Necrotizing Enterocolitis with Dr. Gail Besner

Necrotizing enterocolitis, we see it all the time. Yet somehow there are still so many things we don't understand. What is the optimal medical management? How do you know when to operate? Do you drain? Do you do a laparotomy? Do we do a primary anastomosis or do we bring out stomas? There's so much we still don't know, but at least we have people doing the research on it to help us understand. And today we're going to be talking to one of those people, Doctor Gail Besner from Nationwide Children's Hospital, who's gonna go in deep about how do we manage these difficult situations and necrotizing enterocolitis. Stay Current is a multimedia publication designed to keep healthcare professionals up to date with standards of care and new emerging ideas. Stay Current is created and edited by Todd Ponsky, Ian Glenn, and Sophia Abdulhai and is recorded and produced at Akron Children's Hospital in Akron, Ohio. Welcome to Stay Current in Pediatric Surgery. This is Todd Ponsky from Akron Children's Hospital, and today we're gonna be talking about necrotizing enterocolitis, certainly a challenging condition that many of us see probably more often than we'd like. And so today for this audio chapter we brought in an expert, Doctor Gail Besner, who is the chief of the department of pediatric Surgery at Nationwide Children's Hospital in Columbus, Ohio. Gail, thanks for joining us today. Todd, it's a pleasure. Thanks so much for the invitation. Gail. I know that not only are you busy clinically, but you also have a very robust research lab. What exactly are you studying in your lab? So we're very interested in determining novel therapeutic strategies for intestinal injury, and we're particularly interested in necrotizing enterocolitis because as you can imagine as pediatric surgeons we face this on a very frequent basis in the neonatal intensive care unit and it's so particularly frustrating. Because the reality is that despite 6 decades of research, we really don't know exactly what causes neck, and we still are quite some ways from finding an absolute cure for the disease. So I have dedicated my academic career towards necrotizing enterocolitis research in the hopes of finding something that can prevent this disease from occurring in babies in the future. Yeah, and we all appreciate the work you're doing because we're eagerly awaiting more knowledge about how we should be treating some of these tough cases. So speaking of tough situations, let's dig right in, Gail, and maybe you can help us with some of these scenarios. Let's say that the neonatal intensive care unit called you about an X 27 week preemie who is now 3 weeks old, and they weigh 1000 g. The baby, after being fed, started having some abdominal distention, and the nurse noticed some increased gastric residuals. They also noticed that the baby had bloody stool just before they called you. They obtained an abdominal X-ray which showed some questionable pneumatosis but no free air. Tell us how you would start off by evaluating and treating this patient. So this is not an uncommon scenario for patients that we actually get consulted on in the neonatal intensive care unit. So we all really have to know how to approach this particular patient population. And as you and I know, these patients are extremely vulnerable. The fact that the baby has documented pneumatosis on X-ray certainly points to the problem being in the abdomen. And it's our job to figure out what the differential diagnosis is. So like with any patient, we're going to start with a good history. Hopefully there are caregivers around that will, you know, give us the history of what the feeding regimen has been for the baby because I think you mentioned that the baby is 3 weeks old now, what medications the baby has been on, because certain medications, as you know, might predispose the baby towards getting necrotizing enterocolitis, particularly the administration of indomethacin. So we want to get a good history. So indomethacin not only predisposes babies to an isolated ileal perforation, but also to necrotizing enterocolitis, is that correct? Yes, correct. OK, great. So while we're talking about medications that may predispose to neck, let me ask you, do PPIs and H2 blockers and other acid suppression medications predispose or increase the chances of the development of neck? So yes, you really don't want to stop the acidification of the stomach. So it is believed that we should hold off on medications that will neutralize the gastric acid. And in fact, as you probably know, there have been many, many strategies to try to Prevent neck over the decades, and one old strategy was to administer acid into the stomach with the thought that it would decrease the incidence of necrotizing enterocolitis. That obviously hasn't taken off because we're not doing it, but the point is you don't want to neutralize the acid that the baby is producing. So yes, I think that that's true. OK, great, thanks for clarifying that. So back to this case, so you've taken a complete history now what? And of course we want to do a detailed physical exam. So we're going to examine the whole entire baby, but we want to pay particular attention to the abdominal examination and also the scrotal examination in a boy, because if you have intestinal contents leaking into your abdomen, then sometimes you can get. Swelling and discoloration of the scrotum in these premature babies if they have a patent prosthesis vaginalis as well. But in terms of the abdominal exam, we're going to look for any abdominal wall discoloration. Sometimes you can get redness of the abdominal wall from an inflammatory process. Sometimes you can get a darkish discoloration of the abdominal wall if there is necrosis of the underlying bowel loop. So we want to look for that. We want to look for abdominal distention that could be either due to dilated loops of intestine from the disease process itself, or it could be due to