Outcomes of surgery for necrotizing enterocolitis and spontaneous intestinal perforation in Finland during 1986-2014

International Comparison of Surgical Management Practices for Necrotizing Enterocolitis in Neonates: Insights from Cohorts in the Netherlands and Finland

Surgical management of necrotizing enterocolitis (NEC) can result in significant morbidity and mortality. Surgical management varies in the absence of international evidence-based guidelines. We aimed to gain insight into practice variation between expert centers in the Netherlands and Finland.Bicentric retrospective cohort study including all infants treated surgically for NEC (Bell's stage ≥IIA) in two centers in the Netherlands and Finland between 2000 and 2021. Main outcomes were preoperative, intraoperative, and 3-month postoperative characteristics.We included 191 patients (122 Dutch and 69 Finnish). Median gestational age and birth weight were lower in Finnish patients (median [min.-max.]: 25 + 4/7 [23 + 0/7-39 + 0/7] vs. 28 + 2/7 [23 + 6/7-41 + 6/7], p < 0.001, and 795 g [545-4,000] vs. 1,103 g [420-3,065], p < 0.001). Indication for surgery was mostly pneumoperitoneum in Finnish patients (56.5% vs. 37.7%; p = 0.02) versus clinical deterioration on conservative treatment in Dutch patients (51.6% vs. 23.2%; p < 0.001). A fixed-bowel loop was also more often an indication in Finland (20.3% vs. 3.3%; p < 0.001. Ostomy creation was more common in Finnish patients (92.8% vs. 53.3%; p < 0.001) and primary anastomosis in Dutch patients (29.5% vs. 4.4%; p < 0.001). Open-close procedures occurred in 13.9% of Dutch cases, versus 1.4% of Finnish cases (p = 0.004). Mortality at 3 months was comparable when excluding open-close procedures (24.8% vs. 19.1%; p = 0.46).We observed varying populations, indications for surgery, and surgical approaches in NEC between the Netherlands and Finland. The occurrence of open-close procedures is 10-fold higher (13.9% vs. 1.4%) in the Netherlands compared to Finland. Long-term outcomes remain to be studied. These results point toward significant practice variation and strengthen the need for European management guidelines.

Data-independent acquisition-based blood proteomics unveils predictive biomarkers for neonatal necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is a life-threatening condition affecting preterm infants, sometimes necessitating surgical treatment. This study aimed to analyze differentially expressed proteins (DEPs) and access their biological and clinical significance in the plasma of neonates with NEC. Peripheral blood samples were collected from NEC infants at various time points, and plasma was separated. Data-independent acquisition (DIA) technology was utilized to identify DEPs among NEC patients at different stages. Bioinformatic analyses, including Gene Ontology and Kyoto Encyclopedia of Genes and Genomes, and protein-to-protein interaction analyses were performed on the DEPs. External datasets, along with receiver operating characteristic curves and gene set enrichment analysis, were used to clinically and biologically validate the findings. DEPs between the NEC and pre-NEC groups indicated reduced protein, heme, nitrogen, and purine nucleotide biosynthesis during NEC formation. In addition, enriched DEPs among the NEC groups at different time points suggested reconstructed extracellular matrix, aberrant B-lymphocyte immune responses, and decreased glycosaminoglycan levels during NEC progression. These findings were both clinically and biologically validated using external datasets. Our study highlights the clinical and biological relevance of proteomics in NEC patients. This study demonstrates key pathways involved in NEC pathogenesis and establishes DIA mass spectrometry as a powerful and noninvasive tool for evaluating and predicting NEC formation and progression.

Risk factor analysis and nomogram prediction model construction for NEC complicated by intestinal perforation

OBJECTIVE

To investigate the clinical characteristics of neonatal necrotizing enterocolitis (NEC) complicated by intestinal perforation and predict the incidence of intestinal perforation in NEC.

METHODS

Neonates diagnosed with NEC at the Affiliated Hospital of Zunyi Medical University from January 2012 to May 2022 were enrolled, and the clinical data were collected and analyzed retrospectively. The patients were divided into two groups based on intestinal perforation occurrence or not. Mann-Whitney U tests, t-tests, chi-square tests, and fisher's exact tests were performed between-group comparisons. Logistic and lasso regressions were applied to screen independent risk factors for concomitant bowel perforation, and R software (RMS package) was used to formulate the nomogram prediction model. In addition, the receiver operating curve (ROC) and the calibration curve were drawn to verify the predictive power, while decision curve analysis (DCA) was constructed to evaluate the clinical applicability of the nomogram model.

