From
StayCurrentMD
Surgical Decision-Making in Necrotizing Enterocolitis: Imaging, Timing, and Operative Strategies
With Dr. Augusto Zani & Dr. Juan Gurria & Dr. Simon Eaton · hosted by Lizzy Lee, PA-C & Dr. Todd Ponsky
Chapter 5 of 5
Closure timing
Stoma Closure Timing and Summary of Key Points
Cued at 9:45 · press play
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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
Abdominal X-rays for NEC have sensitivity between 13 and 25%
High-risk ultrasound findings for bowel perforation include pneumoperitoneum, focal fluid collections, and complex fluid
Intermediate-risk ultrasound findings include increased bowel wall ecogenicity, absent perfusion, portal venous gas, and bowel thinning or thickening
In NEC, the diseased bowel is a symptom or result of the illness, not the cause of the illness
The disease process in NEC still progresses even after resection, which is the problem of operating too early
In stable babies with a limited segment of necrotic bowel (approximately 10 cm), resection with primary anastomosis may not result in poor outcomes
Data shows primary anastomosis is better than stoma or clip-and-drop in well babies
Decision to proceed with anastomosis after clip-and-drop depends on hemodynamic markers: correcting lactic acid, correcting thrombocytopenia, and weaning off inotropes
The SAT trial was a randomized controlled trial with final eligibility determined by surgeon's judgment during laparotomy
In the SAT trial, randomization occurred intraoperatively after the surgeon determined the baby was hemodynamically stable
A systematic review and meta-analysis by Bonnie Jasani from Toronto Sick Kids examined mucous fistula refeeding, but the evidence isn't strong so far
A randomized controlled trial of mucous fistula refeeding timed to full enteral feeds is currently ongoing
A recent paper in Journal of Surgical Research shows that early stoma closure (before 8 weeks) appears to be safe
The early stoma closure study is very underpowered, and in the less-than-8-weeks group, 2 infants had repeat episodes of NEC
The Toskin mixed-method study is an ongoing preparation for a randomized trial in the UK examining timing of stoma closure
Surgeons need to be prepared to have some negative laparotomies when operating based on clinical suspicion and ultrasound findings without free air on X-ray
A 2023 study in Pediatric Radiology suggests ultrasound can detect bowel wall thinning, perfusion abnormalities, and fluid collections that X-ray misses
The long-term benefit of primary anastomosis may not be seen in immediate survival outcomes
The clip-and-drop method involves removing necrotic bowel segment, stapling the ends, and returning in 24-48 hours to assess bowel hemodynamics before committing to stoma or anastomosis
In the SAT trial, mortality was similar between primary anastomosis and stoma groups
Babies who received primary anastomosis in the SAT trial got off parenteral nutrition significantly sooner than those with stoma
Babies with primary anastomosis were able to return to enteral feeding more quickly and had fewer intestinal complications than those with stoma