intestinal perforation with leakage of intestinal contents out of the intestinal loops, or it could just be inflammatory ascites. So we want to look for distention. We want to look for pain and tenderness so you can, even if the baby is intubated, get a sense of whether there's tenderness to palpation of the abdomen on these little babies, and we certainly want to look for things like a palpable mass. We want to look for any evidence of peritonitis as we would with any child or patient that we think has an intraabdominal inflammatory process going on. So I think that, you know, all those things are very important and of course look at any lab test that the patient may have already had. That's great and I love the point you made about the scrotum. You really have to take the diaper off to do a complete physical exam on a baby with neck. So Gail, you mentioned labs. What labs would you be ordering? Well, I would certainly want to look at a CBC with a platelet count. Often these babies can mount an increased white blood cell count because of the inflammatory process going on, but I actually get more worried when the patients are neutropenic and they have a low white blood cell count, because to me that means that they, you know, may have overwhelming sepsis that they're not compensating for. Likewise, I like to look at the platelet count because if you have, you know, endotoxemia and gra gram-negative septicaemia, you can end up becoming thrombocytopenic, and a low platelet count is also very important to have knowledge about if you end up operating on the patient because you want to optimize the condition of the patient prior to, you know, making a surgical incision. And of course the hemoglobin, if they're having bloody stools, they could have an associated low hemoglobin. So I think that all of those things are of importance to me. And then of course we want to look at any X-ray examinations that the patient may have had, either plain films or, you know, sometimes an ultrasound might be helpful as well. Do you draw a blood gas at this point, at this point in time in the patient's history? Well, I think that, you know, certainly if the patient is hemodynamically unstable in any way, I would assume that a blood gas will have been drawn. And so we want to look at for acidosis. based deficit, etc. So yes, I do think that that's important. Sometimes lactic acid levels may be drawn. Unfortunately, there's no one test that, you know, shows whether you have an ischemic or necrotic bowel. But if you take all of these tests in combination with each other, you can get a sense as to how sick you think the patient is. And you mentioned X-rays. Tell me how you order your X-rays. So it's very important to get plain film of the X-ray, but you also want to get either a cross table lateral or a lateral decubitus film, because sometimes free air can be quite subtle, and we wouldn't want to miss free air. So I think a prone cross table lateral and a sick baby who the nurses may not want to turn is perfectly acceptable. But you don't want to just get a plain film. You want to get something that will increase your chance of being able to visualize even a small amount of free air. OK, Gay, so here's the million dollar question. How do you know when to operate on the child? Yeah, so most of these patients are going to start with medical management unless they're so unstable that you have to rush them immediately to the operating room. And so the question is how long are you going to wait until you think medical management has failed and surgical management is indicated. So sometimes right off the bat we know right away. So for example, if we're consulted and the patient has free air, we know that they need some kind of a surgical intervention, either a drain placement or a laparotomy. But there are other telltale signs that might indicate that you need to go to the OR as well. So for example, clinical deterioration in the face of what we would consider maximum medical management is probably an indication for surgery. A fixed loops of intestine on serial X-rays are not, in my opinion, an absolute indication for surgery, but it sure is going to start to make bells and whistles go off in your mind that the patient is not going in the direction that you want them to go in. Likewise, portal venous air, I find to be a concerning and a worrisome sign, but again, I don't consider it an absolute indication because I I have had patients that have portal venous air and go on to improve with medical management and don't end up needing an operation, but those things like fixed loops of bowel and serial films, the development of portal venous air, which sometimes can be quite fleeting, those are worrisome signs that make you, you know, think you really better be on the watch and be available to do an operation if you need to. OK, so you have a patient, you think they have necrotizing enterocolitis, but don't quite meet the criteria for an operation. What is medical management of neck? So I think that the medical management of these patients includes several things that have to happen altogether. Number one, we're going to withhold feeds. So if the baby's being fed, we're going to stop all feeds. We're going to insert an orogastric tube into the stomach of the baby so that we can decrease or decompress the stomach and therefore take any pressure off the intestinal loops. We're going to start broad spectrum antibiotic therapy on the patient. And then we're going to do serial abdominal exams, serial labs, and serial X-rays to try to see longitudinally which direction we think the baby is going in in terms of are they responding to this medical management and are they stabilizing or are they deteriorating and getting worse. This is great, Gail, and I actually have so many questions for you. Sometimes at our hospital we make the diagnosis of neck and we tell them to place an NG tube for decompression, and oftentimes they leave a. Feeding tube in place, a small