A meta-analysis of peritoneal drainage versus laparotomy for perforated necrotizing enterocolitis*

Presented at the 2000 Annual Meeting of the Section of Surgery of the American Academy of Pediatrics, Chicago, Illinois, October 28-November 1, 2000.
https://doi.org/10.1053/jpsu.2001.25764Get rights and content

Abstract

Background/Purpose: Both primary peritoneal drainage (PPD) and laparotomy (LAP) are used widely for treatment of perforated necrotizing enterocolitis (NEC). Published reports include only anecdotes and small series. The authors used techniques of meta-analysis to determine which treatment is most effective. Methods: The authors identified published studies reporting surgical treatment of NEC from January 1, 1978 to December 31, 1999; there were 10 studies (n = 475). The authors were contacted and all available raw patient data for use in meta-analysis (n = 190) were obtained. The authors used logistic regression to determine the relative survival rate after PPD and LAP, controlling for the effect of gestational age and institution. Results: The combined probability of survival in the 10 published studies did not show an advantage for PPD (55%) or LAP (67%; P =.27). When the authors corrected for the effect of birth weight on survival rate, they still did not observe a difference (P =.67). A marked bias in treatment assignment was found with smaller babies undergoing PPD than LAP (931 g versus 1,615 g, respectively; P =.0004). Analysis of raw data showed an even greater bias in treatment assignment. The authors found increased survival rate for LAP versus PPD (62.3% v 35.6%; P =.0009). However, a logistic regression model could not overcome the bias in assignment of patients with a much higher expected mortaltiy rate to PPD. Conclusions: Using currently available data, it is not possible to determine whether PPD or LAP is superior. Bias in treatment assignment precludes conclusions regarding comparative survival. Only a randomized trial will determine which operation is best for the treatment of perforated NEC. J Pediatr Surg 36:1210-1213. Copyright © 2001 by W.B. Saunders Company.

Section snippets

Materials and methods

We identified all published studies in the English-language literature reporting surgical treatment of NEC from 1978 through 1999. We identified 10 studies reporting use of PPD and LAP in 475 patients.2, 3, 4, 5, 6, 7, 8, 9, 10, 11 We analyzed the birth weight, gestational age, type of operation, and survival rate of patients from each study. Data on comorbid conditions associated with prematurity were not uniformly available.

We next contacted the authors of these studies and obtained raw data

Published data analysis

Table 1 lists studies by author, birth weight, gestational age, type of operation, and survival rate.

. Comparison of Type of Operation, Gestational Age, Birth Weight, and Survival With Perforated NEC Published Data

Empty CellPPDLAP
StudyNo.GA (wk)*BW (g)*Survival Rate (%)No.GA (wk)*BW (g)*Survival Rate (%)
Cheu et al251291,15818 (35)41321,87531 (76)
Takamatsu et al34278084 (100)3333
Morgan et al4292799423 (79)20321,85418 (90)
Azarow et al544281,10027 (61)42311,70024 (57)
Snyder et al612291,1343 (25)91311,62852

Discussion

Despite extensive analysis of published studies and individual patient data, we were not able to determine the relative merits of PPD and LAP for perforated NEC. This was primarily because of the marked bias in treatment assignment. This bias was significant in published data and even more pronounced in unpublished raw data from 3 large centers.

There is agreement that the highest quality data are generated from a randomized controlled clinical trial.12 However, these type of data often are not

Acknowledgements

The authors thank the following individuals for providing us with patient data used in this report: Charles Snyder, MD, Children's Mercy Hospital, Kansas City, MO; Adine Moore, MD, Hospital for Sick Children, Toronto, ON; Thomas Curran, MD, Emmanuel Hospital, Portland, OR; and Eugene McGahren, MD, University of Virginia, Charlottesville, VA.

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    Citation Excerpt :

    Previous studies have shown a much higher rate of PPD ranging from 17% to 49% in surgically treated VLBW infants [23–25]. Moss et al. reported in a meta-analysis that higher birth weight infants were more likely to have laparotomy than PPD, which would explain the low rate of PPD in our cohort [26]. A more recent systematic review showed similar results regarding gestational age and birth weight [27], albeit a smaller difference than Moss [26]; in addition, there was a much higher rate of mortality in the PPD group.

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*

Address reprint requests to R. Lawrence Moss, MD, Division of Pediatric Surgery, Packard Children's Hospital, 725 Welch Rd, Palo Alto, CA 94304.

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