Update Course Rewind 2025: Updates in NEC Management

Hi everyone, I'm Lizzie Lee, PA from Cincinnati Children's Hospital Medical Center. I'm also joined by Maggie Koenig, nurse practitioner from Cincinnati Children's. Today, Doctor Augusto Zanni, Doctor Simon Eaton, and Doctor Dan Osley from Cincinnati Children's will discuss updates in necrotizing entercolitis management. In the world of neonatal intensive care, few words carry as much weight as neck, necrotizing enterocolitis. Neck is a disease that moves with terrifying speed, turning a stable premature infant into a surgical emergency in hours. Despite decades of research, many questions on management of neck still remain. Let's hear from pediatric surgeon Doctor Augusto Zani. We still don't know what causes it for our surgeons, how do we really diagnose it? What's the right time to operate? Are there some babies that are too sick to be operated on? And then when we do an operation, which one, when do we restart feeds for these babies, which antibiotics, and for how long do we refeed the mucus fstu if you have one? Today, we're exploring a few of these surgical dilemmas. Let's check out our case. We have a 28 week male infant, 900 g on CPAP, on trophic feeds, EPM and TPN. It's day 12 of life, baby develops abdominal distention, episodes of vomiting and bloody stool. On exam, there's abdominal distention, bloody stool, and tachycardia. The labs confirm acidosis and a high CRP. But when the X-ray comes back, it's equivocal, no free air, just bubbles in the intestine. The team starts triple antibiotics and bowel rest, but how do we follow up when the standard X-ray isn't giving us the full story? Maybe it's not that popular, but the ultrasound really gives you a lot of more clues that the abdominal X-ray. Abdominal X-rays are highly specific, but very low sensitivity. Studies show a sensitivity between 13 and 25%. Think about that. A sensitivity as low as 13%. That means for every 10 babies with surgical neck, an X-ray might only catch one or two in the early stages. The panel pointed to a 2023 study in pediatric radiology, suggesting that ultrasound can see what the X-ray misses the thinning of the bowel wall, the profusion, and the silent fluid collections. We want to know when the baby has surgical neck, when we need to operate. An ultrasound scan can tell you a little bit more about. The bowel, bowel wall thickening, thinning, perfusion, peristalsis, what's inside the abdomen, what happens at the level of the peritoneum and the liver. It's a shift in thinking, moving from the static snapshot of an X-ray to the dynamic view of an ultrasound. The panel points to specific high risk findings that should make a surgeon lean toward intervention, even without that classic sign of free air. High ones are pneumoperitoneum, full of fluid collections, complex flu fluid, these are more concerning for bowel perforation. Intermediate, you have increased bowel wall ecogenicity, absent perfusion, per venous gas, bowel thinning and thickening. The more of these found, the more likely surgery is needed. Let's get back to our clinical scenario. Day 14, baby gets worse, uh, more abdominal distention, acidosis, started on otropes, high vent settings, blood transfusion needed. We do an X-ray and there's free air. What to do next is the classical controversy in necrotizing enterocolitis management. Do you place a drain at the bedside, or do you take this fragile 9000 human to the operating room for a laparotomy? And if you do operate, do you bring the ball out as a stoma, or do you perform an anastomosis, sewing the healthy ends back together immediately? The majority actually would do laparotomy, so we decide to proceed with surgery, which kind of surgery? Let's say the baby is in stable condition. Do you do a resection and anastoma, resection and anastomosis, clip and drop? All of this depends on how sick the baby is. Let's say the baby is in stable condition. Clearly, yeah, because I can't tell. They're sick post-op. This is the problem I have. They're sick post-op, whether you do the anastomosis or not. Doctor Todd Ponsky, pediatric surgeon from Cincinnati Children's, also chimes in. Bowel is a symptom, is a result of the illness. It's not the cause of the illness. The disease still progresses, even that's the problem of going too early. You resect, it's still progressing. That fear of progression is what keeps many surgeons from sewing the bowel back together immediately, especially when dealing with ultra low birth weight neonates. Not all babies are the same. There are those ones in which you open up, you just need to bring up a stoma because they're too unstable. But the ones in which, as I said, let's say 10 centimeter of a segment, you remove it, so you have a source control. Not necessarily they do so poorly. Afterwards, in the long run, there is a benefit. You might not see the benefit with immediate survival, though. The data shows it's better. If I feel like the baby is well, I would be convinced to do a primary anastomosis cause I do agree, doing a stoma, doing a silo clip and drop, maybe they won't do as well. Instead, some opt for a clip and drop method, removing the necrotic segment, stapling the ends, and coming back in 24 to 48 hours to check the hemodynamics of the gut. Before committing to a stoma or an anastomosis. The data shows that right now, I'm a clip and dropper. I would come back 24, 48 hours later, I would not do a stoma. Because I feel like I would have an answer in a couple of days. Pediatric surgeon Doctor Juan Gurria also chimes in here. I think it depends on human dynamics, right? If your lactate is correcting, if your thrombocytopen is correcting, if you're getting off inotropes, right? And you come back the next morning and the bowel looks potentially viable, you're resecting 5 instead of 3. 