Timing of Optimal Surgical Intervention for Neonates with Necrotizing Enterocolitis

Abstract

Up to half of all patients with necrotizing enterocolitis require acute surgical treatment. Determining when to operate on these patients can be challenging. Utilizing a combination of clinical and metabolic indicators, we sought to identify the optimal timing of surgical intervention. A retrospective chart review was conducted on patients with necrotizing enterocolitis from 2001 to 2010. Previously validated clinical (abdominal erythema, palpable abdominal mass, hypotension), radiographic (pneumoperitoneum, portal venous gas, fixed bowel loop, severe pneumatosis intestinalis), and laboratory (acidosis, bacteremia, hyponatremia, bandemia, neutropenia, thrombocytopenia) indicators were assessed for the ability to predict the need for acute surgical intervention as a simple indicator score, based on the sum of the indicators listed above. A total of 197 patients were included. One hundred and twenty-four procedures (28 peritoneal drains, 96 laparotomy) were performed on 122 patients (62%). Median indicator score was 4 (range: 0–8). Logistic regression identified abdominal erythema (odds ratio [OR] = 3.3, P = 0.001), acidosis (OR = 2.6, P = 0.004), and hypotension (OR = 1.9, P = 0.05) as independently associated with surgical intervention. A significant increase in surgical intervention was noted for patients with indicator score of 3 or more. In conclusion, if three or more indicators exist, operative intervention is very likely required. In the absence of pneumoperitoneum, abdominal erythema, acidosis, and hypotension are especially important.

Variability in Antibiotic Regimens for Surgical Necrotizing Enterocolitis Highlights the Need for New Guidelines

“…An absolute indication for surgical intervention is pneumoperitoneum. Additionally, neonates with worsening pneumatosis, acidosis, sustained platelet drop, and hypotension have been shown to be high risk for requiring operative intervention [13,17,18]. Given the specific indications for surgical intervention in NEC, we felt that analyzing these patients would give is a more uniform and homogenous study population [11][12][13].…”

Are Scores Reliable in Predicting the Need for Surgery and Mortality in Necrotizing Enterocolitis?

“…24 The scores we used had proved to be helpful in their original publications. 7,8,14 However, when calculated for our patients presenting with NEC Bell's stage II and III, the agreement between predicted outcome by the score and the real outcome was poor. In kappa statistic, a value of þ1 means perfect agreement, 0 is equal with what can be expected by chance, and À1 means complete lack of agreement.…”

“…Three scores were individually calculated for every patient according to the methodology of the original publications: the NEC score, 7 the Metabolic Derangement Acuity Score (MDAS), 8 and a score developed in Detroit (Detroit score) 14 (see scores' description in ►Table 1). The NEC score analyzes the relation between its four criteria and the survival and the management of the patients, that is, need for surgery.…”

“…This uncertainty for clinical decision-making has inspired a variety of algorithms including scores, all of them combining various clinical variables, radiological signs, and laboratory tests, in the hope to facilitate therapeutic decision-making and/or predict mortality. [7][8][9][10][11][12][13][14] However, except for one, 10 no study has been published to evaluate the reliability of these scores. In this present analysis, we aim to assess the agreement of existing scores predicting the need for surgery and/or mortality in our patients, compared with real outcome, and analyze if there is agreement between the different scores.…”

Necrotizing Enterocolitis

“…Pneumoperitoneum is not a very reliable clinical feature for surgical NEC and is observed in less than half of all infants with intestinal perforation or necrosis [15,39]. Clinical deterioration despite maximal medical therapy is considered a relative indication for surgical intervention.…”