Multiple spontaneous small bowel anastomosis in premature infants with multisegmental necrotizing enterocolitis

Optimizing Nutritional Strategies to Prevent Necrotizing Enterocolitis and Growth Failure after Bowel Resection

Necrotizing enterocolitis (NEC), the first cause of short bowel syndrome (SBS) in the neonate, is a serious neonatal gastrointestinal disease with an incidence of up to 11% in preterm newborns less than 1500 g of birth weight. The rate of severe NEC requiring surgery remains high, and it is estimated between 20–50%. Newborns who develop SBS need prolonged parenteral nutrition (PN), experience nutrient deficiency, failure to thrive and are at risk of neurodevelopmental impairment. Prevention of NEC is therefore mandatory to avoid SBS and its associated morbidities. In this regard, nutritional practices seem to play a key role in early life. Individualized medical and surgical therapies, as well as intestinal rehabilitation programs, are fundamental in the achievement of enteral autonomy in infants with acquired SBS. In this descriptive review, we describe the most recent evidence on nutritional practices to prevent NEC, the available tools to early detect it, the surgical management to limit bowel resection and the best nutrition to sustain growth and intestinal function.

Necrotizing enterocolitis totalis: High mortality in the absence of an aggressive surgical approach

BACKGROUND

Necrotizing enterocolitis is the leading case of gastrointestinal-related morbidity in premature infants. Necrotizing enterocolitis totalis is an aggressive form of necrotizing enterocolitis, which has traditionally been managed with comfort care. Recent advances in management of short bowel syndrome have resulted in some reported long-term survival.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, studies that reported outcomes in children with necrotizing enterocolitis totalis were identified. The definition of necrotizing enterocolitis totalis was captured along with length of follow-up, patient demographics, and outcomes.

RESULTS

A total of 766 articles were screened, of which 166 were selected for full article review. Of these, 32 articles included data on 414 patients with necrotizing enterocolitis totalis. In the majority of studies (52%), necrotizing enterocolitis totalis was not defined. Aggressive surgical therapy (defined as bowel resection or fecal diversion) was undertaken in 32 patients (7.7%), with a mortality rate of 68.8%. In contrast, nonaggressive surgical therapy was undertaken in 382 patients (92.3%), and the mortality in these patients was 95%. Long-term outcomes for necrotizing enterocolitis totalis survivors, such as length of time on parenteral nutrition, progression to liver and/or small bowel transplant, and quality of life, were not reported.

CONCLUSION

We found that there is no accepted definition of necrotizing enterocolitis totalis. Aggressive surgical therapy is rarely pursued, which likely drives the overall high mortality rate. This study underscores the importance of standardizing the definition of necrotizing enterocolitis totalis and capturing short and long-term outcomes prospectively. With more aggressive surgical therapy, more infants are likely to survive this abdominal catastrophe, which was once thought to be uniformly fatal.

Does Surgical Management Alter Outcome in Necrotizing Enterocolitis?

Necrotizing enterocolitis occurs in 14% of infants less than 1000 g. Preoperative management varies widely, and the only absolute indication for surgery is pneumoperitoneum. Multiple biomarkers and scoring systems are under investigation, but clinical practice is still largely driven by surgeon judgment. Outcomes in panintestinal disease are poor, and multiple creative approaches are used to preserve bowel length. Overall, recovery is complicated in the short and long term. Major sequelae are stricture, short gut syndrome, and neurodevelopmental impairment. Resolving controversies in surgical necrotizing enterocolitis care requires multicenter collaboration for centralized data and tissue repositories, benchmarking, and carrying out prospective randomized controlled trials.

Outcomes analysis after percutaneous abdominal drainage and exploratory laparotomy for necrotizing enterocolitis in 4,657 infants

PURPOSE

Necrotizing enterocolitis (NEC) is a common acquired gastrointestinal disease of infancy that is strongly correlated with prematurity. Both percutaneous abdominal drainage and laparotomy with resection of diseased bowel are surgical options for treatment of NEC. The objective of the present study is to compare outcomes of patients who were treated either with bowel resection/ostomy (BR/O), percutaneous drainage (PD) or Both procedures for NEC in a retrospective analysis.

METHODS

A retrospective analysis was performed using data from the Agency for Healthcare Research and Quality, extracted from a combination of the Nationwide Inpatient Sample (NIS) and Kids' Inpatient Database (KID) from 1988 to 2005. Multiple logistic regression analyses were performed for in-hospital mortality associated with PD, BR/O or Both procedures for management of NEC. In addition, linear regression was performed for length of stay and total hospital charges. Odds ratios were calculated using the BR/O category as the reference group.

