Mortality and intestinal failure in surgical necrotizing enterocolitis

Fresh Hemorrhages in Intestinal Resection Margins Are Associated with Unfavorable Clinical Outcomes in Preterm Infants with Necrotizing Enterocolitis with Surgical Intervention

BACKGROUND

Necrotizing enterocolitis (NEC) is a common disease in premature infants. If conservative treatment does not respond, surgical removal of the necrotic section of bowel is common practice. This study investigates whether there is a correlation between the histopathological findings and the postoperative clinical course of the children who have undergone surgery. To date, only a few detailed studies on a possible correlation have been published.

METHODS

The surgical specimens of 49 infants diagnosed with NEC in the years 2010-2019 were re-evaluated. The histologic specimens were examined for tissue viability and hemorrhage of the resection margins, peritonitis or perforation of the central resection segment. The groups were divided according to the clinical outcome: death, postoperative complications and patients without complications.

RESULTS

5 of 49 (10.2%) children died, 22 children (44.9%) required reoperation, while 22 (44.9%) had no complications. Univariate and multivariate analyses showed a significant association between fresh hemorrhage in the resection margins and postoperative outcome. In our data, correlation between the vitality of the resection margins or the extent of necrosis and the postoperative course was not seen.

CONCLUSION

This retrospective study shows a significant correlation between a fresh hematoma in the tissue of the resection margin and the clinical prognosis. Fresh bleeding in the resection margins was associated with increased morbidity with stenosis and possibly another surgical intervention. In contrast, no further correlation was found between the vitality of the tunica mucosae, the tunica muscularis or peritonitis in the resection margin or central part of the NEC specimen and the clinical course. In summary, it can be said that the presence of a fresh hematoma at the resection margin is significantly linked to a poorer clinical outcome for the infants with NEC surgery. Other histopathological findings of the surgical specimen with regard to the clinical course show now significant correlation and, therefore, the histological examination mainly serves the medico-legal documentation and quality assurance of the NEC operation.

Ileal lengthening through internal distraction: A novel procedure for ultrashort bowel syndrome

Purpose

Ultrashort bowel syndrome is a rare, but morbid surgical problem without effective treatment. Recent clinical analysis has demonstrated the critical influence of ileal length on ultimate enteral autonomy. Surgical techniques to increase ileal length in nondilated bowel do not exist. We describe a novel technique to lengthen ileum in children with ultrashort bowel syndrome.

Methods

Beginning in May 2021 prospective candidate children were identified. Candidacy for ileal tube lengthening included diagnosis of ultrashort bowel syndrome, intact ileocecal valve with remnant ileum, and proximal intestinal stoma or draining gastrostomy. Informed consent was obtained. Following laparoscopic lysis of adhesions, a balloon catheter was inserted through a left flank stab incision and into the lumen of the remnant ileum around a purse string suture. Cecopexy was performed in the right-lower quadrant. Clips were used to mark the cecum and the proximal extent of ileum. The catheter length was fixed externally at the completion of the procedure. Serial x-rays were used to measure distraction effect while increasing tension was applied to the catheter over the subsequent weeks. Ileal tube lengthening was performed until the end of the catheter was reached or the tube was dislodged. A contrast study was performed at the completion of lengthening. Intestinal length at time of restoration of continuity and clinical outcomes were recorded.

Results

Four infants were enrolled from May 2021-July 2023. Diagnoses leading to ultrashort bowel syndrome were mesenteric teratoma, necrotizing enterocolitis, and multiple intestinal atresia. At the time of restoration of intestinal continuity, a median of 1.75 cm (45 %) additional ileal length was achieved at a median of 25.5 days. There were no serious complications following ileal tube lengthening and no additional operative interventions were required.

Conclusions

Ileal lengthening through internal distraction is a feasible surgical intervention to salvage ileum for infants with ultrashort bowel syndrome. Ileal tube lengthening may result in distraction enterogenesis, providing a novel intervention to increase intestinal length.

Level of evidence

IV (Case series without comparison group).

Laparotomy versus Peritoneal Drainage as Primary Treatment for Surgical Necrotizing Enterocolitis or Spontaneous Intestinal Perforation in Preterm Neonates: A Systematic Review and Meta-Analysis

AIM

to systematically review and meta-analyze the impact on morbidity and mortality of peritoneal drainage (PD) compared to laparotomy (LAP) in preterm neonates with surgical NEC (sNEC) or spontaneous intestinal perforation (SIP).

