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Sun Y, Gao Z, Hong W, Gong X, Cai C. Analysis of Postoperative Outcomes and Extrauterine Growth Retardation in Preterm Infants with Necrotizing Enterocolitis: A Retrospective Study. Am J Perinatol 2024; 41:e1190-e1196. [PMID: 36646098 PMCID: PMC11139500 DOI: 10.1055/s-0042-1760445] [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] [Received: 08/27/2022] [Accepted: 12/08/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVE High mortality and extrauterine growth retardation (EUGR) remain serious problems in preterm infants after necrotizing enterocolitis (NEC) surgery. This study investigated the risk factors for mortality and EUGR in preterm infants after NEC surgery. STUDY DESIGN The risk factors were analyzed retrospectively by univariate analysis and multivariate logistic regression analysis in 52 preterm infants, who underwent NEC surgery and were hospitalized in neonatology department of Shanghai Children's Hospital between May 2014 and December 2021. Patients were divided into survival and death groups. Survivors were divided into two groups according to whether EUGR occurred when they achieved full enteral feeding after surgery. RESULTS The mortality of preterm infants after NEC surgery was 26.9% (14/52). About 55.3% (21/38) of survivors developed postoperative EUGR. (1) Age at surgery, proportion of shock, and intestinal perforation differed significantly between the survival and death groups (p = 0.001, 0.005, and 0.02, respectively). Shock (p = 0.02, odds ratio [OR] = 8.86, 95% confidence interval [CI]: 1.43-55.10) and intestinal perforation (p = 0.03, OR = 6.12, 95% CI: 1.16-32.41) were significant risk factors for death. (2) Compared with the non-EUGR group, proportion of preoperative EUGR, postoperative 1-week calories, and parenteral nutrition time differed significantly in EUGR group (p = 0.001, 0.01, and 0.04, respectively). Preoperative EUGR (p = 0.02, OR = 18.63, 95%CI: 1.77-196.42) was a significant risk factor for postoperative EUGR. CONCLUSION Shock and intestinal perforation are significant risk factors for death in preterm infants after NEC surgery. Survivors are prone to EUGR, and preoperative EUGR is a significant risk factor. In addition, adequate caloric intake and achievement of full enteral feeding as soon as possible may be beneficial to improve EUGR of preterm infants after NEC surgery. KEY POINTS · Shock and intestinal perforation are risk factors for death in preterm infants after NEC surgery.. · Preoperative EUGR is a risk factor for postoperative EUGR in preterm infants after NEC surgery.. · Active correction of shock and avoiding intestinal perforation may help improve the outcomes..
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Affiliation(s)
- Yifan Sun
- Department of Neonatology, School of Medicine, Shanghai Jiao Tong University, Shanghai Children's Hospital, Shanghai, China
| | - Zhen Gao
- Department of Neonatology, School of Medicine, Shanghai Jiao Tong University, Shanghai Children's Hospital, Shanghai, China
| | - Wenchao Hong
- Department of Neonatology, School of Medicine, Shanghai Jiao Tong University, Shanghai Children's Hospital, Shanghai, China
| | - Xiaohui Gong
- Department of Neonatology, School of Medicine, Shanghai Jiao Tong University, Shanghai Children's Hospital, Shanghai, China
| | - Cheng Cai
- Department of Neonatology, School of Medicine, Shanghai Jiao Tong University, Shanghai Children's Hospital, Shanghai, China
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Herzlich J, Mandel D, Marom R, Mendelsohn R, Eshel Fuhrer A, Mangel L. Blood Glucose, Lactate and Platelet Count in Infants with Spontaneous Intestinal Perforation versus Necrotizing Enterocolitis-A Pilot Study. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1028. [PMID: 37371260 DOI: 10.3390/children10061028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/09/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023]
Abstract
The incidence of spontaneous intestinal perforation (SIP) increases up to 10% with decreasing gestational age (GA). We aimed to explore early biomarkers for predicting SIP in preterm infants. In this case-control study, neonates born at ≤34 weeks GA diagnosed with SIP were compared with GA and/or birth-weight-matched neonates diagnosed with necrotizing enterocolitis (NEC). Laboratory markers assessed prior and adjacent to the day of SIP or NEC diagnosis were evaluated. The cohort included 16 SIP and 16 matched NEC infants. Hyperlactatemia was less frequent in SIP than in NEC infants (12% vs. 50%, p = 0.02). The platelets count was lower in SIP than in NEC infants (p < 0.001). Glucose levels strongly correlated with lactate levels (p = 0.01) only in the NEC group. The odds of being diagnosed with SIP decreased as lactate levels increased (OR = 0.607, 95% CI: 0.377-0.978, p = 0.04). Our results suggest that a combination of laboratory markers, namely glucose and lactate, could help differentiate SIP from NEC at early stages so that, in the presence of an elevated blood glucose, an increase in blood lactate was associated with a decrease in the odds of being diagnosed with SIP.
