Damage control laparotomy for generalized necrotizing enterocolitis

Abstract

Macroscopic generalized necrotizing enterocolitis (G-NEC) is associated with a very high mortality in neonates. In some instances, however, multiple bowel segments are necrotic, with most of the remaining small bowel damaged but viable. In these selected patients morbidity can be reduced and survival increased with an aggressive and early surgical approach. We have termed this approach damage control laparotomy (DCL). Over a 5(1/2)-year period, all neonates with G-NEC with adequate length of viable small bowel were subjected to DCL. The procedure is characterized by a resuscitative period of a few hours followed by laparotomy and resection of dead/perforated bowel. The bowel ends are either anastomosed or tied, and the bowel is returned to the abdomen to allow full tissue demarcation. Re-look laparotomy is performed 3-4 days later, at which time any new necrotic bowel is excised and re-joined, to achieve small bowel continuity. In this prospective study, 104 neonates with G-NEC underwent operation; 27 neonates (26%) were considered to have an adequate potential length of viable bowel and were selected for DCL. Nineteen neonates survived in the follow-up period. Early mortality was due to sepsis syndrome in 6 patients, and late mortality in 2 neonates was secondary to the short bowel syndrome. The DCL procedure is another step toward improving survival in surgical G-NEC; this technique avoids proximal stomas and their complications, and at the same time it preserves the best possible bowel length.

Neonatal gut injury and infection rate: impact of surgical debridement on outcome

“…Factors associated with this increased risk of cholestasis include: Lack of enteral feedings, sepsis, removal of large segments of intestine, and prolonged hyperalimentation [16]. Fifteen percent DEB infants in current study underwent removal of large gangrenous segments of intestine contributing to cholestasis.…”

“…Fifteen percent DEB infants in current study underwent removal of large gangrenous segments of intestine contributing to cholestasis. Termination of enterocolonic continuity or short bowel length independently increased the risk for cholestasis in DEB infants [16]. Preservation of enterocolonic continuity and small bowel length although desirable may not be achievable in some infants because of extensive bowel necrosis.…”

“…Any or all of these may be manifestations of an abdominal abscess, fecal peritonitis or a sealed necrotic segment of perforated bowel. DEB should be considered as one of the management options in these infants when they fail to show improvement [16][17][18]. Unless these infants are able to achieve sustained enteral nutrition, they will eventually succumb either to catheter related Results are expressed as mean ± SD; NS not significant; level of significance, P £ 0.05 infectious complications, liver failure, or to respiratory failure complicated by abdominal distention and sepsis.…”

“…Preservation of enterocolonic continuity and small bowel length although desirable may not be achievable in some infants because of extensive bowel necrosis. Early enteral feedings to the extent permitted by the remainder bowel length may prevent or diminish development of cholestasis [16][17][18].…”

Intestinal stenting in preterm, very-low-birth-weight infants with necrotizing enterocolitis and multiple perforations

“…There are a variety of possible methods of treatment such as peritoneal drainage; drainage and later laparotomy; resection and ostomies; resection and anastomosis; resection and clipping the bowel ends with a second-look procedure; laparoscopy to evaluate NEC extension; and, as noted in the present study, in infants with potential major loss of bowel, resection and stenting, letting the remaining bowel achieving anastomose spontaneously [1][2][3][4][5][6][7][8][9][10][11][12][13].…”