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PubMed2005

Predictors of gangrenous necrotizing enterocolitis and extent of disease. Early laparotomy versus peritoneal drainage.

OBJECTIVE: Evaluation of known predictors of gangrene in neonates with necrotizing enterocolitis (NEC) and identification of those suggestive of severe disease, requiring expeditious laparotomy rather than primary peritoneal drainage as a definitive treatment. METHODS: This is a retrospective review of data collected from the medical records of newborns with confirmed NEC, treated at the Maternity and Children's Hospital, Dammam, Kingdom of Saudi Arabia, from May 1993 to May 2004. Fifty-five cases were selected for the study, 23 had successful medical management and 32 underwent laparotomy. Of this group, 15 had peritoneal drainage prior to laparotomy. Nine known clinical, radiological and laboratory features suspicious of bowel perforation or gangrene were evaluated. The operated group was classified according to the extent of disease into isolated, multifocal or pan intestinal and the distribution of these 9 criteria was calculated for each of the 3 groups. Comparison was then carried out between the group with isolated NEC and those with extensive disease. RESULTS: Isolated NEC was present in 8 (25%), multifocal NEC in 19 (59%) and pan intestinal NEC in 5 (16%) of the operated cases. Pneumoperitoneum and palpable abdominal mass were the most specific and predictive signs of perforated or gangrenous bowel in NEC. Severe pneumatosis intestinalis and gasless abdomen were also highly specific and predictive of the same but had a low prevalence. Abdominal wall erythema, persistent metabolic acidosis, portal vein air, gasless abdomen and severe pneumatosis intestinalis were found to be associated with severe or extensive gangrene. Palpable abdominal mass and fixed dilated loops were increased in cases of isolated NEC. Portal vein air was associated with the highest mortality. CONCLUSION: Pneumoperitoneum, though the only absolute evidence of bowel perforation, cannot predict the extent of disease. Peritoneal drainage is a useful stabilizing procedure but the presence of any of the above mentioned criteria which are associated with severe disease necessitate a quick decision in favor of laparotomy. The absence of these signs, however, cannot rule out extensive or progressive NEC and failure to improve after peritoneal drainage also requires an emergency laparotomy, regardless of birth weight or gestational age.

Abdomen↗
PubMed1975

Neonatal necrotizing enterocolitis. Evolution of new principles in management.

Over a three-year period, we have operated on 30 infants with necrotizing enterocolitis. Because of the increased experience with this lesion, we have evolved reliable guidelines for both early diagnosis and operative treatment of necrotizing enterocolitis. Initial therapy was nonsurgical in most cases and included gastrointestinal tract decompression, systemic antibiotics, and correction of fluid, electrolyte, and metabolic abnormalities. Absolute indications for surgery and thought to be prima facie evidence for bowel necrosis were (1) cellulitis of the anterior abdominal wall, (2) free intraperitoneal air, (3) a single dilated intestinal segment present on serial roentgenograms, (4) clinical deteioration in the presence of appropriate medical therapy, and (5) persistent abdominal tenderness. Although all 30 patients operated on had necrotic bowel proved at histologic examination, 21 survived (70%). All patients listed as survivors, with the exception of two, have had intestinal tract continuity reestablished and are doing well.

Age Factors↗
PubMed2003

Surgical necrotizing enterocolitis: are intestinal lesions more severe in infants with low birth weight?

