Stay Current Throwbacks Necrotizing Enterocolitis with Dr. Gail Besner
With Dr. Gail Besner · hosted by Dr. Rod Girardo & Dr. Todd Ponsky & Dr. Rod Girardo · StayCurrentMD
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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 six decades of research, the exact cause of necrotizing enterocolitis remains unknown and there is no absolute cure.
Indomethacin administration predisposes babies to both isolated ileal perforation and necrotizing enterocolitis.
Acid suppression medications (PPIs, H2 blockers) should be avoided in at-risk neonates because neutralizing gastric acid may increase NEC risk.
In premature babies with patent processus vaginalis, intestinal contents leaking into the abdomen can cause scrotal swelling and discoloration.
Neutropenia (low white blood cell count) in a baby with suspected NEC is more concerning than leukocytosis because it may indicate overwhelming sepsis that the baby cannot compensate for.
Thrombocytopenia can result from endotoxemia and gram-negative septicemia in NEC, and platelet count is important to know before surgery to optimize the patient's condition.
Cross-table lateral or lateral decubitus films are essential in addition to plain films because free air can be quite subtle and easily missed.
Free air on imaging is an absolute indication for surgical intervention (either drain or laparotomy) in NEC.
Fixed loops of intestine on serial x-rays are not an absolute indication for surgery but are a concerning sign that the patient is not improving.
Portal venous air is a worrisome sign but not an absolute indication for surgery; some patients with portal venous air improve with medical management.
Medical management of NEC includes withholding feeds, orogastric tube decompression, broad-spectrum antibiotics, and serial monitoring (exams, labs, x-rays).
Small French feeding tubes are inadequate for gastric decompression in NEC; they should be replaced with larger orogastric tubes.
There is likely tremendous diversity in antibiotic regimens for NEC across the United States, possibly depending on bacterial colonization patterns in individual ICU environments.
Abdominal x-rays should be obtained at regular intervals (approximately every 8 hours) during medical NEC management, not waiting 12-24 hours between films.
Babies should remain NPO for at least 7-10 days (preferably a week and a half) after medical NEC treatment before attempting to restart feeds.
Stricture formation after medical NEC typically occurs in the colon, usually near the splenic flexure, but can occur anywhere.
When evaluating for post-NEC stricture, contrast enema should be performed before upper GI with small bowel follow-through because strictures are more common in the colon and waiting for contrast to pass through obstructed small bowel is time-consuming.
Serial abdominal examinations over time are more valuable than a single examination for determining need for surgery in NEC without absolute indications.
At a recent NEC conference in London, 100% of European surgeons reported performing laparotomy for NEC; none use peritoneal drainage.
The MOSS and PIERO randomized controlled trials showed no difference in overall mortality between peritoneal drainage and laparotomy for NEC.
Babies who receive peritoneal drains instead of laparotomy may have worse neurological outcomes at 1-2 years post-NEC, though early mortality is similar.
The NEST trial randomized 300 babies to peritoneal drainage versus laparotomy and will assess neurological outcomes at 18-22 months, with results expected in 1-2 years (from 2017).
Spontaneous intestinal perforation (SIP) can cause hemodynamic instability similar to NEC through systemic inflammatory response syndrome, making clinical differentiation difficult.
Peritoneal drain placement can be performed at bedside with local anesthesia through a small right lower quadrant transverse incision using a quarter-inch Penrose drain.
Making the drain incision too large can lead to hernia formation after drain removal.
Some babies with peritoneal drains continue to produce stool from the drain for weeks, and if this persists for approximately two weeks, conversion to laparotomy should be considered.
When operating on a baby with extensive adhesions after drain placement, surgeons should know when to stop if causing multiple serosal tears and enterotomies, as continuing may worsen the outcome.
Creating a proximal diverting stoma is helpful when extensive adhesions prevent safe complete exploration, as it controls the perforation and diverts the fecal stream.
Peritoneal drains should be advanced out gradually over several days starting at 7-10 days post-placement, rather than removing all at once.
For laparotomy in NEC, a supraumbilical transverse incision is used, with extreme care required to avoid liver and spleen injury in premature infants.
Even minimal trauma to the liver in premature babies can cause subcapsular hematomas that can lead to exsanguination.
NEC is differentiated from SIP intraoperatively: SIP presents as one small localized perforation, while NEC shows more diffuse disease with pneumatosis involving more than one area.
Some surgeons internationally perform primary anastomosis after NEC resection, but many US surgeons create stomas due to concern about anastomotic healing in critically ill premature infants.
Bringing stoma and mucous fistula out close together through the main incision allows for more limited reoperation at stoma closure compared to separate sites.
Stomas should be tacked to fascia (not matured) and a small distal end should protrude to prevent recession under the fascia, though sloughing of the distal end can still occur.
When bowel appears injured but not clearly necrotic (thin-walled, brownish, with pneumatosis but diffusely similar), it may be appropriate to not resect, leave the abdomen open to reduce pressure, and return for second-look operation in 24-48 hours.
For multiple skip lesions in NEC, if they are close together and can be resected without creating short bowel syndrome, resecting all may be preferable to multiple anastomoses.
Multiple anastomoses can be performed with proximal diversion so that if one anastomosis fails to heal, it is distal to the diversion and less problematic.
Clip-and-drop technique (resecting dead bowel, clipping ends, replacing in abdomen for later definitive surgery) can be lifesaving in very unstable patients when time does not permit multiple anastomoses.
Stoma reversal is typically performed when the baby reaches approximately 2000 grams, though earlier reversal is indicated for TPN-induced cholestasis or inability to nourish due to high stoma output.
Refeeding through mucous fistula is done selectively (not routinely), primarily for very high-output stomas where most nutrition is lost through the stoma.
Mucous fistulas often stricture, preventing refeeding access; leaving a small soft catheter in the mucous fistula post-operatively can maintain access for refeeding.
The chance of a premature baby with NEC totalis surviving long enough to receive small bowel-liver transplant is very close to zero.
Babies with NEC totalis who survive on TPN for months to years will develop irreversible liver injury, and even if they reach transplant size, small bowel transplant outcomes remain suboptimal.
Pneumothorax can dissect through the diaphragm into the abdomen in premature babies with severe lung disease, mimicking intra-abdominal free air; this must be ruled out before attributing pneumoperitoneum to bowel perforation.
In a hemodynamically unstable baby with pneumoperitoneum, inserting an angiocatheter through the abdominal wall to release pressure is a useful temporizing measure while mobilizing the OR.
A recent Journal of Pediatric Surgery article showed substantial decrease in TPN use with mucous fistula refeeding.
The NEST trial results published in fall 2021 showed no overall difference in death or neurodevelopmental impairment between laparotomy and drainage groups.
In the NEST trial, neonates with a preoperative diagnosis of necrotizing enterocolitis (versus isolated intestinal perforation) had approximately 20% decrease in death rate with laparotomy compared to drainage.