METHODS

Medical databases were searched until June 2022 for studies comparing PD and LAP as primary surgical treatment of preterm neonates with sNEC or SIP. The primary outcome was survival during hospitalization; predefined secondary outcomes included need for parenteral nutrition at 90 days, time to reach full enteral feeds, need for subsequent laparotomy, duration of hospitalization and complications.

RESULTS

Three RCTs (N = 493) and 49 observational studies (N = 19,447) were included. No differences were found in the primary outcome for RCTs, but pooled observational data showed that, compared to LAP, infants with sNEC/SIP who underwent PD had lower survival [48 studies; N = 19,416; RR 0.85; 95% CI 0.79-0.90; GRADE: low]. Observational studies also showed that the subgroup of infants with sNEC had increased survival in the LAP group (30 studies; N = 9370; RR = 0.82; 95% CI 0.72-0.91; GRADE: low).

CONCLUSIONS

Compared to LAP, PD as primary surgical treatment for sNEC or SIP has similar survival rates when analyzing data from RCTs. PD was associated with lower survival rates in observational studies.

Clinical determinants of intestinal failure and death in preterm infants with surgical necrotizing enterocolitis

OBJECTIVE

We sought to investigate the clinical determinants of intestinal failure and death in preterm infants with surgical NEC.

METHODS

Retrospective comparison of clinical information between Group A = intestinal failure (Parenteral nutrition (PN) >90 days) and death and Group B = survivors and with PN dependence < 90 days in preterm infants with surgical NEC.

RESULTS

Group A (n = 99/143) had a lower mean gestational age (26.4 weeks [SD3.5] vs. 29.4 [SD 3.5]; p = 0.013), lower birth weight (873 gm [SD 427g] vs. 1425 gm [894g]; p = <0.001), later age of NEC onset (22 days [SD20] vs. 16 days [SD 17]; p = 0.128), received surgery later (276 hours [SD 544] vs. 117 hours [SD 267]; p = 0.032), had cholestasis, received dopamine (80.6% vs. 58.5%; p = 0.010) more frequently and had longer postoperative ileus time (19.8 days [SD 15.4] vs. 11.8 days [SD 6.5]; p = <0.001) and reached full feeds later (93 days [SD 45] vs. 44 [SD 22]; p = <0.001) than Group B.On multivariate logistic regression, higher birth weight was associated with lower risk (OR 0.35, 95% CI 0.15-0.82; p = 0.016) of TPN > 90 days or death. Longer length of bowel resected (OR 1.76, 95% CI 1.02-3.02; p = 0.039) and longer postoperative ileus (OR 2.87, 95% CI 1.26-6.53; p = 0.011) were also independently associated with TPN >90days or death adjusted for gestational age and antenatal steroid treatment.

CONCLUSION

In preterm infants with surgical NEC, clinical factors such as lower birth weight, longer bowel loss, and postoperative ileus days were significantly and independently associated with TPN >90 days or death.

Initial surgical treatment of necrotizing enterocolitis: a meta-analysis of peritoneal drainage versus laparotomy

