Clinical Spectrum and Outcomes of Neonatal Necrotizing Enterocolitis

A comparative study on in vitro models of necrotizing enterocolitis induced by single and combined stimulation

BACKGROUND AND STUDY AIMS

Necrotizing enterocolitis (NEC) is a severe gastrointestinal disease in neonates. In vitro model is an indispensable tool to study the pathogenesis of NEC. This study explored the effects of different stress factors on intestinal injury in vitro.

MATERIAL AND METHODS

Rat intestinal epithelial cell line-6 (IEC-6) cells were exposed to different stressors, including lipopolysaccharide (LPS), cobalt chloride (CoCl2), and a combination of both. We estimated the cell viability, the expression of inflammatory cytokines and tight junction proteins.

RESULTS

The decrease in IEC-6 cell viability was observed after stimulation by CoCl2 alone or in combination with LPS, but not after stimulation with LPS alone. The expression of interleukin6 (IL-6) and tumornecrosisfactoralpha (TNFα) increased in each group. After stimulation with CoCl2 alone or in combination with LPS, a decrease in Claudin-1 was observed, but an increase was detected after stimulation with LPS alone. Zona occludens 1 (ZO-1) decreased in both mRNA and protein levels after combined stimulation.

CONCLUSION

The combined stimulation of LPS and CoCl2 on IEC-6 cells could simultaneously induce severe inflammation and barrier damage, which may better simulate the pathological process of NEC.

In-hospital mortality among neonates with necrotising enterocolitis in Ethiopia: a systematic review and meta-analysis

OBJECTIVE

To assess the pooled in-hospital mortality among neonates with necrotising enterocolitis (NEC) in Ethiopia.

DESIGN

This was a systematic review and meta-analysis reported based on the Preferred Reporting Items for Systematic Review and Meta-analysis guideline.

DATA SOURCES

African Journals Online, PubMed/Medline, Google Scholar, Cochrane Library and repositories of Ethiopian Universities.

ELIGIBILITY CRITERIA

Published and unpublished articles that had reported the in-hospital mortality among neonates with NEC in Ethiopia were included, whereas, articles with no abstracts and/or inaccessible full texts, citations, reviews, commentaries editorials, conference abstracts, anonymous reports and articles reported in non-English language were excluded.

DATA EXTRACTION AND SYNTHESIS

Articles that passed the eligibility criteria were assessed for their quality using the quality appraisal criteria for prevalence studies. Data extraction and cleaning were done by using the Microsoft Excel work sheet, and data were analysed by STATA V.11.0 using the random effects model at 95% CI. Test of heterogeneity, publication bias, sensitivity analysis, subgroup analysis and meta-regression were performed.

RESULTS

A total of 12 articles involving 588 neonates were included. The pooled in-hospital mortality among neonates with NEC in Ethiopia was found to be 70.0% (95% CI=60.0% to 80.0%; I2=87.5%). There was significant difference in mortality by study population as the in-hospital mortality among neonates with NEC was 83.0% (95% CI=76.0% to 89.0%; I2=42.8%; five studies) in preterm neonates and 73.0% (95% CI=60.0% to 86.0%; I2=66.3%; four studies) in low birthweight neonates (p<0.001).

CONCLUSION

The in-hospital mortality of neonates with NEC in Ethiopia was found to be high in which 7 out of 10 neonates diagnosed with NEC ends with death. Therefore, the currently available NEC prevention strategies should be evaluated for individual units and introduced where possible.

Influencing factors for surgical treatment in neonatal necrotizing enterocolitis: a systematic review and meta-analysis

BACKGROUND

Necrotizing enterocolitis (NEC) is a complex disease characterized by gastrointestinal inflammation and is one of the most common gastrointestinal emergencies in neonates. Mild to moderate cases of NEC require medical treatment, whereas severe cases necessitate surgical intervention. However, evidence for surgical indications is limited and largely dependent on the surgeon's experience, leading to variability in outcomes. The primary aim of this study is to identify the risk factors for surgical intervention in neonatal NEC, which will aid in predicting the optimal timing for surgical intervention.

METHODS

A literature search was conducted in PubMed, Embase, and Web of Science databases for case-control studies exploring risk factors for NEC requiring surgical intervention. The search was completed on June 16, 2024, and data analysis was performed using R Studio 4.3.2.

RESULTS

18 studies were included, comprising 1,104 cases in the surgery group and 1,686 in the medical treatment group. The meta-analysis indicated that high C-reactive protein (CRP) levels [OR = 1.42, 95% CI (1.01, 1.99)], lower gestational age [OR = 0.52, 95% CI (0.3, 0.91)], sepsis [OR = 2.94, 95% CI (1.87, 4.60)], coagulation disorder [OR = 3.45, 95% CI (1.81, 6.58)], lack of enteral feeding [OR = 3.18, 95% CI (1.37, 7.35)], and hyponatremia [OR = 1.22, 95% CI (1.07, 1.39)] are significant risk factors for surgical treatment in neonatal NEC.

CONCLUSIONS

High CRP levels, coagulation disorders, sepsis, lower gestational age, lack of enteral feeding, and hyponatremia are significant risk factors for surgical intervention in neonatal NEC. These findings have potential clinical significance for predicting surgical risk.

