Update Course Rewind: Laparotomy Over PPD 2022

One of the biggest questions in the neonatal surgery is often whether to do a laparotomy or a peritoneal drain placement for babies with necrotizing enterocolitis. I'm Ellen in Cisco at Cincinnati Children's and Dr. Paul Yazurzak reviewed this topic at the 2022 pediatric surgery update course. So we have a five-day-old 28-week premature infant weighing 1250 grams who develops feeding intolerance, abdominal distension, and hematochezia. Abdominal radiographs demonstrate pneumatosis intestinalis and pneumoperitoneum. Resuscitation and systemic antibiotics are initiated. The options of primary peritoneal drainage or primary laparotomy were discussed with the family. Current evidence suggests a possible benefit of laparotomy over primary peritoneal drainage for what? I guess the question for me and maybe in the room is how small is too small to do a laparotomy? The nest trial and the papers from this, the cutoff was around a kilogram. Everybody feels safe with that. But how small have people done laparotomies in safely? I know we had a case like this recently and there was a lot of debate. I think this baby was 23 weeks in one day. And I think our hospital was 23 weeks, so because it was one day older than that, we decided to survive the baby. And I wanted to place a drain and the neonatology unit wanted me to do an exploratory laparotomy because their bias is towards that. And then the whole discussion came up, why are we doing anything? And so it was just a debate, I think everyone had a different opinion. More recent data from a prospective but non-randomized cohort study from the NICHD Neonatal Research Network showed no difference in survival, intestinal strictures, or intra-abdominal abscesses. But they did see a potential improvement in long-term neurodevelopmental outcomes. So this, one of my patients, clearly very sick, clearly NEC. Sometimes it's that gray area where people argue, well, it's just a sip, a drain will do fine, you don't need to operate. But sometimes it's hard to say unless you're looking at the ball, that it's necrotizing enterocolitis in the first place. The latest evidence suggests a possible benefit of primary laparotomy over primary peritoneal drainage when it comes to neurodevelopmental outcomes. Of patients who underwent initial laparotomy, about 38% of them developed neurodevelopmental impairment, while about 68% of the patients who underwent primary peritoneal drainage developed later neurodevelopmental impairment. We're getting lower and lower every year in terms of gestational age and size for patients that we're offering surgery to. That's the first debate. If you decide that the baby meets your ethical or whatever criteria to do anything, then the second question is, if you think they need treatment, is their size and age enough of a reason for you to decide which treatment based on their age and weight? So one of the questions that was brought up is whether a drain is a definitive treatment for improved survival. That's the challenge, and that's the thing we don't know. If the baby's going to die, they'll die with their laparotomy or a drain. If the baby's going to survive, they'll survive to at least 24 to 48 hours with a laparotomy or a drain, maybe. I don't know. And I think when I, the way I interpret the nest trial and everything else that's going on is that, well, for that survival piece, it's still not 100% clear. Neurodevelopmental outcomes, different story. So a patient like this to me is the perfect patient. You put a drain in and see if they get better and at least you can buy a little bit of time to have more discussions and decide what to do. The ultimate decision is ours, but I do believe that working with the neonatology team on the decision to operate is actually prudent. If you're covering a community hospital's NICU and they have free air, does that change your management? Versus a drain versus laparotomy? I think if it's a hospital set up for neonatal surgery, it would not. Because the baby could eventually be transferred even after your treatment, whether it was a laparotomy or a drain if it need be. But I think this is becoming more and more in our face because neonatology is surviving younger and younger and the separation between surgery and neonatology is that chasm is starting to widen because what they can survive is different than what we should be doing. And so that's a new problem for us. Thanks for joining Dr. Paul Yak and the rest of the AP Professional Development Committee for this update course rewind. Be sure to check out more pediatric surgical content on the Stay Current app. Along with Cincinnati Children's, we're sharing knowledge to improve child health around the globe.