Necrotizing enterocolitis (NEC) in premature infants is associated with high morbidity and mortality, and the optimal intervention remains uncertain. To compare the mortality of primary peritoneal drainage versus primary peritoneal laparotomy as initial surgical intervention for NEC. All data were extracted from PubMed, Embase, and the Cochrane Library. Studies published up to December 2021. Patients with NEC. Studies centered on primary peritoneal drainage and primary peritoneal laparotomy as the initial surgical treatment. Mortality outcomes were available for both interventions. Randomized controlled trials, retrospective cohort studies, and case series in peer-reviewed journals. Language limited to English. Odds ratio (OR) with 95% confidence intervals (CIs) was used to evaluate mortality outcome. Subgroup analyses and linear regression were performed to ascertain the association between mortality pre-specified factors. Data of 1062 patients received peritoneal drainage and 2185 patients received peritoneal laparotomy from five case series, five retrospective cohort studies, and three randomized controlled trials. Peritoneal drainage caused similar mortality (OR 1.49, 95% CI 0.99-2.26) compared with peritoneal laparotomy as initial surgical management for NEC infants. The subgroup analysis of study design, sample size, birth weight, and sex showed similar findings, but inconsistent results were found for country (USA: 1.47, 95% CI 0.90-2.41; Canada: 2.53, 95% CI 0.30-21.48; Australia: 10.29, 95% CI 1.03-102.75; Turkey: 0.09, 95% CI 0.01-0.63) and gestational age (age mean difference < 3: 1.23, 95% CI 0.72-2.11; age mean difference ≥ 3: 2.29, 95% CI 1.04-5.05). No statistically significance was found for the linear regression between mortality and sample size (P = 0.842), gestational age (P = 0.287), birth weight (P = 0.257), sex (P = 0.6). Small sample size, high heterogeneity, NEC, and spontaneous intestinal perforation (SIP) had to be analyzed together, lack of selection criteria for the future selection of an intervention, and no clear, standardized procedures.   Conclusion: There was no significant difference in mortality between peritoneal drainage and laparotomy as initial surgical intervention. The results suggest that either intervention could be used in selected patients. What is Known: • Necrotizing enterocolitis (NEC) in premature infants is associated with high morbidity and mortality, and the optimal intervention remains uncertain. What is New: • No significant difference of mortality between peritoneal drainage and laparotomy as initial surgical intervention.

Temporal and seasonal variations in incidence of stage II and III NEC-a 28-year epidemiologic study from tertiary NICUs in Connecticut, USA

OBJECTIVE

To investigate seasonality and temporal trends in the incidence of NEC.

STUDY DESIGN

A retrospective cohort study from two tertiary NICUs in northern and central Connecticut involving 16,761 infants admitted over a 28-year period. Various perinatal and neonatal risk factors were evaluated by univariate, multivariate, and spectral density analyses.

RESULTS

Incidence of NEC was unchanged over the 28 years of study. Gestational age, birth weight, and birth-months (birth in April/May) were independently associated with stage II or III NEC even after adjusting for confounding factors (p < 0.05). Yearly NEC incidence showed a multi-modal distribution with spectral density spikes approximately every 10 years.

CONCLUSION(S)

Temporal and seasonal factors may play a role in NEC with a peak incidence in infants born in April/May and periodicity spikes approximately every 10 years. These trends suggest non-random and possibly environmental factors influencing NEC.

Historical aspects of probiotic use to prevent necrotising enterocolitis in preterm babies

Over the last few decades, numerous studies have evaluated probiotic use for the prevention of necrotising enterocolitis in preterm babies. Early 'proof of concept' studies evaluating whether probiotics are capable of colonising the preterm gut have translated into multiple observational studies, small and large randomised controlled trials. Some show evidence of benefit while others have produced disappointing results. In this paper, we review the history of probiotic use in preterm babies for NEC prevention in an attempt to explain why uncertainty exists and why this intervention has not been universally adopted into routine neonatal practice.

Gastrointestinal sequelae after surgery for necrotising enterocolitis: a systematic review and meta-analysis

OBJECTIVES

To document what types of gastrointestinal sequelae were described after surgery for necrotising enterocolitis (NEC) and to analyse their frequency.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Medline, EMBASE and the Cochrane library (CENTRAL) from 1990 to October 2016.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included studies, which provided original data on the occurrence of gastrointestinal sequelae in patients surviving surgery for NEC. Meta-analysis and metaregression to assess heterogeneity were performed for studies including 10 or more patients with gastrointestinal strictures, recurrence of NEC, intestinal failure (IF) and adhesion ileus.

RESULTS

Altogether 58 studies, including 4260 patients, met the inclusion criteria. Strictures were reported to occur in 24% (95% CI 17% to 31%) of surviving patients, recurrence of NEC in 8% (95% CI 3% to 15%), IF in 13% (95% CI 7% to 19%) and adhesion ileus in 6% (95% CI 4% to 9%). Strictures were more common following enterostomy (30%; 95% CI 23% to 37%) than after primary anastomosis (8%; 95% CI 0% to 23%) and occurred more often after enterostomy without bowel resection than with bowel resection. We found considerable heterogeneity in the weighted average frequency of all sequelae (I² range: 38%-90%). Intestinal outcomes were poorly defined, there were important differences in study populations and designs, and the reported findings bear a substantial risk of bias.