PURPOSE: This study examines whether the intestinal lesions of necrotizing enterocolitis (NEC) in infants undergoing surgery are more severe in patients with extremely low birth weight (BW). METHODS: Between 1980 and 2000, 128 infants underwent laparotomy for NEC: 90 in the acute phase, and 38 for secondary stenosis. Resections were limited to areas of transparietal bowel necrosis and to secondary stenoses. The authors studied the extent of initial bowel lesions at initial laparotomy, and, in the survivors, the extent of bowel resections and the existence of digestive sequelae, with a median follow-up of 24 (range, 1 to 247) months. Children with BW < or =1,000 g (group 1, 22 patients) and greater than 1,000 g (group 2, 103 patients) were compared by using chi(2) and t test. RESULTS: Patients' survival rate was 87%: 68% and 91% in the groups 1 and 2, respectively (P =.01). No significant difference between the 2 groups was seen: (1) for the rate of patients with panintestinal lesions at initial surgery (12%); (2) in the survivors, the ratio of remaining to total length of jejuno-ileum (mean 88%), the number of colonic segments resected (mean 1.2), the rate of survivors without distal ileum (34%), ileo-caecal valve (39%), or right colon (29%); and (3) for the existence of digestive symptoms, even minor, at last follow-up (25%). CONCLUSIONS: Although the prognosis of surgical NEC was worse in infants with extremely low birth weight, the intestinal lesions were not found more severe in these patients.

Acute Disease↗
PubMed2005

Oral probiotics reduce the incidence and severity of necrotizing enterocolitis in very low birth weight infants.

OBJECTIVE: We evaluated the efficacy of probiotics in reducing the incidence and severity of necrotizing enterocolitis (NEC) in very low birth weight (VLBW) infants. PATIENTS AND METHODS: A prospective, masked, randomized control trial was conducted to evaluate the beneficial effects of probiotics in reducing the incidence and severity of NEC among VLBW (<1500 g) infants. VLBW infants who started to fed enterally and survived beyond the seventh day after birth were eligible for the trial. They were randomized into 2 groups after parental informed consents were obtained. The infants in the study group were fed with Infloran (Lactobacillus acidophilus and Bifidobacterium infantis) with breast milk twice daily until discharged. Infants in the control group were fed with breast milk alone. The clinicians caring for the infants were blinded to the group assignment. The primary outcome was death or NEC (>or= stage 2). RESULTS: Three hundred sixty-seven infants were enrolled: 180 in the study group and 187 in the control group. The demographic and clinical variables were similar in both groups. The incidence of death or NEC (>or= stage 2) was significantly lower in the study group (9 of 180 vs 24 of 187). The incidence of NEC (>or= stage 2) was also significantly lower in the study when compared with the control group (2 of 180 vs 10 of 187). There were 6 cases of severe NEC (Bell stage 3) in the control group and none in the study group. None of the positive blood culture grew Lactobacillus or Bifidobacterium species. CONCLUSION: Infloran as probiotics fed enterally with breast milk reduces the incidence and severity of NEC in VLBW infants.

Bifidobacterium↗
PubMed1984

[Necrotizing enterocolitis of the newborn infant].

The experience at the Hospital for Pediatric Surgery in Dortmund with 47 cases of necrotizing enterocolitis in 16 years are reviewed. 43 patients had been transferred from pediatric hospitals for immediate operation. 7 newborns had developed gastric perforation, 25 previously intestinal perforation. 4 patients had undergone laparotomy for other indication before. The chance to survive the necrotizing process is smaller in case of inflammation of the small bowel than of the large bowel. The current knowledge about necrotizing enterocolitis is summarized, including modern aspects about the indication to operate.

Birth Weight↗
PubMed1996

Increased risk of necrotizing enterocolitis in premature infants with patent ductus arteriosus treated with indomethacin.

OBJECTIVE: The authors evaluated the risk of necrotizing enterocolitis (NEC) in very low birth weight infants receiving indomethacin (INDO) to close patent ductus arteriosus (PDA). BACKGROUND DATA: Controversy exists regarding the best method of managing very low birth weight infants with PDA and whether to employ medical management using INDO or surgical ligation of the ductus. METHODS: Two hundred fifty-two premature infants with symptomatic PDA were given intravenously INDO 0.2 mg/kg every 12 hours x 3 in an attempt to close the ductus. Patients were evaluated for sex, birth weight, gestational age, ductus closure, occurrence of NEC, bowel perforation, and mortality. RESULTS: There were 135 boys and 117 girls. The PDA closed or became asymptomatic in 224 cases (89%), whereas 28 (11%) required surgical ligation. Ninety infants (35%) developed evidence of NEC after INDO therapy. Fifty-six were managed medically; surgical intervention was required in 34 of 90 cases (37.8%) or 13% of the entire PDA/INDO study group. Bowel perforation was noted in 27 cases (30%). Factors associated with the onset of NEC included gestational age < 28 weeks, birth weight < 1 kg, and prolonged ventilator support. The overall mortality rate was 25.5%, but was higher in infants with NEC versus those without. The highest mortality was noted in perforated NEC cases. The PDA/INDO patients were compared with a control group of 764 infants with similar sex distribution, birth weights, and gestational ages without PDA who did not receive INDO. Necrotizing enterocolitis occurred in 105 of 764 control patients (13.7%), including 13 (12.3%) with perforation. The overall mortality rate of controls was 25%, which was similar to the overall 25.5% mortality rate in the PDA/INDO study group. CONCLUSION: These data indicate that there is increased risk of NEC and bowel perforation in premature infants with PDA receiving INDO. Mortality was higher in the PDA/INDO group with NEC than those PDA/INDO infants without NEC.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed2007