Delayed episode of necrotising enterocolitis in an ex-preterm infant after intravitreal administration of low-dose ranibizumab for the treatment of retinopathy of prematurity

Retinopathy of prematurity (ROP) and necrotising enterocolitis (NEC) are complications of prematurity. Despite being quite different in terms of incidence, pathogenesis and consequences, both share a pathogenic role of aberrant vascularisation: increased in ROP, deficient for NEC. Current therapy for ROP includes the use of anti-vascular endothelial growth factor (anti-VEGF) agents, which are able to interrupt retinal hypervascularity. Despite being delivered intravitreously, anti-VEGF used in ROP can be absorbed into circulation and exert systemic effects. We present here a case of an ex-27 weeks gestational age infant, presenting multiple NEC risk factors, treated at 2 months of age with low-dose ranibizumab, who developed a large bowel NEC episode in the first week after treatment. We believe that this further report of an association between anti-VEGF agents and NEC could be interesting for the identification of children at risk of severe adverse events and stimulating further research on the topic.

Simple Scoring System that Predicts the Need for Surgical Intervention in Infants with Necrotizing Enterocolitis

BACKGROUND AND AIMS

It is difficult to identify those preterm infants who require surgical intervention. This study examined the predictive factors for bowel resection in infants with definitive and advanced necrotizing enterocolitis (NEC). We then developed a scoring system to better predict the need for surgical intervention.

METHODS

A total of 203 infants with modified Bell's stage 2 or higher NEC from January 2018-December 2020 were identified for this study. A retrospective study evaluated the association between several comprehensive variables and surgical intervention using a multiple logistic regression analysis, and then a scoring system was developed based on the sum of coefficients (β).

RESULTS

Of the 135 patients who met the inclusion criteria, 57 infants underwent a surgical intervention. The multivariable logistic regression analysis showed that birth weight (regression coefficient, β = 1.30), PCT (β = 2.33), not having received enteral nutrition before the diagnosis of NEC (β = 2.13), acidosis (β = 1.57), respiratory alkalosis (β = 2.42), hypokalemia (β = 2.14), peritonitis (β = 2.87) and coagulation disorders (β = 1.78) were associated with the occurrence of bowel resection. A scoring system ranging from 0-17 was developed based on the total coefficient obtained. It was found that a cut-off score of 5 may distinguish those infants needing surgical intervention from other infants with NEC.

CONCLUSION

We successfully developed a clinical decision-making tool associated with the need for surgical intervention among infants with advanced NEC. The risk scoring system could accurately identify infants who would benefit from surgical intervention.

Short-term and mid-term effects of thoracoscopic repair of esophageal atresia: No anastomotic leaks or conversions to open technique

The frequency rate of esophageal anastomosis leaks after thoracoscopic correction of esophageal atresia (EA) in the current literature is reported as 5.6%-24.7% and a conversion rate of 2%-53%. The objective of this retrospective study was to examine the characteristics of EA and analysis of the safety and efficacy of EA repair with the use of the thoracoscopic approach in a single academic center, as well as risk factors analysis in the context of short-term and mid-term follow-up status. A retrospective analysis of the management of all consecutive newborns affected by EA hospitalized in our department over a period between 2013 and 2022, including preoperative, perioperative, and postoperative management, together with the outcome, complications and long-term follow-up status was performed. A total of 38 patients with a median birth weight of 2,570 g (range; 1,020-3,880) were treated over the study period, including 30/38 (78.9%) with additional congenital anomalies. Overall, 30 patients underwent primary anastomosis of the esophagus and eight underwent a multistaged procedure, with or without an initial ligation of the tracheoesophageal fistula and delayed primary anastomosis. Overall survival for all patients was 0.894 ± 0.050, with a median follow-up of 4.5 years. We noted neither anastomotic leaks nor conversions to open technique in our cohort. Implementation of vancomycin prophylaxis was successful in preventing postoperative central venous access-related infectious complications. At the end of the follow-up, 85% of patients have a Lansky performance score ≥80. Risk factors analysis for length of hospitalization, overall survival, Lansky performance status, and neurological impairment were analyzed. In conclusion, we have found that the outcome of thoracoscopic repair of EA in terms of surgery-dependent morbidity (anastomosis leakage, conversion rate to open surgery), provides benefit to those previously reported in the literature, regardless of the prognostic criteria of the classification system.

Risk factors and a simple scoring system for predicting bowel resection in infants with NEC

BACKGROUND AND AIMS

We intended to investigate the predictors for bowel resection in infants with necrotizing enterocolitis (NEC). We further developed a scoring system for better predicting bowel resection.

METHODS

A total of 207 infants who underwent surgical management at Children's Hospital, Chongqing Medical University between April 2008 and December 2020 were identified for the following investigation. Bowel resection was reviewed among the infants who underwent the procedure. Potential parameters related to bowel resection were explored using a multiple logistic regression method, and then a scoring system was developed.

RESULTS

Among the 207 patients who underwent operative intervention that were reviewed, 109 infants underwent bowel resection. Multivariate logistic regression analysis showed that birth weight, hypotension, neutropenia, pneumoperitoneum, acidosis, and intestinal wall thickness were predictors related to the occurrence of bowel resection. A 6-point scoring system was further developed based on the obtained total coefficient, and the infants could be divided into low-, moderate- and high-risk groups according to cut values of 7 and 13.

CONCLUSION

The results of this study demonstrated that severe NEC features and low birth weight were associated with bowel resection. The risk scoring system could accurately separate infants that were suspected to have bowel loss during surgery.