CONCLUSIONS

Gastrointestinal sequelae in neonates surviving surgery for NEC are frequent. Long-term follow-up assessing defined gastrointestinal outcomes is warranted.

Agreement between study designs: a systematic review comparing observational studies and randomized trials of surgical treatments for necrotizing enterocolitis

Background: It is unknown whether observational studies comparing laparotomy versus peritoneal drainage for surgical treatment of necrotizing enterocolitis (NEC) in preterm infants differ from randomized controlled trials (RCTs) of the same interventions. Further, in the absence of sufficient RCT evidence, it is uncertain how best to use existing observational data to guide clinical decision making.Methods: We performed a systematic review and meta-analysis of articles comparing laparotomy versus peritoneal drainage for preterm infants with NEC. Two authors independently searched PubMed and the Cochrane Database of Systematic Reviews, from 1 January 1990 to 1 May 2017 and selected articles that: (1) included low birthweight (<2500 g) or preterm (<37-week gestation) infants, (2) compared laparotomy versus peritoneal drainage for NEC, and (3) reported all-cause mortality (primary outcome) in both groups. The same two authors extracted data about study outcomes and about study quality, which was assessed using the Consolidated Standards of Reporting Trials (CONSORT) checklist for reporting of RCTs and Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for reporting of observational studies. Random-effects meta-analysis was used to generate weighted odds ratios (OR).Results: Twenty-five observational studies and two RCTs met all eligibility criteria. Outcomes were reported for 16,288 patients: 16,103 from observational studies and 185 from RCTs. Meta-analysis of observational studies demonstrated significantly lower mortality after laparotomy, as compared to peritoneal drainage (pooled OR 0.54, 95% CI 0.34-0.84). In contrast, RCTs demonstrated no difference in mortality (pooled OR 0.85, 95% CI 0.47-1.54). In post hoc analyses, observational studies were separated into two subgroups: low versus high quality of reporting, based on the STROBE checklist. Observational studies with low quality of reporting significantly favored laparotomy (pooled OR 0.38, 95% CI 0.18-0.81). In contrast and similar to RCTs, observational studies with high quality of reporting showed no difference in mortality (pooled OR 0.67, 95% CI 0.37-1.19).Conclusions: Neither RCTs nor observational studies with high quality of reporting demonstrate differences in mortality when preterm infants with surgical NEC are managed with laparotomy or peritoneal drainage. While RCTs remain a gold standard for evaluation of therapies, results from high quality observational studies may approximate the results of RCTs and might guide clinical practice until adequate RCT evidence is available.

The effect of gestational age on clinical and radiological presentation of necrotizing enterocolitis

BACKGROUND/PURPOSE

To test the hypothesis that clinical and radiological features of necrotizing enterocolitis vary with gestational age in all neonates with NEC and in subgroup of surgically treated patients.

METHODS

This was a retrospective study case series. NEC cases treated in Stockholm County from 2009 to 2014 were identified in the National Quality Register. Patients were included in the study if they had a verified NEC diagnosis and they were divided into 2 groups according to the gestational age.

RESULTS

A total of 89 patients were included. Of these 60 (67.4%) neonates had a gestational age <28 and 29 (32.6%) infants ≥28weeks. Surgical NEC patients were 57 (64%). Pneumatosis intestinalis at the abdominal radiographs was noted significantly more often in neonates born at ≥28weeks of gestation (86.2%) compared to extremely preterm newborns (60.0%). Neonates born at ≥28weeks of gestation presented more often bloody stools (58.6%) compared to extremely preterm newborns (20.0%). In surgical NEC patients gasless abdomen was detected in 35.6% of the neonates born <28weeks compared to 6.7% of the more mature neonates.

CONCLUSIONS

Extremely preterm neonates with NEC show less specific clinical and radiological signs of NEC compared to more mature neonates. This suggests that Bell's classification is not adequate for the diagnosis and staging of NEC in extremely preterm neonates.

LEVEL OF EVIDENCE

III.