French feeding tube, is that adequate, or do you ask them to replace it with a larger caliber Salem sump or relogel? So we have the same observation that can absolutely happen. And unfortunately those tiny little feeding tubes, as nice as they are for feeding, are not good for gastric decompression. So yes, I would ask for the feeding tube to be removed and for an oral gastric tube to be placed, and that way you'll get the best decompression that you can possibly get. OK, great. So, Next question. You mentioned antibiotics. Any particular antibiotic regimen that you like, or as long as it's broad spectrum, it's OK? So I think if it's broad coverage if it's, it's OK, but I believe that there's probably a tremendous amount of diversity amongst antibiotic regimens across the United States. And in fact with one of the neck groups that I'm currently associated with, we're about to do a national survey of what antibiotics. Are administered to babies like this, and I think that we're going to be shocked because I don't think that there's a right or a wrong answer, and I think that maybe it depends on the bacterial colonization of your intensive care unit environment, and I think that, you know, we're going to see a huge diversity amongst antibiotic regimens. So I think broad spectrum antibiotics are critical. Some nurseries, I do believe, probably use antifungal agents as well, but antibiotics are the mainstay. OK, next question. Relating to abdominal X-rays, I know that at some institutions they like to get X-rays at a regular routine interval and other places only get X-rays if there's a change in clinical status. What do you guys do there at Nationwide Children's? Well, I don't know that there's a right or wrong answer, but we do get them at intervals, and it makes no sense to get them too frequently. But I wouldn't want to wait 12 or 24 hours before the next set of X-rays. So I think at least, you know, every 8 hours makes sense to me, and that's what, you know, I would write for in this type of a patient. OK, so if you have a patient that has necrotizing enterocolitis, but they haven't met criteria for surgery and so you've decided to treat them medically with NPO. Uh, OG or NGD compression and antibiotics, how long do you keep them on that medical neck watch until you start feeding them? I would say at least 1 week to 10 days. I would probably feel more comfortable with a week and a half. And then, you know, again, you're going to start very, very slowly and work the baby up on their feeds and then see how they respond to that. Because remember that some of these babies have repeated episodes of necrotizing enterocolitis, and even if you have only one episode of necrotizing enterocolitis and you're eventually fed. If you're not tolerating those feeds, you have to think in the back of your mind as to whether the baby might have developed a complication from their medical neck, namely stricture formation, which typically when these babies get it usually occurs in the colon, usually occurs in the left colon near the splenic flexure, but really could occur anywhere. So you have to worry about stricture formation in the baby post neck who's not tolerating their feeds well. OK, so I think you just answered my next question. So that if you suspect a stricture, do you routinely start with a contrast enema or do you go to an upper GI with small bowel follow through first? I like to discuss these things with the radiologist beforehand, but if I had to choose, I would start with a contrast enema and then do the upper GI, small bowel follow through, because if you do it the other way around, you're going to be waiting a long time for that contrast to, you know, work its way all the way out of the small bowel, especially if the patient is partially obstructed, and it might just be easier to start with the contrast from below, especially because by the odds, the, you know, strictures are more common in the colon after, after medical. OK, great. So now back to this patient who has really no absolute indication for surgery. There's no free air, and they've been treated medically. They have good NGD compression and broad-spectrum antibiotics. But here's the million dollar question. Without an absolute indication, How do you know when to operate on these patients? I know that in my practice, I have a rule of three. If there's, usually, if there's about 3 relative indications, that's usually the time that I would say it's time to operate. What do you use as a guide to when to operate on patients who don't have an absolute indication for surgery? So I think your observation about a multitude and a summation of some of these soft signs is very useful, but I still believe that it's a matter of serial abdominal exams. I think it's very hard, you know, if you just examine the baby once and think that you know what to do or what the right answer is, but I do think that serial abdominal exams are important. And if you see worsening distention, worsening, you know, signs of peritoneal irritation, Hemodynamic instability with increasing needs for pressor support, renal shutdown with no urine production, you know, it starts to build up and it's like building blocks. And if you have, you know, A, B, and C, it's time to think about surgery irrespective of whether you have a hard indication. I think it becomes obvious as you watch the patient over a period of time. OK, so Gayle, now this patient, who again is about 1000 g, X 27 week preemie. Just isn't quite doing that well with medical management. He's worsening. Uh, his abdomen is becoming more distended. He's got abdominal wall erythema. He has a dropping pH and dropping platelets. He has fixed loops of bowel on his X-ray and portal venous air. So you're thinking he might need to go to the operating room. Tell me what's going through your head about how do you prepare the patient for surgery and exactly what you might be doing in the operating room. So I think that you're at the point now where you