RESULTS

One hundred eighty neonates with NEC were included, of which 48 had intestinal perforations, and 132 did not; the overall incidence of intestinal perforation was 26.67% (48/180). Bloody stool (OR = 5.60), APTT ≥ 50 s (OR = 3.22), thrombocytopenia (OR = 4.74), and hypoalbuminemia (OR = 5.56) were identified as independent risk variables for NEC intestinal perforation (P < 0.05) through multivariate logistic regression analysis. These factors were then applied to develop a nomogram prediction model (C-index = 0.838) by using the R software. The area under the curve (AUC) for the nomogram in the training and validation cohorts were 0.838 (95% Cl: 0.768, 0.908) and 0.802 (95% CI: 0.659, 0.944), respectively. The calibration curve shown that the nomogram has a good predictive ability for predicting the risk of intestinal perforation occurrence. And the decision curve and clinical impact curve analyses demonstrated good clinical utility of the nomogram model.

CONCLUSION

We found that Bloody stool, APTT ≥ 50 s, Thrombocytopenia, and hypoalbuminemia could be used as independent risk factors for predicting intestinal perforation in neonates with NEC. The nomogram model based on these variables had high predictive values to identify NEC patients with intestinal perforation.

Development of artificial neural networks for early prediction of intestinal perforation in preterm infants

Intestinal perforation (IP) in preterm infants is a life-threatening condition that may result in serious complications and increased mortality. Early Prediction of IP in infants is important, but challenging due to its multifactorial and complex nature of the disease. Thus, there are no reliable tools to predict IP in infants. In this study, we developed new machine learning (ML) models for predicting IP in very low birth weight (VLBW) infants and compared their performance to that of classic ML methods. We developed artificial neural networks (ANNs) using VLBW infant data from a nationwide cohort and prospective web-based registry. The new ANN models, which outperformed all other classic ML methods, showed an area under the receiver operating characteristic curve (AUROC) of 0.8832 for predicting IP associated with necrotizing enterocolitis (NEC-IP) and 0.8797 for spontaneous IP (SIP). We tested these algorithms using patient data from our institution, which were not included in the training dataset, and obtained an AUROC of 1.0000 for NEC-IP and 0.9364 for SIP. NEC-IP and SIP in VLBW infants can be predicted at an excellent performance level with these newly developed ML models. https://github.com/kdhRick2222/Early-Prediction-of-Intestinal-Perforation-in-Preterm-Infants.

The Outcome of Blood Transfusions in Conservative and Surgical Necrotizing Enterocolitis and Spontaneous Intestinal Perforation

INTRODUCTION

 In necrotizing enterocolitis (NEC), blood transfusions (BTs) are a disputed factor concerning the etiology and the outcome. We assessed retrospectively the effects of preonset BT on the outcome of NEC and spontaneous intestinal perforation (SIP).

MATERIALS AND METHODS

 With ethical consent, we reviewed the hospital records of 113 neonates from 2002 to 2019 with surgical NEC (NECs) (n = 57), conservatively treated NEC (NECc) (n = 20), and SIP (n = 36). The onset was defined as the day of surgery (NECs and SIP) or diagnosis (NECc). The effects of preonset BT (total, beyond 48 hours, and within 48 hours) were compared with the effects of birth weight (BW), gestational age (GA), intracerebral hemorrhage, respiratory distress syndrome, septicemia, and patent ductus arteriosus. Main outcome measure was 2-week mortality, and secondary measures were small intestinal loss and days on parenteral nutrition (PN).

RESULTS

 Overall mortality (8.9%) was predicted independently by BT total and BT beyond 48 hours, risk ratio (RR) = 1.1 to 1.2 (95% confidence interval [CI] = 1.0-1.4), p = 0.01 to 0.02, and BW and GA, RR = 0.7 to 1.0 (95% CI = 0.5-1.0), p = 0.02 to 0.04. Mortality in NECs (12%) was predicted by BT total and BT beyond 48 hours only, RR = 1.1 to 1.2 (95% CI = 1.0-1.5), p = 0.03 to 0.04. BT within 48 hours of onset did not predict mortality. No factors were related with secondary outcome measures or with mortality in patients with SIP or NECc.

CONCLUSION

 In NECs, preoperative BT and BT given more than 48 hours before surgery were correlated with slightly increased 2-week mortality but not with small intestinal loss or duration of PN.

Spontaneous intestinal perforation (SIP) will soon become the most common form of surgical bowel disease in the extremely low birth weight (ELBW) infant

Recent data have revealed declines in the prevalence rates of NEC over the last decade in premature infants. In contrast, SIP has either remained steady or risen during the same epoch. These trends are consistent with our knowledge of the clinical arena. The ability to discern SIP contamination within NEC datasets has slowly improved. Additionally, quality improvement efforts are being utilized to reduce NEC through stewardship of antibiotics, acid inhibitors, central lines and blood products, as well as optimization of human milk diets. These forces are moving us to a new era, where NEC will no longer be the dominant surgical intestinal disease of the extremely preterm neonate. Indeed, in the extremely low birth weight (ELBW) population, SIP may already be the most prevalent reason for abdominal surgery. In this perspective, the reader will find supporting data and references for these assertions as well as predictions for the future.