Correlation of sonographic findings and outcome in necrotizing enterocolitis.

BACKGROUND: There is little in the literature regarding the use of gray-scale and Doppler sonography of the bowel in necrotizing enterocolitis (NEC) and how findings depicted by this modality might assist in predicting outcome and influence management. OBJECTIVE: To correlate sonographic findings with outcome in NEC. MATERIALS AND METHODS: This was a retrospective analysis of clinical and abdominal ultrasonography (AUS) findings in NEC from January 2003 to December 2005. AUS findings were evaluated for portal venous gas, free gas, peritoneal fluid, bowel wall thickness, echogenicity, perfusion and intramural gas. Patients were categorized into two groups, according to their outcome. RESULTS: A total of 40 infants were identified who had AUS for NEC prior to any surgical intervention. Group A comprised 18 neonates treated medically and recovered fully, and group B comprised 22 neonates who required surgery or died. Free gas (six patients) and focal fluid collections (three patients) were only found in group B. Increased bowel wall echogenicity, absent bowel perfusion, portal venous gas, bowel wall thinning, bowel wall thickening, free fluid with echoes and intramural gas were seen in both groups, but more frequently in group B. Anechoic free fluid was seen more frequently in group A. Increased bowel perfusion was seen equally in both groups. CONCLUSION: An adverse outcome was associated with the sonographic findings of free gas, focal fluid collections or three or more of the following: increased bowel wall echogenicity, absent bowel perfusion, portal venous gas, bowel wall thinning, bowel wall thickening, free fluid with echoes and intramural gas. Sonographic findings are useful in predicting outcome and therefore might help guide management.

Ascitic Fluid↗
PubMed2006

Laboratory parameters predictive of developing necrotizing enterocolitis in infants born before 33 weeks of gestation.

PURPOSE: The aim of this study was to identify laboratory findings predictive of necrotizing enterocolitis (NEC). METHODS: Prospective follow-up of 140 infants of less than 33 weeks of gestation. Twenty-six infants developed NEC (grades I to III, criteria of Bell et al [Ann Surg 1978;187:1-7]) (NEC group). For each, 2 birth-weight, gestational age- and postnatal age-matched controls were selected (control group). Blood counts, glucose and electrolyte levels, C-reactive protein, and acid-base balance 3 days, 2 days, and 1 day before and at the onset of NEC and at corresponding ages from the controls were recorded. RESULTS: Metabolic acidosis occurred, the platelet levels decreased, and the blood glucose increased on successive days in the infants with grade NEC II-III. At the onset of NEC, the infants had significantly lower platelet and higher blood glucose levels compared with controls. More than half of infants with intestinal perforation had leukocyte levels above 30 x 10(9)/L and pH less than 7.25, and their mean blood glucose levels increased to more than 1.5 mmol/L in 24 hours. The remaining parameters were not useful. CONCLUSION: A persistent metabolic acidosis, decreasing platelet, and increasing blood glucose level on several successive days might predict a developing NEC, and leukocyte values above 30 x 10(9)/L, pH less than 7.25, and a blood glucose rise by 1.5 mmol/L or more within 24 hours predict NEC with intestinal perforation. Such findings should alert the physician to look for signs of NEC in a preterm infant.