have to talk seriously about going to the operating room with the parents because there are enough signs that point you towards surgical management with failure of medical management in this patient. And I think at this point, since we don't really know what the best therapy for these patients is, then I think it's fair to offer the parents a choice of procedures because there are two different ways you can handle this patient. One is exploratory laparotomy, as you know, and the other is placement of a peritoneal drain. And I wish that we were so smart that we knew which is better for these patients, and I think that in the next year or so we will have a very good sense of that with the results of the ongoing Nest trial, necrotizing enterocolitis surgery trial that is concluding now. I think a year or two from now we'll have a much better idea as to which procedure is better, but if you just look at things like mortality, The difference in mortality between these two surgical options is pretty much indecipherable from each other, so whichever procedure you choose, the chance of the baby surviving is about the same, and the chance of the baby not surviving is about the same. So there are two surgical options that one could undertake in this in this example. I just came back from a neck conference in London and I polled the audience to see what percent of the surgeons there do peritoneal drainage versus laparotomy, and 100% of the surgeons do a laparotomy and no one puts in a drain in Europe, which I thought was just fascinating. Yeah, you know, the drain, no drain thing seems to be a moving target. I know that I used to put in a lot more drains than I do now. I seem to go more towards laparotomy than I used to. Tell me, what are the downsides to putting in a drain? So the two randomized control trials of peritoneal drainage versus laparotomy, one being the MOSS trial in the United States and the other being the Piero trial in Europe, really didn't show any difference in overall mortality, whether you put a drain in or whether you do a laparotomy for neck. But the problem is that those two studies really looked at early endpoints rather than delayed endpoints of neurological recovery. And one of the fascinating observations is that it appears that babies who have peritoneal drains put in instead of laparotomy may do worse from the neurological standpoint if you look at the neurological outcomes a year or two after recovery from necrotizing enterocolitis. So the ongoing necrotizing enterocois surgery trial or NET trial that's occurring in the United States now, which is almost over, will have randomized 300 babies to peritoneal drainage versus laparotomy, and it will look at neurological outcomes at 18 to 22 months after recovery from neck. And these babies will undergo detailed neurological assessments, and I think it will be imperative that we see what the results of that trial are because even though mortality may not be different between the two operations, we certainly wouldn't want to do the lesser of the operations, meaning we wouldn't want. Just put in a peritoneal drain and find that the babies are doing neurologically worse a year or two down the road, because if that in fact is the finding, then we really need to seriously consider doing laparotomy on these babies instead of drain placement. Well, Gail, like I said before, you know, I've moved more towards laparotomy. And I feel like I've done that because I think it's a quicker fix to the problem that a lot of the kids I put drains on, I'm probably gonna end up doing a laparotomy on eventually anyways. Tell me where my thinking is flawed. I don't in fact think that your thinking is flawed, and I think that, or I predict that in the next year or two we're going to move towards laparotomy versus peritoneal drainage on the majority of these babies. We could all be wrong, but I suspect that neurological outcomes are going to be better in babies who have undergone laparotomy with removal of all of that inflammatory necrotic tissue. Because when you see what we leave in sometimes by putting in a peritoneal drain, it's just inconceivable to think that the baby could get over that insult, because remember, some of the babies with peritoneal drains end up getting a laparotomy so that we open the abdomen and we see what's actually in there, and it's often quite, you know, striking in terms of the degree of dead bowel that's actually in there. All right, Gay, so maybe you can help me here. I used to believe, and maybe this is wrong, that the extreme patients were the ones that ended up getting the drain, the ones who were so sick they were too unstable to go to the operating room, or the ones that looked so good that I suspect they have an intestinal perforation, and they would do well with a drain. But it sounds like what I'm hearing is that may not be so simple. So are there any criteria that can help me make that decision between laparotomy or drain? So unfortunately there aren't criteria that are going to help you make that decision. Now at the 15 or so sites across the United States where institutions are participating in the Nest trial, which is still ongoing but almost done. It's been very easy for us because the baby gets randomized and we're told what to do so it didn't really require a lot of thought, but I, I still think that with the information we have now you can't be faulted for doing one or the other. however, my sense is that I think. We're going to find worsened neurological outcomes in babies that get drains placed versus babies that get laparotomy, and we're going to know in the next, you know, 1 to 2 years. So I think we may be treating necrotizing enterocolitis a little bit differently once those results are out compared to how we're treating them now. Now just a question, if you had a strong clinical suspicion that because the baby wasn't so sick that maybe they had a spontaneous intestinal perforation. Would that change your management decision