RESULTS

There were 4,238 patients identified who underwent BR/O, 286 for PD, and 133 for Both procedures for NEC. Patients undergoing PD had a 5.7 times higher odds of death compared to patients treated with BR/O (p < 0.05) alone; patients receiving Both procedures did not have significantly higher odds of death compared to the BR/O group. Patients who underwent PD had a shorter length of stay (43 days; p < 0.05) and lower total hospital charges ($173,850; p < 0.05) in comparison to patients treated with BR/O. Length of stay and total hospital charges were greater in patients who received Both procedures, compared to those receiving BR/O alone, but this was not statistically significant.

CONCLUSION

In this nationwide sample of infants with NEC, outcomes for peritoneal drainage alone were poorer than those for bowel resection and enterostomy and for Both procedures. Increased overall mortality and shorter length of stay and hospital charges suggest higher early mortality associated with peritoneal drainage alone. Risk stratifying these groups using prematurity, birth weight, and number of concurrent diagnoses yielded equivocal results. A more detailed study will be needed to determine whether the patient populations that underwent initial laparotomy and bowel resection are substantially different from those that receive peritoneal drainage, or whether differences in outcome may be directly attributable to the type of procedure performed.

Intestinal stenting in preterm, very-low-birth-weight infants with necrotizing enterocolitis and multiple perforations

We present 2 cases of necrotizing enterocolitis with multiple intestinal perforations or areas of segmental bowel necrosis in preterm, very-low-birth-weight infants. We reviewed their charts and researched the related literature. We used SILASTIC (Silmag, Argentina) intestinal stents to avoid multiple formal bowel anastomosis or stomas and longer resections, and to reduce operative time. In the first case, we externalized the stent through the first and last perforation; and in the second, through a proximal jejunostomy and the orifice left after an appendectomy. This method was useful in avoiding short bowel syndrome in both infants, and they were discharged successfully. They are currently 31/2 and 2 years old, respectively, eating without any restriction and with mild developmental delays. Treatment of preterm infants with multiple bowel perforations or areas of bowel necrosis requires a maximal effort to preserve as much intestinal length as possible. Use of the SILASTIC stent technique provides a good treatment variant in selected cases to preserve bowel length, reduce operative time, and avoid short bowel syndrome.

Operative strategies for necrotizing enterocolitis: The prevention and treatment of short-bowel syndrome

Necrotizing enterocolitis (NEC) is the leading cause of short-bowel syndrome (SBS) in infancy. Studies on the acute medical and surgical management of NEC have traditionally focused on short-term morbidity and mortality, with less emphasis on long-term outcomes. Acute surgical management of NEC involves the often competing priorities of controlling sepsis and preserving bowel length. Bowel-preserving strategies for NEC, designed to limit SBS, are based on peritoneal drainage, limited resection, or a combination of both. Drainage-based strategies are generally favored in smaller neonates, while laparotomy-based strategies are favored in larger patients, especially those with a more limited extent of intestinal injury. Comparisons of drainage-based approaches and resection-based approaches are limited by confounding variables, and neither approach is clearly superior with regard to subsequent SBS. These traditional as well as more creative approaches to bowel preservation have application in NEC, yet they depend on a series of patient and treatment characteristics that include the ability of diseased but viable bowel to recover both absorptive and motility function after acute NEC, the ability of the infant to tolerate appropriately drained intraperitoneal contamination, and the ability of the injured intestine to subsequently undergo intestinal adaptive change. In addition, there are a series of operative options that have been designed to mitigate the impact of SBS once it is established. These procedures are not uniquely applied exclusively for NEC-induced SBS. However, strategies that slow intestinal transit, improve peristaltic function, or enhance mucosal absorptive function each have application in the management of SBS.

Surgical therapy for necrotizing enterocolitis: bringing evidence to the bedside

Necrotizing enterocolitis is the most common surgical emergency in the neonatal intensive care unit. Despite decades of research that have led to a growing knowledge base about this disease, NEC continues to challenge the pediatric surgeon. In this review, we will examine the development of surgical therapy for NEC in the context of the supportive evidence, or lack thereof, for treatment approaches. We will discuss issues of indications for surgical intervention, primary peritoneal drainage versus laparotomy, enterostomy versus primary anastamosis and issues surrounding NEC totalis.

Use of intraluminal stents in multiple intestinal atresia

Multiple intestinal atresia presents a difficult technical problem because of extreme loss of intestinal length, disparity of residual bowel wall size, and discontinuity of multiple short intestinal segments. The authors report on a 3,000-g infant with gastroschisis complicated by intrauterine volvulus and multiple intestinal atresias who was treated successfully with intraluminal stenting and sutureless anastomoses. A total of 25 cm of small bowel was salvaged including 13 segments each measuring 1 to 8 cm in length. Subsequent radiographic studies showed spontaneous anastomosis with a compartmental configuration of the residual bowel and decreased transit time. Five months postoperatively, the patient was weaned off total parenteral nutrition completely and one year later is growing and gaining weight with 4 to 6 bowel movements per day.