Necrotizing enterocolitis (NEC) is a devastating intestinal disease that primarily affects premature and low-birth-weight infants, often requiring urgent surgical intervention. A new comprehensive review published in the World Journal of Pediatric Surgery synthesizes current evidence to guide surgeons in making difficult decisions about when and how to operate, with a focus on preserving functional bowel and improving long-term outcomes.
The review, conducted by researchers at Nationwide Children's Hospital in Columbus, Ohio, addresses the high stakes of surgical NEC: while mortality for medically managed NEC is around 7%, it escalates to 20-30% when surgery becomes necessary. Survivors often face complications such as strictures, short bowel syndrome (SBS), nutritional deficiencies, and neurodevelopmental impairments. The absence of a specific biomarker and the overlap with spontaneous intestinal perforation (SIP) further complicate clinical judgment.
Central to the review is the comparison between peritoneal drainage (PD) and exploratory laparotomy. PD is less invasive and can be performed at the bedside, making it suitable for extremely low-birth-weight infants who may not tolerate surgery. However, if the infant does not improve, rescue laparotomy may be required. Earlier randomized trials showed similar survival rates between the two approaches, but a more recent multicenter randomized controlled trial found that among infants with a preoperative diagnosis of NEC, death or neurodevelopmental impairment occurred in 69% after laparotomy versus 85% after PD, with a 97% Bayesian probability favoring laparotomy in this subgroup.
The review also examines reconstruction options after bowel resection, weighing stoma creation versus primary anastomosis. Primary anastomosis is preferred when the infant is stable and the remaining bowel is viable. For extensive disease, bowel-sparing techniques such as damage control surgery, 'clip and drop', diverting jejunostomy, 'patch, drain and wait', and intraluminal stenting are discussed. These approaches aim to minimize bowel loss and preserve intestinal length, which is critical for long-term nutritional autonomy.
Emerging perioperative tools are also evaluated, including indocyanine green fluorescence angiography (ICG-FA) to assess intestinal perfusion in real time, direct peritoneal resuscitation (DPR) to improve microcirculation, and mucous fistula refeeding to enhance enteral adaptation and reduce dependence on total parenteral nutrition (TPN). While promising, the authors note that these techniques require further validation through well-controlled studies before becoming standard practice.
The authors emphasize that operative care for NEC cannot be reduced to a single preferred procedure. Decisions must be individualized based on the infant's clinical stability, the extent of intestinal injury, and the potential for bowel preservation. They advocate for a multidisciplinary approach that integrates risk stratification tools like the Neonatal Sequential Organ Failure Assessment (nSOFA), imaging, and laboratory findings to identify high-risk infants early.
This review has significant implications for neonatal and pediatric surgical teams. By providing a structured framework, it encourages a shift away from a one-size-fits-all approach toward more tailored interventions that balance immediate survival with long-term quality of life. As the authors conclude, the ultimate goal is not just to control the acute disease but to preserve functional bowel, reduce complications, and support neurodevelopment in these vulnerable patients.