Intestinal failure after necrotising enterocolitis: incidence and risk factors in a Swedish population-based longitudinal study

BACKGROUND AND OBJECTIVE

Paediatric intestinal failure (IF) is a disease entity characterised by gut insufficiency often related to short bowel syndrome. It is commonly caused by surgical removal of a large section of the small intestine in association with necrotising enterocolitis (NEC), which usually affects premature infants. This study investigated the incidence and risk of IF in preterm infants with or without NEC.

DESIGN

A matched cohort study to investigate the incidence and risk factors for IF in a population-based setting in Sweden from 1987 to 2009 using the Swedish Patient Register.

PARTICIPANTS

Infants with a diagnosis of NEC (n=720) were matched for gestational age and year of birth with reference individuals without NEC (n=3656). The study cohort was censored at death, IF or at end of follow-up (2 years of age). We calculated HRs with 95%CIs for IF using Cox regression, adjusting for pertinent perinatal factors.

RESULTS

IF was 15 times more common in the infants with NEC compared with the reference infants (HR=7.2, with 95% CI 3.7 to 14.0). Other risk factors for IF were small for gestational age, extreme preterm birth and abdominal surgery. Neonatal mortality in infants with NEC decreased from 20.6% in 1987-1993 to 10.4% in 2007-2009.

CONCLUSION

IF was more common in the infants with NEC but was also linked to extreme preterm birth, a history of abdominal surgery and small for gestational age. IF was more common at the end of the study period, indicating that it increases when more preterm infants with NEC survive the neonatal period.

Effects of probiotics on experimental necrotizing enterocolitis: a systematic review and meta-analysis

BackgroundMeta-analyses of randomized controlled trials (RCTs) suggest that probiotics decrease the risk of necrotizing enterocolitis (NEC) in preterm infants. Many animal RCTs have evaluated probiotics for preventing NEC. We systematically reviewed the literature on this topic.MethodsThe protocol for systematic review of animal intervention studies (SYRCLE) was followed. Medline, Embase, ISI Web of Science, e-abstracts from the Pediatric Academic Society meetings, and other neonatal conferences were searched in December 2015 and August 2016. RCTs comparing probiotics vs. placebo/no probiotic were included.ResultsA total of 29 RCTs were included (Rats: 16, Mice: 7, Piglets: 3, Quail: 2, Rabbit: 1; N~2,310), with 21 reporting on histopathologically confirmed NEC; remaining 8 assessed only pathways of probiotic benefits. Twenty of the 21 RCTs showed that probiotics significantly reduced NEC. Pooling of data was possible for 16/21 RCTs. Meta-analysis using random-effects model showed that probiotics significantly decreased the risk of NEC (203/641 (31.7%) vs. 344/571 (60.2%); relative risk: 0.51; 95% confidence interval (CI): 0.42-0.62; P<0.00001; I2=44%; number needed to treat: 4; 95% CI: 2.9, 4.3).ConclusionProbiotics significantly reduced NEC via beneficial effects on immunity, inflammation, tissue injury, gut barrier, and intestinal dysbiosis.

Predicting Mortality or Intestinal Failure in Infants with Surgical Necrotizing Enterocolitis

OBJECTIVE

To compare existing outcome prediction models and create a novel model to predict death or intestinal failure (IF) in infants with surgical necrotizing enterocolitis (NEC).

STUDY DESIGN

A retrospective, observational cohort study conducted in a 2-campus health system in Atlanta, Georgia, from September 2009 to May 2015. Participants included all infants ≤37 weeks of gestation with surgical NEC. Logistic regression was used to model the probability of death or IF, as a composite outcome, using preoperative variables defined by specifications from 3 existing prediction models: American College of Surgeons National Surgical Quality Improvement Program Pediatric, Score for Neonatal Acute Physiology Perinatal Extension, and Vermont Oxford Risk Adjustment Tool. A novel preoperative hybrid prediction model was also derived and validated against a patient cohort from a separate campus.

