Necrotizing Enterocolitis with Dr. Gail Besner
With Dr. Gail Besner · hosted by Dr. Todd Ponsky · StayCurrentMD
Cued at 37:35 · stops at 38:20 · press play
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Despite 6 decades of research, the exact cause of necrotizing enterocolitis is unknown and there is no absolute cure for the disease.
Indomethacin administration predisposes babies to both isolated ileal perforation and necrotizing enterocolitis.
PPIs, H2 blockers, and other acid suppression medications predispose to or increase chances of NEC development; gastric acid neutralization should be avoided.
In premature babies with patent processus vaginalis, intestinal contents leaking into the abdomen can cause scrotal swelling and discoloration.
Neutropenia and low white blood cell count are more concerning than elevated white count in NEC, suggesting overwhelming sepsis that the patient is not compensating for.
Thrombocytopenia can result from endotoxemia and gram-negative septicemia in NEC; low platelet count is important to know before surgery to optimize patient condition.
Cross-table lateral or lateral decubitus X-ray films are essential in addition to plain films because free air can be quite subtle and easily missed.
Pneumoperitoneum (free air) is an absolute indication for surgical intervention, either drain placement or laparotomy.
Clinical deterioration in the face of maximum medical management is an indication for surgery.
Fixed loops of intestine on serial X-rays are not an absolute indication for surgery but are a worrisome sign that the patient is not improving.
Portal venous air is a concerning and worrisome sign, but not an absolute indication for surgery; some patients with portal venous air improve with medical management and don't need operation.
Medical management of NEC includes withholding feeds, inserting orogastric tube for gastric decompression, starting broad-spectrum antibiotic therapy, and performing serial abdominal exams, labs, and X-rays.
Small French feeding tubes are not adequate for gastric decompression in NEC; feeding tube should be removed and replaced with orogastric tube.
There is tremendous diversity in antibiotic regimens for NEC across the United States; broad-spectrum coverage is critical but specific regimen may depend on bacterial colonization of the intensive care unit environment.
At Nationwide Children's Hospital, abdominal X-rays are obtained at intervals (approximately every 8 hours) rather than waiting 12-24 hours between films.
Medical management (NPO, decompression, antibiotics) should continue for at least 1 week to 10 days, preferably a week and a half, before starting feeds.
Some babies have repeated episodes of necrotizing enterocolitis.
Post-NEC stricture formation typically occurs in the colon, usually near the splenic flexure in the left colon, but can occur anywhere.
For suspected post-NEC stricture, contrast enema is preferred as initial study over upper GI with small bowel follow-through because strictures are more common in colon and contrast from below avoids long wait time if patient is partially obstructed.
Serial abdominal exams are important for surgical decision-making; worsening distention, signs of peritoneal irritation, hemodynamic instability with increasing pressor support, and renal shutdown with no urine production build up to indicate need for surgery.
At London NEC conference, 100% of European surgeons polled perform laparotomy for NEC and no one places peritoneal drains.
Two randomized controlled trials (MOSS trial in US and PIERO trial in Europe) of peritoneal drainage versus laparotomy showed no difference in overall mortality.
MOSS and PIERO trials looked at early endpoints rather than delayed endpoints of neurological recovery.
Babies who have peritoneal drains instead of laparotomy may do worse from neurological standpoint if neurological outcomes are examined 1-2 years after recovery from NEC.
The ongoing NEST trial (necrotizing enterocolitis surgery trial) in the United States has randomized 300 babies to peritoneal drainage versus laparotomy and will examine neurological outcomes at 18-22 months after recovery from NEC with detailed neurological assessments.
Dr. Besner predicts that in the next 1-2 years, practice will move towards laparotomy versus peritoneal drainage for the majority of NEC babies, with neurological outcomes expected to be better in babies who undergo laparotomy with removal of inflammatory necrotic tissue.
Babies with peritoneal drains can have striking degree of dead bowel remaining in abdomen, as seen when some drain patients subsequently undergo laparotomy.
Systemic inflammatory response syndrome can make patients just as sick and hemodynamically unstable from isolated intestinal perforation as from necrotizing enterocolitis.
After peritoneal drain placement, significant proportion of patients continue to decline and require subsequent laparotomy.
Peritoneal drain placement is a bedside procedure performed with small amount of local anesthesia using small transverse incision in right lower quadrant; incision must not be too large to prevent subsequent hernia.
Quarter-inch Penrose drain is used for peritoneal drainage; drain is passed gently multiple times without forcing to avoid bleeding, then sutured in place.