leaning more towards a peritoneal drain versus laparotomy? So I used to think that the babies who do well with insertion of a peritoneal drain and end up avoiding laparotomy are the babies that just have spontaneous intestinal perforation. But I'm not so sure that that's necessarily correct. And if you look at some of those studies, like, you know, the Piero study of peritoneal drainage versus laparotomy, I think that there was some suggestion in there that you can get just as sick and just as hemodynamically unstable from the systemic inflammatory response syndrome with an intestinal perforation, an isolated intestinal perforation, as you can from necrotizing enterocolitis. So the answer is yes and no. I still think that if you have one little area of perforation, you're probably going to do better with a drain than if you have a belly full of dead bowel, but again, you know, each patient is individual and you just have to personalize your care for each particular patient. All right, Gail. So given all that discussion about drains versus laparotomy, let's go through some scenarios. So, let's say there is a very low birth weight baby who's now, let's say 1100 g, uh, the baby's 4 weeks old, uh, and has been ramping up on feeds and all of a sudden developed free air. Baby's not so sick. How do you manage that patient? So again, the very small baby who develops a bowel perforation after several weeks of life could have spontaneous intestinal perforation. It still could be neck. I think it could be either one, but it certainly could be a spontaneous intestinal perforation. So again, I believe that there's no right or wrong answer in terms of peritoneal drainage versus laparotomy, and I would probably offer both. And if the parents choose a peritoneal drain, I'm fine with that. But if you do go that route, you have to be really careful, in my opinion, about watching them afterwards to see if the drain is going to be enough because there is a significant proportion of patients whereby you can put the drain in and they're going to continue to decline and do badly and they end up needing a laparotomy. OK, so let's dig deeper into this then. So tell me, let's say the parents did go for a peritoneal drain and you agree with the decision. How do you do that? So the nice thing about the peritoneal drain is it's a much smaller procedure and it can be done at the bedside with a tiny little amount of local anesthesia. And essentially we make a small transverse incision in the right lower quadrant. We're going to use a 1/4 inch Penrose drain, so the incision, you know, definitely doesn't have to be any bigger than that. In fact, if you make the incision too big, it's a problem because then you can get a hernia once the drain is out. So you want to kind of limit the size of the incision. And you're going to just, you know, get into the abdominal cavity with a hemostat. Often you'll get a rush of air or stool that comes out from the incision. Initially, if you look at the papers on peritoneal drainage, some people advocate instilling some saline to try to wash the baby out, and some people don't do that. And then you're going to insert your drain very carefully. And if you look at the pictures, for instance, that are in the moss paper of perineal drainage versus laparotomy. They show a picture of the little plastic drain curving around to all four quadrants of the abdomen, and I think that's a really hard thing to achieve because you're putting it in blindly and really who knows where it's going. I think the thing is, you know, pass it several times, don't force anything because you don't want to make anything bleed, and, you know, as much as you can get in gently, that's fine. And then, you know, I of course sew it in place so it doesn't come out. Now some people do make a counterincision on the other side of the abdomen and bring it out the other side. I generally don't do that. I generally make one incision in the right lower quadrant and gently introduce the drain in that fashion. Thanks Gail for what seems like it could be a pretty simple procedure, there's quite a bit of variation on placing a drain as you mentioned, some people split the drain, some people make a counter incision, some people irrigate. I actually do irrigate and I, I do that to keep the drain patent, but it sounds like you don't feel there's a need for that. I think that's fine to squirt saline in there. I have no problem with that. I don't think that, you know, if there's stool everywhere, you're probably not going to do much really doing that, but I think a little gentle irrigation is fine. OK, so let's take the scenario that you place the peritoneal drain and the baby continues to produce stool from the drain for weeks and weeks. So let's say 2 weeks go by and you decide now it's time to just go to the operating room, convert over to laparotomy because the baby's not doing well. And you get into the operating room and it is just stuck and there's adhesions everywhere and as you're going through you're getting serosal tear after serosal tear and enterotomies. What do you do in this situation? So that's an incredibly challenging position to be in, and it probably results from the fact that you're unfortunately perhaps forced to operate at the wrong period of time when the inflammatory process in the abdomen is the absolute worst. And sometimes I think that one of the smartest decisions that a surgeon can. Make is to know when to get out and to stop. And if you're starting to get serosal tears and you're making the situation worse than it was originally, then it's time to get out now. Maybe you can figure out where the proximal bowel is and give the patient a diverting stoma. That would be helpful. Because then the area of perforation is controlled and it's diverted and you've done the baby some good. So I would try to make a proximal stoma, but you just can't keep going because the more enterotomies you make and the more serosal tears and injuries you make, the