The role of peritoneal drains in treatment of perforated necrotizing enterocolitis: Recommendations from recent experience

doi:10.1016/S0022-3468(98)90476-6

Journal of Pediatric Surgery

Volume 33, Issue 10, October 1998, Pages 1468-1470

https://doi.org/10.1016/S0022-3468(98)90476-6 Get rights and content

Abstract

Background/Purpose: Intraperitoneal drains have been used in the treatment of perforated necrotizing enterocolitis (NEC), especially in infants less than 1,000 g, yet their role is still debated. The authors wished to examine their more recent experience in the treatment of NEC to make recommendations for operative management.

Methods: The authors reviewed the records of all infants seen between 1989 and 1995 who had clinical and radiological evidence of NEC at the Hospital for Sick Children, Toronto, Ontario. One hundred sixty-seven infants were treated for NEC and 73 (44%) infants required surgical intervention.

Results: Forty-five patients had perforated NEC; 23 were treated initially by peritoneal drainage and 22 by primary laparotomy. The 23 newborns who had peritoneal drainage were of significantly lower birth weight, and 19 (83%) of these infants required subsequent laparotomy for worsening disease. The overall mortality rate for perforated NEC was 36%.

Conclusion: Insertion of a peritoneal drain is still useful in resuscitating small critically ill infants with NEC; however, the majority of these infants will also require laparotomy.