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Affiliation(s)
- Jacky Herzlich
- Department of Neonatology, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Dror Mandel
- Department of Neonatology, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Ronella Marom
- Department of Neonatology, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Rafael Mendelsohn
- Department of Neonatology, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Audelia Eshel Fuhrer
- Department of Pediatric Surgery, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Laurence Mangel
- Department of Neonatology, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
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Mimatsu H, Onoda A, Kazama T, Nishijima K, Shimoyama Y, Go S, Ueda K, Takahashi Y, Matsumoto T, Hayakawa M, Sato Y. Dedifferentiated fat cells administration ameliorates abnormal expressions of fatty acids metabolism-related protein expressions and intestinal tissue damage in experimental necrotizing enterocolitis. Sci Rep 2023; 13:8266. [PMID: 37217485 DOI: 10.1038/s41598-023-34156-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 04/25/2023] [Indexed: 05/24/2023] Open
Abstract
Neonatal necrotizing enterocolitis (NEC) is a serious disease of premature infants that necessitates intensive care and frequently results in life-threatening complications and high mortality. Dedifferentiated fat cells (DFATs) are mesenchymal stem cell-like cells derived from mature adipocytes. DFATs were intraperitoneally administrated to a rat NEC model, and the treatment effect and its mechanism were evaluated. The NEC model was created using rat pups hand fed with artificial milk, exposed to asphyxia and cold stress, and given oral lipopolysaccharides after cesarean section. The pups were sacrificed 96 h after birth for macroscopic histological examination and proteomics analysis. DFATs administration significantly improved the survival rate from 25.0 (vehicle group) to 60.6% (DFAT group) and revealed a significant reduction in macroscopical, histological, and apoptosis evaluation compared with the vehicle group. Additionally, the expression of C-C motif ligand 2 was significantly decreased, and that of interleukin-6 decreased in the DFAT group. DFAT administration ameliorated 93 proteins mainly related to proteins of fatty acid metabolism of the 436 proteins up-/down-regulated by NEC. DFATs improved mortality and restored damaged intestinal tissues in NEC, possibly by improving the abnormal expression of fatty acid-related proteins and reducing inflammation.
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Affiliation(s)
- Haruka Mimatsu
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, 65 Tsurumai-Cho Showa-Ku, Nagoya, 466-8550, Japan
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Atsuto Onoda
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, 65 Tsurumai-Cho Showa-Ku, Nagoya, 466-8550, Japan
- Faculty of Pharmaceutical Sciences, Sanyo-Onoda City University, Sanyo-Onoda, Yamaguchi, Japan
| | - Tomohiko Kazama
- Department of Functional Morphology, Division of Cell Regeneration and Transplantation, Nihon University School of Medicine, Tokyo, Japan
| | - Koji Nishijima
- Center for Perinatal, Maternal and Neonatal Medicine, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Yoshie Shimoyama
- Department of Pathology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shoji Go
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, 65 Tsurumai-Cho Showa-Ku, Nagoya, 466-8550, Japan
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuto Ueda
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, 65 Tsurumai-Cho Showa-Ku, Nagoya, 466-8550, Japan
| | - Yoshiyuki Takahashi
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Taro Matsumoto
- Department of Functional Morphology, Division of Cell Regeneration and Transplantation, Nihon University School of Medicine, Tokyo, Japan
| | - Masahiro Hayakawa
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, 65 Tsurumai-Cho Showa-Ku, Nagoya, 466-8550, Japan
| | - Yoshiaki Sato
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, 65 Tsurumai-Cho Showa-Ku, Nagoya, 466-8550, Japan.
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Irtan S, Reignier PL, Durandy A, Hervieux E, Constant I, Lemale J, Soreze Y, Leger PL, Audry G, Rambaud J, Guellec I. Feasibility of open abdomen surgery treatment for near fatal necrotizing enterocolitis in preterm infants. J Pediatr Surg 2022; 57:1336-1341. [PMID: 34696919 DOI: 10.1016/j.jpedsurg.2021.09.044] [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: 05/04/2021] [Revised: 09/24/2021] [Accepted: 09/26/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Necrotizing Enterocolitis (NEC) remained a dramatic complication leading to death or neonatal morbidities in preterms. For some, Intra-Abdominal Hypertension (IAH) and Abdominal Compartment Syndrome worsened the multi-organ failure. An open abdomen surgery could be an alternative to conventional surgical treatment to move beyond this stage. OBJECTIVES To retrospectively describe the clinical course, pre- and post-operative features of preterms suffering from severe NEC with IAH treated by open abdomen surgery and referred to our center from October 2007 to September 2019. Our secondary objective is to identify various risk factors for mortality in this population. METHODS Data on neonatal, clinical, biological, pre and post-operative features and outcome were collected. Univariate analyses were performed to compare their pre and post-operative features stratifying on outcome. RESULTS Among 29 included patients, 14 (48%) survived to discharge without short bowel syndrome. Death was associated with an earlier postnatal age at NEC (16.3 ± 9.1 versus 31.3 ± 25.9 days; p = 0.004) and followed a withdrawal of treatment in 60% of cases. Surgery was associated with a significant improvement of respiratory and hemodynamic features (decrease of mean ventilator pressure from 13.1 ± 5.4 to 11.3 ± 4.0 cmH2O, p < 0.001), oxygen requirement (mean FiO2 decreased from 65.0% ± 31.2 to 49.0% ± 24.6, p < 0.001) and inotropic score (from 38.6 ± 70.1 to 29.9 ± 64.3, p < 0.001). In the survival group, pre and post-operative findings exhibited a significant increase of serum lactate concentrations from 2.7 ± 1.6 to 11.0 ± 20.3 mmol/L (p = 0.02) but a similar pH. CONCLUSION Open abdomen surgery could be considered to rescue preterms with near fatal NEC. IAH and Abdominal Compartment Syndrome in these preterms should be investigated through further studies. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Sabine Irtan