worse it's going to be for the baby in the long run. OK, so now let's take the scenario that the baby developed neck. You placed the drains, and the baby actually did quite well. Baby recovered, stopped putting stool out of the drain, and they look great. So now what do you do? So then you have to decide in your mind when you're going to start to advance the drain out, and I would probably do that over a period of several days rather than just immediately withdrawing it all at once. And perhaps you might want to start thinking about doing that at maybe 7 to 10 days after the operation. And every day I would just advance a little bit more out of the abdominal cavity until the drain is completely out. I wouldn't be too enthusiastic about doing that if there's continual leakage of stool at the drain site, which can happen, in which case I think you have to really try to figure out if there is, you know, an ongoing area of leakage. And then you have to ask, you know, there, there's also a difference of opinion as to whether you should get an upper GI small bowel follow-through before you take it. That was my question, and some of my partners do and some of us don't. And I again, I don't think there's a right or a wrong answer, but I would certainly consider doing that if there's ongoing leakage of stool out of the drain site. OK, but in your practice, if the baby's doing well, they're not leaking stool from the drain, you back out the drain, you just slowly start advancing feeds. We, we often do that, but if we do that, if we, if we start feeds without a contrast study and they don't tolerate it, then I really feel compelled that I must get a contrast study just to make sure that everything is OK. OK, now changing the scenario, let's say from the beginning the same baby, you made the decision that rather than putting in a drain you went towards laparotomy. Talk me through how you perform the operation, strategies you employ in this type of procedure, and then we'll go through some different scenarios. Sure. So if the baby is stable enough, the baby can go to the operating room to have this procedure. If the baby is so hemodynamically unstable or perhaps on very high oscillator settings or whatnot, and you think that you can't even safely move the baby to the operating room, then of course you can bring the operating room to the bedside and do the operation in the intensive care unit with the presence of the, you know, the surgical team and the and the anesthesiologists. But either way, wherever I do the operation, If I'm going to do a laparotomy, I make a supraumbilical transverse incision, and you know, the skin is extraordinarily thin, so you have to be very careful even entering the abdomen, especially when there are underlying loops of dilated bowel. You certainly wouldn't want to make your incision and immediately make an enterotomy, so you have to be careful about that. You have to be careful about bleeding. So hopefully we resuscitated the patient. Preoperatively and at least partially corrected any platelet abnormalities or coagulation abnormalities, and I would absolutely have blood products available for the operation. I would have packed red blood cells available. I'd have platelets available and some perhaps some fresh frozen plasma available. So through a super umbilical transverse incision, we get in the abdomen and it's incredibly important on these very fragile premature babies not to hurt the liver and not to hurt the spleen. If you even look at the liver the wrong way or touch it the wrong way, you can get a subcapsular hematoma that a baby can exsanguinate from a premature baby like this. So I always try to counsel the residents, you can't overstate the fact that you can't hurt the liver in these babies and you can't hurt the spleen in these babies. And those kinds of injuries actually can occur with insertion of a peritoneal drain as well. You can also create bleeding, so you have to be very careful. And then of course you're going to assess the integrity of the intestines, and you're going to decide whether there are necrotic loops about. that need to be resected and hopefully there'll also be some viable loops of bowel that will be able to be kept in and you're going to determine then if the baby has necrotizing enterocolitis or spontaneous intestinal perforation. So if it's just one small localized area of perforation. That's SIP. If it's more diffuse disease with pneumatosis and involves, you know, more than one tiny little area, then that's necrotizing enterocolitis, and I sometimes find the too hard to differentiate preoperatively. I've been fooled before thinking it's one and it turns out to be the other. OK, so let's go through some scenarios. Let's say when you open the belly, you find that there's one isolated area of disease right at the terminal ileum. It looks very sick and probably dead, but no actual perforation. And let's say that the length of total bowel involved is a couple of centimeters. So that's the best case scenario that you can find because this baby is going to lose a very limited length of intestine. There are places around the world where surgeons would resect that area of bowel and do a primary anastomosis, just put the kid back together, and, and that would be the end of it. I think that we're less likely to do that in the United States, although I'm sure there are some surgeons who would do that. I err on the side of being a little bit cautious, and I usually make stomas in these patients because I'm just so worried about them not being able to heal their anastomosis. So I typically do do a resection with a stoma and a mucous fistula in those patients, and then, you know, I'll just close it when the patient is bigger, at least 2000 g, and once they're well and stable. Yeah, actually, that was the area of controversy that I wanted to bring up. I know a lot of people are talking about primary anastomosis. Like you, I still lean towards uh doing stomas. So let's talk