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Updates and recommendations on the surgical management of NEC
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Citation Excerpt :
Three of the infants survived, one developed an intestinal stricture later on, and two passed later on but with reportedly intact gastrointestinal tracts. PD became an option for very small, critically ill infants, but later published conclusions advised that the majority of the neonates who undergo PD placement will still require a laparotomy due to progression of disease.34 Additionally, it was argued that PD does not allow for exploration and assessment of bowel disease involvement.
Necrotizing enterocolitis is a severe gastrointestinal disease of the infant. It most commonly targets those that are born prematurely. NEC has been associated with initiation of feeds and in most cases, it can be managed with antibiotics and bowel rest. However, in up to half of the cases, intestinal perforation, peritonitis, and failure of medical treatment will require surgical intervention. The following review will discuss the surgical approach to managing NEC, based on an updated review of practice patterns and recently published literature.
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Peritoneal drainage is associated with higher survival rates for necrotizing enterocolitis in premature, extremely low birth weight infants
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To evaluate peritoneal drainage (PD) and laparotomy ± resection/ostomy (LAP) as initial approaches to the surgical management of necrotizing enterocolitis (NEC) in premature, extremely low birth weight (ELBW) infants.
Kids' Inpatient Database (2003-2012) was searched for cases of NEC (International Classification of Diseases, ninth revision, Clinical Modification [ICD-9-CM] 777.5x) in premature (<37 weeks), extremely low birth weight (<1000 g) infants. Infants were admitted at <28 days of life. Propensity score (PS)-matched analyses were performed, using end points of hospital mortality, length of stay (LOS), and cost of hospitalization. Cases were matched 1:1 on 48 confounding variables (demographic, clinical, and hospital characteristics and 39 comorbidities).
On PS-matched comparison, PD had higher survival versus LAP, P = 0.0009. LOS and cost were higher for PD versus LAP, P < 0.003. Survival rates did not differ between PD + LAP and PD-only treatments. LOS and cost were higher for PD + LAP versus PD-only, P < 0.02. PD + LAP infants had higher survival versus LAP, P = 0.0193. LOS and cost were higher for PD + LAP, P < 0.005.
A risk-adjusted PS-matched analysis of operative management in premature, ELBW infants with NEC found higher survival rates associated with PD placement versus LAP, whether PD was used as definitive treatment or with subsequent LAP even after controlling for potential contributors to selection bias (i.e., stability influencing management preference).
Trajectory of Metabolic Derangement in Infants with Necrotizing Enterocolitis Should Drive Timing and Technique of Surgical Intervention
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Seven clinical metrics of metabolic derangement (MD7) have improved the timing of surgical intervention in infants with necrotizing enterocolitis (NEC). We compared surgical NEC outcomes based on MD7 at our center (unit S) with a similar center (unit B) that based its intervention on abdominal radiograph.
Premature infants undergoing surgical care for NEC were evaluated. MD7 included positive blood culture, acidosis, bandemia, hyponatremia, thrombocytopenia, hypotension, and neutropenia. Surgical recommendations were stratified as observation or intervention. Good outcomes included full enteric feeding by discharge and poor outcomes were death or dependence on parenteral nutrition. For unit S and unit B, the frequency, median, and mode of MD7 component per case were determined for observation and intervention. Mann-Whitney U test and Wilcoxon matched pairs were used to compare positive MD7 frequency for observation with intervention. Institutional mortality was compared and metabolic severity of unit cohorts was evaluated by incidence of MD7 in each.
From March 2005 to July 2008, forty-one infants at unit S underwent 62 surgical evaluations. Observation was elected in 38 (median 1 MD7 per case, mode 0). Operative intervention occurred in 24 (median 4 MD7 per case, mode 4). Proportional MD7 difference between observation and intervention was significant (p = 0.018, U = 6). From February 2007 to December 2008, sixty-five unit B infants received 81 evaluations, recommending 37 observations (median 2 MD7 per case, mode 2), and 44 interventions (median 3 MD7 per case, mode 3). MD7 proportions between observation and intervention were not significant (p = 0.318, U = 16). Poor outcomes rates for unit S and unit B infants were 24% and 66%, respectively (p = 0.0001). Severity of MD7 did not differ between institutions (p = 0.53, U = 19).
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Citation Excerpt :
These results did not change when the data were stratified for birth weight and the presence of pneumatosis on abdominal radiographs. However, in the nonrandomized arm of the same study, the infants who underwent laparotomy had better outcomes than those who underwent PD.97-105 This finding suggests that the use of careful clinical judgment to decide whether to perform laparotomy or PD can lead to improved outcomes when compared with random or indiscriminate selection of the surgical procedure.
Necrotizing enterocolitis (NEC) is a devastating illness that predominantly affects premature neonates. The mortality associated with this disease has changed very little during the last two decades. Neonates with NEC fall into two categories: those who respond to medical management alone and those who require surgical treatment. The disease distribution may be focal, multifocal, or panintestinal. Surgical treatment should therefore be based on disease presentation. Recent studies have added significant insight into our understanding of the pathogenesis of NEC. Several groups have shown that upregulation of nitric oxide plays an integral role in the development of epithelial injury in NEC. As a result, some treatment strategies have been aimed at abrogating the toxic effects of nitric oxide. In addition, several investigators have reported the cytoprotective effect of epidermal growth factor, which is found in high levels in breast milk, on the intestinal epithelium. Thus, fortification of infant formula with specific growth factors could soon become a preferred strategy to accelerate intestinal maturation in the premature neonate to prevent the development of NEC. One of the most devastating complications of NEC is the development of short bowel syndrome (SBS). The current treatment of SBS involves intestinal lengthening procedures or bowel transplantation. A novel emerging method for treating SBS involves the use of tissue-engineered intestine. In laboratory animals, tissue-engineered small intestine has been shown to be successful in treating intestinal failure. This article examines recent data regarding surgical treatment options for NEC as well as emerging treatment modalities.

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The role of peritoneal drains in treatment of perforated necrotizing enterocolitis: Recommendations from recent experience

Abstract

J Pediatr

J Ped Surg

J Ped Surg

J Ped Surg

Necrotizing enterocolitis

N Engl J Med

Acute necrotizing enterocolitis in infancy: A review of 64 cases

Pediatrics

Necrotizing enterocolitis in the newborn: Operative indications

Ann Surg

Necrotizing enterocolitis: Factors affecting mortality in 101 surgical cases

Surgery

Neonatal necrotizing enterocolitis: Experience with 100 consecutive surgical patients

World J Surg

Changing trends in necrotizing enterocolitis, experience with 302 cases in two decades

Ann Surg