Enterocolitis, Necrotizing↗
PubMed1999

Necrotizing enterocolitis: extent of disease and surgical treatment.

PURPOSE: The aim of this study was to evaluate the results of surgical treatment of necrotizing enterocolitis (NEC) according to the extent of disease and to establish if resection of the ileocecal valve represents a poor prognostic factor. METHODS: The authors reviewed all cases of NEC (n = 161) treated in our hospital during the last 11 years; of these, 83 required surgical intervention. Definitions used by the authors include isolated, disease in a single intestinal segment; multifocal, disease in two or more intestinal segments; and pan-intestinal, majority of small and large bowel involved. RESULTS: Twenty-five neonates had isolated NEC, 46 neonates had multifocal NEC, and 12 had pan-intestinal involvement. Survival rate was affected by the extent of intestinal involvement, the lowest survival rate (33%) being noticed in neonates with pan-intestinal involvement. In patients with isolated NEC, postoperative complications and survival rate were not affected by the modality of operative treatment. Conversely, in patients with multifocal NEC, survival rate was higher (85%) after resection and primary anastomosis compared with enterostomy (50%; P =.03). Resection of the ileocecal valve was not associated with increased morbidity and mortality. CONCLUSIONS: (1) Resection and primary anastomosis is a valid treatment option in both isolated and multifocal NEC. (2) Neonates with NEC adapt rapidly to the loss of the ileocecal valve.

Anastomosis, Surgical↗
PubMed2001

Prognostic factors of mortality in newborns with necrotizing enterocolitis submitted to exploratory laparotomy.

PURPOSE: The aim of this study was to identify and assess mortality predictive factors in newborns with necrotizing enterocolitis (NEC) requiring emergency exploratory laparotomy. METHODS: A prospective study of 91 newborns with NEC submitted to exploratory laparotomy was conducted. Clinical outcomes were death and survival 60 days after surgery. Nine variables were analyzed: weight at birth, gestational age, intrauterine growth, sex, gas in the portal vein at abdominal x-ray, pneumoperitoneum, extent of the disease, operative strategies, and extension of bowel resection. Univariate and multivariate analyses were performed to identify mortality predictors. RESULTS: Mean weight at birth was 1,676 +/- 634.8 g, and mean gestational age was 34 +/- 2.8 weeks. Thirty-nine newborns (42.9%) presented intrauterine growth retardation. Operative techniques included bowel resection with enterostomy (80 patients), bowel resection with primary anastomosis (10 patients), and decompressive enterostomy (1 patient). Six deaths occurred caused by co-existing disease. NEC-related mortality rate was 46.15% (42 of 91). CONCLUSIONS: Two variables, intrauterine growth retardation, and diffuse bowel involvement, were predictive of mortality according to both univariate and multivariate analyses. Site of bowel involvement seems to be important mortality predictors in infants with NEC requiring surgery. The size of our population did not allow statistical analysis of this relationship. Further studies should focus on examining this aspect.

Analysis of Variance↗
PubMed1994

Risk factors and severity indices in necrotizing enterocolitis.

In retrospective analysis we set up a chart review of 61 consecutively newborn infants with proven diagnosis of necrotizing enterocolitis. The 26 female and 35 male infants were admitted to the intensive care unit of the Department of Pediatric Surgery from 1985 to 1991. Birth weights varied from 790 to 4680 g (mean value 2408 +/- 853), gestational ages from 27 to 43 weeks (mean value 36 +/- 4.0); 33 patients received conservative treatment and 28 patients were operated on. An analysis of operated (group 1) and conservatively (group 2) treated patients revealed no statistically significant difference in birth weight, gestational age, peripartal complications or type of feeding. Yet a few parameters measured at admission remained as severity indices. Operated babies had significantly higher counts of immature granulocytes and an elevation in the I:T-ratio, as well as lower counts of total granulocytes, lymphocytes, platelets and lower weights of the placenta. However, when taking into account the gestational age, the results showed that these parameters became insignificant in the low birthweight group below 34 weeks, and were of higher validity in the gestational age group over 35 weeks. In the latter group, C-reactive protein also proved to be a good parameter with statistical significance respecting the severity of necrotizing enterocolitis.

