Portal venous air: The poor prognosis persists*

Presented at the 2000 Annual Meeting of the Section on Surgery of the American Academy of Pediatrics, Chicago, Illinois, October 28-November 1, 2000.
https://doi.org/10.1053/jpsu.2001.25732Get rights and content

Abstract

Background/Purpose: The prognostic importance of portal vein air (PVA) in babies with necrotizing enterocolitis (NEC) has been controversial. This study compares the outcome in babies with NEC and PVA treated surgically versus those with medical management. Methods: Forty neonates in the neonatal intensive care unit (NICU; 1995 through 1999) had (PVA) during their hospitalization. Babies were analyzed for gestational age (GA), birth weight (BW), and survival after operative versus medical management. Results: The average GA was 26 weeks, average BW was 1,173 g. Twenty-three patients (57.5%) tolerated full feedings and 8 (20%) partial feedings at diagnosis. All 40 babies required intubation at birth with 23 (57.5%) requiring reintubation with onset of PVA. In all cases, PVA was present within 24 hours of onset of abdominal distension, feeding intolerance, or heme-positive stools. Two cases of PVA “resolved” only to recur later in the patients' courses. Thirty-two patients (80%) manifested pneumatosis intestinalis on abdominal radiographs, and 8 (20%) had perforations. Acidosis was present in 25 (63%) patients, and vasopressor support (dopamine) was required in 15 (38%), with 2 patients requiring support only preoperatively. Initial management consisted of bowel rest, fluid resuscitation, orogastric decompression, and broad-spectrum antibiotics. Operation was performed in 31 (78%). Seventeen underwent resection with ostomy formation with 6 deaths and 11 survivors. Four underwent resection using the clip and drop back method, with one death and 3 requiring an ostomy at second look laparotomy. Ten had NEC totalis and closure of the abdomen only. Overall operative mortality rate was 17 of 31 (54%). Nine seemingly stable patients were treated nonoperatively. Six had progressed disease and died before salvage laparotomy could be performed, whereas 3 (33%) survived without further therapy. Conclusions: PVA has been a relative indication for operation. This view has been challenged by the survival of some patients without laparotomy. Although nonoperative therapy seems appealing in hemodynamically stable patients without acidosis, our data confirm the poor prognosis of infants with PVA and NEC. J Pediatr Surg 36:1143-1145. Copyright © 2001 by W.B. Saunders Company.

Section snippets

Materials and methods

A retrospective analysis of all infants with NEC that presented with or in whom portal venous air developed between 1995 and 1999 (n = 40) at the James Whitcomb Riley Hospital for Children, Indianapolis, IN was performed. Parameters evaluated included gestational age, birth weight, need for intubation, onset of symptoms, radiographic findings, feeding intolerance, bloody stools, metabolic acidosis, need for hemodynamic support, and outcome. Patients who underwent operative intervention were

Results

The average gestational age was 26 weeks (range, 23 to 41 weeks) and average birth weight 1,173 g (range, 650 to 3,300 g). Twenty-one infants (52%) weighed less than 1,000 g. Before the development of NEC, 23 infants (57.5%) were tolerating full feedings and 8 (20%) partial feedings. All 40 infants required endotracheal intubation at birth, and 23 (57.5%) required reintubation at the onset of PVA. In all cases, PVA was present within 24 hrs of onset of abdominal distension, feeding intolerance,

Discussion

NEC continues to be a common problem particularly in premature infants of low birth weight. Although this condition affects nearly 2% of all infants admitted to the NICU, the incidence increases to nearly 10% among very low birth weight babies (< 1,000 g).2, 4, 5 With improvements in the management of hyaline membrane disease and other comorbidities, the overall survival rate of infants who have NEC has improved.6 The mortality rate of infants with NEC who require surgical intervention has

Cited by (50)

  • Necrotizing Enterocolitis

    2023, Principles of Neonatology
  • Current Status of Necrotizing Enterocolitis

    2019, Current Problems in Surgery
    Citation Excerpt :

    Several studies have linked portal venous gas to disease severity and higher rates of morality77,118-120 (Fig 6). Additionally, infants with portal venous gas, particularly ELBW infants, have been found to have a higher rate of NEC totalis (defined as >75%-80% bowel necrosis).77,121,122 It is also theorized that radiographic signs of perforation and bowel necrosis develop later in ELBW infants, potentially leading to delays in treatment.122,123

  • Necrotizing Enterocolitis and Short Bowel Syndrome

    2018, Avery's Diseases of the Newborn: Tenth Edition
  • Surgical necrotizing enterocolitis

    2017, Seminars in Perinatology
  • Necrotizing Enterocolitis and Short Bowel Syndrome

    2017, Avery's Diseases of the Newborn, Tenth Edition
View all citing articles on Scopus
*

Address reprint requests to Karen W. West, MD, JW Riley Hospital for Children, 702 Barnhill Dr, Suite 2500, Indianapolis, IN 46202-5200.

View full text