RESULTS

Among 147 patients with surgical NEC, discrimination in predicting death or IF was greatest with American College of Surgeons National Surgical Quality Improvement Program Pediatric (area under the receiver operating characteristic curve [AUC], 0.84; 95% CI, 0.77-0.91) when compared with the Score for Neonatal Acute Physiology Perinatal Extension II (AUC, 0.60; 95% CI, 0.48-0.72) and Vermont Oxford Risk Adjustment Tool (AUC, 0.74; 95% CI, 0.65-0.83). A hybrid model was developed using 4 preoperative variables: the 1-minute Apgar score, inotrope use, mean blood pressure, and sepsis. The hybrid model AUC was 0.85 (95% CI, 0.78-0.92) in the derivation cohort and 0.77 (95% CI, 0.66-0.86) in the validation cohort.

CONCLUSIONS

Preoperative prediction of death or IF among infants with surgical NEC is possible using existing prediction tools and, to a greater extent, using a newly proposed 4-variable hybrid model.

Postoperative characteristics of infants who developed necrotizing enterocolitis with different postnatal ages

Our goal was to investigate the surgical procedures, postoperative complications, and survival with regard to different onset timing of necrotizing enterocolitis (NEC).We performed a retrospective review of medical records with a diagnosis of NEC between 2005 and 2016. The cutoff was set at 10 days for early onset ≤10 days and late onset over 10 days. Propensity score matching was performed to adjust for any baseline differences. In 53 paired patients, clinical outcomes, including, mortality, postoperative complications, and length of neonatal intensive care unit (NICU) stay, were evaluated on the basis of early or late-onset NEC.Successful 1:1 matching propensity score matching was performed with 208 infants. Mortality for early-onset NEC infants was lower than that of early late NEC infants (P = .026). A lower overall postoperative complication rate, including infectious complications [19 (35.8) vs 29 (54.7); odds ratio, 0.462, confidence interval (CI) 0.212-1.008, P = .039], was noted in patients with early-onset NEC compared with infants with late-onset NEC. NICU stay and major complication were marginal different between the 2 groups. Comparison of feeding outcomes revealed that the time to achieve full enteral feeds was significantly longer for those with late-onset NEC (18.1 ± 11.5 vs 26.3 ± 15.6, P = .008).The infants who develop NEC after 10 days of life do influence postoperative outcome survival or other clinically important outcomes after laparotomy.

Current Research on the Epidemiology, Pathogenesis, and Management of Necrotizing Enterocolitis

Despite decades of research on necrotizing enterocolitis, we still do not fully understand the pathogenesis of the disease, or how to prevent or how to treat it. However, as a result of recent significant advances in the microbiology, molecular biology, and cell biology of the intestine of preterm infants and infants with necrotizing enterocolitis, there is some hope that research into this devastating disease will yield some important translation into effective prevention, more rapid diagnosis, and novel therapies.

Current research in necrotizing enterocolitis

Despite decades of research on necrotizing enterocolitis, we still do not fully understand the pathogenesis of the disease, how to prevent or how to treat the disease. However, as a result of recent significant advances in the microbiology, molecular biology, and cell biology of the intestine of premature infants and infants with necrotizing enterocolitis, there is some hope that research into this devastating disease will yield some important translation into improved outcomes.

Probiotics and necrotizing enterocolitis

Probiotics for the prevention of necrotizing enterocolitis have attracted a huge interest. Combined data from heterogeneous randomised controlled trials suggest that probiotics may decrease the incidence of NEC. However, the individual studies use a variety of probiotic products, and the group at greatest risk of NEC, i.e., those with a birth weight of less than 1000 g, is relatively under-represented in these trials so we do not have adequate evidence of either efficacy or safety to recommend universal prophylactic administration of probiotics to premature infants. These problems have polarized neonatologists, with some taking the view that it is unethical not to universally administer probiotics to premature infants, whereas others regard the meta-analyses as flawed and that there is insufficient evidence to recommend routine probiotic administration. Another problem is that the mechanism by which probiotics might act is not clear, although some experimental evidence is starting to accumulate. This may allow development of surrogate endpoints of effectiveness, refinement of probiotic regimes, or even development of pharmacological agents that may act through the same mechanism. Hence, although routine probiotic administration is controversial, studies of probiotic effects may ultimately lead us to effective means to prevent this devastating disease.

Safety of octreotide in hospitalized infants

BACKGROUND

Octreotide is used off-label in infants for treatment of chylothorax, congenital hyperinsulinism, and gastrointestinal bleeding. The safety profile of octreotide in hospitalized infants has not been described; we sought to fill this information gap.