Analysis of Variance↗
PubMed2000

Expression of inducible nitric oxide synthase and interleukin-12 in experimental necrotizing enterocolitis.

BACKGROUND: Previous investigators have relied on administration of pro-inflammatory cytokines or invasive surgical procedures to reproduce the morphologic changes of necrotizing enterocolitis (NEC) in rats. However, these artificial insults do not mimic the human disease. We developed a reproducible model of NEC in rats that more closely resembles human NEC and determined the pattern of inflammatory cytokine expression in this model. MATERIALS AND METHODS: Newborn rats were randomized into four groups. Groups 1 and 2 were breast-fed, while Groups 3 and 4 were gavaged with formula thrice daily. In addition, Groups 2 and 4 were subjected to 3 min of hypoxia thrice daily, prior to each feeding. The rats were killed on day 4 and the distal 2 cm of terminal ileum was harvested for morphological studies and analysis of inflammatory cytokine mRNA expression. RESULTS: Nearly 70% of formula-fed neonatal rats displayed moderate or severe morphological abnormalities resembling human NEC. Breast-fed pups had normal histology. The terminal ileum from rats with abnormal histology demonstrated increased inducible nitric oxide synthase (iNOS) expression, decreased interleukin-12 (IL-12) mRNA expression, and enterocyte apoptosis. There was a trend toward upregulation of IFN-gamma mRNA, but no difference in expression of TNF-alpha mRNA. Hypoxia did not significantly alter intestinal morphology or mRNA expression. CONCLUSIONS: Formula-fed neonatal rats, with or without hypoxia, exhibit morphological changes in the intestinal epithelium similar to those seen in patients with acute NEC. The mechanism likely involves upregulation of iNOS mRNA, enterocyte apoptosis, and decreased IL-12 production in the intestinal epithelium. This model may offer a simple reproducible method for inducing experimental NEC.

Animals↗
PubMed2002

Intraluminal casein model of necrotizing enterocolitis for assessment of mucosal destruction, bacterial translocation, and the effects of allopurinol and N-acetylcysteine.

An intraluminal casein model (ICM) of necrotizing enterocolitis (NEC) is able to produce small-bowel changes reminiscent of human NEC in neonatal animals. We studied bacterial translocation (BT) in NEC induced by using the ICM in neonatal piglets. We also studied whether allopurinol (AL) and N-acetylcysteine (NAC) have an effect on BT and mucosal changes in the ICM of NEC. Twenty-eight neonatal piglets were randomized into four groups. NEC was induced in 21 by injecting casein-d-gluconate into a loop of terminal ileum: group Cas (n = 7) had no premedication, in group Cas/AL (n = 7) intravenous (i.v.) Al (100 mg/kg), and in group Cas/NAC (n = 7) i.v. NAC (200 mg/kg) was given. Group Sham (n = 7) had the ileum injected with 0.9% saline with no premedication. Immediately after the injection a mesenteric lymph node (MLN) adjacent to the loop was harvested for quantitative aerobic bacterial culture; 4 h after the injection another MLN and samples of spleen, liver, kidney, and lung were harvested and cultured. Comparison of the incidence of samples with positive bacterial cultures and the number of colony-forming units (CFU) in samples was made between groups. The severity of NEC in the ileum was graded from 0 to 3 according to macroscopic and histologic findings. NEC changes in the bowel were most severe in Cas piglets, less severe in Cas/NAC piglets ( P < 0.5), and sham piglets had the least severe changes ( P < 0.05). piglets with NEC changes in the ileum had a higher incidence of BT into the MLN than piglets without NEC changes ( P < 0.05), but the difference in CFU was not significant ( P > 0.05). In Cas and Cas/NAC piglets a high incidence of BT into the MLN was noted as early at -5 min after casein injection. The incidence of BT into the MLN was significantly higher in Cas and Cas/NAC piglets than in Sham piglets ( P < 0.05), the difference in CFU being not significant ( P > 0.05). BT in Cas/Al piglets was not significantly different from that of Cas piglets ( P > 0.05), but less than in Cas/NAC piglets ( P < 0.05). Four hours after casein injection into the ileum there was significant BT into the MLN. Premedication with NAC was associated with less severe NEC changes, but neither NAC nor AL significantly affected BT.