about that. Tell me how you do your stomas. Do you bring them out through separate incisions? Do you bring them out through the laparotomy incision? Do you keep them separated? Do you keep them together? Do you mature them? Talk to me about how you do these stomas. So, you know, in the old days, these babies are so sick that you need to get them in and out of the operating room within an hour. And I think that care is better nowadays, and we have a little, you know, more luxury of time, but we don't want to prolong the operation. So I do bring the stomas out through the incision. I do bring them out close to each other so that the functional end and the mucous fistula are right near each other, if at all possible, such that when I go back to the operating room a month or two later to close them, it's more limited operation, and I don't have to make some big, you know, open up the whole entirety of the. Incision necessarily because they're right next to each other and I don't mature them. I just bring them out through the incision and tack them down to the fascia so that they don't fall in, which is a problem if they if they do. And then you just have to watch them because no matter how careful you make these stomas, sometimes the distal end will slough off. So you do want to leave a little distal end sticking out so that they don't, you know, recede and recess back under the fascia, and then you just have to watch them. Carefully to make sure that they're viable. Yeah, Gail, I do the same as you. I bring them out through the incision and my partners give me grief. They say it's hard to bag the stomas when they're brought out through the incisions. How do you respond to that? I think that if your enterosomal therapists are high quality, as I'm sure ours are, and you know, just work with it, then it's not that much of a problem. The problem gets a little more complicated if. wound opens. So I do close these wounds, and if you have to open the wound, then it is a bit messy. But you know, nowadays we have such great dressings and we have wound vacs and all these things that we can do to, you know, keep wounds clean. So I think that it's not such a horrible situation. All right, so Gayle, let's take this tough scenario. You go into the belly and You find something pretty not well defined. It's not dead. You see some bowel that looks sick. It has some pneumatosis, very thin walled, brownish discoloration, but not quite dead. How do you know what to do in that situation? You have to decide in your mind whether there is something to resect or not. I think sometimes if we go into the operating room a little too early on these patients, you see just what you described. It kind of looks like, you know, it's injured, but it's not necrotic, and it all kind of looks diffusely the same. And so sometimes I think it's perfectly acceptable to not resect at that point and to simply do nothing. You may want to leave the abdomen open if there are a lot of dilated loops of bowel so that you don't add to the pressure which may compromise the blood flow, and you may just say to yourself, you know, I'm not going to resect today. I'm going to wait 24 to 48 hours and see how the baby does and come back, you know, for a second look operation. I think that's sometimes a useful thing to do. Yep, and as you said, that's what can happen if you go too early. All right, let's take a situation where you go in and you find the dreaded multiple skip lesions. What strategies do you use for that? So the multiple skip lesions are really a nuisance. If they're very close to each other, and you can resect them all without creating short bowel syndrome, then you may just want to do that rather than having multiple anastomosis. Of course, it's usually not that easy, and often they're, you know, at different areas of the intestine. In tract. And so one thing that you can do is resect the patches and do multiple anastomoses, but leave a proximal diverted stoma so that the anastomoses are distal to diversion such that if there's a problem with healing of one of them, it won't be that big a deal because they're you're diverted proximal to that anyway. Have you ever tried clipping and dropping? So yes, I have clipped and dropped, and you know, quite often it might be a very unstable patient where you just don't have time, you know, or the luxury to take the time to do multiple anastomosis, and I think, you know, that can be a life saving maneuver. And again, you're just going to resect what's dead, perhaps, clip the ends, put it back in, and come back on another day once the baby is more stabilized. OK, so it sounds like you don't routinely do the so-called putting green where you bring out multiple stomas throughout the abdomen. I won't say I've never done that, and I have done that, and it can get really confusing and really messy, and I try to avoid it if I can. OK, so how and when do you decide to reverse the stomas? Also, some people are now talking about early stoma reversal, and I want to hear your thoughts about that as well. So typically what I've done is we, certainly you want the baby to be stable and well at that point, hopefully being fed. If it's a very high stoma, these can be sometimes the babies can be sometimes very challenging to feed, and you can consider refeeding if you make a mucous fistula, which is one of the nice things about a mucous fistula versus a Hartmann. But I in general have waited until they're about 2000 g in size. I think that the anastomosis is a little easier. Make when the baby's a little bit bigger, but I would certainly not hesitate to go in sooner if the baby is developing any signs of TPN-induced cholestasis of the liver or if you can't, you know, nourish the baby because they have a very high stoma. So there are some things that would compel me to go in sooner, but if the baby's very stable, being fed, gaining weight nicely, there's nothing wrong with waiting until the baby's about 2000 g. OK, so do you wait a mandatory 2 