Operating during peak inflammatory process (e.g., 2 weeks after drain with ongoing stool output) can result in severe adhesions, serosal tears, and enterotomies; sometimes smartest decision is to stop operation, create proximal diverting stoma if possible, and avoid making situation worse.
After successful drain placement with patient recovery, drain should be advanced out over several days starting at 7-10 days post-operation rather than withdrawing all at once.
Continual leakage of stool at drain site is concerning; upper GI small bowel follow-through should be considered before drain removal if ongoing stool leakage present.
If feeds are started after drain removal without contrast study and patient doesn't tolerate feeds, contrast study becomes mandatory to ensure everything is intact.
For laparotomy, if baby is too hemodynamically unstable or on very high oscillator settings to safely transport to OR, operation can be performed at bedside in ICU with surgical team and anesthesiologists.
Laparotomy uses supraumbilical transverse incision; extreme care needed due to thin skin and underlying dilated bowel to avoid immediate enterotomy.
Patient should be resuscitated preoperatively with at least partial correction of platelet and coagulation abnormalities; blood products (packed red blood cells, platelets, fresh frozen plasma) must be available for operation.
It is critically important not to injure liver or spleen in premature babies during laparotomy; even minimal trauma can cause subcapsular hematoma that baby can exsanguinate from.
Spontaneous intestinal perforation (SIP) presents as one small localized area of perforation, while NEC is more diffuse disease with pneumatosis involving more than one tiny area; differentiation can be difficult preoperatively.
Some surgeons worldwide perform primary anastomosis after limited NEC resection; in the United States, surgeons are less likely to do primary anastomosis due to concern about anastomotic healing in these patients.
Dr. Besner typically performs resection with stoma and mucous fistula rather than primary anastomosis, with stoma closure when patient is bigger (at least 2000g) and stable.
Stomas are brought out through laparotomy incision with functional end and mucous fistula positioned close together to facilitate limited reoperation for closure; stomas are tacked to fascia but not matured.
Distal end of stoma must protrude slightly because it can slough off; leaving small distal end prevents recession under fascia.
When bowel appears injured but not clearly necrotic (thin-walled, brownish discoloration, pneumatosis but not dead), acceptable approach is to not resect and perform second-look operation in 24-48 hours.
Abdomen may be left open if there are many dilated loops of bowel to avoid adding pressure that may compromise blood flow.
For multiple skip lesions that are very close together, can resect all without creating short bowel syndrome rather than having multiple anastomoses.
For separated skip lesions, can perform multiple anastomoses with proximal diverted stoma so anastomoses are distal to diversion; if anastomotic healing problem occurs, it won't be major issue because of proximal diversion.
Clip and drop technique (resecting dead bowel, clipping ends, replacing in abdomen, returning for anastomosis when baby more stable) can be life-saving maneuver in very unstable patients without time for multiple anastomoses.
Stoma reversal typically performed when baby is stable, well, hopefully feeding, and approximately 2000g in size; anastomosis is easier when baby is bigger.
Earlier stoma reversal is indicated if baby develops TPN-induced cholestasis or cannot be nourished due to very high stoma output.
Mucous fistula refeeding is done selectively rather than routinely, particularly for very high output stomas where any nourishment given comes directly out the stoma.
Mucous fistula often strictures post-operatively, losing opportunity for refeeding; if serious about refeeding (e.g., after massive resection with very high stoma), consider leaving small soft catheter in mucous fistula post-op to maintain access.
NEC totalis is one of most tragic findings on exploratory laparotomy for NEC; chance of baby living to be old enough for small bowel-liver transplant is very close to zero.
For very small premature baby with NEC totalis, current technology cannot get baby through this devastating problem; no one would be criticized for explaining severity to parents and providing comfort care after closing abdomen.
In Dr. Besner's experience, chance of baby with NEC totalis surviving months-to-years of required TPN is very low; TPN will irreversibly injure liver, and even if baby lives to transplant size, small bowel transplant results remain suboptimal.
Small subset of premature patients with severe lung disease can develop pneumothorax that dissects through diaphragm into abdomen, causing pneumoperitoneum; must confirm problem is in abdomen rather than chest.
For extremely unstable patient (e.g., 800g on jet ventilation and pressors) with pneumoperitoneum and severe distention, angiocatheter can be inserted through abdominal wall to release pneumoperitoneum as temporizing maneuver while mobilizing for definitive operation.
Recent Journal of Pediatric Surgery article showed substantial decrease in TPN use with mucous fistula refeeding.