Acetylcysteine↗
PubMed2007

Endothelial nitric oxide synthase in human intestine resected for necrotizing enterocolitis.

OBJECTIVE: To determine the expression and function of endothelial nitric oxide synthase (eNOS) in submucosal arterioles harvested from human intestine resected for necrotizing enterocolitis (NEC) or congenital bowel disease. STUDY DESIGN: eNOS expression was determined by using immunohistochemistry. The arteriolar diameter was measured in vitro at pressures of 10 to 40 mm Hg and also in response to the eNOS agonist acetylcholine (ACh), the exogenous nitric oxide (NO) donor S-nitroso-N-acetylpenicillamine, and the smooth muscle relaxant papaverine. Arteriolar release of NO in response to ACh was determined with a Sievers NOAnalyzer. Hemodynamics were also determined at flow rates of 50 and 100 microL/min. RESULTS: eNOS was present in microvessels from both groups, but NEC arterioles failed to demonstrate physiological evidence of eNOS function: they constricted in response to pressure, failed to dilate or generate NO in response to ACh, and failed to dilate in response to flow. However, they dilated in response to exogenous NO and papaverine, indicating functional vascular smooth muscle and vasodilator reserve. CONCLUSION: eNOS-derived NO, a vasodilator in the newborn intestine, did not contribute to vasoregulation in arterioles harvested from intestine resected for NEC. These vessels were constricted; lack of eNOS-derived NO may contribute to this vasoconstriction.

Arterioles↗
PubMed2004

Rotavirus-associated necrotizing enterocolitis: an insight into a potentially preventable disease?

PURPOSE: The aim of this study was to test the hypothesis that rotavirus-associated necrotizing enterocolitis (NEC + RV) differs from NEC associated with other organisms (NEC-RV). METHODS: Neonates with modified Bell stage II or higher NEC were identified. Demographic, clinical, and outcome information was collected prospectively. Fecal specimens from all infants were tested for confirmation of rotavirus infection (RVI) by immunoelectron microscopy (IEM). RESULTS: Of 2,444 admissions in the neonatal intensive care unit (NICU), 129 (5.3%) had NEC. Thirty-eight (29%) were rotavirus positive. The 2 groups did not differ in maternal or neonatal characteristics. Stage III or higher NEC was more common in the NEC-RV infants (62% v. 39%; P =.032), whereas recurrence was more common in NEC + RV group (P <.0001). The predominant distribution of nondiffuse pneumatosis (n = 52) was right sided in NEC-RV group and left sided in NEC + RV group (P <.0001). Surgical intervention (SI) did not differ between the 2 groups. The complications and mortality rates also were similar. Severe pneumatosis (P =.009) and severe thrombocytopenia (Platelet count < 50,000/mm3; P <.0001) increased, while human milk feedings decreased (P =.022) the odds for surgery. The annual distribution of NEC + RV paralleled RVI in the community. CONCLUSIONS: Generally, NEC + RV is a less severe disease than NEC - RV as classified by modified Bell staging. However, it can reach advanced stages obscuring distinction from NEC - RV. Indications for surgery should not be altered by identification of RVI in these infants. Monitoring RVI in the community, adhering to infection control measures, human milk feedings, and improving neonatal immunity against RVI may reduce the incidence of NEC + RV.

Community-Acquired Infections↗
PubMed1999

The role of peritoneal drainage for intestinal perforation in infants with and without necrotizing enterocolitis.