35 potentially. To move beyond gut feelings, we have to look at the data, specifically the SAT trial, a randomized control trial led by the team at Great Ormond Street and Doctor Augusto Zani. This trial didn't just look at survival, it looked at the quality of recovery. Here's pediatric surgeon, Doctor Simon Eaton, who called in from London to also join our panel discussion. We designed a randomized control trial and the final decision on eligibility was dependent on the surgeon's judgment during the laparotomy. Doctor Zani actually did randomize a lot of patients in this trial. You're in the middle of the operation, and this means that the baby is hemodynamically stable, and then you would then scrub and go to the computer and go for randomization. Now you can tell. you that the fellows, when it was like an anastomosis, were like, oh my God, now we're doing this to 500 grammers, but they were the strongest believers when they saw how these babies progressed afterwards. The results were striking. While mortality was similar in both groups, the babies who received a primary anastomosis, the ones sewn back together immediately, got off parenteral nutrition significantly sooner. In addition, they were able to get back to eating real food more quickly and had fewer intestinal complications than those with the stoma. Here's pediatric surgeon, Doctor Simon Eaton. So, moving on to the clinical scenario, in this particular patient, after having decided to do a primary anastomosis, the patient then became markedly clinically unstable. So the decision was taken to do a stoma instead. But the journey doesn't end in the operating room. As mentioned, in our clinical scenario, our patient actually became markedly unstable during surgery, forcing the team to pivot and place a stoma instead. This brings up the next challenge, mucous fistula refeeding, recycling the upper stoma output into the lower bowel to keep it healthy. Mucous fistula refeeding is a practice that many clinicians swear by, although formal evidence is still catching up. So where are we in? In terms of evidence for mucous fistulary feeding. There has been a systematic review and meta-analysis from Bonnie Jasani, a neonatologist from Toronto, Sick Kids. The evidence isn't strong so far. Luckily, there is a randomized controlled trial that's going on at the moment, a randomized controlled trial of mucous fistula refeeding, timed to full enteral feeds. Finally, we look at the time of stoma closure. Historically, surgeons waited months. Now the tide is turning. Toward earlier intervention, sometimes when the patient is less than 8 weeks old. Optimal timing of sober closure, recent paper in Journal of Surgical Research basically showing that it seems to be safe to close early. There were, however, some caveats to this research study. This study is very underpowered. In less than 8 weeks, there were 2 infants that had a repeat episode of NEC. More research is still needed, and there's a new trial studying timing of stoma closure called the. Skin mixed methods study. The article is linked in the show notes below. There is an ongoing preparation for a randomized trial in the UK. Personal practice check. So take a message from our group on this session is that you can use an ultrasound if the X-ray is equivocal. Primaryastomosis is a viable option in stable babies, because fistula feeding seems to be nutritionally advantageous, and ostomy closure can safely be performed early, earlier than 8 weeks. We leave you with one final thought from the room, a reminder that in the face of a low sensitivity X-ray, sometimes you just have to trust your colleagues and your technology. I think you need to be prepared to have some negative laparotomies. There will be some in which unfortunately, you think it's perforated, actually it's not, but definitely if there's like turbid-free fluid, there's something going on there. But you don't see that in the X-ray, and so you got to trust your radiologist to some extent. All right, let's sum up what we learned today about neck. Ultrasound may be a game changer in neck diagnosis, especially when X-rays are inconclusive, offering earlier clues like bowel wall thinning and fluid collections that can help identify surgical neck before free air even appears. The biggest surgical decisions in neck remain debated, including when to operate and whether to perform a stoma. Emerging evidence from the stat trial suggests stable infants receiving primary anastomosis. May recover faster with earlier return to feeds and fewer intestinal complications. Neck care extends far beyond the operating room, with evolving practices like mucous fistula refeeding and earlier stoma closure showing promise, but stronger clinical trial data is still needed. Thank you so much for listening. We hope you loved this episode. Please follow Stay Current MD on social media, give us a rating and subscribe to our YouTube channel. And don't forget to download the Stay Current app to find more content.