METHODS

We identified all infants exposed to at least 1 dose of octreotide from a cohort of 887,855 infants discharged from 333 neonatal intensive care units managed by the Pediatrix Medical Group between 1997 and 2012. We collected laboratory and clinical information while infants were exposed to octreotide and described the frequency of baseline diagnoses, laboratory abnormalities, and clinical adverse events (AEs).

RESULTS

A total of 428 infants received 490 courses of octreotide. The diagnoses most commonly associated with octreotide use were chylothorax (50%), pleural effusion (32%), and hypoglycemia (22%). The most common laboratory AEs that occurred during exposure to octreotide were thrombocytopenia (47/1000 infant-days), hyperkalemia (21/1000 infant-days), and leukocytosis (20/1000 infant-days). Hyperglycemia occurred in 1/1000 infant-days and hypoglycemia in 3/1000 infant-days. Hypotension requiring pressors (12%) was the most common clinical AE that occurred during exposure to octreotide. Necrotizing enterocolitis was observed in 9/490 (2%) courses, and death occurred in 11 (3%) infants during octreotide administration.

CONCLUSION

Relatively few AEs occurred during off-label use of octreotide in this cohort of infants. Additional studies are needed to further evaluate the safety, dosing, and efficacy of this medication in infants.

Primary laparotomy is effective and safe in the treatment of necrotizing enterocolitis

INTRODUCTION

There is ongoing controversy regarding the surgical treatment of necrotizing enterocolitis (NEC) in infants with extremely low birth weight (ELBW). We hypothesize that primary laparotomy is a safe and effective treatment for all infants with surgical NEC.

METHODS

We retrospectively compared a group of ELBW infants (<1,000 g, group A, n = 39) with preterm infants (≥1,000 g, group B, n = 18) with surgical NEC during a 4-year period (10/2008-09/2012). Indications for emergency operation were Bell stages IIIa or IIIb. The main outcome measure was survival. Data were analyzed using Chi squared test and Spearman's rank correlation coefficient.

RESULTS

Fifty-seven patients were included with a gestational age from 24 to 30 weeks in group A and 27-38 weeks in group B. There were no significant differences in Bell stage (IIIa; IIIb) and NEC type (focal; segmental; pannecrosis). The operative techniques were not significantly different between the groups and included resection and stoma formation in 44 of 57 (77 %) patients; resection and anastomosis in 6 of 57 (11 %); and inspection only, followed by withdrawal of care, in 7 of 57 (12 %). Overall mortality was 10 of 57 (17 %) with no significant difference between the groups. The only significant correlation was observed between the length of necrotic bowel and mortality. In total, 7 of 57 infants required repeated surgery after initial treatment. We observed stoma complications in 36 % of the patients in group A and 21 % in group B without the need of stoma revision. All stomas were successfully closed at the time of the study. One of 44 patients with stoma closure required a relaparotomy due to bowel obstruction.

CONCLUSIONS

Early primary laparotomy is safe and effective for the management of surgical NEC in ELBW infants. Outcome of affected infants is not influenced by age or weight at surgery but by the length of necrotic bowel.

Stem cells as a potential therapy for necrotizing enterocolitis

INTRODUCTION

Necrotizing enterocolitis (NEC) is a severe gastrointestinal disease of neonates, especially those born prematurely, that remains an important cause of morbidity and mortality. Although current treatments such as inotropes, antibiotics and ventilation are supportive, there is an urgent need for novel therapies that specifically target the affected intestine.

AREAS COVERED

We briefly introduce the disease and the effects on intestinal epithelia. We provide a brief description of amniotic fluid stem (AFS) cells, and then describe some recent data in which AFS cells were beneficial in an animal model of NEC and a potential mechanism is described. The effects of AFS cells are compared with data on bone marrow mesenchymal stem cells. The potential implications of these findings for therapy are discussed.

EXPERT OPINION

The current data are promising and demonstrate that stem cells do have an effect in rodent models of NEC. However, the short timescale, limited ability for longitudinal evaluation and uncertain clinical relevance of these models means that there are considerable challenges to be overcome before attempting stem cell therapy in clinical trials. Nevertheless, these data open up novel areas of research into a prevention or therapy for this devastating disease.