Surgical necrotizing enterocolitis

Abstract

Although currently available data are variable, it appears that the incidence of surgical necrotizing enterocolitis (NEC) has not decreased significantly over the past decade. Pneumoperitoneum and clinical deterioration despite maximal medical therapy remain the most common indications for operative treatment. Robust studies linking outcomes with specific indications for operation are lacking. Promising biomarkers for severe NEC include fecal calprotectin and S100A12; serum fatty acid-binding protein; and urine biomarkers. Recent advances in ultrasonography make this imaging modality more useful in identifying surgical NEC and near-infrared spectroscopy (NIRS) is being actively studied. Another fairly recent finding is that regionalization of care for infants with NEC likely improves outcomes. The neurodevelopmental outcomes after surgical treatment are known to be poor. A randomized trial near completion will provide robust data regarding neurodevelopmental outcomes after laparotomy versus drainage as the initial operative treatment for severe NEC.

Necrotising Enterocolitis - epidemiology and imaging

“…203 Pneumoperitoneum (PP) on AR is often stated to be an "absolute indication" for surgery, 70,202 but only 88% of our survey respondents, stated that it would "always" prompt surgical intervention. More problematic, it is known to be missing in a great proportion of infants with perforated NEC.…”

“…99,199,200 Heida found decreasing frequencies of surgical interventions from 53% in 2005-2007 to 29% in 2011-2013, with pneumoperitoneum increasing its share of indications for surgery from 47 to 63%. 201 ❖ Indications for Surgery The only generally accepted indication for surgery is PP on AR, 70,202,203 as a sign of intestinal perforation. Especially in the extremely low birth weight infants, however, the sensitivity of radiographic signs is low, 26,39 PP is known to be missing in a great proportion of infants with perforated NEC.…”

“…71 Clinical indications for surgical intervention include deterioration in spite of maximal medical treatment, abdominal erythema or a palpable abdominal mass. 144,199,203 The potential of biomarkers to distinguish serious NEC, that may require surgery, from milder disease, is being explored. 205 Blakely reported that, in 156 infants undergoing laparotomy or drainage for NEC or SIP, the indication was PP in 64%, clinical deterioration despite medical therapy in 66%, PVG in 14%, abdominal wall erythema in 28%, infected ascites in 5%, and other factors in 26%.…”

“…91 The results of others have been contradictory in this respect. 25,83,90,98,[218][219][220] Some claim that the incidence is probably unchanged, and that variations depend on the confusion over how to define NEC, 198,203,221 which, with its multifactorial aetiology, is rather the common result of several pathophysiological pathways than one disease entity. 18 Apart from discrepancies in case definition and the inclusion or exclusion of mild cases, possible explanations for variations of NEC incidence within and between populations may be differences in the composition of populations in terms of gestational ages, distribution of risk factors, protective factors, and comorbidities, as well as clinical practices.…”

“…The introduction of new methods for monitoring, such as biomarkers and NIRS, 203,205 may influence the role of imaging in this context. Although most survey respondents thought that US would, at least sometimes, be useful, the often repeated objections of availability and operator dependency 211 were expressed, as were concerns about the validity of ultrasonographic findings.…”