Necrotizing Enterocolitis with Dr. Gail Besner
With Dr. Gail Besner · hosted by Dr. Todd Ponsky · StayCurrentMD
Cued at 14:40 · stops at 15:25 · 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, we don't know exactly what causes NEC and are still quite some ways from finding an absolute cure.
Indomethacin 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; you don't want to neutralize gastric acid.
In premature babies with NEC, intestinal contents can leak into the scrotum through a patent processus vaginalis, causing scrotal swelling and discoloration.
Neutropenia (low white blood cell count) is more worrisome than elevated WBC in NEC because it suggests overwhelming sepsis that the patient is not compensating for.
Thrombocytopenia can result from endotoxemia and gram-negative septicemia in NEC, and knowledge of platelet count is important for optimizing patient condition prior to surgery.
There is no single test that shows whether you have ischemic or necrotic bowel, but taking all tests in combination gives a sense of how sick the patient is.
For imaging in suspected NEC, you need plain film plus either cross-table lateral or lateral decubitus film because free air can be quite subtle and you don't want to miss it.
Free air on imaging is an absolute indication for surgical intervention (either drain 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 going in the right direction.
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 antibiotics, and performing serial abdominal exams, labs, and X-rays.
Small French feeding tubes are not adequate for gastric decompression in NEC; they should be replaced with an orogastric tube.
There is tremendous diversity in antibiotic regimens for NEC across the United States, possibly depending on bacterial colonization of the ICU environment.
For serial X-rays in NEC, obtaining them every 8 hours is reasonable; getting them too frequently makes no sense, but waiting 12-24 hours is too long.
Patients with NEC should be kept NPO with NG decompression and antibiotics 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.
Stricture formation is a complication of medical NEC that should be suspected in babies not tolerating feeds post-NEC; strictures typically occur in the colon, usually near the splenic flexure, but can occur anywhere.
For suspected stricture post-NEC, starting with contrast enema is preferred over upper GI with small bowel follow-through because strictures are more common in the colon and contrast from above takes long to transit, especially if partially obstructed.
Serial abdominal exams are critical for determining when to operate on NEC patients without absolute indications; worsening distention, peritoneal signs, hemodynamic instability with increasing pressor needs, and renal shutdown build up like building blocks to indicate need for surgery.
Two surgical options for NEC are exploratory laparotomy and peritoneal drain placement.
The ongoing NEST trial (necrotizing enterocolitis surgery trial) is concluding and will provide results in the next 1-2 years comparing peritoneal drainage versus laparotomy.
Mortality difference between peritoneal drainage and laparotomy for NEC is indecipherable; survival chance is about the same with either procedure.
At a NEC conference in London, 100% of surgeons polled do laparotomy and no one puts in a drain in Europe.
The MOSS trial (United States) and PIERO trial (Europe) showed no difference in overall mortality between peritoneal drainage and laparotomy for NEC, but these studies looked at early endpoints rather than delayed neurological outcomes.
Babies who have peritoneal drains instead of laparotomy may do worse neurologically if you look at outcomes 1-2 years after recovery from NEC.
The NEST trial will randomize 300 babies to peritoneal drainage versus laparotomy and assess neurological outcomes at 18-22 months after NEC recovery 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 likely better in babies who undergo laparotomy with removal of inflammatory necrotic tissue.
When peritoneal drains are placed and babies subsequently undergo laparotomy, the degree of dead bowel actually present is often quite striking and it's inconceivable the baby could get over that insult.
There are no criteria that help decide between laparotomy or drain for NEC; with current information you can't be faulted for doing either one.
You can get just as sick and hemodynamically unstable from systemic inflammatory response syndrome with an isolated intestinal perforation as from necrotizing enterocolitis.
Peritoneal drain placement is a bedside procedure with tiny amount of local anesthesia, using a small transverse incision in the right lower quadrant for a 1/4 inch Penrose drain.
If the incision for peritoneal drain is made too big, it's a problem because the patient can get a hernia once the drain is out.