BACKGROUND/PURPOSE: This report reviews our experience using peritoneal drainage (PD) as initial therapy for intestinal perforation in premature infants with and without necrotizing enterocolitis (NEC). METHODS: A chart review was conducted of 18 consecutive premature infants who underwent PD for intestinal perforation from 1995 to 1998. Infants were divided into two groups. Group 1 consisted of eight infants who had intestinal perforation without evidence of NEC. Group 2 consisted of 10 infants who had perforation associated with evidence of NEC. A cohort of 10 infants with intestinal perforation treated with primary laparotomy between 1990 and 1995 was identified by chart review for historical control. RESULTS: All infants improved immediately after PD. In group 1, all survived. Seven (88%) recovered systemically after PD. Of these, five (63%) never required laparotomy. Two (25%) required delayed laparotomy. One infant (12%) failed to continue to improve 48 hours after PD and underwent urgent laparotomy and recovered. In group 2, eight (80%) infants survived. Six (60%) recovered from NEC after PD, but five required delayed laparotomy for obstruction or persistent drainage. Four infants (40%) failed to progress from their initial improvement after PD. Three underwent laparotomy; two recovered and one had total intestinal necrosis and died. The fourth infant died without exploration and total intestinal necrosis was discovered during autopsy. Thus, seven of eight survivors (88%) in group 2 required laparotomy at some point in their course. CONCLUSIONS: In premature infants with intestinal perforation, PD allows acute improvement and usually systemic recovery. In infants without evidence of NEC, PD may afford definitive treatment. In contrast, infants with evidence of NEC will likely require laparotomy, but initial PD may allow systemic stabilization and recovery of much of the involved intestine before laparotomy.

Drainage↗
PubMed2004

An epidemic of gastroenteritis and mild necrotizing enterocolitis in two neonatal units of a University Hospital in Rome, Italy.

In the summer of 1999 a cluster of 18 cases of necrotizing enterocolitis (NEC) occurred in a University Hospital in Rome, Italy. The cases presented with mild clinical and radiological signs, and none died. Seventy-two per cent had a birth weight of > 2500 g, 66.7% had a gestational age of > 37 weeks, 30% presented with respiratory diseases and/or hypoglycaemia. All cases occurred within 10 days of birth and between 5 and 7 days after two clusters of diarrhoea (14 cases). The NEC outbreak had two phases; most cases in the first phase occurred in the at-risk unit, whereas those in the second phase occurred in the full-term unit. In the multivariate analysis, invasive therapeutic procedures, pathological conditions and formula feeding were associated with NEC. Although no predominant common bacteria were isolated, we suggest an infective origin of this outbreak.

Birth Weight↗
PubMed2000

Surgery is safe in very low birthweight infants with necrotizing enterocolitis.

The aim of this study was to determine how the operative event itself affects very low birthweight (VLBW) infants (< 1500 g) with necrotizing enterocolitis (NEC) undergoing surgery, and to try to identify preventable factors leading to perioperative morbidity and mortality. Eighty-five VLBW infants developed NEC during a 6-year period; 34 of those required emergent celiotomies. Data were collected retrospectively from hospital charts available on 33 infants. Birthweight ranged from 566 g to 1415 g (mean +/- SD: 961+/-262 g) and gestational age from 24 to 34 wk (28+/-3.2 wk). Thirty infants had been fed premature formula (first feed at 5+/-3.6 d) prior to the onset of symptoms and three had not been fed at all. Age at NEC symptoms was 19+/-15 d. Infants < 1000 g developed NEC much longer after the first feed compared to infants > 1000 g (p < 0.002; t-test). In 42% of the children, intraoperative blood pressure fell at least 20% from the preoperative value. Body temperature dropped from a preoperative 36.5+/-0.340 degrees C to 35.5+/-1.20 degrees C (p < 0.005), although in all children two or more heating devices were employed in the operating room. All infants survived the procedure. Six infants with pannecrosis died within 72 h of the operative event. In an appropriate setting, operative intervention under general anesthesia is well tolerated by VLBW infants with NEC. Since hypothermia was a major problem, the authors have modified their approach and now no longer transport these infants to the operating room. Instead, these infants are operated upon in the neonatal intensive care unit, directly on an infant radiant warmer system.

Digestive System Surgical Procedures↗