- Department of Visceral and Neonatal Pediatric Surgery, Sorbonne University, Armand Trousseau University Hospital, APHP.6, Paris, France
| | - Pierre-Louis Reignier
- Department of Visceral and Neonatal Pediatric Surgery, Sorbonne University, Armand Trousseau University Hospital, APHP.6, Paris, France
| | - Amélie Durandy
- Neonatal Intensive Care Unit, CH Poissy Saint-Germain-en-Laye, Poissy, France
| | - Erik Hervieux
- Department of Visceral and Neonatal Pediatric Surgery, Sorbonne University, Armand Trousseau University Hospital, APHP.6, Paris, France
| | - Isabelle Constant
- Department of Anesthesiology and Intensive Care, Sorbonne University, Armand Trousseau University Hospital, GRC 29, APHP.6, Paris, France
| | - Julie Lemale
- Nutrition and Gastroenteterology, Pediatric Department, Sorbonne University, Armand Trousseau University Hospital, APHP.6, France
| | - Yohan Soreze
- Neonatal and Pediatric Care Unit, Sorbonne University, Armand Trousseau University Hospital, AP-HP.6, Paris, France
| | - Pierre-Louis Leger
- Neonatal and Pediatric Care Unit, Sorbonne University, Armand Trousseau University Hospital, AP-HP.6, Paris, France
| | - Georges Audry
- Department of Visceral and Neonatal Pediatric Surgery, Sorbonne University, Armand Trousseau University Hospital, APHP.6, Paris, France
| | - Jérôme Rambaud
- Neonatal and Pediatric Care Unit, Sorbonne University, Armand Trousseau University Hospital, AP-HP.6, Paris, France
| | - Isabelle Guellec
- Neonatal and Pediatric Care Unit, Sorbonne University, Armand Trousseau University Hospital, AP-HP.6, Paris, France.
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Sinha CK, Ashworth I, Martin S, Bhayat S, Kulkarni A. Do more mature preterm babies with surgical necrotizing enterocolitis predominantly develop the colonic disease? WORLD JOURNAL OF PEDIATRIC SURGERY 2021; 4:e000246. [DOI: 10.1136/wjps-2020-000246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 02/28/2021] [Accepted: 03/01/2021] [Indexed: 11/03/2022] Open
Abstract
BackgroundThe primary aim was to scrutinize our hypothesis: “Do more mature preterm (MMP) babies with surgical necrotizing enterocolitis (NEC) predominantly develop the colonic disease and are different in their response and behaviour in comparison to exceedingly preterm (EP) babies?” Secondary outcomes were to define time taken in developing NEC, time from diagnosis to laparotomy, requirement of parenteral nutrition (PN), and ventilatory support.MethodsWe defined MMP babies as ≥30 weeks of gestation and EP babies as ≤29 weeks+6 days of gestation. Inclusion criteria were all babies <37 weeks with NEC requiring surgery (called surgical NEC group). Data were collected retrospectively and analyzed using QuickCalcs.ResultsOf the total, 41% (97/234) of babies underwent laparotomy between 2010 and 2019. Totally, 81% were EP and 19% were MMP babies. Pure colonic involvement was seen in 9% of EP babies in comparison to 56% in the MMP babies (p=0.0001). Involvement of only the small bowel was seen in two-thirds of EP babies in comparison to only one-third in MMP babies (p=0.01). EP cohort required PN for 82 days (median) in comparison to 17 days (median) in the MMP cohort (p=0.001). Ventilation requirement in the EP group versus the MMP group was 24 vs 9 days (median), respectively (p=0.0006).ConclusionsMMP babies predominantly developed colonic disease, whereas EP babies predominantly developed small bowel disease. EP babies required a longer duration of PN and ventilation support. This study opens a new area of research to differentiate pathogenesis and maturation patterns of the small and large bowels in babies with NEC.
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Byun J, Kim HY, Jung SE, Yang HB, Kim EK, Shin SH, Kim HS. Comparison of Acute Abdominal Surgical Outcomes of Extremely-Low-Birth-Weight Neonates according to Differential Diagnosis. J Korean Med Sci 2019; 34:e222. [PMID: 31496138 PMCID: PMC6732259 DOI: 10.3346/jkms.2019.34.e222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 07/26/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Improvements in perinatal intensive care have improved survival of extremely-low-birth-weight (ELBW) neonates, although the risk of acute abdomen has increased. The differential diagnosis resulting in abdominal surgery can be categorized into necrotizing enterocolitis (NEC), spontaneous intestinal perforation (SIP), meconium-related ileus (MRI), and meconium non-related ileus (MNRI). The purpose of this study was to review our experience with abdominal surgery for ELBW neonates, and to evaluate characteristics and prognosis according to the differential diagnosis. METHODS Medical records of ELBW neonates treated between 2003 and 2015 were retrospectively reviewed. RESULTS Of 805 ELBW neonates, 65 (8.1%) received abdominal surgery. The numbers of cases by disease category were 29 for NEC, 18 for SIP, 13 for MRI, and 5 for MNRI. Ostoma formation was performed in 61 (93.8%) patients; primary anastomosis without ostoma was performed in 4 (6.2%). All patients without ostoma formation experienced re-perforation of the anastomosis site. Seven patients had 30-day postoperative mortality (6 had NEC). Long-term survival of the surgical and non-surgical groups was not statistically different. NEC was a poor prognostic factor for survival outcome (P = 0.033). CONCLUSION Abdominal surgery for ELBW neonates is feasible. Ostoma formation can lead to reduced complications compared to primary anastomosis.
