% CIs, p values for test for overall effect) and compared by chi2.

RESULTS

7843 children (821 with NEC) were included in the meta-analysis. Median follow-up was 20 months (range 12 to 156). Overall, 45% of children who had neonatal NEC were neurodevelopmentally impaired. Infants with NEC were significantly more likely than infants of similar age and gestation who did not develop NEC to be neurodevelopmentally impaired (1.6 (1.3 to 2.0), p = 0.0001) including a higher risk of cerebral palsy (1.5 (1.2 to 2.0), p = 0.001), visual (2.3 (1.0 to 5.1), p = 0.04), cognitive (1.7 (1.4 to 2.2), p<0.0001) and psychomotor impairment (1.7 (1.3 to 2.2), p<0.0001). The odds ratio of neurodevelopmental impairment was also 2.3 times higher in neonates with Bell's stage III disease or requiring surgery ((1.5 to 3.6), p = 0.0001).

CONCLUSIONS

NEC is associated with significantly worse neurodevelopmental outcome than prematurity alone. Presence of advanced NEC and need for surgery increase the risk of neurological impairment.

The role of the intestinal barrier in the pathogenesis of necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is the leading cause of death from gastrointestinal disease in neonates and is increasing in frequency because of recent advances in neonatal care. NEC develops in a stressed preterm infant in the setting of intestinal barrier disruption, systemic inflammation, and leads to, multisystem organ failure. The intestinal barrier lies at the interface between microbes within the intestinal lumen and the immune system of the host, and has both immunological and mechanical components. These components serve to protect the host from invading pathogens and, at the same time, provide a surface area for nutrient absorption. Factors that lead to impairments in the function of the intestinal barrier may predispose the host to the invasion of gut-derived microbes and to the development of systemic inflammatory disease. This process, termed "bacterial translocation," may be compounded during instances in which the mechanisms that regulate the repair of the intestinal barrier are disrupted. Bacterial translocation is of particular concern to the newborn patient, in which immaturity of the mechanical barrier and incomplete development of the host immune system combine to render the host at particular risk for the development of intestinal inflammation. This review will serve to provide an overview of recent evidence regarding the components of the intestinal barrier, and the mechanisms by which disruptions in barrier function may contribute to the pathogenesis of NEC.

Exploratory laparotomy or peritoneal drain? Management of bowel perforation in the neonatal intensive care unit

Premature infants in the neonatal intensive care unit are at risk for necrotizing enterocolitis (NEC) and bowel perforation. Unfortunately the mortality and morbidity for intestinal perforation in neonates, especially extremely low-birth-weight infants (VLBW), is high. The criterion standard traditional management for bowel perforation has been exploratory laparotomy (LAP). Another less invasive alternative treatment modality for selected intestinal perforation is primary peritoneal drainage (PPD). The role and efficacy of PPD as a definitive treatment instead of laparotomy remains to be determined. To better appreciate the emergence and evolving role of PPD in the management of intestinal perforation in NEC or isolated intestinal perforation, 8 selected research articles will be reviewed. Findings from these studies will be summarized to address the original purpose of PPD as a rescue and stabilizing measure for VLBW infants with complicated NEC, the expanded and superior role of PPD when it is used for VLBW infants with isolated ileal perforation, and PPD not as a sole surgical management but as an adjunct therapy to LAP in perforated NEC for the VLBW infants.

Surgical therapy for necrotizing enterocolitis: bringing evidence to the bedside

Necrotizing enterocolitis is the most common surgical emergency in the neonatal intensive care unit. Despite decades of research that have led to a growing knowledge base about this disease, NEC continues to challenge the pediatric surgeon. In this review, we will examine the development of surgical therapy for NEC in the context of the supportive evidence, or lack thereof, for treatment approaches. We will discuss issues of indications for surgical intervention, primary peritoneal drainage versus laparotomy, enterostomy versus primary anastamosis and issues surrounding NEC totalis.

P-selectin expression, neutrophil infiltration, and histologic injury in neonates with necrotizing enterocolitis

BACKGROUND/PURPOSE

P-selectin promotes adherence of leukocytes to the endothelium in inflammatory processes. The aim of this study was to investigate the expression of P-selectin and its role in the development of inflammation in neonates with necrotizing enterocolitis (NEC).

METHODS

Twenty-nine intestinal specimens from 13 neonates with NEC and 7 control neonates with congenital gastrointestinal abnormalities were studied. Histologic damage, immunohistochemical expression of P-selectin, and polymorphonuclear cell infiltrate were graded blindly. Mann-Whitney U and Spearman rank tests were used to compare grades.

RESULTS

Expression of P-selectin was increased in NEC compared with controls in both medium-sized vessels (P = .03) and in the microcirculation (P = .03). P-selectin expression on medium-sized vessels correlated with the degree of histologic injury (P = .02, r = 0.425). P-selectin expression was greatest in areas of active inflammation but markedly lower in necrotic areas. The degree of polymorphonuclear cell infiltration strongly correlated with P-selectin expression on both medium-sized vessels (P = .004, r = 0.513) and the microcirculation (P = .001, r = 0.578).

CONCLUSIONS

Expression of P-selectin is increased in medium-sized vessels and in the microcirculation in intestinal specimens of neonates with NEC compared with neonatal controls. Expression of P-selectin is associated with the recruitment of polymorphonuclear cells and the severity of histologic injury, although P-selectin expression is lost in necrotic tissue.