months, or is it more about their weight? I think it's more about, you know, how they're gaining weight and how well they look clinically and whether they're suffering from any sequelae of TPN. OK, so let's go back again. Let's say during your laparotomy, you ended up doing a jejunal resection and brought out a stoma and a mucous fistula. Do you routinely refeed your mucous fistulas in this situation? I don't routinely refeed, but if it's a very high output stoma, I would be compelled to refeed simply because you're any nourishment that you're giving them is coming right out your stoma. So in that case it may be useful to refeed. So I wouldn't say I do it routinely. I do it selectively though. So there was a recent article in the Journal of Pediatric Surgery that showed Substantial decrease of the use of TPN with refeeding. And so I'm encouraged by this and I'm considering to start refeeding since this is something I have not done really much in the past. You have to be careful when you make that mucous fistula because often it strictures and you lose the opportunity to refeed. So if you Really serious about refeeding because let's say you did a massive resection, you have a very high stoma. One could consider leaving a small little soft catheter in the mucus fistula post-op so that you don't, you know, lose access to it because it is very frustrating when you take the time to make the mucus fistula and then when you go to refeed, you can't find the opening. You know, one trick that I was taught by my partner Oliver Soldis is to use the nipple of a bottle, tape it on the abdominal wall, and put the The catheter through the nipple into the stoma and it keeps it in place. Um, I know people used to use that for gastrostomy tubes, and it's a nice little trick. All right, so let's go back again to change the scenario. When you went in to do your laparotomy, you actually found neck totalis. So how do you manage that? So I think neck totalis is one of the most tragic findings that one can find on exploratory laparotomy for a baby with necrotizing enterocolitis, and the chance of a baby who has true necrotizing enterocolitis totalis. And who may undergo a resection, the chance of them living to be old enough to get what will probably end up being a small bowel liver transplant is really very close to zero. So, I think this is the tragic case where you have to go out and talk to the parents and give them a very realistic understanding of what the situation is. And I think that if it's a very small premature baby, unfortunately we just don't have the technology in this day and age to get that baby through this issue, through this devastating problem. So no one, I don't think, would be criticized for explaining to the parents the severity of the problem and just closing the abdomen and giving the baby comfort care. It's even more challenging if you have a full term baby who has a similar problem from the rotation or something like that, but that's the one case scenario that we probably hate the most as a pediatric surgeon. What do you tell the parents? They say, Well, I read about small bowel transplant. Is it possible my child could live long enough to get to the age where they could get a small bowel transplant? Yeah, I just think you have to be really realistic with them. And in my experience, the chance of that baby living through, you know, the months to years of TPN that they're going to require is going to, you know, irreversibly injure their liver. And even if they live to be big enough, the results of small bowel transplant are still suboptimal at this point. And I just in general think that that's a no-win situation in my experience. All right, so let's take a totally different situation. Let's say that you were called about an 800 g baby that developed acute onset of abdominal distention and was found to have pneumoperitoneum, and the baby's on jet ventilation and is hypotensive and is on pressors. What might be going on with this baby and how do you approach this? One thing that we haven't touched on is you really do need to make sure that the problem is in the abdomen, and there is a very small subset of patients, not, not, not necessarily this patient. We'll get to this patient in a minute, but there are some patients who are premature, have horrible lung disease, get a pneumothorax, and the pneumothorax necessitates through the diaphragm into the abdomen, and you get consulted for free air. So just in the back of our minds, remember to make sure that the problem isn't in the chest and that the problem really is in the abdomen. But in this patient, you're suggesting that the problem really is in the abdomen, and this is a patient who is hemodynamically unstable on pressures, etc. And if on abdominal exam they're very distended, and I think you said that there was free air, this is a great patient to take a little angio catheter, put it right through the abdominal wall, and release that pressure as a temporizing maneuver. Because it always takes some period of time to mobilize the OR or to get ready to do an operation, and you may not be able to afford the luxury of waiting very long on a very unstable patient like this. So put in an angio catheter, release the pneumoperitoneum, and it'll buy you some time, hopefully. Well, Gail, I have to tell you this has been one of my favorite recordings that we've done. I love talking to you and hearing your thoughts on this very complicated issue, especially since, uh, it's something that we see so often and have very few answers about exactly what we should be doing, and we hope to maybe have you back again next year for an update when you get the results of the Nest trial. Thank you very much for doing this with us today. Grateful that you asked me to do this. It was a lot of fun and I certainly hope that we can do an update in the next year or two. All right, Gail, thank you so much. Thank you so much. Have a great day. 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