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Affiliation(s)
- Jeik Byun
- Department of Pediatric Surgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun Young Kim
- Department of Pediatric Surgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea.
| | - Sung Eun Jung
- Department of Pediatric Surgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hee Beom Yang
- Department of Pediatric Surgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ee Kyung Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Han Shin
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Han Suk Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
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New insights into necrotizing enterocolitis: From laboratory observation to personalized prevention and treatment. J Pediatr Surg 2019; 54:398-404. [PMID: 29980346 PMCID: PMC6344311 DOI: 10.1016/j.jpedsurg.2018.06.012] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 05/21/2018] [Accepted: 06/03/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND/PURPOSE Necrotizing enterocolitis (NEC) is a devastating disease of prematurity that develops after feeding, often without warning, and results in diffuse intestinal necrosis leading to sepsis and death in many cases. The lack of improvement in overall survival is influenced by nonspecific diagnostic modalities as well as inexact and nonpersonalized treatment strategies. METHODS/RESULTS Recently, we and others have shown that NEC develops in response to exaggerated bacterial signaling in the premature intestine, as a consequence of elevated expression and activity of the bacterial receptor toll-like receptor 4 (TLR4), which is important for normal gut development. Breast milk is a powerful TLR4 inhibitor, while mutations in TLR4 genes lead to increased NEC risk in humans, providing proof-of-concept for its role in NEC. Recently, a drug discovery approach has revealed a novel class of TLR4 inhibitors which are being developed for personalized approaches to NEC treatment. CONCLUSION This review will highlight the current understanding of the role of bacterial signaling in NEC pathogenesis, and will describe advances in diagnosis, prevention and treatment of NEC that may hopefully improve survival for these most fragile patients. SYSTEMATIC REVIEW Level of Evidence: Level II.
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Abstract
Necrotizing enterocolitis occurs in 14% of infants less than 1000 g. Preoperative management varies widely, and the only absolute indication for surgery is pneumoperitoneum. Multiple biomarkers and scoring systems are under investigation, but clinical practice is still largely driven by surgeon judgment. Outcomes in panintestinal disease are poor, and multiple creative approaches are used to preserve bowel length. Overall, recovery is complicated in the short and long term. Major sequelae are stricture, short gut syndrome, and neurodevelopmental impairment. Resolving controversies in surgical necrotizing enterocolitis care requires multicenter collaboration for centralized data and tissue repositories, benchmarking, and carrying out prospective randomized controlled trials.
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Affiliation(s)
- Benjamin D Carr
- Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, 1540 East Hospital Drive, SPC 4211, Ann Arbor, MI 48108, USA
| | - Samir K Gadepalli
- Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, 1540 East Hospital Drive, SPC 4211, Ann Arbor, MI 48108, USA.
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Teresa C, Antonella D, de Ville de Goyet Jean. New Nutritional and Therapeutical Strategies of NEC. Curr Pediatr Rev 2019; 15:92-105. [PMID: 30868956 DOI: 10.2174/1573396315666190313164753] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 10/09/2018] [Accepted: 03/06/2019] [Indexed: 11/22/2022]
Abstract
Necrotizing enterocolitis (NEC) is an acquired severe disease of the digestive system affecting mostly premature babies, possibly fatal and frequently associated to systemic complications. Because of the severity of this condition and the possible long-term consequences on the child's development, many studies have aimed at preventing the occurrence of the primary events at the level of the bowel wall (ischemia and necrosis followed by sepsis) by modifying or manipulating the diet (breast milk versus formula) and/or the feeding pattern (time for initiation after birth, continuous versus bolus feeding, modulation of intake according clinical events). Feeding have been investigated so far in order to prevent NEC. However, currently well-established and shared clinical nutritional practices are not available in preventing NEC. Nutritional and surgical treatments of NEC are instead well defined. In selected cases surgery is a therapeutic option of NEC, requiring sometimes partial intestinal resection responsible for short bowel syndrome. In this paper we will investigate the available options for treating NEC according to the Walsh and Kliegman classification, focusing on feeding practices in managing short bowel syndrome that can complicate NEC. We will also analyze the proposed ways of preventing NEC.
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Affiliation(s)
- Capriati Teresa
- Artificial Nutrition in Pediatric Children's Hospital, Bambino Gesu, Rome, Italy
| | - Diamanti Antonella
- Artificial Nutrition in Pediatric Children's Hospital, Bambino Gesu, Rome, Italy
| | - de Ville de Goyet Jean
- Pediatric Department for the Treatment and Study of abdominal Disease and Abdominal Transplants, ISMETT-UPMC, Palermo, Italy
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Cobb AN, Wong YM, Brownlee SA, Blanco BA, Ezure Y, Paddock HN, Kuo PC, Kothari AN. Perioperative support, not volume, is necessary to optimize outcomes in surgical management of necrotizing enterocolitis. Am J Surg 2016; 213:502-506. [PMID: 27871683 DOI: 10.1016/j.amjsurg.2016.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 11/04/2016] [Accepted: 11/07/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND This study examines the relationship between hospital volume of surgical cases for necrotizing enterocolitis (NEC) and patient outcomes. METHODS A retrospective cross-sectional review was performed using the HCUP SID for California from 2007 to 2011. Patients with NEC who underwent surgery were identified using ICD-9CM codes. Risk-adjusted models were constructed with mixed-effects logistic regression using patient and demographic covariates. RESULTS 23 hospitals with 618 patients undergoing NEC-related surgical intervention were included. Overall mortality rate was 22.5%. There were no significant differences in the number of NICU beds (p = 0.135) or NICU intensivists (p = 0.469) between high and low volume hospitals. Following risk adjustment, no difference in mortality rate was observed between high and low volume hospitals respectively (24.0% vs. 20.3%, p = 0.555). CONCLUSIONS Our observation that neonates with NEC treated at low-volume centers have no increased risk of mortality may be explained by similar availability of NICU and intensivists resources across hospitals.