Oesophageal atresia with very low birth weight: Clinical characteristics and long-term outcome

AIM OF THE STUDY

An assessment of the clinical data and outcome of patients with oesophageal atresia (OA) with very low birth weight (VLBW) was completed.

METHOD

With ethical consent, we reviewed the records of 327 successive patients with OA from 1980 to 2020. Main outcome measures survival and oesophageal repair were compared between patients with VLBW(≤1500 g) and with BW>1500 g.

RESULTS

Thirty-four (10%) patients had VLBW. Gross types of OA in VLBW were similar as in other patients: A (15%/7%), B (3%/3%), C (78%/82%), D (3%/4%), E (0%/7%), F (0%/1%) (p = 0.16-0.99). In VLBW the incidence of congenital heart disease (CHD) (47%) and trisomy 13/18 and Cri du Chat (15%) were higher than in BW>1500 g (23% and 1%), (p = 0.001 both). In VLBW one-month mortality was 35% vs 4% in patients with BW>1500 g (p < 0.001), overall mortality 56% and 8% (p < 0.001), respectively. Cause of one-month mortality in VLBW (12 patients) were CHD w/wo chromosomal abnormality (n = 7), cerebral hemorrhage (n = 2), gastric perforation (n = 1), anastomotic leakage (n = 1) and pulmonary hemorrhage (n = 1). Of VLBW patients 79% and of other patients 99% underwent oesophageal repair (p < 0.001). Repair in VLBW patients included early (n = 18) or delayed (n = 5) end-to-end anastomosis and reconstruction (n = 4). Anastomotic complications occurred in 24% of patients with VLBW and in 17% with BW>1500 g, (p = 0.31). From 1980-2000 to 2001-2020 survival in VLBW changed from 11% to 81% (p = 0.002). During 2001 - 2020 all VLBW patients underwent repair.

CONCLUSION

OA with VLBW had high incidence of life-threatening associated anomalies and decreased survival. Recently survival and rate of oesophageal repair have improved significantly.

Late Abdominal Reoperations after Surgery for Necrotizing Enterocolitis and Spontaneous Intestinal Perforation

INTRODUCTION

 The aim of this study was retrospective assessment of late major reoperations after surgery for necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) in neonates.

MATERIALS AND METHODS

 Appropriate ethical consent was obtained. Data collection was by review of hospital records of 165 successive prematures who underwent surgery for NEC (n = 99) or SIP (n = 66) from 1986 to 2019. Outcome measures were late major abdominal surgeries or endoscopies that occurred after the primary surgical treatment, closure of enterostomies, and weaning from parenteral nutrition (PN). We assessed also risk factors for late abdominal surgeries.

RESULTS

 Hundred and twenty-six (76%) patients (NEC, n = 70, 71% and in SIP, n = 56, 85%) survived. Median follow-up was 13 (interquartile range: 5.9-23) years. Nineteen (15%) patients underwent late abdominal surgery with 0% mortality. Most common was surgery for small bowel obstruction (SBO) in 12(9.5%) patients (NEC, n = 5; 7.0%, SIP, n = 7; 13%, p = 0.36) with 10-year cumulative risk of 8.7 (95% confidence interval [CI]: 3.5-14). Long duration of PN and development of intestinal failure associated cholestasis (IFAC) increased the risk of SBO surgery, relative risk: 1.0-3.2 (95% CI: 1.0-9.1), p = 0.02-0.03. Other surgeries included serial transverse enteroplasty (NEC, n = 2), incisional hernia repair (n = 3), cholecystectomy (n = 1), and ovarian torsion (n = 1). Twenty (29%) NEC and four (7%) SIP patients required endoscopic assessment of postoperative symptoms (p = 0.003).

CONCLUSION

 Late abdominal reoperations occurred in 15% of patients with NEC and SIP with nil mortality. SBO was the main indication. Risk of SBO was similar between NEC and SIP. Long PN and IFAC increased the risk of SBO.

Necrotising enterocolitis-A 15-year outcome report from a UK specialist centre

AIMS

Necrotising enterocolitis (NEC) is a disease associated with high mortality and morbidity, low birthweight and prematurity are risk factors. This study reports outcomes of babies having emergency laparotomy for NEC, examining institutional trends and exploring impact of multiple variables on mortality at 30 days and 1 year post-operatively.

