Effect of time of diagnosis to surgery on outcome, including long-term neurodevelopmental outcome, in necrotizing enterocolitis

Abstract

A systematic review of the PubMed and EMBASE databases was carried out to determine if time from diagnosis to surgery affects outcomes in necrotising enterocolitis. The study was registered on the PROSPERO website. Studies reporting both time to surgery and at least one clinical outcome measure in infants undergoing surgery for NEC were included. The initial search returned 1121 articles. After removing duplicates, title, and abstract screening, 49 remained for full-text review. Of these, only two reported both timing of surgery for NEC and at least one clinical outcome. The total number of neonates included was 202. Outcomes reported were death and/or parenteral nutrition use 28 days post surgery in one study and white matter brain injury in the other. No statistically significant association was found between any of the outcomes reported and timing of surgery. There were, however, significant differences associated with non-modifiable risk factors, such as age and gestation, at presentation. However, very few studies report this as a variable. Given the continuing poor outcomes and heterogeneous nature of NEC and its treatments, further large-scale prospective studies are required to examine the impact of timing of surgery, alongside other, potentially modifiable factors on outcome in NEC.

Development of a Prediction Model for Surgery or Early Mortality at the Time of Initial Assessment for Necrotizing Enterocolitis

“…A systematic review of observational studies failed to show any association between prognosis and time between diagnosis of NEC and surgery. 3 Analysis of prospective use of the prediction model using the HASOFA score is necessary to assess (1) whether serial assessments of HASOFA score can help with earlier decision-making for transfer, surgical intervention, or both if meeting criteria and (2) whether this actually decreases mortality and morbidity.…”

“…This age group was chosen as they are at the highest risk of NEC. [1][2][3]5 In the NICU database, suspected NEC was originally defined by the presence of abdominal distention and feeding intolerance (vomiting or increased gastric residuals lasting for at least 24 h) in the absence of X-ray evidence of intramural air, perforation, meconium plug syndrome, Hirschsprung's disease, or definitive surgical or autopsy findings of NEC. Proven NEC was defined by abdominal distention in association with (a) the unequivocal presence of intramural air on abdominal radiogram, (b) perforation seen on abdominal radiogram, clinical evidence as suggested by erythema and induration of the abdominal wall, or intra-abdominal abscess formation, (c) characteristic findings of NEC observed at surgery or at autopsy, (d) stricture formation following an episode of suspected NEC.…”

“…Necrotizing enterocolitis (NEC) is a multifactorial gastrointestinal process which results in 20 to 30% mortality and significant multisystem, notably gastrointestinal and neurological morbidity. [1][2][3] Most cases of NEC (90%) occur in preterm infants, with a prevalence of 2 to 7% among very low birthweight (VLBW, <1,500 g) infants and 6 to 10% among extremely low birthweight (ELBW, <1,000 g) infants. 4,5 Among VLBW infants with NEC, surgical intervention is necessary in 27 to 52%.…”

Development of a multivariable prediction model for necrotizing enterocolitis stage III or mortality within a week among preterm infants at the time of initial evaluation for necrotizing enterocolitis: A retrospective cohort study

“…Necrotizing enterocolitis (NEC) is a multifactorial gastrointestinal process which can result in 20-30% mortality and signi cant multisystem, notably gastrointestinal and neurological morbidity [1][2][3]. Most cases of NEC (90%) occur in preterm infants, with a prevalence of 2-7% among very low birthweight (VLBW, < 1500 g) infants and 7-13% among extremely low gestational age (GA) infants [1][2][3]. Among VLBW infants with NEC, surgical intervention is necessary in 27-52% [4].…”

“…If use of serial assessments of the prediction model using PACSOFAH score is validated in other centers, this model could be used as a screening tool at the time of initial evaluation for babies with suspected or proven NEC for hospitals without in house surgical resources.Limitations of this study include the single center observational retrospective design over a long period of time, lack of serial measurements of the PACSOFAH and the NSOFA scores and assessments of the prediction model, multiplicity of secondary analyses without adjustment of P values, and lack of prospective external validation of the PACSOFAH score in another institution. A systematic review failed to show any association between prognosis and time between diagnosis of NEC and surgery[3]. Analysis of prospective use of the prediction model using the PACSOFAH score is necessary to assess (1) whether serial assessments of the prediction model can help with earlier decision making for transfer, surgical intervention or both if meeting criteria and (2) whether this actually decreases mortality and morbidity.In summary, a multivariate prediction model was developed using a new score, the PACSOFAH score (combining Pneumoperitoneum, Abdominal Compartment Syndrome and NSOFA score with Acidemia, Hyperglycemia, and Hyperkalemia), GA and use of inotropes within a week.…”