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Affiliation(s)
- Adrienne N Cobb
- Loyola University Medical Center, Department of Surgery, Maywood, IL, USA; One:MAP Section of Surgical Analytics, Department of Surgery, Loyola University Chicago, USA
| | - Yee M Wong
- Loyola University Medical Center, Department of Surgery, Maywood, IL, USA
| | - Sarah A Brownlee
- Loyola University Medical Center, Department of Surgery, Maywood, IL, USA; One:MAP Section of Surgical Analytics, Department of Surgery, Loyola University Chicago, USA
| | - Barbara A Blanco
- One:MAP Section of Surgical Analytics, Department of Surgery, Loyola University Chicago, USA
| | - Yoshiki Ezure
- One:MAP Section of Surgical Analytics, Department of Surgery, Loyola University Chicago, USA
| | - Heather N Paddock
- Loyola University Medical Center, Department of Surgery, Maywood, IL, USA; Loyola University Medical Center, Department of Pediatrics, Maywood, IL, USA
| | - Paul C Kuo
- Loyola University Medical Center, Department of Surgery, Maywood, IL, USA; One:MAP Section of Surgical Analytics, Department of Surgery, Loyola University Chicago, USA.
| | - Anai N Kothari
- Loyola University Medical Center, Department of Surgery, Maywood, IL, USA; One:MAP Section of Surgical Analytics, Department of Surgery, Loyola University Chicago, USA
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Heo JS, Jung YH, Lee J, Shin SH, Kim EK, Kim HS, Choi JH. Prognosis and Predictive Factors according to Extent of Involvement in Necrotizing Enterocolitis among Very Low Birth Weight Infants. NEONATAL MEDICINE 2015. [DOI: 10.5385/nm.2015.22.2.98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Ju Sun Heo
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Young Hwa Jung
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Juyoung Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Han Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Ee-Kyung Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Jung-Hwan Choi
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
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Sho S, Neal MD, Sperry J, Hackam DJ. A novel scoring system to predict the development of necrotizing enterocolitis totalis in premature infants. J Pediatr Surg 2014; 49:1053-6. [PMID: 24952787 DOI: 10.1016/j.jpedsurg.2013.10.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 09/27/2013] [Accepted: 10/28/2013] [Indexed: 01/05/2023]
Abstract
BACKGROUND/PURPOSE Necrotizing enterocolitis totalis (NEC-totalis) is the severest form of NEC, with mortality rate of almost 100% even in the busiest neonatal centers. Despite such a prognosis, its risk factors remain elusive. We seek to identify clinical and laboratory parameters that differentiate NEC-totalis from NEC, and to use these factors to develop a scoring system to identify patients at risk for NEC-totalis upon presentation. METHOD NEC patients were identified from our electronic medical record using ICD9 code. Diagnosis of NEC-totalis was based on operative and autopsy reports. Patients were divided into 2 groups: NEC-but-no-totalis and NEC-totalis. Clinical/laboratory data were obtained for each group. T-test, multivariate logistic regression and backward stepwise regression analysis were performed to identify risk factors for NEC-totalis and these risk factors were formulated into a "Totalis Score." RESULT Among 157 NEC patients, 13 had NEC-totalis. NEC-totalis patients, compared to NEC alone, had fewer platelets, older age at diagnosis of NEC and greater phosphorus and creatinine levels. A 0-5 point scale "Totalis Score" based on these risk factors had sensitivity of 92% and a specificity of 78% for the diagnosis of NEC-totalis. CONCLUSION Low platelet, high phosphorus, high creatinine and older age at diagnosis of NEC were associated with a greater risk of developing NEC-totalis.
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Affiliation(s)
- Shonan Sho
- Division of Pediatric Surgery Children's Hospital of Pittsburgh, Pittsburgh, PA, 15224; Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15224
| | - Matthew D Neal
- Division of Pediatric Surgery Children's Hospital of Pittsburgh, Pittsburgh, PA, 15224; Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15224
| | - Jason Sperry
- Division of Pediatric Surgery Children's Hospital of Pittsburgh, Pittsburgh, PA, 15224; Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15224
| | - David J Hackam
- Division of Pediatric Surgery Children's Hospital of Pittsburgh, Pittsburgh, PA, 15224; Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15224.