METHODS

Case records of babies with ICD coding for NEC were examined from 2000 to 2015. After exclusions, 243 cases were identified-confirmed by operative findings and histology. Cohort demographics and trends in mortality were investigated, and the relationship of common variables to mortality was modelled with univariate and multivariate logistic regression to generate a mortality prediction tool.

RESULTS

Mean gestational age was 28 + 4 weeks. A 30-day mortality was 18.9%. Gestation, birthweight and area of bowel affected were significant of outcome (mortality), and the presence of pre-operative pneumoperitoneum was strongly correlated. Year of surgery and congenital cardiac pathology requiring intervention were not significant. Using multivariate regression modelling, a mortality outcome prediction tool has been developed.

CONCLUSION

Good survival following operation for NEC (>70%) is feasible, even in those babies born extremely premature (<28 weeks) and post-operatively re-located to tertiary NICUs. With increasing gestational age (>32 weeks), mortality is uncommon.

Role of Nutrition in Prevention of Neonatal Spontaneous Intestinal Perforation and Its Complications: A Systematic Review

Background: Spontaneous intestinal perforation (SIP) is a devastating complication of prematurity, and extremely low birthweight (ELBW < 1000 g) infants born prior to 28 weeks are at highest risk. The role of nutrition and feeding practices in prevention and complications of SIP is unclear. The purpose of this review is to compile evidence to support early nutrition initiation in infants at risk for and after surgery for SIP. Methods: A search of PubMed, EMBASE and Medline was performed using relevant search terms according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Abstracts and full texts were reviewed by co-first authors. Studies with infants diagnosed with SIP that included information on nutrition/feeding practices prior to SIP and post-operatively were included. Primary outcome was time to first feed. Secondary outcomes were incidence of SIP, time to full enteral feeds, duration of parenteral nutrition, length of stay, neurodevelopmental outcomes and mortality. Results: Nineteen articles met inclusion criteria—nine studies included feeding/nutrition data prior to SIP and ten studies included data on post-operative nutrition. Two case series, one cohort study and sixteen historical control studies were included. Three studies showed reduced incidence of SIP with initiation of enteral nutrition in the first three days of life. Two studies showed reduced mortality and neurodevelopmental impairment in infants with early feeding. Conclusions: Available data suggest that early enteral nutrition in ELBW infants reduces incidence of SIP without increased mortality.

The outcome of Bishop-Koop procedure compared to divided stoma in neonates with meconium ileus, congenital intestinal atresia and necrotizing enterocolitis

To determine the potential value and suitability of Bishop-Koop procedure (BK) compared to divided stoma (DS) in neonates with meconium ileus (MI), congenital intestinal atresia (CIA), and necrotizing enterocolitis (NEC).A retrospective data collection from 2000 to 2019 on neonates undergoing BK and DS formation and closure for MI, CIA, and NEC was conducted. Ostomy related complications following both procedures were analyzed.One hundred two consecutive patients managed with a BK (n = 57, 55.8%) and DS (n = 45, 44.2%) for MI (n = 38, 37.2%), CIA (n = 31, 30.5%), and NEC (n = 33, 32.3%) were analyzed. Mean operating time for ostomy creation did not differ significantly between BK and DS groups (156 ± 54 vs 135 ± 66.8 min, P = .08). The prevalence of stoma-related complications following BK and DS formation was 8.7% and 31.1%, respectively (P = .005). The complication rate after BK and DS closure was 3.5% and 6.7%, respectively (P = .65). The operating time for ostomy reversal and length of hospital stay after stoma closure were significantly shorter in BK group (82.2 ± 51.4 vs 183 ± 84.5 min and 5.5 ± 2.7 vs 11.3 ± 3.9 days, P < .001).BK procedure is safe, reliable, and suitable technique in neonatal surgery with low complications rate following ostomy creation as well as shorter operating time and length of hospital stay after ostomy closure compared to DS ostomies. Surgeons should keep this technique as an alternative approach in their repertoire.

Necrotizing Enterocolitis: Long Term Complications

Necrotizing enterocolitis (NEC) remains the most threatening gastrointestinal complication of prematurity leading to high mortality, morbidity and cost. Common complications of NEC include neurodevelopmental delay, failure to thrive, gastrointestinal problems including strictures and adhesions, cholestasis, short bowel syndrome with or without intestinal failure that can be difficult to manage. Infants who develop NEC benefit from close follow-up for early diagnosis and treatment of complications. Those who present with severe complications such as intestinal failure benefit from a multidisciplinary approach involving careful assessment and treatment. Studies done so far are limited in providing a long-term prognosis. Here we review some of these complications. More studies with a longer follow-up period are needed to better understand the later comorbidities that develop in babies with NEC.