When placing peritoneal drain, pass it several times gently without forcing to avoid bleeding; it's hard to achieve the drain curving to all four quadrants as shown in published pictures.
After peritoneal drain placement, if baby continues producing stool from drain for weeks and you convert to laparotomy, you may be forced to operate at the wrong time when inflammatory process is at its worst, resulting in extensive adhesions and serosal tears.
One of the smartest surgical decisions is knowing when to get out and stop; if you're getting serosal tears and making the situation worse during difficult NEC laparotomy, it's time to stop.
In difficult NEC laparotomy with extensive adhesions, try to make a proximal diverting stoma to control the area of perforation, but don't keep going if making multiple enterotomies and serosal injuries.
For successful peritoneal drain management, advance the drain out over several days starting at 7-10 days post-operation rather than withdrawing it all at once.
Don't advance peritoneal drain out if there's continual leakage of stool at the drain site; this suggests ongoing area of leakage.
There is difference of opinion about whether to get upper GI small bowel follow-through before removing peritoneal drain; it should be considered if there's ongoing stool leakage.
If baby does well after drain removal without contrast study but doesn't tolerate feeds, then contrast study is compelled to ensure everything is OK.
For NEC laparotomy, if baby is hemodynamically unstable or on very high oscillator settings and can't be safely moved to OR, bring the OR to bedside and operate in the ICU.
For NEC laparotomy, make supraumbilical transverse incision; skin is extraordinarily thin so be careful entering abdomen, especially with underlying dilated bowel loops.
For NEC laparotomy, have blood products available (packed RBCs, platelets, fresh frozen plasma) and partially correct platelet and coagulation abnormalities preoperatively.
In premature babies undergoing NEC laparotomy, it's incredibly important not to hurt the liver or spleen; even looking at or touching the liver wrong can cause subcapsular hematoma that a baby can exsanguinate from.
Liver and spleen injuries can occur with peritoneal drain insertion as well.
Spontaneous intestinal perforation (SIP) is one small localized area of perforation; NEC is more diffuse disease with pneumatosis involving more than one tiny area. These can be hard to differentiate preoperatively.
Some surgeons around the world resect limited NEC and do primary anastomosis; this is less common in the United States where surgeons typically make stomas due to concern about anastomotic healing.
For NEC stomas, bring functional end and mucous fistula out through the laparotomy incision close to each other (facilitating later closure), tack to fascia without maturation.
No matter how carefully NEC stomas are made, sometimes the distal end will slough off, so leave a little distal end sticking out so it doesn't recede under the fascia.
High-quality enterostomal therapists can manage stomas brought out through the incision; the problem gets more complicated if the wound opens.
For indeterminate bowel viability during NEC laparotomy (injured but not necrotic, diffusely the same appearance), it's acceptable to not resect, leave abdomen open to avoid pressure compromising blood flow, and return for second-look operation in 24-48 hours.
For multiple skip lesions in NEC, if very close together and can resect without creating short bowel syndrome, do that rather than multiple anastomoses; otherwise do multiple anastomoses with proximal diverted stoma so anastomoses are distal to diversion.
Clip-and-drop technique (resect dead bowel, clip ends, put back in, return another day) can be life-saving in very unstable NEC patients without time for multiple anastomoses.
The 'putting green' approach (bringing out multiple stomas throughout abdomen) can get really confusing and messy; try to avoid if possible.
For stoma reversal timing, typically wait until baby is stable, well, hopefully being fed, and about 2000g (anastomosis is easier when baby is bigger); go in sooner if TPN-induced cholestasis develops or can't nourish baby due to very high stoma.
Stoma reversal timing is more about weight gain, clinical appearance, and TPN sequelae than a mandatory 2-month waiting period.
Refeeding mucous fistula is done selectively (not routinely) for very high-output stomas where any nourishment given comes right out the stoma.
Mucous fistulas often stricture and you lose the opportunity to refeed; if serious about refeeding (e.g., massive resection, very high stoma), consider leaving a small soft catheter in the mucous fistula post-op to maintain access.