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Lambertz A, Binnebösel M, Röth A, Orlikowsky T, Neumann UP, Steinau G, Klink CD. Postoperative outcome in premature infants with open abdomen. Hernia 2014; 18:351-6. [DOI: 10.1007/s10029-014-1226-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Accepted: 01/26/2014] [Indexed: 11/30/2022]
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Muller A, Schurink M, Bos AF, Hulzebos CV, Martijn A, Hulscher JBF, Kooi EMW. Clinical importance of a fixed bowel loop in the treatment of necrotizing enterocolitis. Neonatology 2014; 105:33-8. [PMID: 24247082 DOI: 10.1159/000355064] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 08/13/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND The need for surgical treatment in neonates with necrotizing enterocolitis (NEC) is associated with high mortality. Although pneumoperitoneum and progressive disease are generally accepted indications for surgery, it is unclear whether a fixed bowel loop (FBL) should prompt surgery. OBJECTIVE To determine the relationship between an FBL, type of treatment, and death in the management of NEC. METHODS Retrospective analysis (January 2000-December 2011) of all neonates with definite NEC in a tertiary neonatal intensive care unit. FBL was defined as a persistent (i.e. >24 h) dilated intestinal segment present on serial abdominal X-rays. RESULTS NEC was diagnosed in 141 neonates (median gestational age 30 weeks; median birth weight 1,340 g). An FBL was reported in 38 (27%) patients, of whom 18 were treated surgically. Mortality among FBL patients was independent of the type of treatment (surgical versus conservative): 8/18 and 7/20, respectively (p = 0.55). Of the 103 patients without FBL, 37 (36%) were treated surgically, which is comparable to the FBL group. Again, mortality was not related to the type of treatment (surgical versus conservative): 5/37 and 6/66, respectively (p = 0.49). The presence of an FBL was associated with mortality: more patients with an FBL (15/38, 39%) died than without an FBL (11/103, 11%; odds ratio 5.45, 95% confidence interval 2.21-13.45; p < 0.01). CONCLUSIONS In NEC patients, an FBL is associated with increased mortality. On its own it has moderate significance to guide treatment. Nevertheless, because it reflects disease severity, early recognition is important and prompt (surgical) treatment should be considered.
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Affiliation(s)
- Anoek Muller
- Department of Pediatric Surgery, Beatrix Children's Hospital, University of Groningen, The Netherlands
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Ganapathy V, Hay JW, Kim JH, Lee ML, Rechtman DJ. Long term healthcare costs of infants who survived neonatal necrotizing enterocolitis: a retrospective longitudinal study among infants enrolled in Texas Medicaid. BMC Pediatr 2013; 13:127. [PMID: 23962093 PMCID: PMC3765805 DOI: 10.1186/1471-2431-13-127] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 08/09/2013] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Vaidyanathan Ganapathy
- Department of Clinical Pharmacy and Pharmaceutical Economics & Policy, University of Southern California, 3335 S Figueroa Street, Unit A, Los Angeles, CA 90089-7273, USA
| | - Joel W Hay
- Department of Clinical Pharmacy and Pharmaceutical Economics & Policy, University of Southern California, 3335 S Figueroa Street, Unit A, Los Angeles, CA 90089-7273, USA
- Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA 90089-7273, USA
| | - Jae H Kim
- Department of Pediatrics, University of California San Diego, San Diego, California, USA
| | - Martin L Lee
- Prolacta Bioscience, City of Industry, CA 91746, USA
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Guelfand M, Santos M, Olivos M, Ovalle A. Primary anastomosis in necrotizing enterocolitis: the first option to consider. Pediatr Surg Int 2012; 28:673-6. [PMID: 22526554 DOI: 10.1007/s00383-012-3092-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/02/2012] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Miguel Guelfand
- Exequiel González Cortes Hospital for Children and Clinica Las Condes, Santiago, Chile.
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Abstract
Necrotizing enterocolitis (NEC) is the most common acquired gastrointestinal disease of premature neonates and is a serious cause of morbidity and mortality. NEC is one of the leading causes of death in neonatal intensive care units. Surgical treatment is necessary in patients whose disease progresses despite medical therapy. Surgical options include peritoneal drainage and laparotomy, with studies showing no difference in outcome related to approach. Survivors, particularly those requiring surgery, face serious sequelae.
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Rakshasbhuvankar A, Rao S, Minutillo C, Gollow I, Kolar S. Peritoneal drainage versus laparotomy for perforated necrotising enterocolitis or spontaneous intestinal perforation: a retrospective cohort study. J Paediatr Child Health 2012; 48:228-34. [PMID: 22112238 DOI: 10.1111/j.1440-1754.2011.02257.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Abhijeet Rakshasbhuvankar
- Telethon Institute for Child Health Research, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
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Ganapathy V, Hay JW, Kim JH. Costs of necrotizing enterocolitis and cost-effectiveness of exclusively human milk-based products in feeding extremely premature infants. Breastfeed Med 2012; 7:29-37. [PMID: 21718117 DOI: 10.1089/bfm.2011.0002] [Citation(s) in RCA: 152] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE This study evaluated the cost-effectiveness of a 100% human milk-based diet composed of mother's milk fortified with a donor human milk-based human milk fortifier (HMF) versus mother's milk fortified with bovine milk-based HMF to initiate enteral nutrition among extremely premature infants in the neonatal intensive care unit (NICU). METHODS A net expected costs calculator was developed to compare the total NICU costs among extremely premature infants who were fed either a bovine milk-based HMF-fortified diet or a 100% human milk-based diet, based on the previously observed risks of overall necrotizing enterocolitis (NEC) and surgical NEC in a randomized controlled study that compared outcomes of these two feeding strategies among 207 very low birth weight infants. The average NICU costs for an extremely premature infant without NEC and the incremental costs due to medical and surgical NEC were derived from a separate analysis of hospital discharges in the state of California in 2007. The sensitivity of cost-effectiveness results to the risks and costs of NEC and to prices of milk supplements was studied. RESULTS The adjusted incremental costs of medical NEC and surgical NEC over and above the average costs incurred for extremely premature infants without NEC, in 2011 US$, were $74,004 (95% confidence interval, $47,051-$100,957) and $198,040 (95% confidence interval, $159,261-$236,819) per infant, respectively. Extremely premature infants fed with 100% human-milk based products had lower expected NICU length of stay and total expected costs of hospitalization, resulting in net direct savings of 3.9 NICU days and $8,167.17 (95% confidence interval, $4,405-$11,930) per extremely premature infant (p < 0.0001). Costs savings from the donor HMF strategy were sensitive to price and quantity of donor HMF, percentage reduction in risk of overall NEC and surgical NEC achieved, and incremental costs of surgical NEC. CONCLUSIONS Compared with feeding extremely premature infants with mother's milk fortified with bovine milk-based supplements, a 100% human milk-based diet that includes mother's milk fortified with donor human milk-based HMF may result in potential net savings on medical care resources by preventing NEC.
