Exploratory laparotomy in the management of confirmed necrotizing enterocolitis
Lakhoo K., Morgan RD., Thakkar H., Gupta A., Grant HW., Wagener S., Willetts IE.
© 2015 Annals of Pediatric Surgery. Introduction: Necrotizing enterocolitis (NEC) is a serious gastrointestinal emergency in newborn infants. Surgical management includes primary peritoneal drainage and/or exploratory laparotomy with bowel resection. This study describes obstetric complications, postnatal comorbidities, surgical care and intermediate postoperative outcomes in all infants with surgically and/or histologically proven NEC, who underwent exploratory laparotomy at our tertiary referral centre. Materials and methods: We conducted a retrospective review between January 2005 and December 2010. Results are reported as median (range). Fisher's exact test (two tailed) was used for statistical analysis. A P-value of 0.05 or less was considered statistically significant. Results: A total of 71 infants had suspected (Bell's stage ≥ 1) NEC. Of them, 32 infants underwent laparotomy for stage 2-3 NEC. We excluded 11 infants with surgically and/or histologically proven spontaneous intestinal perforation. In the remaining 21 infants with confirmed NEC, median gestational age was 27 weeks (23-39 weeks) and median birth weight was 720 g (440-3510 g). NEC was suspected after a median 14 days of life (1-49 days of life). Fifteen patients (71%) were initially managed medically for a median total of 8 days (1-25 days). Laparotomy was performed after a median of 7 days ( < 1-35 days) from the suspicion of NEC. Eleven infants (52%) underwent bowel resection and enterostomy, four infants (19%) underwent bowel resection with primary anastomosis and one infant (5%) underwent proximal diverting jejunostomy. Bowel perforation was seen in seven patients (33%). Necrosis totalis was evident in five patients (24%). There were 12 postoperative deaths (57% mortality), and seven deaths (58%) occurred during the first 30 days. Infants who died were more likely to have had absent/reversed enddiastolic flow (n=5, P= 0.64), intrauterine growth retardation (n=5, P = 0.18) or a gestational birth weight between 501 and 750 g (n=9, P = 0.08). In the surviving children (n= 9), the median length of hospital stay was 134 days (87-190 days) and postoperative sequelae were frequently seen. Conclusion: The morbidity and mortality for infants with confirmed NEC who undergo laparotomy remain high in infants despite optimal medical and surgical care.