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Affiliation(s)
- Vaidyanathan Ganapathy
- Department of Clinical Pharmacy & Pharmaceutical Economics & Policy, University of Southern California, Los Angeles, California 90089-7273, USA
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Eicher C, Seitz G, Bevot A, Moll M, Goelz R, Arand J, Poets C, Fuchs J. Surgical management of extremely low birth weight infants with neonatal bowel perforation: a single-center experience and a review of the literature. Neonatology 2012; 101:285-92. [PMID: 22286302 DOI: 10.1159/000335325] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Accepted: 11/19/2011] [Indexed: 12/15/2022]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) and focal intestinal perforation (FIP) are major causes of morbidity in infants with extremely low birth weight (ELBW). OBJECTIVE To evaluate the surgical procedures applied, and the survival and long-term outcome of ELBW infants with NEC and FIP in a single-center study. METHODS Inborn and outborn ELBW infants (<1000 g) with NEC and FIP were analyzed retrospectively from 2002 to 2007. Data collected include surgical procedures, survival as well as complications, length of partial parenteral nutrition and hospital stay. The short-term and long-term outcomes after 2-7 years were assessed and compared with a matched control group. RESULTS Out of 280 ELBW infants, 28 underwent surgery, 19 because of FIP and 9 for NEC. Fourteen infants in the FIP group were treated with primary laparotomy and 5 with peritoneal drainage (PD). In the NEC group, only 1 infant was treated with PD. PD was used for unstable patients and was always followed by secondary laparotomy after stabilization. Five of 28 (18%) surgically treated ELBW infants and 4 (14%) matched controls died. The following complications occurred in the surgical group: complete (n = 1) or minor wound dehiscence (n = 4), stoma prolapse (n = 5), parastomal hernia (n = 2), stoma fistula (n = 1), and wound infection (n = 2). Dependency on parenteral nutrition was significantly shorter in infants with FIP, while there were no differences in time to stoma closure and length of hospital stay between those with FIP and those with NEC. Eleven of 23 (47.8%) surviving patients with FIP or NEC showed developmental delay, compared with 9 of 24 (37.5%) in the controls. CONCLUSIONS The management of EBLW infants with NEC and FIP remains challenging. Our treatment approach was associated with low mortality. Developmental delay seems to be caused by extreme prematurity rather than NEC- or FIP-related bowel perforation.
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Affiliation(s)
- Carmen Eicher
- Department of Pediatric Surgery and Urology, University Children's Hospital, Tübingen, Germany.
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Genzel-Boroviczeny O. Leitlinie zur nekrotisierenden Enterokolitis (NEK). Monatsschr Kinderheilkd 2011. [DOI: 10.1007/s00112-011-2412-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Peritoneal drainage versus laparotomy as an initial treatment in complicated necrotizing enterocolitis. ANNALS OF PEDIATRIC SURGERY 2011. [DOI: 10.1097/01.xps.0000399433.86272.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Abstract
Necrotizing enterocolitis (NEC) is a leading cause of death among patients in the neonatal intensive care unit, carrying a mortality rate of 15-30%. Its pathogenesis is multifactorial and involves an overreactive response of the immune system to an insult. This leads to increased intestinal permeability, bacterial translocation, and sepsis. There are many inflammatory mediators involved in this process, but thus far none has been shown to be a suitable target for preventive or therapeutic measures. NEC usually occurs in the second week of life after the initiation of enteral feeds, and the diagnosis is made based on physical examination findings, laboratory studies, and abdominal radiographs. Neonates with NEC are followed with serial abdominal examinations and radiographs, and may require surgery or primary peritoneal drainage for perforation or necrosis. Many survivors are plagued with long term complications including short bowel syndrome, abnormal growth, and neurodevelopmental delay. Several evidence-based strategies exist that may decrease the incidence of NEC including promotion of human breast milk feeding, careful feeding advancement, and prophylactic probiotic administration in at-risk patients. Prevention is likely to have the greatest impact on decreasing mortality and morbidity related to NEC, as little progress has been made with regard to improving outcomes for neonates once the disease process is underway.
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Affiliation(s)
- Loren Berman
- Department of Surgery, Yale University School of Medicine, New Haven, CT 06520-8062, USA
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Hollingsworth CL, Rice HE. The Duke Abdominal Assessment Scale: initial experience. Expert Rev Gastroenterol Hepatol 2010; 4:569-74. [PMID: 20932142 DOI: 10.1586/egh.10.52] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Plain abdominal radiographs are the current standard imaging modality of choice in the evaluation of patients with clinically suspected necrotizing enterocolitis. The time interval between radiographic exams varies with the severity of disease and may range from every 6 h to every 24 h. Radiographs are often also obtained at any point of acute clinical deterioration. Evaluation of the abdominal radiographic series is critical as the findings may alter patient management and can be an indication for surgical intervention. For these reasons, it is essential that the radiographic findings are communicated to the referring neonatologist in a clear and consistent manner. Inherent variability and lack of consistency in radiology reporting makes it difficult for the referring clinician to incorporate radiographic reports into his/her treatment algorithm. Assigning abdominal radiographic findings in necrotizing enterocolitis to a numerical scale that increases as the disease progresses provides objective terminology in lieu of subjective descriptors and may facilitate communication to our clinical colleagues. With this task in mind, the Duke Abdominal Assessment Scale was created as a 10-point numerical scale of plain film bowel gas pattern findings designed to reflect progressive disease and increased certainty of the diagnosis of necrotizing enterocolitis.
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Radiographic predictors of disease severity in neonates and infants with necrotizing enterocolitis. AJR Am J Roentgenol 2009; 193:1408-13. [PMID: 19843760 DOI: 10.2214/ajr.08.2306] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of our study was to validate a radiographic scale, the Duke abdominal assessment scale (DAAS), as a tool for predicting the severity of disease in neonates and infants with suspected necrotizing enterocolitis (NEC). MATERIALS AND METHODS Study group patients (n = 43) underwent at least two two-view abdominal radiographic series within 48 hours of surgical intervention for suspected NEC complications. Control group patients (n = 86) were patients with suspected NEC who did not undergo surgery for suspected NEC complications. DAAS scores were assigned by two pediatric radiologists with 20 and 6 years' experience. RESULTS The initial radiographs of 26 of 43 (60.5%) patients in the study group showed fixed bowel loops (10/43, 23.3%), highly probable or definite pneumatosis (9/43, 20.9%), or portal venous gas (7/43, 16.3%). These findings had progressed to pneumoperitoneum on the follow-up series in 20 (46.5%) study group patients. Among the control group, three patients (3.5%) had highly probable or definite pneumatosis, and none had fixed bowel loops, portal venous gas, or pneumoperitoneum. Patients with higher DAAS scores were more likely to undergo surgical intervention than patients with lower scores (odds ratio, 1.69; 95% CI, 1.40-2.03). A receiver operating characteristic curve analysis showed good overall performance (c statistic = 0.83) for predicting eventual surgical intervention in the study group with higher DAAS scores. CONCLUSION The DAAS provides a standardized 10-point radiographic scale that increases with disease severity when using need for surgical intervention as a surrogate for severe NEC. For every 1-point increase in the DAAS score, patients were statistically significantly more likely to have severe disease as measured by need for surgical intervention.
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Peritoneal drainage versus laparotomy for necrotizing enterocolitis and intestinal perforation: a meta-analysis. J Surg Res 2009; 161:95-100. [PMID: 19691973 DOI: 10.1016/j.jss.2009.05.007] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2009] [Revised: 01/13/2009] [Accepted: 05/01/2009] [Indexed: 11/21/2022]
Abstract
BACKGROUND To determine whether peritoneal drain (PD) or laparotomy (LAP) is the most effective intervention in premature neonates with necrotizing enterocolitis (NEC) or intestinal perforation (IP). METHODS A systematic review of the published literature between January 2000 and December 2008 was undertaken. Prospective studies with at least 25 patients in each of the PD and LAP arms were selected. Gestational age, birth weight, operation, and mortality data were extracted. RESULTS Five prospective studies (two level I, three level II) with 523 (273 PD, 250 LAP) participants followed for mortality met selection criteria. Using a fixed effect model, the combined estimate indicates an increased mortality of 55% with PD (OR 1.55, 95% CI: 1.08-2.22, P=0.02) without statistical heterogeneity (chi(2)=5.88, P=0.21). PD patients were 0.78 wk younger (P =0.0002) and 67 g smaller (P =0.0006). Analysis of the three level II trials yielded a combined estimate indicating an excess mortality of 89% with PD patients (95% CI: 1.20-2.98, P =0.006) without statistical heterogeneity (chi(2)=3.74, P=0.15). CONCLUSIONS PD is associated with 55% excess mortality compared with LAP. Pediatric surgeons must individually assess and select patients with NEC and IP for optimal surgical therapy.
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Kim JE, Yoo HS, Kim HE, Park SK, Jeong YJ, Choi SH, Seo HJ, Chang YS, Seo JM, Park WS, Lee SK. Gastrointestinal surgery in very low birth weight infants: Clinical characteristics. KOREAN JOURNAL OF PEDIATRICS 2009. [DOI: 10.3345/kjp.2009.52.3.295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Ji Eun Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hye Soo Yoo
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hea Eun Kim
- Division of Pediatric Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Soo Kyoung Park
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoo Jin Jeong
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seo Heui Choi
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun Joo Seo
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yun Sil Chang
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Meen Seo
- Division of Pediatric Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Soon Park
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Suk Koo Lee
- Division of Pediatric Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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